0
CaseCase
 74 year old male, recent carotid doppler74 year old male, recent carotid doppler
following episode of dizziness...
QuestionsQuestions
 Is this amaurosis fugax?Is this amaurosis fugax?
 What is this patient’s risk for stroke?What is thi...
Amaurosis FugaxAmaurosis Fugax
……and the role ofand the role of
Carotid EndarterectomyCarotid Endarterectomy
COL Beverly R...
OutlineOutline
 Definition and etiologies of transient visual lossDefinition and etiologies of transient visual loss
 Cl...
DefinitionDefinition
 Painless unilateral transient loss of vision,Painless unilateral transient loss of vision,
partial ...
Transient visual loss
Amaurosis
Fugax
Transient Visual Obscuration
Binocular Monocular
(TMB)
Retinal
Migraine
Cortical Mig...
Etiologies:Etiologies:
Transient visual lossTransient visual loss
 Occlusive retinal artery diseaseOcclusive retinal arte...
Clinical Features:Clinical Features:
SymptomsSymptoms
 Abrupt or gradual monocular* visual loss,Abrupt or gradual monocul...
Clinical features:Clinical features:
Retinal findingsRetinal findings
Acute infarctionAcute infarction
Opaque and gray (e...
Hollenhorst PlaqueHollenhorst Plaque
Retina and Vitreous, Basic and Clinical Science Course,
AAO 1996
Cotton-wool SpotCotton-wool Spot
Retina and Vitreous, Basic and Clinical
Science Course, AAO 1996
PathophysiologyPathophysiology
 Atheromatous degeneration and stenosis of theAtheromatous degeneration and stenosis of th...
PathophysiologyPathophysiology
 Microemboli occludes retinal vessels, thenMicroemboli occludes retinal vessels, then
frag...
Branch Retinal ArteryBranch Retinal Artery
OcclusionOcclusion
Retina and Vitreous, Basic and Clinical Science Course,
AAO ...
Evaluation:Evaluation:
Transient Monocular BlindnessTransient Monocular Blindness
 Consider disorders with greatest morbi...
Evaluation:Evaluation:
Transient Monocular BlindnessTransient Monocular Blindness
Under age 40Under age 40
 Migraine hist...
Cerebrovascular diseaseCerebrovascular disease
A spectrum of signs, symptoms,A spectrum of signs, symptoms,
and stroke ris...
Amaurosis FugaxAmaurosis Fugax
and Stroke Riskand Stroke Risk
Isn’t if funny that I went blindIsn’t if funny that I went b...
Amaurosis Fugax (AF)Amaurosis Fugax (AF)
& Stroke Risk& Stroke Risk
 Early studies and reports uncontrolledEarly studies ...
Carotid Endarterectomy (CEA):Carotid Endarterectomy (CEA):
Historical PerspectiveHistorical Perspective
1954: CEA introduc...
NASCETNASCET
1987-19961987-1996
North American Symptomatic CarotidNorth American Symptomatic Carotid
Endarterectomy TrialE...
NASCETNASCET
MedicalMedical SurgicalSurgical AbsoluteAbsolute
DifferenceDifference
Rel RiskRel Risk
Reduction NNTReduction...
NASCET:NASCET:
Amaurosis & Stroke RiskAmaurosis & Stroke Risk
 The Risk of Stroke in Patients With First-EverThe Risk of ...
NASCET Medical SubgroupNASCET Medical Subgroup::
High grade stenosisHigh grade stenosis
 129 patients with first TIA129 p...
NASCET Medical SubgroupNASCET Medical Subgroup::
High Grade StenosisHigh Grade Stenosis
 HTIAs: older, higher risk factor...
NASCET Medical Subgroup:NASCET Medical Subgroup:
Risk Factors w/ High Grade StenosisRisk Factors w/ High Grade Stenosis
RT...
NASCET Medical Subgroup:NASCET Medical Subgroup:
Outcomes w/ High Grade StenosisOutcomes w/ High Grade Stenosis
RTIA (n=59...
NASCET Surgical Subgroup:NASCET Surgical Subgroup:
OutcomesOutcomes
 328 surgically treated patients328 surgically treate...
NASCET:NASCET:
Amaurosis & Stroke RiskAmaurosis & Stroke Risk
 The Risk of Stroke in Patients With First-EverThe Risk of ...
NASCET Subgroups:NASCET Subgroups:
Prognosis of TMB (transientPrognosis of TMB (transient
monocular blindness)monocular bl...
NASCET Subgroups:NASCET Subgroups:
Prognosis of TMBPrognosis of TMB
 HTIAs: older, higher risk factorsHTIAs: older, highe...
NASCET Med/Surg SubgroupsNASCET Med/Surg Subgroups::
Isolated TMB vs TIAIsolated TMB vs TIA
ICA stenosisICA stenosis TMBTM...
NASCET Med/Surg SubgroupsNASCET Med/Surg Subgroups::
Isolated TMB vs TIAIsolated TMB vs TIA
TMBTMB
(N=397)(N=397)
Hemisphe...
NASCET Med/Surg SubgroupsNASCET Med/Surg Subgroups::
Three year stroke riskThree year stroke risk
NASCET Medical SubgroupsNASCET Medical Subgroups::
Collaterals & 3 year stroke riskCollaterals & 3 year stroke risk
 TMB ...
NASCET Med/surg SubgroupNASCET Med/surg Subgroup::
Isolated TMB (N=397)Isolated TMB (N=397)
 Median # of TMB episodes: 3 ...
NASCET Medical SubgroupNASCET Medical Subgroup::
Stroke Risk FactorsStroke Risk Factors
 TMB with > 50% stenosisTMB with ...
Amaurosis Fugax & Stroke Risk:Amaurosis Fugax & Stroke Risk:
NASCET findingsNASCET findings
 TMB has high stroke risk if ...
Spectrum of clinical stroke riskSpectrum of clinical stroke risk
Amaurosis
Fugax (2% -?6%)
TIA
(3.7%)
Minor
Stroke (6.1%)
...
ConclusionsConclusions
 Amaurosis Fugax is caused by ischemia to theAmaurosis Fugax is caused by ischemia to the
retina, ...
ReferencesReferences
 Benavente, et al. Prognosis after TransientBenavente, et al. Prognosis after Transient
Monocular Bl...
ReferencesReferences
 Sacco et al. Guidelines for Prevention of StrokeSacco et al. Guidelines for Prevention of Stroke
in...
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  1. 1. CaseCase  74 year old male, recent carotid doppler74 year old male, recent carotid doppler following episode of dizzinessfollowing episode of dizziness 50-79% right carotid stenosis50-79% right carotid stenosis  PMH- coronary artery disease,PMH- coronary artery disease, hypertension, hyperlipidemiahypertension, hyperlipidemia  Spell consisting of “fuzzy vision”, uncertain ifSpell consisting of “fuzzy vision”, uncertain if monocular, lasting minutes up to 15 minutes,monocular, lasting minutes up to 15 minutes, with associated “tingling left side of face”with associated “tingling left side of face”
  2. 2. QuestionsQuestions  Is this amaurosis fugax?Is this amaurosis fugax?  What is this patient’s risk for stroke?What is this patient’s risk for stroke?  Is carotid endarterectomy indicated in thisIs carotid endarterectomy indicated in this case?case?
  3. 3. Amaurosis FugaxAmaurosis Fugax ……and the role ofand the role of Carotid EndarterectomyCarotid Endarterectomy COL Beverly Rice Scott MD Neurology and Neuro-ophthalmology Madigan Army Medical Center
  4. 4. OutlineOutline  Definition and etiologies of transient visual lossDefinition and etiologies of transient visual loss  Clinical features & pathophysiologyClinical features & pathophysiology  Evaluation of transient monocular blindnessEvaluation of transient monocular blindness  Amaurosis Fugax and Stroke RiskAmaurosis Fugax and Stroke Risk North American Symptomatic CarotidNorth American Symptomatic Carotid Endarterectomy Trial (NASCET)Endarterectomy Trial (NASCET)  Spectrum of ocular ischemic syndromes andSpectrum of ocular ischemic syndromes and stroke riskstroke risk
  5. 5. DefinitionDefinition  Painless unilateral transient loss of vision,Painless unilateral transient loss of vision, partial or complete, related to retinalpartial or complete, related to retinal arterial microembolization orarterial microembolization or hypoperfusionhypoperfusion ““fleeting darkness or blindnessfleeting darkness or blindness”” Retinal transient ischemic attack (RTIA)Retinal transient ischemic attack (RTIA) transient monocular blindness (TMB)transient monocular blindness (TMB) Accounts for 25% of anterior circulation transientAccounts for 25% of anterior circulation transient ischemic attacks (TIAs).ischemic attacks (TIAs).
  6. 6. Transient visual loss Amaurosis Fugax Transient Visual Obscuration Binocular Monocular (TMB) Retinal Migraine Cortical Migraine Heart disease Arteritis
  7. 7. Etiologies:Etiologies: Transient visual lossTransient visual loss  Occlusive retinal artery diseaseOcclusive retinal artery disease AtheroembolicAtheroembolic, cardioembolic, arteritic,, cardioembolic, arteritic, hematological disorders, congenital, orbital tumorhematological disorders, congenital, orbital tumor  Low retinal artery pressureLow retinal artery pressure  Ocular ischemia syndromeOcular ischemia syndrome, arteriovenous fistula,, arteriovenous fistula, congestive heart failure, anemiacongestive heart failure, anemia  Optic disc disease and anomaliesOptic disc disease and anomalies  Papilledema, Glaucoma, DrusenPapilledema, Glaucoma, Drusen  VasospasmVasospasm ((ophthalmic migraineophthalmic migraine))  MiscellaneousMiscellaneous
  8. 8. Clinical Features:Clinical Features: SymptomsSymptoms  Abrupt or gradual monocular* visual loss,Abrupt or gradual monocular* visual loss, progressing from peripheral toward center of fieldprogressing from peripheral toward center of field  +/- descending/ ascending shade, partial or complete+/- descending/ ascending shade, partial or complete  ‘‘looking through fog’looking through fog’  Visual disturbance: Dark, foggy, gray, whiteVisual disturbance: Dark, foggy, gray, white  Minutes (1-5 minutes, occasionally longer);Minutes (1-5 minutes, occasionally longer); full resolution takes 10-20 minutesfull resolution takes 10-20 minutes  PainlessPainless  StereotypedStereotyped  Usually occurs in isolationUsually occurs in isolation **may be difficult to distinguish monocular from binocular visualmay be difficult to distinguish monocular from binocular visual lossloss
  9. 9. Clinical features:Clinical features: Retinal findingsRetinal findings Acute infarctionAcute infarction Opaque and gray (early)Opaque and gray (early) ““bright plaques” of cholesterol or otherbright plaques” of cholesterol or other microemboli; may persist weeks to yearsmicroemboli; may persist weeks to years Cotton-wool spotCotton-wool spot Segmental arteriolar mural opacificationSegmental arteriolar mural opacification Optic disc pallor, arteriolar narrowing (late)Optic disc pallor, arteriolar narrowing (late)
  10. 10. Hollenhorst PlaqueHollenhorst Plaque Retina and Vitreous, Basic and Clinical Science Course, AAO 1996
  11. 11. Cotton-wool SpotCotton-wool Spot Retina and Vitreous, Basic and Clinical Science Course, AAO 1996
  12. 12. PathophysiologyPathophysiology  Atheromatous degeneration and stenosis of theAtheromatous degeneration and stenosis of the cervical carotid arteriescervical carotid arteries  Estimated 27% - 67% w/ amaurosis or retinal strokesEstimated 27% - 67% w/ amaurosis or retinal strokes  Retinal emboliRetinal emboli Cholesterol crystalsCholesterol crystals Platelet aggregatesPlatelet aggregates Fibrin and blood cellsFibrin and blood cells Neutral fatNeutral fat  VasospasmVasospasm Primary thrombosis of retinal arteries does not occurPrimary thrombosis of retinal arteries does not occur
  13. 13. PathophysiologyPathophysiology  Microemboli occludes retinal vessels, thenMicroemboli occludes retinal vessels, then fragment and pass into retinal peripheryfragment and pass into retinal periphery  If disaggregation with reconstitution ofIf disaggregation with reconstitution of blood flow does not occur, ischemicblood flow does not occur, ischemic damage to the inner retinal layers may bedamage to the inner retinal layers may be irreversibleirreversible
  14. 14. Branch Retinal ArteryBranch Retinal Artery OcclusionOcclusion Retina and Vitreous, Basic and Clinical Science Course, AAO 1996
  15. 15. Evaluation:Evaluation: Transient Monocular BlindnessTransient Monocular Blindness  Consider disorders with greatest morbidity andConsider disorders with greatest morbidity and most common disordersmost common disorders  Consider age, stereotypy of eventsConsider age, stereotypy of events  Physical examPhysical exam (blood pressure, carotid/cardiac exam)(blood pressure, carotid/cardiac exam)  Ophthalmologic ExamOphthalmologic Exam  Visual acuity, visual fields, relative afferent pupil defectVisual acuity, visual fields, relative afferent pupil defect  dilated fundus exam (emboli, anomalous discs)dilated fundus exam (emboli, anomalous discs)  Visual fieldsVisual fields  Electroretinogram – diminished B-waveElectroretinogram – diminished B-wave amplitudeamplitude
  16. 16. Evaluation:Evaluation: Transient Monocular BlindnessTransient Monocular Blindness Under age 40Under age 40  Migraine history, familyMigraine history, family  Echocardiogram w/Echocardiogram w/ bubblebubble  CBC, ESR, ANA,CBC, ESR, ANA, antiphospholipidantiphospholipid antibodiesantibodies  stop birth control pillstop birth control pill  stop smokingstop smoking Over age 40Over age 40  History for giant cellHistory for giant cell arteritis, polymyalgia,arteritis, polymyalgia, coronary artery disease,coronary artery disease, stroke & risk factorsstroke & risk factors  ESR, Creactive Protein ifESR, Creactive Protein if older than 50)older than 50)  Carotid DopplerCarotid Doppler  Echocardiogram w/ bubbleEchocardiogram w/ bubble  MRA , CT angiographyMRA , CT angiography  Fluorescein angiogramFluorescein angiogram  Carotid angiographyCarotid angiography
  17. 17. Cerebrovascular diseaseCerebrovascular disease A spectrum of signs, symptoms,A spectrum of signs, symptoms, and stroke risksand stroke risks Asymptomatic Asymptomatic w/ signs of atherosclerotic Cerebrovascular disease Symptomatic Atherosclerotic Cerebrovascular disease Low risk High risk
  18. 18. Amaurosis FugaxAmaurosis Fugax and Stroke Riskand Stroke Risk Isn’t if funny that I went blindIsn’t if funny that I went blind in the wrong eye”in the wrong eye” CM Fisher. Transient monocular blindness associated withCM Fisher. Transient monocular blindness associated with hemiplegia.hemiplegia. Archives OphthalmologyArchives Ophthalmology, 1952., 1952. What is the relationship of AF and the otherWhat is the relationship of AF and the other ocular ischemic syndromes to theocular ischemic syndromes to the carotid arteries?carotid arteries?
  19. 19. Amaurosis Fugax (AF)Amaurosis Fugax (AF) & Stroke Risk& Stroke Risk  Early studies and reports uncontrolledEarly studies and reports uncontrolled  Different populationsDifferent populations  Causes aggregatedCauses aggregated  Best studied ocular ischemic syndromeBest studied ocular ischemic syndrome  Prognosis following AF considered morePrognosis following AF considered more favorable than TIA, unless severe stenosisfavorable than TIA, unless severe stenosis  Prognosis altered by carotid endarterectomy?Prognosis altered by carotid endarterectomy?  Stroke risk estimated 2-4% prior to NASCETStroke risk estimated 2-4% prior to NASCET
  20. 20. Carotid Endarterectomy (CEA):Carotid Endarterectomy (CEA): Historical PerspectiveHistorical Perspective 1954: CEA introduced1954: CEA introduced 1959-70: Joint Study of1959-70: Joint Study of Extracranial Arterial OcclusionExtracranial Arterial Occlusion surgery: 32% stroke risksurgery: 32% stroke risk medical: 39% stroke riskmedical: 39% stroke risk operative M&M of 11.4%operative M&M of 11.4% CEA benefit if 3% morbidityCEA benefit if 3% morbidity 1970: 15,000 operations/yr1970: 15,000 operations/yr 1980s: 100,000 operations/yr1980s: 100,000 operations/yr Practical Neurology, Vol 4, 2005.
  21. 21. NASCETNASCET 1987-19961987-1996 North American Symptomatic CarotidNorth American Symptomatic Carotid Endarterectomy TrialEndarterectomy Trial (NASCET)(NASCET)  2885 patients enrolled ; TIA/stroke 120 days2885 patients enrolled ; TIA/stroke 120 days  1583 patients(54.9%) -- TIA1583 patients(54.9%) -- TIA  1302 patients (45%) – nondisabling stroke1302 patients (45%) – nondisabling stroke  carotid stenosis; angio confirmedcarotid stenosis; angio confirmed  moderate (30-69%) ; severe (70-99%)moderate (30-69%) ; severe (70-99%)  Established CEA over medical RX in patientsEstablished CEA over medical RX in patients with high grade stenosis (>70%)with high grade stenosis (>70%)
  22. 22. NASCETNASCET MedicalMedical SurgicalSurgical AbsoluteAbsolute DifferenceDifference Rel RiskRel Risk Reduction NNTReduction NNT 70-99%70-99% 26.0%26.0% 9.0%9.0% 17%17% 65%65% 88 50-70%50-70% 22%22% 16%16% 6%6% 39% 1539% 15 Cumulative risk for ipsilateral stroke in symptomatic Carotid Endarterectomy trials at 2 years < 50% , CEA not better than ASA (aspirin)
  23. 23. NASCET:NASCET: Amaurosis & Stroke RiskAmaurosis & Stroke Risk  The Risk of Stroke in Patients With First-EverThe Risk of Stroke in Patients With First-Ever Retinal vs Hemispheric Transient IschemicRetinal vs Hemispheric Transient Ischemic Attacks and High-grade Carotid Stenosis.Attacks and High-grade Carotid Stenosis. Archives of NeurologyArchives of Neurology. 1995.. 1995.  Prognosis after Transient Monocular BlindnessPrognosis after Transient Monocular Blindness Associated with Carotid-Artery Stenosis.Associated with Carotid-Artery Stenosis. NEJMNEJM.. 20012001
  24. 24. NASCET Medical SubgroupNASCET Medical Subgroup:: High grade stenosisHigh grade stenosis  129 patients with first TIA129 patients with first TIA 59 retinal TIAs (RTIAs)59 retinal TIAs (RTIAs) 70 with hemispheric TIAs (HTIAs)70 with hemispheric TIAs (HTIAs)  Characterize the features and course ofCharacterize the features and course of subgroups with high grade stenosissubgroups with high grade stenosis  Compare outcomes with RTIAs to HTIAsCompare outcomes with RTIAs to HTIAs  Average follow-up: 19monthsAverage follow-up: 19months Arch Neurol. 1995; 52
  25. 25. NASCET Medical SubgroupNASCET Medical Subgroup:: High Grade StenosisHigh Grade Stenosis  HTIAs: older, higher risk factorsHTIAs: older, higher risk factors  RTIAs: higher risk for smokingRTIAs: higher risk for smoking  Longer delay for medical treatment forLonger delay for medical treatment for RTIAs (48 days vs 15.2 days )RTIAs (48 days vs 15.2 days )  Estimates for stroke risk at 2 yearsEstimates for stroke risk at 2 years RTIAs 16.6% +/- 5.5%RTIAs 16.6% +/- 5.5% HTIAs 43.5% +/- 6.7%HTIAs 43.5% +/- 6.7% Arch Neurol. 1995; 52
  26. 26. NASCET Medical Subgroup:NASCET Medical Subgroup: Risk Factors w/ High Grade StenosisRisk Factors w/ High Grade Stenosis RTIA (n=59)RTIA (n=59) HTIA (n=70)HTIA (n=70) Mean ageMean age 61.561.5 66.966.9 Male genderMale gender 59%59% 70%70% hypertensionhypertension 59.3%59.3% 64.3%64.3% diabetesdiabetes 17%17% 21%21% heart attackheart attack 6.8%6.8% 18.6%18.6% AnginaAngina 27.1%27.1% 40%40% ClaudicationClaudication 13.6%13.6% 15.7%15.7% HyperlipidemiaHyperlipidemia 30.5%30.5% 40.0%40.0% Smoking (5yrs)Smoking (5yrs) 61%61% 51.4%51.4% Antiplatelet RxAntiplatelet Rx 20.3%20.3% (delayed, 48d)(delayed, 48d) 25.7% (15 d)25.7% (15 d)
  27. 27. NASCET Medical Subgroup:NASCET Medical Subgroup: Outcomes w/ High Grade StenosisOutcomes w/ High Grade Stenosis RTIA (n=59)RTIA (n=59) HTIA (n=70)HTIA (n=70) Ipsilateral stroke, minorIpsilateral stroke, minor 77 1717 majormajor 00 88 retinalretinal 11 22 Contralateral strokeContralateral stroke 00 00 retinal strokeretinal stroke 00 11 Vascular deathVascular death 00 22 MIMI 11 22 Arch Neurol. 1995; 52
  28. 28. NASCET Surgical Subgroup:NASCET Surgical Subgroup: OutcomesOutcomes  328 surgically treated patients328 surgically treated patients 5.8% perioperative stroke5.8% perioperative stroke 9% 2 year stroke rate9% 2 year stroke rate  54 surgical treated patients with RTIA54 surgical treated patients with RTIA 2 minor perioperative strokes (4%)2 minor perioperative strokes (4%) One stroke (2%) 17 months post-opOne stroke (2%) 17 months post-op 6.8% stroke risk at 2 years6.8% stroke risk at 2 years
  29. 29. NASCET:NASCET: Amaurosis & Stroke RiskAmaurosis & Stroke Risk  The Risk of Stroke in Patients With First-EverThe Risk of Stroke in Patients With First-Ever Retinal vs Hemispheric Transient IschemicRetinal vs Hemispheric Transient Ischemic Attacks and High-grade Carotid Stenosis.Attacks and High-grade Carotid Stenosis. Archives of NeurologyArchives of Neurology. 1995.. 1995.  Prognosis after Transient MonocularPrognosis after Transient Monocular Blindness Associated with Carotid-ArteryBlindness Associated with Carotid-Artery Stenosis.Stenosis. NEJMNEJM. 2001. 2001
  30. 30. NASCET Subgroups:NASCET Subgroups: Prognosis of TMB (transientPrognosis of TMB (transient monocular blindness)monocular blindness)  Compared 397 patients withCompared 397 patients with isolated TMBisolated TMB (medical and surgical subgroups) to 829(medical and surgical subgroups) to 829 patients with hemispheric TIAspatients with hemispheric TIAs  Compared stroke risk for TMB and HTIAs inCompared stroke risk for TMB and HTIAs in patients withpatients with high grade stenosis with andhigh grade stenosis with and without collateralswithout collaterals  IdentifiedIdentified risk factorsrisk factors for ipsilateral stroke infor ipsilateral stroke in patients withpatients with carotid stenosis > 50%carotid stenosis > 50%
  31. 31. NASCET Subgroups:NASCET Subgroups: Prognosis of TMBPrognosis of TMB  HTIAs: older, higher risk factorsHTIAs: older, higher risk factors  TMB: higher risk for smoking, increased highTMB: higher risk for smoking, increased high grade stenosis, higher incidence of collateralsgrade stenosis, higher incidence of collaterals  Medically treated TMB had 3 year ipsilateralMedically treated TMB had 3 year ipsilateral stroke risk approx ½ HTIAstroke risk approx ½ HTIA  Surgically treated TMB showed 30-day strokeSurgically treated TMB showed 30-day stroke rate ½ of HTIA (3.6% vs 7.4%)rate ½ of HTIA (3.6% vs 7.4%)  Stroke risk increased with degree of carotidStroke risk increased with degree of carotid stenosis and specific stroke risk factorsstenosis and specific stroke risk factors
  32. 32. NASCET Med/Surg SubgroupsNASCET Med/Surg Subgroups:: Isolated TMB vs TIAIsolated TMB vs TIA ICA stenosisICA stenosis TMBTMB (N=397)(N=397) Hemispheric TIAHemispheric TIA (N=829)(N=829) < 50%< 50% 28.5%28.5% 50%50% 50-69%50-69% 30.5%30.5% 29.8%29.8% 70-94%70-94% 31.7%31.7% 16%16% Near occlusionNear occlusion 9.3%9.3% 3.7%3.7%NEJM. Vol 345,2001
  33. 33. NASCET Med/Surg SubgroupsNASCET Med/Surg Subgroups:: Isolated TMB vs TIAIsolated TMB vs TIA TMBTMB (N=397)(N=397) HemisphericHemispheric TIATIA (N=829)(N=829) CollateralCollateral Circulation *Circulation * 24.2%24.2% 6.9%6.9% *Collateral circulation = filling of the ACA, PComA, or ophthalmic artery NEJM. Vol 345,2001
  34. 34. NASCET Med/Surg SubgroupsNASCET Med/Surg Subgroups:: Three year stroke riskThree year stroke risk
  35. 35. NASCET Medical SubgroupsNASCET Medical Subgroups:: Collaterals & 3 year stroke riskCollaterals & 3 year stroke risk  TMB w/ collaterals (N=25) 2.9%TMB w/ collaterals (N=25) 2.9%  HTIAs w/ collaterals (N=30) 16.7%HTIAs w/ collaterals (N=30) 16.7%  TMB w/o collaterals (N=44) 16.0%TMB w/o collaterals (N=44) 16.0%  HTIAs w/o collaterals (N=69) 44.4%HTIAs w/o collaterals (N=69) 44.4% NEJM. Vol 345,2001
  36. 36. NASCET Med/surg SubgroupNASCET Med/surg Subgroup:: Isolated TMB (N=397)Isolated TMB (N=397)  Median # of TMB episodes: 3 (1-7)Median # of TMB episodes: 3 (1-7) 5% had >45 episodes5% had >45 episodes Median duration : 4 minutes (1-10min)Median duration : 4 minutes (1-10min) 5% had episode > 60min5% had episode > 60min No correlation to carotid stenosisNo correlation to carotid stenosis 3 year stroke risk (N= 198, medical)3 year stroke risk (N= 198, medical) 1 episode -- 10.4 %1 episode -- 10.4 %  >2 episodes-- 8.2 %>2 episodes-- 8.2 % NEJM. Vol 345,2001
  37. 37. NASCET Medical SubgroupNASCET Medical Subgroup:: Stroke Risk FactorsStroke Risk Factors  TMB with > 50% stenosisTMB with > 50% stenosis Age > 75Age > 75 Male sexMale sex h/o hemispheric TIA or strokeh/o hemispheric TIA or stroke h/o intermittent claudicationh/o intermittent claudication Ipsilateral stenosis 80-94%Ipsilateral stenosis 80-94% No collaterals on angiographyNo collaterals on angiography NEJM. Vol 345,2001
  38. 38. Amaurosis Fugax & Stroke Risk:Amaurosis Fugax & Stroke Risk: NASCET findingsNASCET findings  TMB has high stroke risk if high gradeTMB has high stroke risk if high grade carotid stenosis, though less than HTIAscarotid stenosis, though less than HTIAs  Higher collaterals improve prognosisHigher collaterals improve prognosis  Age, gender, h/o stroke/TIA,& claudicationAge, gender, h/o stroke/TIA,& claudication may alter stroke riskmay alter stroke risk  CEA reduces stroke risk if surgeon has lowCEA reduces stroke risk if surgeon has low complication ratecomplication rate  Perioperative risk for stroke and death wasPerioperative risk for stroke and death was lower in patients with TMBlower in patients with TMB
  39. 39. Spectrum of clinical stroke riskSpectrum of clinical stroke risk Amaurosis Fugax (2% -?6%) TIA (3.7%) Minor Stroke (6.1%) Major Stroke (9%) Low risk High risk Estimated Annual Stroke Rates Asymptomatic Stenosis (2%) Asymptomatic Bruit (2%) AION BRAO Asymptomatic retinal emboli Acute & Chronic Ocular Ischemic Syndrome
  40. 40. ConclusionsConclusions  Amaurosis Fugax is caused by ischemia to theAmaurosis Fugax is caused by ischemia to the retina, often associated with carotid stenosis,retina, often associated with carotid stenosis, and is a risk factor for strokeand is a risk factor for stroke  Prognosis is better for patients with amaurosisPrognosis is better for patients with amaurosis fugax treated both medically and surgicallyfugax treated both medically and surgically compared to patients with hemispheric TIAs.compared to patients with hemispheric TIAs.  Amaurosis Fugax should be recognized, withAmaurosis Fugax should be recognized, with strong consideration for carotid endarterectomystrong consideration for carotid endarterectomy with high grade carotid stenosis, vascular riskwith high grade carotid stenosis, vascular risk factors present, and low complication rate offactors present, and low complication rate of procedure in your centerprocedure in your center
  41. 41. ReferencesReferences  Benavente, et al. Prognosis after TransientBenavente, et al. Prognosis after Transient Monocular Blindness Associated with CarotidMonocular Blindness Associated with Carotid Artery Stenosis.Artery Stenosis. NEJMNEJM, Vol 345(15), 2001., Vol 345(15), 2001.  Easton and Wilterdink. Carotid Endarterectomy:Easton and Wilterdink. Carotid Endarterectomy: Trials and Tribulations.Trials and Tribulations. Ann NeurologyAnn Neurology. Vol. Vol 35.1994.35.1994.  Glaser.Glaser. Neuro-ophthalmology.Neuro-ophthalmology. 33rdrd ed. 1999ed. 1999  Mizener, et al. Ocular Ischemic Syndrome.Mizener, et al. Ocular Ischemic Syndrome. OphthalmologyOphthalmology, Vol 104, 1997., Vol 104, 1997.  Rizzo. Neuroophthalmologic Disease of theRizzo. Neuroophthalmologic Disease of the Retina.Retina. Neuro-ophthalmology.Neuro-ophthalmology.
  42. 42. ReferencesReferences  Sacco et al. Guidelines for Prevention of StrokeSacco et al. Guidelines for Prevention of Stroke in patients with ischemic stroke or transientin patients with ischemic stroke or transient ischemic attack.ischemic attack. StrokeStroke. Feb 2006.. Feb 2006.  Streifler, et al. The Risk of Stroke in PatientsStreifler, et al. The Risk of Stroke in Patients with First-Ever Retinal vs Hemispheric Transientwith First-Ever Retinal vs Hemispheric Transient Ischemic Attacks and High-grade CarotidIschemic Attacks and High-grade Carotid Stenosis.Stenosis. Archives of Neurology,Archives of Neurology, Vol 52(3),Vol 52(3), 1995.1995.  Wilterdink and Easton. Vascular event rates inWilterdink and Easton. Vascular event rates in patients with atherosclerotic cerebrovascularpatients with atherosclerotic cerebrovascular disease.disease. Arch NeurologyArch Neurology. Vol 49. 1992. Vol 49. 1992
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