What s Hot in Neuro-Op Cerebrovascular Disease. Transient Ischemic Attacks CEREBROVASCULAR DISEASE KEY POINTS CEREBROVASCULAR DISEASE KEY POINTS
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1 What s Hot in Neuro-Op Cerebrovascular Disease Leonard V. Messner, OD, FAAO James L. Fanelli, OD, FAAO CEREBROVASCULAR DISEASE KEY POINTS 1. CLASSIFICATION OF TIAs 2. OCULAR SIGNS & SYMPTOMS OF CAROTID ATHEROSCLEROTIC DISEASE 3. WORK-UP FOR PATIENTS WITH CAD 4. MANAGEMENT OPTIONS CEREBROVASCULAR DISEASE KEY POINTS 1. CLASSIFICATION OF TIAs 2. OCULAR SIGNS & SYMPTOMS OF CAROTID ATHEROSCLEROTIC DISEASE 3. WORK-UP FOR PATIENTS WITH CAD 4. MANAGEMENT OPTIONS Transient Ischemic Attacks Hemispheric Retinal Posterior circulation Hemispheric TIAs (carotid artery TIA) Relatively easy to diagnose Any acute hemiparesis Hemi-sensory loss Aphasia Dysarthria Hemianopia (often described as non-specific vision loss) Retinal TIAs (carotid artery & ophthalmic artery TIA) More difficult to diagnose Acute, monocular vision loss Partial (altitudinal) or complete blackout of vision (not blurry or difficulty focusing) Biousse V. NANOS 2014 Biousse V. NANOS
2 Posterior TIAs (brainstem and occipital lobetia) Difficult to diagnose (high false positives) Acute vertigo, dizziness, gait instability, confusion, dysarthria Visual disturbance (including diplopia & binocular vision loss) particularly if multiple symptoms at the same time Carotid Artery Disease Biousse V. NANOS 2014 Risk Factors for CAD Older age Males African American Hypertension Diabetes mellitus Abnormal serum lipids Obesity Cigarette smoking Pathophysiology Vessel wall shear stress(carotid artery bulb) Endothelial cell damage Fibrin/platelet aggregation Cellular proliferation Atheromatous plaque formation Plaque ulceration Vessel occlusion 2
3 Ocular Signs of CAD Retinal emboli cholesterol platelet-fibrin Retinal artery occlusion Ocular ischemic syndrome Cholesterol Emboli (Hollenhorst Plaques) Yellow/copper-colored Refractile Arterial bifurcation CRA diastoly Originate from degenerating atheroma carotid (common) aorta (rare) Hollenhorst RW. JAMA 1961 C/o TMB OD BVA: 20/20 20/20 82 Y/O Asian Man 3
4 4 months later Platelet-Fibrin Emboli (Fisher Plugs) White-gray vascular casts (plugs) Dull Source: carotid atheroma heart (valves) Fisher CM. Neurology 1959 Retinal Artery Occlusions Branch Retinal Artery Occlusion Central Retinal Artery Occlusion 4
5 Central Retinal Artery Occlusion Acute, painless vision loss FC to LP (slight improvement over time) Preceding TMB (+/-) Retinal emboli (+/-) +RAPD 47 y/o AA Woman C/o acute, painless vision loss OD x 3 days History of type 2 diabetes with retinopathy BVA = HM OD 5
6 67-y/o man VA = HM x 18 hours 6
7 70 y/o AA woman c/o decreased vision OD X 1 week 18 s 26 s 42 s 11 min 45 sec f/u x 2 weeks Evolution of CRAO - OCT Acute Sub acute Chronic Management of CRAO Limited window of opportunity (0-6 hrs???) Conservative treatments don t work!!! Paracentesis doesn t work (some reports of embolic dislodgement)!!!??? 7
8 Etiology of CRAO 1. Embolic: Carotids Aorta Cardiac 2. Inflammatory: GCA 3. Localized thrombus Thrombolytic Tx for CRAO t-pa, streptokinase, urokinase Intravenous v. intra-arterial (delay in Tx!!!) European trial (EAGLE Study) discontinued no difference in outcomes & 10% risk of intracranial bleed Biousse V. NANOS 2008 Efficacy of IV tpa in CRAO: Report from a Randomized Controlled Trial (Chen C, et al. NANOS 2011) Australian study of 16 patients with acute (within 24 hrs.) CRAO randomized to IV tpa vs. placebo No difference in VA between placebo and tpa groups at 6 months Potential benefit if tpa administered within 6 hours of CRAO Benefit of Tx does not justify the risk of IC bleed & stroke Branch Retinal Artery Occlusion Sector of vision loss Asymptomatic 80% improve to 20/40 or better Arterial bifurcation (posterior pole) 90% involve temporal retinal vessels Brown GC, et al. Arch Ophthmol
9 Evaluation of Elderly Patients with Retinal Artery Occlusions Carotid artery disease Cardiac disease Giant-cell arteritis (nonembolic CRAO) 63 y/o man + diabetes & hypertension + atrial fibrilation c/o loss of vision-superior hemifield, OD VA = 20/40, OD 9
10 Manifestations of OIS Ocular Ischemic Syndrome Associated with severe, bilateral carotid atherosclerosis Retinal involvement venous stasis retinopathy Choroidal ischemia Anterior segment involvement Venous Stasis Retinopathy Dilated, non-tortuous veins (Brown ) No disc swelling Mid-peripheral hemorrhage Neovascularization (NVD) Delayed A-V transit time (> 11 sec.) Other signs/symptoms of CAD: TMB light-induced amaurosis orbital pain (improves while lying down) Kearns & Hollenhorst Mayo Clin Proc y/o man VA = 20/20, OU 10
11 a b Choroidal Ischemia c d Progressive vision loss Purple vision (NANOS-2008) Light-induced amaurosis No obvious clinical correlation Delayed & patchy choroidal filling Brown & Magargal Int Ophthlmol y/o woman + light-induced TMB Anterior Segment & Orbital Complications Mild A/C rxn ( ischemic uveitis ) Orbital pain (improves when lying down) trigeminal ischemia Cataract Dilated episcleral vessesl Iris/angle neovascularization neovascular glaucoma Management of OIS Carotid Endarterectomy (CEA) Carotid angioplasty (stenting) PRP/anti-VEGF Carter JE. Stroke
12 Investigation of Carotid Artery Disease Investigation of Carotid Artery Disease Auscultation for bruit Carotid duplex ultrasonography Magnetic resonance angiography (MRA) Computerized tomographic angiography (CTA) Carotid intima media thickness scan (CIMT) Carotid Bruit Audible turbulence Carotid bifurcation Screening test for carotid stenosis 60-75% sensitivity & specificity for significant carotid stenosis Non-Invasive/Minimally Invasive Carotid Imaging Duplex ultrasonography Magnetic resonance angiography (MRA) Computerized tomographic angiography (CTA) Intima Media Thickness (IMT) SauvC JS, et al. JAMA 1993 Duplex Untrasonography Combines: B-mode ultasound (2-d image) Doppler ultrasound (quantitative hemodynamics of blood flow) 86% sensitive & 87% specific for > 50% carotid stenosis Low cost ($ ) 12
13 Magnetic Resonance Angiography (MRA) Time-of-flight (visualization of arteries) Over 90% sensitive and specific for > 70% carotid stenosis $ Computerized Tomographic Angiography (CTA) Contrast-enhanced CT 3-d image of intracranial and extracranial vasculature Simultaneous viewing of skull base and vasculature High-speed and creation of volumetric data set High resolution of plaque morphology 72-y/o AA Man C/o: recent onset right-sided numbness & hemiparesis Transient monocular blindness, OS CT Angio Restricted diffusion Low ADC (acute infarct) DWI ADC Map 13
14 Carotid Intima Media Thickness (IMT) Ultrasonography Office-based screening tool for hemodynamically-significant stenosis & plaque formation (soft vs. calcified) Indirect assessment of coronary artery atherosclerosis (manufacturers claim of 96% agreement) Computed risk score for coronary artery atherosclerosis Mack WJ, et al. Stroke 1993 Tasneem NZ, et al. J Am Soc Echocardiogr 2010 Symptomatic High-Grade Stenosis Symptomatic Moderate Stenosis Management of Carotid Stenosis Carotid Endarterectomy Asymptomatic Carotid Stenosis Symptomatic Low-Grade Stenosis Endarterectomies in U.S Trobe NASCET thousands of cases Clinical Trials North American Symptomatic Carotid Endarterectomy Trial (NASCET) European Carotid Surgery Trial (ECST) Asymptomatic Carotid Atherosclerosis Study (ACAS) 14
15 NASCET 2 Year Results Study terminated early due to overwhelming benefit of CEA vs. best medical management for symptomatic patients with highgrade stenosis (70-99%) 17% absolute risk reduction 70% relative risk reduction NASCET N Engl J Med 1991 % 2 years Symptomatic High-Grade Stenosis Surgery vs. Medical Management: NASCET & ECST Results NASCET ECST CEA Medical NASCET N Engl J Med 1991 ECST Lancet 1991 % 5 years Asymptomatic Carotid Stenosis: ACAS data for > 60% stenosis ACAS CEA Medical ACAS JAMA 1995 Number Needed to Treat to Prevent One Stroke Symptomatic High-Grade Stenosis NNT = 8 Asymptomatic High-Grade Stenosis NNT = 19 Biller & Thies American Family Physician Year Stroke Risk TMB vs. TIA TMB 17% (29%)* TIA 44% (96%)* *75-95% stenosis Easton & Wilterdink Ann Neurol
16 Front-Loaded Stroke Risk 50% of all strokes occur within 48 hours of resolution of TIA symptoms Johnston SC, et al. JAMA 2000 Summary of Treatment Patients with symptomatic high-grade carotid stenosis should be recommended CEA if there are no other contraindications Patients with asymptomatic carotid stenosis may be recommended for CEA (particularly if > 80% stenosis) if surgeon complication rate < 3% and there are no other contraindications Mild - moderate stenosis should be managed medically Kistler & Furie MGH data 2000 Carotid Stenting vs. Endarterectomy EVA-3S Trial French study (20 academic medical centers) 527 patients with high grade stenosis (> 60%) 1-1 randomization (endarterectomy vs. stenting) Premature termination Results endarterectomy vs. stenting 30 day mortality: 3.9% vs. 9.6% 30 day disabling stroke: 1.5% vs. 3.4% 6 month incidence Mas JL, of et stroke/death: al. NEJM % vs. 11.7% International Carotid Stenting Study (ICSS) 1713 patients with symptomatic high grade stenosis 1-1 randomization (endarterectomy vs. stenting) Results endarterectomy vs. stenting 120 day mortality/disabliing stroke: 3.2% vs. 4.0% 120 day stroke, death, procedural infarct: 5.2% vs. 8.5% ICSS Study Group. Lancet 2010 Systematic Review of Stenting vs. Endarterectomy Stenting associated with higher risk of stroke Endarterectomy associated with higher risk of myocardial infarction Both stenting and endarterectomy may be viable based on patient selection characteristics Gahremanpour A, et al. Texas Heart Inst J
17 Cardiac Complications with Carotid Stenosis & Cerebral/Ocular Ischemia CEREBROVASCULAR DISEASE KEY POINTS 30% risk of MI x 5 years 18% mortality rate 1/2 to 2/3 of all deaths with CAD due to heart disease Trobe JD. Ophthalmology 1987 Easton & Wilterdink. Ann Neurol 1994 Pop GAM, et al (Dutch TIA Trial) Arch Neurol CLASSIFICATION OF TIAs 2. OCULAR SIGNS & SYMPTOMS OF CAROTID ATHEROSCLEROTIC DISEASE 3. WORK-UP FOR PATIENTS WITH CAD 4. MANAGEMENT OPTIONS 17
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