Clinical characteristics of vascular neuro-ophthalmology in patients with central retinal artery occlusion_Chinese Journal of Ocular Fundus Diseases

Authors：

Lu Qingli , Liu Zhongzhong , Wang Jing , Liu Pei , Chang Qiaoqiao , Liu Yan , Liu Guozheng , Lin Xuemei , Wang Fang ,  Wu Songdi

Department of Neurology and Neuro-ophthalmology, The First Hospital of Xi’an (The First Affiliated Hospital of Northwestern University), Xi’an 710002, China;

Corresponding?author：

Wu Songdi, Email: wusongdi@gmail.com

Keywords：

Retinal artery occlusion; Carotid stenosis; Vascular neuro-ophthalmology

DOI：

10.3760/cma.j.cn511434-20210601-00284

Video：

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Objective To investigate the clinical characteristics of vascular neuro-ophthalmology in patients with central retinal artery occlusion (CRAO). Methods A single-center, prospective clinical study. From January 2018 to December 2020, 49 eyes of 49 CRAO patients of The Neuro-ophthalmology Department of Xi'an First Hospital were included in the study. Data on patient demographic characteristics, vascular risk factors, disease characteristics, digital subtraction angiography (DSA) imaging characteristics of internal carotid arteries, treatment, treatment-related adverse events, and 1-month follow-up vascular events were collected. All patiens were examined by visual acuity, head CT and or magnetic resonance imaging. At the same time, 35 cases of internal carotid artery vascular DSA were examined; 14 cases of head and neck CT angiography were examined. The anatomical variation of the extracranial segment of the internal carotid artery was divided into tortuous, tortuous, and coiled; the aortic arch was divided into type Ⅰ, type Ⅱ, type Ⅲ, and bovine type. Intravenous thrombolysis, arterial thrombolysis, conservative treatment were performed. The follow-up time was 1 month after treatment. Functional vision was defined as vision ≥20/100. Vascular events were strokes, cardiovascular events, deaths and neovascular glaucoma during follow-up. Results Among 49 eyes of 49 cases, 40 eyes were male (81.6%, 40/49), and 9 eyes were female (18.4%, 9/49); the average age was 60.7±12.9 years. There were 33, 17, and 16 cases with hypertension, type 2 diabetes, and cerebrovascular disease, respectively; 27 and 34 cases had a history of smoking and tooth loss, respectively. Taking antihypertensive, hypoglycemic, antiplatelet aggregation/anticoagulation, and hypolipidemic drugs were 15, 5, 8, and 5 patients, respectively. There were 11 cases of transient amaurosis before the onset, and 17 cases of CRAO after waking up. There were 33 cases (67.3%, 33/49) with infarction of the affected side of the brain tissue. DSA was performed in 35 cases, and the stenosis rate of the internal carotid artery on the affected side was 70%-99% and 100% were 3 (8.6%, 3/35) and 4 (11.4%, 4/35) cases, respectively. The ophthalmic artery on the affected side originated from the external carotid artery in 5 cases (14.3%, 5/35). There were 17 (54.8%, 17/31) and 2 (6.5%, 2/31) cases of tortuousity and kinking in the extracranial segment of the internal carotid artery. There were 15 (42.9%, 15/35), 6 (17.1%, 6/35), and 2 (5.7%, 2/35) cases of aortic arch type Ⅱ, type Ⅲ, and bovine type, respectively. Intravenous thrombolysis and arterial thrombolysis were performed in 13 and 29 cases, respectively. Complications occurred in 2 cases during treatment; 3 cases of symptoms fluctuated after treatment, and 10 cases of asymptomatic new infarcts occurred in imaging studies. Forty-eight cases were treated with antiplatelet aggregation/anticoagulation and hypolipidemic treatment. At discharge and 1 month after treatment, the recovery of functional vision was 7 and 17 cases, respectively. One month after treatment, 1 case died because myocardial infarction; 2 cases of neovascular glaucoma occurred. Conclusion The proportion of CRAO patients with vascular risk factors and internal carotid artery abnormalities on the affected side is relatively high; the prognosis is relatively good after intravenous thrombolysis and/or arterial thrombolysis and secondary stroke prevention.

Citation： Lu Qingli, Liu Zhongzhong, Wang Jing, Liu Pei, Chang Qiaoqiao, Liu Yan, Liu Guozheng, Lin Xuemei, Wang Fang, Wu Songdi. Clinical characteristics of vascular neuro-ophthalmology in patients with central retinal artery occlusion. Chinese Journal of Ocular Fundus Diseases, 2021, 37(10): 775-779. doi: 10.3760/cma.j.cn511434-20210601-00284 Copy

1.	Sacco RL, Kasner SE, Broderick JP, et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke, 2013, 44(7): 2064-2089. DOI: 10.1161/STR.0b013e318296aeca.
2.	Dattilo M, Biousse V, Newman NJ. Update on the management of central retinal artery occlusion[J]. Neurol Clin, 2017, 35(1): 83-100. DOI: 10.1016/j.ncl.2016.08.013.
3.	Agarwal N, Gala NB, Karimi RJ, et al. Current endovascular treatment options for central retinal arterial occlusion: a review[J/OL]. Neurosurg Focus, 2014, 36(1): e7[2014-01-01]. https://pubmed.ncbi.nlm.nih.gov/24380484/. DOI: 10.3171/2013.11.FOCUS13331.
4.	田國紅, 沙炎. 血管神經眼科學疾病淺析[J]. 中國眼耳鼻喉科雜志, 2017, 17(1): 71-76. DOI: 10.14166/j.issn.1671-2420.2016.07.023.Tian GH, Sha Y. A brief analysis of vascular neuro-ophthalmology diseases[J]. Chin J Ophthalmol and Otorhinolaryngol, 2017, 17(1): 71-76. DOI: 10.14166/j.issn.1671-2420.2016.07.023.
5.	王潤生, 雷濤, 王毅, 等. 超選擇性眼動脈及選擇性頸內動脈溶栓治療視網膜中央動脈阻塞的療效觀察[J]. 中華眼底病雜志, 2014, 30(5): 450-453. DOI: 10.3760/cma.j.issn.1005-1015.2014.05.005.Wang RS, Lei T, Wang Y, et al. Super-selective ophthalmic artery or selective carotid artery thrombolytic therapy for central retinal artery occlusion[J]. Chin J Ocul Fundus Dis, 2014, 30(5): 450-453. DOI: 10.3760/cma.j.issn.1005-1015.2014.05.005.
6.	Hayreh SS, Podhajsky PA, Zimmerman MB. Retinal artery occlusion: associated systemic and ophthalmic abnormalities[J]. Ophthalmology, 2009, 116(10): 1928-1936. DOI: 10.1016/j.ophtha.2009.03.006.
7.	Hasan D, Zanaty M, Starke RM, et al. Feasibility, safety, and changes in systolic blood pressure associated with endovascular revascularization of symptomatic and chronically occluded cervical internal carotid artery using a newly suggested radiographic classification of chronically occluded cervical internal carotid artery: pilot study[J/OL]. J Neurosurg, 2018, 2018: E1-10[2018-05-01].https://thejns.org/view/journals/j-neurosurg/130/5/article-p1468.xml. DOI: 10.3171/2018.1.JNS172858. [published online ahead of print].
8.	Weibel J, Fields WS. Tortuosity, coiling, and kinking of the internal carotid artery. Ⅰ. etiology and radiographic anatomy[J]. Neurology, 1965, 15: 7-18. DOI: 10.1212/wnl.15.1.7.
9.	?nan? Y, ?nan? Y, Ay H. The effect of demographic features on aortic arch anatomy and its role in the etiology of cerebrovascular disease[J]. Neuropsychiatr Dis Treat, 2018, 14: 29-35. DOI: 10.2147/NDT.S152194.
10.	中華醫學會神經病學分會, 中華醫學會神經病學分會腦血管病學組. 中國急性缺血性腦卒中診治指南2014[J]. 中華神經科雜志, 2015, 48(4): 246-257. DOI: 10.3760/cma.j.issn.1006-7876.2015.04.002.Chinese Society of Neurology, Chinese Stroke Society. Chinese guidelines for diagnosis and treatment of acute ischemic stroke 2014[J]. Chin J Neurol, 2015, 48(4): 246-257. DOI: 10.3760/cma.j.issn.1006-7876.2015.04.002.
11.	王潤生, 呂沛霖, 張婭萍, 等. 以尿激酶靜脈溶栓為主治療視網膜中央動脈阻塞115例臨床療效觀察[J]. 中華眼底病雜志, 2012, 28(5): 466-471. DOI: 10.3760/cma.j.issn.1005-1015.2012.05.009.Wang RS, Lyu PL, Zhang YP, et al. Intravenous thrombolysis with urokinase for central retinal artery occlusion in 115 patients[J]. Chin J Ocul Fundus Dis, 2012, 28(5): 466-471. DOI: 10.3760/cma.j.issn.1005-1015.2012.05.009.
12.	Schrag M, Youn T, Schindler J, et al. Intravenous fibrinolytic therapy in central retinal artery occlusion: a patient-level meta-analysis[J]. JAMA Neurol, 2015, 72(10): 1148-1154. DOI: 10.1001/jamaneurol.2015.1578.
13.	Bonasia S, Bojanowski M, Robert T. Embryology and anatomical variations of the ophthalmic artery[J]. Neuroradiology, 2020, 62(2): 139-152. DOI: 10.1007/s00234-019-02336-4.
14.	Hayreh SS, Zimmerman MB. Ocular arterial occlusive disorders and carotid artery disease[J]. Ophthalmol Retina, 2017, 1(1): 12-18. DOI: 10.1016/j.oret.2016.08.003.
15.	Wang M, Gao YF, Chen W, et al. Correlation of ischemic ophthalmopathy with lacunar infarction[J]. Int J Ophthalmol, 2020, 13(6): 960-964. DOI: 10.18240/ijo.2020.06.16.
16.	Varma DD, Cugati S, Lee AW, et al. A review of central retinal artery occlusion: clinical presentation and management[J]. Eye (Lond), 2013, 27(6): 688-697. DOI: 10.1038/eye.2013.25.
17.	Joshipura KJ, Hung HC, Rimm EB, et al. Periodontal disease, tooth loss, and incidence of ischemic stroke[J]. Stroke, 2003, 34(1): 47-52. DOI: 10.1161/01.str.0000052974.79428.0c.
18.	Mir TA, Arham AZ, Fang W, et al. Acute vascular ischemic events in patients with central retinal artery occlusion in the United States: a nationwide study 2003-2014[J]. Am J Ophthalmol, 2019, 200: 179-186. DOI: 10.1016/j.ajo.2019.01.009.
19.	Morjaria R, Tsaloumas M, Shah P. An unusual presentation of patent foramen ovale[J/OL]. JRSM Open, 2015, 6(8): 2054270415596320[2015-08-19]. https://pubmed.ncbi.nlm.nih.gov/26380102/. DOI: 10.1177/2054270415596320.
20.	雷濤, 王潤生, 李豫, 等. 經滑車上動脈逆行或頸外動脈順行介入溶栓治療視網膜中央動脈阻塞伴同側頸內動脈閉塞的療效觀察[J]. 中華眼底病雜志, 2018, 34(3): 228-232. DOI: 10.3760/cma.j.issn.1005-1015.2018.03.005.Lei T, Wang RS, Li Y, et al. The effect of interventional thrombolytic therapy for central retinal artery occlusion with ipsilateral internal carotid artery occlusion via supratrochlear artery retrogradely or external carotid artery anterogradely[J]. Chin J Ocul Fundus Dis, 2018, 34(3): 228-232. DOI: 10.3760/cma.j.issn.1005-1015.2018.03.005.
21.	Dumitrascu OM, Newman NJ, Biousse V. Thrombolysis for central retinal artery occlusion in 2020: time is vision![J]. J Neuroophthalmol, 2020, 40(3): 333-345. DOI: 10.1097/WNO.0000000000001027.
22.	Ahn SJ, Kim JM, Hong JH, et al. Efficacy and safety of intra-arterial thrombolysis in central retinal artery occlusion[J]. Invest Ophthalmol Vis Sci, 2013, 54(12): 7746-7755. DOI: 10.1167/iovs.13-12952.
23.	Rudkin AK, Lee AW, Chen CS. Ocular neovascularization following central retinal artery occlusion: prevalence and timing of onset[J]. Eur J Ophthalmol, 2010, 20(6): 1042-1046. DOI: 10.1177/112067211002000603.
24.	Hoyer C, Kahlert C, Guney R, et al. Central retinal artery occlusion as a neuro-ophthalmological emergency: the need to raise public awareness[J]. Eur J Neurol, 2021, 28(6): 2111-2114. DOI: 10.1111/ene.14735.
25.	楊柳, 瞿遠珍. 我國神經眼科專科醫師培養及學科發展現狀淺述[J]. 中國卒中雜志, 2019, 14(6): 630-632. DOI: 10.3969/j.issn.1673-5765.2019.06.021.Yang L, Qu YZ. Neuro-ophthalmologists training and discipline development status[J]. Chin J Stroke, 2019, 14(6): 630-632. DOI: 10.3969/j.issn.1673-5765.2019.06.021.
26.	Youn TS, Lavin P, Patrylo M, et al. Current treatment of central retinal artery occlusion: a national survey[J]. J Neurol, 2018, 265(2): 330-335. DOI: 10.1007/s00415-017-8702-x.

1. Sacco RL, Kasner SE, Broderick JP, et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke, 2013, 44(7): 2064-2089. DOI: 10.1161/STR.0b013e318296aeca.
2. Dattilo M, Biousse V, Newman NJ. Update on the management of central retinal artery occlusion[J]. Neurol Clin, 2017, 35(1): 83-100. DOI: 10.1016/j.ncl.2016.08.013.
3. Agarwal N, Gala NB, Karimi RJ, et al. Current endovascular treatment options for central retinal arterial occlusion: a review[J/OL]. Neurosurg Focus, 2014, 36(1): e7[2014-01-01]. https://pubmed.ncbi.nlm.nih.gov/24380484/. DOI: 10.3171/2013.11.FOCUS13331.
4. 田國紅, 沙炎. 血管神經眼科學疾病淺析[J]. 中國眼耳鼻喉科雜志, 2017, 17(1): 71-76. DOI: 10.14166/j.issn.1671-2420.2016.07.023.Tian GH, Sha Y. A brief analysis of vascular neuro-ophthalmology diseases[J]. Chin J Ophthalmol and Otorhinolaryngol, 2017, 17(1): 71-76. DOI: 10.14166/j.issn.1671-2420.2016.07.023.
5. 王潤生, 雷濤, 王毅, 等. 超選擇性眼動脈及選擇性頸內動脈溶栓治療視網膜中央動脈阻塞的療效觀察[J]. 中華眼底病雜志, 2014, 30(5): 450-453. DOI: 10.3760/cma.j.issn.1005-1015.2014.05.005.Wang RS, Lei T, Wang Y, et al. Super-selective ophthalmic artery or selective carotid artery thrombolytic therapy for central retinal artery occlusion[J]. Chin J Ocul Fundus Dis, 2014, 30(5): 450-453. DOI: 10.3760/cma.j.issn.1005-1015.2014.05.005.
6. Hayreh SS, Podhajsky PA, Zimmerman MB. Retinal artery occlusion: associated systemic and ophthalmic abnormalities[J]. Ophthalmology, 2009, 116(10): 1928-1936. DOI: 10.1016/j.ophtha.2009.03.006.
7. Hasan D, Zanaty M, Starke RM, et al. Feasibility, safety, and changes in systolic blood pressure associated with endovascular revascularization of symptomatic and chronically occluded cervical internal carotid artery using a newly suggested radiographic classification of chronically occluded cervical internal carotid artery: pilot study[J/OL]. J Neurosurg, 2018, 2018: E1-10[2018-05-01].https://thejns.org/view/journals/j-neurosurg/130/5/article-p1468.xml. DOI: 10.3171/2018.1.JNS172858. [published online ahead of print].
8. Weibel J, Fields WS. Tortuosity, coiling, and kinking of the internal carotid artery. Ⅰ. etiology and radiographic anatomy[J]. Neurology, 1965, 15: 7-18. DOI: 10.1212/wnl.15.1.7.
9. ?nan? Y, ?nan? Y, Ay H. The effect of demographic features on aortic arch anatomy and its role in the etiology of cerebrovascular disease[J]. Neuropsychiatr Dis Treat, 2018, 14: 29-35. DOI: 10.2147/NDT.S152194.
10. 中華醫學會神經病學分會, 中華醫學會神經病學分會腦血管病學組. 中國急性缺血性腦卒中診治指南2014[J]. 中華神經科雜志, 2015, 48(4): 246-257. DOI: 10.3760/cma.j.issn.1006-7876.2015.04.002.Chinese Society of Neurology, Chinese Stroke Society. Chinese guidelines for diagnosis and treatment of acute ischemic stroke 2014[J]. Chin J Neurol, 2015, 48(4): 246-257. DOI: 10.3760/cma.j.issn.1006-7876.2015.04.002.
11. 王潤生, 呂沛霖, 張婭萍, 等. 以尿激酶靜脈溶栓為主治療視網膜中央動脈阻塞115例臨床療效觀察[J]. 中華眼底病雜志, 2012, 28(5): 466-471. DOI: 10.3760/cma.j.issn.1005-1015.2012.05.009.Wang RS, Lyu PL, Zhang YP, et al. Intravenous thrombolysis with urokinase for central retinal artery occlusion in 115 patients[J]. Chin J Ocul Fundus Dis, 2012, 28(5): 466-471. DOI: 10.3760/cma.j.issn.1005-1015.2012.05.009.
12. Schrag M, Youn T, Schindler J, et al. Intravenous fibrinolytic therapy in central retinal artery occlusion: a patient-level meta-analysis[J]. JAMA Neurol, 2015, 72(10): 1148-1154. DOI: 10.1001/jamaneurol.2015.1578.
13. Bonasia S, Bojanowski M, Robert T. Embryology and anatomical variations of the ophthalmic artery[J]. Neuroradiology, 2020, 62(2): 139-152. DOI: 10.1007/s00234-019-02336-4.
14. Hayreh SS, Zimmerman MB. Ocular arterial occlusive disorders and carotid artery disease[J]. Ophthalmol Retina, 2017, 1(1): 12-18. DOI: 10.1016/j.oret.2016.08.003.
15. Wang M, Gao YF, Chen W, et al. Correlation of ischemic ophthalmopathy with lacunar infarction[J]. Int J Ophthalmol, 2020, 13(6): 960-964. DOI: 10.18240/ijo.2020.06.16.
16. Varma DD, Cugati S, Lee AW, et al. A review of central retinal artery occlusion: clinical presentation and management[J]. Eye (Lond), 2013, 27(6): 688-697. DOI: 10.1038/eye.2013.25.
17. Joshipura KJ, Hung HC, Rimm EB, et al. Periodontal disease, tooth loss, and incidence of ischemic stroke[J]. Stroke, 2003, 34(1): 47-52. DOI: 10.1161/01.str.0000052974.79428.0c.
18. Mir TA, Arham AZ, Fang W, et al. Acute vascular ischemic events in patients with central retinal artery occlusion in the United States: a nationwide study 2003-2014[J]. Am J Ophthalmol, 2019, 200: 179-186. DOI: 10.1016/j.ajo.2019.01.009.
19. Morjaria R, Tsaloumas M, Shah P. An unusual presentation of patent foramen ovale[J/OL]. JRSM Open, 2015, 6(8): 2054270415596320[2015-08-19]. https://pubmed.ncbi.nlm.nih.gov/26380102/. DOI: 10.1177/2054270415596320.
20. 雷濤, 王潤生, 李豫, 等. 經滑車上動脈逆行或頸外動脈順行介入溶栓治療視網膜中央動脈阻塞伴同側頸內動脈閉塞的療效觀察[J]. 中華眼底病雜志, 2018, 34(3): 228-232. DOI: 10.3760/cma.j.issn.1005-1015.2018.03.005.Lei T, Wang RS, Li Y, et al. The effect of interventional thrombolytic therapy for central retinal artery occlusion with ipsilateral internal carotid artery occlusion via supratrochlear artery retrogradely or external carotid artery anterogradely[J]. Chin J Ocul Fundus Dis, 2018, 34(3): 228-232. DOI: 10.3760/cma.j.issn.1005-1015.2018.03.005.
21. Dumitrascu OM, Newman NJ, Biousse V. Thrombolysis for central retinal artery occlusion in 2020: time is vision![J]. J Neuroophthalmol, 2020, 40(3): 333-345. DOI: 10.1097/WNO.0000000000001027.
22. Ahn SJ, Kim JM, Hong JH, et al. Efficacy and safety of intra-arterial thrombolysis in central retinal artery occlusion[J]. Invest Ophthalmol Vis Sci, 2013, 54(12): 7746-7755. DOI: 10.1167/iovs.13-12952.
23. Rudkin AK, Lee AW, Chen CS. Ocular neovascularization following central retinal artery occlusion: prevalence and timing of onset[J]. Eur J Ophthalmol, 2010, 20(6): 1042-1046. DOI: 10.1177/112067211002000603.
24. Hoyer C, Kahlert C, Guney R, et al. Central retinal artery occlusion as a neuro-ophthalmological emergency: the need to raise public awareness[J]. Eur J Neurol, 2021, 28(6): 2111-2114. DOI: 10.1111/ene.14735.
25. 楊柳, 瞿遠珍. 我國神經眼科專科醫師培養及學科發展現狀淺述[J]. 中國卒中雜志, 2019, 14(6): 630-632. DOI: 10.3969/j.issn.1673-5765.2019.06.021.Yang L, Qu YZ. Neuro-ophthalmologists training and discipline development status[J]. Chin J Stroke, 2019, 14(6): 630-632. DOI: 10.3969/j.issn.1673-5765.2019.06.021.
26. Youn TS, Lavin P, Patrylo M, et al. Current treatment of central retinal artery occlusion: a national survey[J]. J Neurol, 2018, 265(2): 330-335. DOI: 10.1007/s00415-017-8702-x.

Chinese Journal of Ocular Fundus Diseases

Clinical characteristics of vascular neuro-ophthalmology in patients with central retinal artery occlusion

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