Current Guidelines on Management of Amaurosis Fugax and Transient Ischemic Attacks.

ABSTRACT: Transient ischemic attack (TIA) is defined as a transient episode of neurological dysfunction resulting from focal brain, spinal cord, or retinal ischemia, without associated infarction. Consequently, a TIA encompasses amaurosis fugax (AF) that is a term used to denote momentary visual loss from transient retinal ischemia. In this review, we use the word TIA to refer to both cerebral TIAs (occurring in the brain) and AF (occurring in the retina). We summarize the key components of a comprehensive evaluation and management of patients presenting with cerebral and retinal TIA.All TIAs should be treated as medical emergencies, as they may herald permanent disabling visual loss and devastating hemispheric or vertebrobasilar ischemic stroke. Patients with suspected TIA should be expeditiously evaluated in the same manner as those with an acute stroke. This should include a detailed history and examination followed by specific diagnostic studies. Imaging of the brain and extracranial and intracranial blood vessels forms the cornerstone of diagnostic workup of TIA. Cardiac investigations and serum studies to evaluate for etiological risk factors are also recommended.The management of all TIAs, whether cerebral or retinal, is similar and should focus on stroke prevention strategies, which we have categorized into general and specific measures. General measures include the initiation of appropriate antiplatelet therapy, encouraging a healthy lifestyle, and managing traditional risk factors, such as hypertension, dyslipidemia, and diabetes. Specific management measures require the identification of a specific TIA etiology, such as moderate-severe (greater than 50% of stenosis) symptomatic extracranial large vessel or intracranial steno-occlusive atherosclerotic disease, aortic arch atherosclerosis, and atrial fibrillation.

Case Report: Recurrent Transient Monocular Vision Loss Secondary to Protein C Deficiency.

SIGNIFICANCE: Protein C deficiency is a thrombophilic condition that increases the risk of venous and arterial thrombi, the latter of which can cause transient monocular vision loss. In cases of recurrent transient monocular vision loss, in which the typical stroke workup has been unrevealing, investigation for hypercoagulable states is warranted. PURPOSE: This study reports a case of transient monocular vision loss secondary to protein C deficiency in a patient with no known personal or family history of venous thromboembolism and highlights the eye care provider's role in helping with diagnosis of this condition. CASE REPORT: A 59-year-old woman presented with recurrent transient monocular vision loss of the right eye. Her history was remarkable for suffering an ischemic stroke with hemorrhagic conversion shortly after experiencing episodes of transient monocular vision loss. These episodes initially waned but recurred 3 months later. Extensive workup at the time of recurrence of her visual symptoms was unrevealing. Given the timing of her visual symptoms and history of stroke, her presentation was suggestive of transient ischemic attacks. Her previous extensive workup and chronicity of symptoms did not necessitate emergent evaluation. However, additional workup for hypercoagulable conditions was initiated. The testing revealed protein C deficiency, which prompted initiation of oral anticoagulants for stroke prophylaxis. CONCLUSIONS: Transient monocular vision loss is a symptom commonly encountered by eye care providers, which necessitates emergent evaluation to reduce stroke risk if the symptom appears vascular in origin. Testing for hypercoagulable conditions is indicated in patients demonstrating recurrent transient monocular vision loss, even if there is no known personal or family history of venous thromboembolism. Eye care providers need to be aware of this association between hypercoagulable conditions and transient vision loss to aid in prompt diagnosis and treatment with the goal of preventing stroke and permanent vision loss.

Acute Vision Loss.

Acute vision loss can be transient (lasting <24 hours) or persistent (lasting >24 hours). When patients present with acute vision loss, it is important to ascertain the duration of vision loss and whether it is a unilateral process affecting one eye or a bilateral process affecting both eyes. This article focuses on causes of acute vision loss in the nontraumatic setting and provides management pearls to help health care providers better triage these patients.

Features of patients with transient monocular blindness: a multicenter retrospective study in Japan.

BACKGROUND: Transient monocular blindness (TMB) is associated with a transient ischemic attack (TIA). The purpose of this study was to investigate the features of TMB in the Japanese population using data from a multicenter retrospective study of TIA. METHODS: The subjects were consecutive TIA patients admitted to 13 stroke centers within 7 days after symptom onset. We compared clinical characteristics of patients with TMB and those without TMB who had other symptoms of cerebral TIA. RESULTS: A total of 464 patients were registered between January 2008 and December 2009, and 444 patients (283 men, mean age: 68.5 years) were included in the analysis. Thirteen patients (2.9%) presented with TMB. Patients with TMB were less likely to arrive at the specialized stroke center quickly than those without TMB (P = .013). Stenotic lesions in the extracranial internal carotid artery were more common in patients with TMB (33.3% versus 9.1%, P = .022). CONCLUSIONS: TMB was not common in our TIA inpatients. This study suggests that patients with TMB should immediately undergo a diagnostic workup, including brain and vessel imaging, and cardiac evaluation, as is performed in patients with other cerebral TIA symptoms. A larger, prospective cohort is needed to confirm the risks and outcomes of patients with TMB in the Japanese population.

Carotid endarterectomy: where do we stand at present?

PURPOSE OF REVIEW: The introduction of endovascular techniques and improvements in the medical management of atherosclerotic carotid lesions have led to changes in the modern management of stroke. The purpose of this review is to summarize the latest developments in surgical carotid intervention and highlight the current controversies. RECENT FINDINGS: The predominant controversies that dominate the correct surgical management of carotid atherosclerotic disease are: Notwithstanding the results of the Carotid Revascularisation Endarterectomy versus Stenting Trial, does carotid artery stenting produce equivalent outcomes to surgical carotid endarterectomy? Should recent developments in best medical management of these lesions and changing socioeconomic factors restrict the indication for surgical intervention for asymptomatic lesions? What is the ideal time frame for carotid interventions in symptomatic patients? SUMMARY: There is insufficient current or historic evidence to resolve these controversies and further large randomized controlled trials are therefore required. The current knowledge limits are explored.

[Long-term follow-up results of carotid endarterectomy in patients with carotid stenosis and transient monocular blindness].

The study aimed to prove the efficacy of carotid endarterectomy in patients with transient monocular blindness caused by carotid arterial stenosis. 31 patients, aged 45-80 years, were included in the study. All patients were divided in 2 groups: 16 patients from the first group had classic carotid endarterectomy with synthetic patch; 15 patients from the second group were treated conservatively. All operated patients had no stroke or transient ischemic attack and were spared from amaurosis attacks and even showed certain vision sharpness improvement. Whereas the majority of patients from the second group showed the recurrence of the amaurosis fugax attacks after the treatment. Carotid endarterectomy significantly improves the condition of an eye and prevents brain ischemia in patients with transient monocular blindness caused by carotid arterial stenosis.

A unique presentation of Takayasu's arteritis in a 39-year-old male with chest pain, vertigo, and blindness.

Takayasu's arteritis is a rare form of aortic vasculitis, typically described in young Asian females. In this article, we report a unique presentation of type V Takayasu's arteritis in a Hispanic male. To the best of our knowledge, this is the first case of Takayasu's arteritis presenting with the triad of angina, amaurosis fugax, and subclavian steal syndrome. On diagnostic imaging, he was found to have left subclavian and axillary artery stenosis requiring balloon angioplasty. The patient responded to the combination of medical and surgical treatment with full recovery.

Pérdida transitoria de la visión / Transient vision loss

La pérdida transitoria de la visión monocular (PTVM), es un síntoma alarmante relacionado frecuentemente con alteraciones vasculares retinales y puede tener consecuencias importantes desde el punto de vista ocular y vital. Es por ello, que se requiere de un manejo precoz y adecuado. El presente artículo tiene por objeto revisar las principales causas, su presentación, diagnóstico y manejo, como enfermedades oclusivas vasculares y alteraciones el nervio óptico entre otras

Transient monocular vision loss (TMVL) is an alarming symptom often in relation with retinal vascular anomalies that may have severe consequences for vision and life, so it should be evaluated urgently and a prompt approach is needed. This article will review the main causes, its presentation, diagnosis and management such as vascular occlusive diseases and optic nerve abnormalities among others

Amaurosis fugax is in the first place, during attack, medical emergency for ophthalmologist's practice.

This paper is focused on disease Amaurosis Fugax (AF), indicating the necessary urgent therapy in attack of illnesses. In attack, the patient represents ophthalmic case, because of vision lost, but primary process and cause exists even earlier and very often is of chronical character. Authors emphasize sequencing in therapy of AF and accentuate that in 24 hours the cause of the disease may be defined. AF is a syndrome with very different etiopathogenesis, including also big complexity in diagnosis and therapy.

[Vascular transient monocular visual loss]. / Les troubles visuels monoculaires transitoires d'origine vasculaire.

Diagnosis and management of transient monocular visual loss is an emergency. Ocular conditions causing transient visual loss are routinely managed by ophthalmologists. Vascular transient monocular visual loss may result from emboli, hypoperfusion, vasospasm, or venous congestion. Evaluation focuses on the carotid arteries, ophthalmic arteries, the aortic arch, the heart, and rarely hypercoagulable states. Secondary prevention of ischemic events is essential in order to prevent permanent visual loss as well as cerebral ischemic and cardiovascular death. Aggressive treatment of vascular risk factors is usually associated with antiplatelet agents. Anticoagulant and carotid surgery are only rarely required after vascular transient monocular visual loss.

[Amaurosis fugax]. / Amauroza fugace.

Amaurosis fugax is the subjective phenomenon caused by a transient and temporary ceasing of the retinal blood flow. Wray classified amaurosis fugax in four types, according to the mechanisms involved: embolic, hypoperfusion, angiospasm and idiopathic. Amaurosis fugax is an important symptom because it can announce the definite visual loss, an cerebral infaction or even death caused by vascular causes.

Variation between hospitals in patient outcome after stroke is only partly explained by differences in quality of care: results from the Netherlands Stroke Survey.

BACKGROUND AND PURPOSE: Patient outcome is often used as an indicator of quality of hospital care. The aim of this study is to investigate whether there is a straightforward relationship between quality of care and outcome, and whether outcome measures could be used to assess quality of care after stroke. METHODS: In 10 centres in The Netherlands, 579 patients with acute stroke were prospectively and consecutively enrolled. Poor outcome was defined as a score on the modified Rankin scale >or=3 at 1 year. Quality of care was assessed by relating diagnostic, therapeutic and preventive procedures to indication. Multiple logistic regression models were used to compare observed proportions of patients with poor outcome with expected proportions, after adjustment for patient characteristics and quality of care parameters. RESULTS: A total of 271 (47%) patients were dead or disabled at 1 year. Poor outcome varied across the centres from 29% to 78%. Large differences between centres were also observed in clinical characteristics, prognostic factors and quality of care. For example, between hospital quartiles based on outcome, age >or=70 years varied from 50% to 65%, presence of vascular risk factors from 88% to 96%, intravenous fluids when indicated from 35% to 81%, and antihypertensive therapy when indicated from 60% to 85%. The largest part of variation in patient outcome between centres was explained by differences in patient characteristics (Akaike's Information Criterion (AIC) = 134.0). Quality of care parameters explained a small part of the variation in patient outcome (AIC = 5.5). CONCLUSIONS: Patient outcome after stroke varies largely between centres and is, for a substantial part, explained by differences in patient characteristics at time of hospital admission. Only a small part of the hospital variation in patient outcome is related to differences in quality of care. Unadjusted proportions of poor outcome after stroke are not valid as indicators of quality of care.

[Light-induced amaurosis fugax]. / Amaurosis fugax inducida por la luz intensa.

INTRODUCTION: Internal carotid artery atherosclerotic disease may present with a wide variety of ipsilateral ocular symptoms and signs that can herald a devastating stroke. Asymptomatic retinal emboli, transient monocular visual loss (also known as amaurosis fugax) and central retinal artery occlusion are the most common. CLINICAL CASE: A 66-year-old man presented several spells of monocular light-induced amaurosis fugax related to a severe carotid occlusive disease. Ancillary tests showed an exhausted cerebrovascular reactivity and visual evoked potentials demonstrated an increased latency. Following a carotid endarterectomy the patient remained asymptomatic and ancillary tests normalized. DISCUSSION: Our report supports the theory that light-induced amaurosis fugax occurs on a hemodynamic basis. A prompt recognition of this symptom is critical since symptomatic severe carotid stenosis implies a high risk of ipsilateral stroke.

[Differentiated conservative treatment of ocular ischemic syndrome]. / Differentsirovannoe konservativnoe lechenie glaznogo ishemicheskogo sindroma.

The efficiency of differentiated conservative treatment of ocular ischemic syndrome (OIS) was studied. In acute course, drugs improving bloodflow and blood rheology were prescribed. In patients with primary chronic pattern of the syndrome, drugs correcting microcirculation, transcapillary metabolism, and improving metabolism in ischemic tissues were used. After the treatment, visual acuity increased by at least 0.1 diopter in 12.8% patients with acute OIS, the peripheral visual field extended by 21.5% in 11.5%, and the function of the optic nerve improved in 10.5%. Comparative evaluation of results of therapy showed better efficiency in patients with the acute course.

Pulmonary arteriovenous fistula manifesting as amaurosis fugax--case report.

Pulmonary arteriovenous fistula (PAVF) is a rare condition which occasionally causes neurological complications. A 43-year-old female with multiple PAVFs presented with several episodes of amaurosis fugax and transient right hemiparesis. She had no other vascular abnormality, and her human leukocyte antigen haplotype did not coincide with previous patients with hereditary hemorrhagic telangiectasia. She underwent PAVF embolization to prevent further neurological complications, and had an uneventful subsequent clinical course. Amaurosis fugax is a slight neurological symptom and may be an early important sign of PAVF. We stress that PAVFs should be considered in the differential diagnosis of patients with amaurosis fugax who complain of exertional dyspnea or demonstrate cyanosis.

How do general practitioners diagnose and manage patients with transient monocular loss of vision of sudden onset?

Symptoms of transient loss of vision in one eye differ widely. They may have different causes and therefore carry a different prognosis. We studied the influence of differences between characteristics of transient monocular blindness on the diagnosis and management by general practitioners (GPs). A postal questionnaire, was sent to 1600 GPs in The Netherlands along with four case vignettes describing a case history of a 56-year-old man with transient monocular disturbances of vision of sudden onset. We introduced random permutations in the following four elements of the history: partial or complete visual field involved, blurring or blacking out of vision, attacks lasting minutes or hours, and patients having covered either eye during the attack or not. Respondents were asked about the probable diagnosis and the preferred management. For each of the 16 permutations about 50 responses were obtained (overall response rate 54%). Ischemic transient monocular blindness (ITMB) was chosen as the most likely diagnosis in 49%. In 12% primary ocular disease was suspected. Involvement of the complete visual field, blacking out of vision, and short attacks were identified as independent predictors of a diagnosis of ITMB. A diagnosis of ITMB would have resulted in referral to a specialist in 72% of patients. Antithrombotic treatment would have been initiated in only 36% of ITMB patients. GPs consider brief attacks with complete blacking out of vision most typical for retinal ischemia. They refer only three-quarters of patients with probable ITMB to a specialist and start antithrombotic medication in only one-third of these patients. Therefore further education with regard to transient monocular blindness is needed.