Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 89
Filtrar
1.
J Stroke Cerebrovasc Dis ; 30(2): 105531, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33310593

RESUMO

OBJECTIVES: Acute central retinal artery occlusion (CRAO) is an ophthalmologic emergency that often results in permanent vision loss. Over 25% are associated with acute cerebral ischemia. In the absence of existing Level I treatment options, this study aims to examine institutional practice patterns and review the literature to develop a formalized approach to the treatment of CRAO in the era of ischemic stroke protocols. MATERIALS AND METHODS: This is a retrospective review of institutional practices in the workup and treatment of patients diagnosed with acute non-arteritic (NA) CRAO at a single center from January 2017 to August 2020. RESULTS: Of 91 patients managed for acute NA-CRAO, 62.6% were male and average age was 66.4 years. Only 20.9% of patients presented within 4 h of symptom onset. 12.1% of patients had evidence of acute stroke on MRI, and 27.5% had ipsilateral internal carotid artery stenosis >50%. Half (52.7%) did not receive any acute treatment for CRAO, excluding antiplatelet/anticoagulation. 48.5% of patients undergoing acute medical treatment had improved visual acuity compared to 29.4% without treatment (p=0.14). CONCLUSIONS: There is a lack of clear protocol for the management of NA-CRAO. While not reaching statistical significance, our experience mirrors the literature with patients undergoing medical treatment demonstrating improved visual acuity over those without treatment. Given the presence of acute ischemic stroke, carotid disease, and/or stroke risk factors in over 25% of patients with CRAO, multidisciplinary involvement and modern stroke algorithms should be considered for this disease.


Assuntos
Estenose das Carótidas/terapia , Oclusão da Artéria Retiniana/terapia , Visão Ocular , Idoso , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/epidemiologia , Estenose das Carótidas/fisiopatologia , Tomada de Decisão Clínica , Feminino , Humanos , /epidemiologia , Masculino , Recuperação de Função Fisiológica , Oclusão da Artéria Retiniana/diagnóstico por imagem , Oclusão da Artéria Retiniana/epidemiologia , Oclusão da Artéria Retiniana/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do Tratamento
2.
Lancet ; 396(10266): 1927-1940, 2020 12 12.
Artigo em Inglês | MEDLINE | ID: mdl-33308475

RESUMO

Acute retinal vascular occlusions are common causes of visual impairment. Although both retinal artery occlusions and retinal vein occlusions are associated with increased age and cardiovascular risk factors, their pathophysiology, systemic implications, and management differ substantially. Acute management of retinal artery occlusions involves a multidisciplinary approach including neurologists with stroke expertise, whereas treatment of retinal vein occlusions is provided by ophthalmologists. Optimisation of systemic risk factors by patients' primary care providers is an important component of the management of these two disorders.


Assuntos
Neurologistas , Oftalmologistas , Oclusão da Artéria Retiniana/fisiopatologia , Oclusão da Artéria Retiniana/terapia , Oclusão da Veia Retiniana , Fatores Etários , Humanos , Oclusão da Artéria Retiniana/epidemiologia , Oclusão da Veia Retiniana/fisiopatologia , Oclusão da Veia Retiniana/terapia , Fatores de Risco , Acidente Vascular Cerebral/complicações
3.
J Stroke Cerebrovasc Dis ; 29(9): 105002, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32807420

RESUMO

BACKGROUND: Retinal artery occlusion (RAO) can cause acute, painless, and irreversible loss of vision. Using a large sample population database, we investigated the possible impact of RAO and numerous other clinical and non-clinical factors on the risk of developing a subsequent cerebrovascular accident. METHODS: Cases of RAO were obtained from the National Inpatient Sample (NIS) database between 2002 and 2013 using ICD-9 codes. Associated morbidities and procedures were assessed in these cases with a primary hospital admitting diagnosis of stroke. Univariate and multivariate logistic regression analyses were carried out in RAO cases to determine risk factors for stroke. The Bonferroni correction method was applied. RESULTS: The RAO group consisted of 19,809 cases that were separated into stroke (n=1,157, 55% male, mean age: 69±0.4 years) and non-stroke (n=18,652, 55% male, mean age: 68±0.1) cohorts. Age groups associated with reduced risk of stroke with respect to were 20-39 (OR: 0.391), 40-59 (OR: 0.842), and 60-79 (OR: 0.837). No cases of stroke were present for ages < 20. Other factors associated with a reduced stroke risk were carotid stenosis (OR: 0.187), transient ischemic attack (OR: 0.064), coronary artery disease (OR: 0.788), cardiac catheterization (OR: 0.481), and septicemia (OR: 0.333). Factors associated with an increased risk of stroke included hypertension (OR: 1.418), tobacco use (OR: 1.568), valvular disease (OR: 1.359), hyperlipidemia (OR: 1.298), and non-stroke cerebrovascular disease (OR: 2.985). CONCLUSIONS: A large patient population was used to determine that RAO patients with a history of hypertension, hyperlipidemia, tobacco usage, valvular disease, or non-stroke cerebrovascular disease had an increased risk of stroke. Patients below the age of 40 had significantly reduced the odds of stroke. Carotid stenosis, coronary artery disease, transient ischemic attacks, cardiac catheterization, and septicemia were all independently associated with a decreased risk of stroke development in RAO patients.


Assuntos
Oclusão da Artéria Retiniana/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Doenças das Valvas Cardíacas/epidemiologia , Humanos , Hiperlipidemias/epidemiologia , Hipertensão/epidemiologia , Lactente , Recém-Nascido , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Prognóstico , Oclusão da Artéria Retiniana/diagnóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fumar/efeitos adversos , Fumar/epidemiologia , Acidente Vascular Cerebral/diagnóstico , Fatores de Tempo , Estados Unidos/epidemiologia , Adulto Jovem
4.
J Stroke Cerebrovasc Dis ; 29(2): 104446, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31837921

RESUMO

OBJECTIVE: In population-based studies asymptomatic retinal emboli occur in .32%-2.9% of people. Retinal artery occlusion (RAO) may occur concurrently with cerebral stroke but the frequency is unknown. No study has examined how commonly retinal emboli occur in the acute stroke population. We aimed to assess the prevalence of retinal emboli and RAO at the time of carotid territory ischemic stroke. METHODS: Patients were enrolled prospectively after onset of symptoms consistent with the diagnosis of carotid territory ischemic stroke. Every participant underwent pharmacologic dilation of both pupils and bedside funduscopic examination. Emboli were classified as cholesterol, calcific, platelet/fibrin, or other and categorized by the side of occurrence. Stroke was classified as atheroembolic, cardioembolic, embolic stroke of undetermined source, lacunar, or other. Acute RAO was diagnosed by direct visualization of ischemic retinal whitening. RESULTS: Sixty-five patients were enrolled with a mean age of 59.2 years; 23 were female (35.4%). Eleven of 65 subjects (16.9%) had retinal emboli visible on funduscopy; all were cholesterol emboli except a single platelet/fibrin embolus in a patient with atheroembolic source. Six patients (9%) had acute RAO and no RAO was seen in the lacunar or undetermined source subgroups. CONCLUSIONS: Retinal emboli occurred more than 10 times more frequently in the acute stroke patient than in large population-based studies. RAOs also occurred concurrently with ischemic stroke. Although emboli were seen in patients with atheroembolic and cardioembolic sources, all patients with carotid disease had emboli in the ipsilateral eye. Future studies are required to determine if the presence of retinal emboli or RAO may help elucidate an etiology in patients suffering from embolic stroke of undetermined source.


Assuntos
Isquemia Encefálica/epidemiologia , Embolia/epidemiologia , Oclusão da Artéria Retiniana/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Assintomáticas , Isquemia Encefálica/diagnóstico , Embolia/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oregon/epidemiologia , Projetos Piloto , Prevalência , Estudos Prospectivos , Oclusão da Artéria Retiniana/diagnóstico , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Adulto Jovem
5.
J Vasc Surg ; 72(1): 198-203, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31843299

RESUMO

OBJECTIVE: The aim of this study was to determine the subsequent risk of stroke after a diagnosis of retinal artery occlusion (RAO). We hypothesized that the risk would be low and comparable to that of the general population. RAO is relatively rare and often incorrectly diagnosed. We believe our institution is in a unique position to investigate this relationship with both a high-volume eye center and vascular laboratory. METHODS: This was a retrospective, single-institution review of 221 patients diagnosed with RAO from 2004 to 2018, confirmed with fluorescein angiography. Demographics, comorbidities, imaging of the carotid arteries, and prospective events, such as stroke, myocardial infarction (MI), and death, were recorded. Time to first stroke, first MI, and death was estimated using Kaplan-Meier estimation separately and as a composite end point. RESULTS: There were 221 patients identified with a confirmed diagnosis of RAO. The mean age in the cohort was 66.1 years; 53% of patients were male, and 29% were diabetic. Median length of follow-up was 2.2 years. Five patients (2.3%) had a documented stroke; four of the five strokes occurred at the time of RAO, with one that was contralateral occurring at 1.2 years. There were eight MIs (3.6%) in the cohort, two of which resulted in death. Twenty-two patients (10%) experienced a stroke, MI, or death. There were 141 (63.8%) patients who had carotid imaging performed, of whom 20 (14.2%) were found to have >50% stenosis. CONCLUSIONS: The rate of stroke in patients with confirmed RAO was 2.3%; however, excluding concurrent ischemic events, the risk was <1%. The incidence of carotid artery stenosis >50% was 14.2%. The authors conclude that the risk of stroke after confirmed RAO is lower than previously reported and comparable to prior population-based studies of all at-risk adults.


Assuntos
Estenose das Carótidas/epidemiologia , Oclusão da Artéria Retiniana/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Feminino , Angiofluoresceinografia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Ohio/epidemiologia , Prognóstico , Oclusão da Artéria Retiniana/diagnóstico por imagem , Oclusão da Artéria Retiniana/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo
6.
J Neurol ; 267(2): 522-530, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31701329

RESUMO

OBJECTIVE: To assess the risk of recurrent ipsilateral ischemic stroke in patients with symptomatic near-occlusion with and without full collapse. METHODS: Included were consecutive patients eligible for revascularization, grouped into symptomatic conventional ≥ 50% carotid stenosis (n = 266), near-occlusion without full collapse (n = 57) and near-occlusion with full collapse (n = 42). The risk of preoperative recurrent ipsilateral ischemic stroke was analyzed, or, for cases not revascularized within 90 days, 90-day risk was analyzed. RESULTS: The risk of a preoperative recurrent ipsilateral ischemic stroke or ipsilateral retinal artery occlusion was 15% (95% CI 9-20%) for conventional ≥ 50% stenosis, 22% (95% CI 6-38%) among near-occlusion without full collapse and 30% (95% CI 16-44%) among near-occlusion with full collapse (p = 0.01, log rank test). In multivariate analysis, near-occlusion with full collapse had a higher risk of recurrent ipsilateral ischemic stroke (adjusted HR 2.6, 95% CI 1.3-5.3) and near-occlusion without full collapse tended to have a higher risk (adjusted HR 2.0, 95% CI 0.9-4.5) than conventional ≥ 50% stenosis. Only 24% of near-occlusion with full collapse underwent revascularization, common causes for abstaining were misdiagnosis as occlusion (31%), deemed surgically unfeasible (21%) and low perceived benefit (10%). CONCLUSIONS: Symptomatic carotid near-occlusion has a high short-term risk of recurrent ipsilateral ischemic stroke, especially near-occlusion with full collapse.


Assuntos
Isquemia Encefálica/etiologia , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Revascularização Cerebral , Oclusão da Artéria Retiniana/etiologia , Acidente Vascular Cerebral/etiologia , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/epidemiologia , Estenose das Carótidas/epidemiologia , Estenose das Carótidas/cirurgia , Angiografia Cerebral , Revascularização Cerebral/estatística & dados numéricos , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Oclusão da Artéria Retiniana/epidemiologia , Risco , Acidente Vascular Cerebral/epidemiologia
7.
J Stroke Cerebrovasc Dis ; 28(6): 1495-1499, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30935808

RESUMO

INTRODUCTION: Atrial fibrillation (AF) is a major cause of ischemic stroke and Transient Ischemic Attack (TIA) and investigation for paroxysmal AF is recommended following an embolic brain event. In contrast, retinal ischemic monocular blindness is traditionally considered most linked to carotid artery disease (CAS) and investigating for AF is less vigilant. We aimed to determine the prevalence of AF in patients with ischemic monocular blindness. METHODS: Consecutive records of all patients presenting to a daily TIA clinic with transient or permanent ischemic monocular blindness were reviewed, January 2014-October 2016. RESULTS: Of 400 patients, 224 (56.0%) were male, mean age 64.5 years (SD 15.1). A total of 263 (66%) presented with transient and 137 (34%) with permanent ischemic monocular blindness. ECG was performed in 364 patients (91%) but only 211 (52%) had further cardiac monitoring. The vast majority (97.3%) had carotid imaging. Thirty-six patients (9%) were found to have AF while 53 (14%) had ipsilateral CAS. Median ABCD2 score was 1 in AF and non-AF groups. Only 55% of known AF patients were anticoagulated at presentation, despite all having CHADVASC2 score greater than or equal to 1. Patients with AF had more hypertension (P = .004), previous TIA (P = .002), previous stroke (P = .044) and ischemic heart disease (P = .022) with no difference in age (P = .791), diabetes (P = .563), smoking (P = .460) nor hypercholesterolaemia (P = .083). CONCLUSIONS: A total of 9% of patients with ischemic monocular blindness had AF. This is an underestimate, as only 53% of patients had prolonged cardiac monitoring. Known AF was suboptimally managed with only 55% receiving anticoagulation despite being eligible.


Assuntos
Fibrilação Atrial/epidemiologia , Cegueira/epidemiologia , Isquemia Encefálica/epidemiologia , Ataque Isquêmico Transitório/epidemiologia , Oclusão da Artéria Retiniana/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Visão Monocular , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Amaurose Fugaz/epidemiologia , Amaurose Fugaz/fisiopatologia , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Cegueira/diagnóstico , Cegueira/fisiopatologia , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Ecocardiografia , Eletrocardiografia , Feminino , Humanos , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/fisiopatologia , Londres/epidemiologia , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Recidiva , Oclusão da Artéria Retiniana/diagnóstico , Oclusão da Artéria Retiniana/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Adulto Jovem
9.
Mayo Clin Proc ; 94(2): 236-241, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30711121

RESUMO

OBJECTIVE: To determine the risk of ischemic stroke, transient ischemic attack (TIA), and amaurosis fugax around the time of central retinal artery occlusion (CRAO). PATIENTS AND METHODS: Patients at Mayo Clinic sites with a diagnosis code of CRAO from January 1, 2001, through September 9, 2016, were reviewed. New CRAOs were confirmed, and ischemic stroke, TIA, and amaurosis fugax events were tallied within 15 days before and after CRAO. RESULTS: Three hundred patients with CRAO were included in the study cohort. The median age at the time of CRAO was 72 years (range, 19-100 years), and 158 (53%) were male patients. Overall, 16 patients (5.3%) had symptomatic ischemic stroke around the time of CRAO, with 7 strokes (2.3%) occurring 15 days before CRAO, 4 (1.3%) occurring simultaneously with CRAO, and 5 (1.7%) occurring after CRAO. Transient ischemic attack and amaurosis fugax were seen in 5 (1.7%) and 26 (8.7%) patients, respectively. It was found that 7% (9/128) of patients with embolic CRAO had a stroke around the time of CRAO as compared with 1.3% (2/149) of patients with an unknown cause of CRAO. CONCLUSION: Symptomatic stroke, TIA, or amaurosis fugax is common around the time of CRAO. Therefore, CRAOs require urgent embolic work-ups.


Assuntos
Oclusão da Artéria Retiniana/complicações , Medição de Risco/métodos , Acidente Vascular Cerebral/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia por Tomografia Computadorizada , Feminino , Seguimentos , Humanos , Incidência , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Oclusão da Artéria Retiniana/diagnóstico , Oclusão da Artéria Retiniana/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Ultrassonografia , Estados Unidos/epidemiologia , Adulto Jovem
10.
J Am Heart Assoc ; 8(3): e010509, 2019 02 05.
Artigo em Inglês | MEDLINE | ID: mdl-30712440

RESUMO

Background Monocular vision loss, attributed to either central retinal artery occlusion ( CRAO ), branch retinal artery occlusion ( BRAO ), or ocular ischemic syndrome ( OIS ), is thought to be associated with an increased prevalence of cerebral infarcts. However, there is a paucity of data substantiating this. We aimed to investigate this relationship in a Canadian center and further understand the importance of associated internal carotid artery stenosis in potential clinical decision making. Methods and Results We performed a retrospective cohort study at a comprehensive stroke center of patients presenting initially with CRAO , BRAO , or OIS to a centralized ophthalmology center over a 5-year period. Patients were followed for 3 years for the occurrence of a hemispheric stroke. We identified 83 affected eyes, with 31 CRAO , 35 BRAO , and 17 OIS patients. Before ocular diagnosis, 32.3%, 11.4%, and 41.2% of CRAO , BRAO , and OIS patients, respectively, experienced a symptomatic stroke. Of the remaining patients, 4.8%, 12.9%, and 40%, respectively, suffered a hemispheric stroke within 3 years of ocular diagnosis. Logistic regressions suggested that for CRAO and BRAO patients together, the degree of ipsilateral internal carotid artery stenosis is unable to predict the occurrence of a stroke ( P=0.18), whereas our model correctly predicted a stroke in 82.4% of OIS patients ( P=0.005). Conclusions CRAO , BRAO , and OIS are associated with significantly increased symptomatic stroke rates. Degree of ipsilateral internal carotid artery stenosis may not be useful in risk stratification for these patients, suggesting that they should be triaged appropriately for stroke risk-factor management, independent of internal carotid artery stenosis.


Assuntos
Infarto Cerebral/etiologia , Oclusão da Artéria Retiniana/complicações , Medição de Risco/métodos , Visão Monocular/fisiologia , Idoso , Idoso de 80 Anos ou mais , Canadá/epidemiologia , Infarto Cerebral/diagnóstico , Infarto Cerebral/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Prevalência , Oclusão da Artéria Retiniana/diagnóstico , Oclusão da Artéria Retiniana/epidemiologia , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Tomografia Computadorizada por Raios X , Ultrassonografia Doppler
11.
Am J Ophthalmol ; 200: 179-186, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30689989

RESUMO

PURPOSE: Central retinal artery occlusion (CRAO) confers a high risk of acute vascular ischemic events, including stroke and myocardial infarction (MI). Understanding the burden and risk factor profile of these ischemic events can serve as a valuable guide for ophthalmologists in the management and appropriate referral of these patients. DESIGN: Retrospective cross-sectional study. METHODS: The Nationwide Inpatient Sample (NIS) was queried to identify all inpatient admissions with a diagnosis of CRAO in the United States between the years 2003 and 2014. The primary outcome measure was the incidence of in-hospital acute vascular ischemic events. RESULTS: There were an estimated 17 117 CRAO inpatient admissions. The mean age was 68.4 ± 0.1 years and 53% of patients were female. The incidence of in-hospital stroke and acute MI were 12.9% and 3.7%. The incidence of stroke showed an increasing trend over the years, almost doubling in 2014 in comparison to 2003 (15.3% vs 7.7%). The combined risk of in-hospital stroke, transient ischemic attack, acute MI, or mortality was 19%. Female sex, hypertension, carotid artery stenosis, aortic valve disease, smoking, and alcohol dependence or abuse were positive predictors of in-hospital stroke. CONCLUSION: There is a significant burden of vascular risk factors, associated with an increased risk of in-hospital stroke, acute MI, and death in CRAO patients. The risk of CRAO-associated stroke is highest in women and in those with a history of hypertension, carotid artery stenosis, aortic valve disease, smoking, or alcohol abuse.


Assuntos
Isquemia Encefálica/epidemiologia , Infarto do Miocárdio/epidemiologia , Oclusão da Artéria Retiniana/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Estudos Transversais , Feminino , Hospitais/estatística & dados numéricos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Oclusão da Artéria Retiniana/diagnóstico , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Estados Unidos/epidemiologia , Acuidade Visual
12.
J Stroke Cerebrovasc Dis ; 27(10): 2781-2791, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30060907

RESUMO

Central retinal artery occlusion (CRAO) is a medical emergency that, if not treated, may result in irreversible loss of vision. It continues to be an important cause for acute painless loss of vision. Amaurosis fugax or "transient CRAO" has long been considered an equivalent of transient cerebral ischemic event. Animal models, in addition to data from retrospective and randomized clinical studies, provide valuable insights into the time interval for irreversible retinal ischemia. Subset analyses from 2 large studies of patients with CRAO show benefit from treatment with thrombolysis within 6 hours from symptoms onset. Significant workflow improvements after the intra-arterial therapy trials for acute ischemic stroke have occurred world over in last 5 years. Patients with CRAO are uniquely suited to receive maximum benefits from the changes in workflow for treatment of patient's acute ischemic stroke. Just as in clinical triage of acute ischemic stroke, correct and timely diagnosis of patients with CRAO may help in preventing visual loss. The approach to acute ocular ischemia should mimic that used for acute brain ischemia. Comprehensive stroke centers would be ideal triage centers for these patients in view of availability of multidisciplinary participation from vascular neurology, neuroendovascular surgery, and ophthalmology. Time is Retina!


Assuntos
Amaurose Fugaz/prevenção & controle , Tratamento Conservador/métodos , Fibrinolíticos/administração & dosagem , Oclusão da Artéria Retiniana/terapia , Terapia Trombolítica/métodos , Procedimentos Cirúrgicos Vasculares , Visão Ocular , Amaurose Fugaz/diagnóstico , Amaurose Fugaz/epidemiologia , Amaurose Fugaz/fisiopatologia , Animais , Tomada de Decisão Clínica , Comorbidade , Tratamento Conservador/efeitos adversos , Fibrinolíticos/efeitos adversos , Humanos , Oclusão da Artéria Retiniana/diagnóstico , Oclusão da Artéria Retiniana/epidemiologia , Oclusão da Artéria Retiniana/fisiopatologia , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Tempo para o Tratamento , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos
13.
PLoS One ; 13(8): e0201627, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30091989

RESUMO

There is a globally increasing prevalence and incidence of diabetes mellitus (DM). Prolonged hyperglycaemia could lead to both macrovascular damage, such as carotid artery atherosclerosis, and microvascular damage, such as retinal arteriolar narrowing, and might contribute to retinal artery occlusion (RAO). Accordingly, it is important to determine whether DM is a contrubuting factor of RAO. We conducted a retrospective cohort study that included 241,196 DM patients from the Longitudinal Cohort of Diabetes Patients Database who were recruited between 2003 and 2005. An age- and sex-matched non-DM control group included the same number of patients who were selected from the Taiwan Longitudinal Health Insurance Database of 2000. Relevant data of each patient were collected from the index date until December 2013. The incidence and risk of RAO were calculated and compared between the DM and non-DM groups. The hazard ratio for RAO was calculated using Cox proportional hazards regression analysis after adjusting for confounders. The cumulative incidence rate of RAO was calculated by Kaplan-Meier analysis. In total, 317 patients with DM and 144 controls developed RAO during the follow-up period, leading to an incidence rate of RAO in DM patients that was 2.30 times (95% confidence interval [CI] = 1.89-2.80) greater than that in controls. After adjustment for potential confounders, patients with DM were 2.11 times (95% CI, 1.71-2.59) more likely to develop RAO in the total study cohort. In conclusion, DM increases the risk of RAO, which is an interdisciplinary emergency. Close collaboration between endocrinologists and ophthalmologists is important in managing RAO following DM.


Assuntos
Bases de Dados Factuais , Diabetes Mellitus/fisiopatologia , Oclusão da Artéria Retiniana/etiologia , Adulto , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Incidência , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Oclusão da Artéria Retiniana/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Taiwan/epidemiologia , Adulto Jovem
14.
BMC Cardiovasc Disord ; 18(1): 91, 2018 05 10.
Artigo em Inglês | MEDLINE | ID: mdl-29743025

RESUMO

BACKGROUND: The inter-relationships of atrial fibrillation (AF) to retinal vascular occlusions (whether retinal artery occlusion (RAO) or retinal venous occlusion (RVO)) remain unclear. It is unknown if a presentation of retinal artery or venous occlusions may indicate a new onset cardiac arrhythmia. To shed light on this association, we investigated the risk of new onset AF in patients with known RAO and RVO. METHODS: Patients with retinal occlusions from 1997 to 2011 were identified through Danish nationwide registries and matched 1:5 according to sex and age. Cumulative incidence and unadjusted rates of AF according to retinal vascular occlusions (i.e. RAO or RVO) were determined. Hazard ratios (HR) of AF according to retinal vascular occlusion were adjusted for hypertension, diabetes, vascular disease and prior stroke/systemic thromboembolism/transient ischemic attack. RESULTS: One thousand three hundred sixty-eight cases with retinal vascular occlusions were identified (median age 71.4 (inter quartile range (IQR); 61.2-79.8), 47.3% male). RAO constituted 706 cases (51.6%) and RVO 529 (38.7%). The rate of incident AF amongst all cases with retinal vascular occlusion was 1.74 per 100 person-years (95% confidence interval (CI), 1.47-2.06) compared to 1.22 (95% CI, 1.12-1.33) in the matched control group. The rate of AF in RAO was 2.01 (95% CI, 1.6-2.52) and 1.52 (1.15-2.01) in RVO. HRs of incident AF adjusted for cardiovascular comorbidities were 1.26 (95% CI; 1.04-1.53, p = 0.019) for any retinal vascular occlusion, 1.45 (95% CI; 1.10-1.89, p = 0.015) for RAO, and 1.02 (95% CI; 0.74-1.39, p = 0.920) for RVO. CONCLUSIONS: A new diagnosis of retinal vascular occlusion in patients without prior AF was associated with increased risk of incident AF, particularly amongst patients with RAO. Awareness of AF in patients with retinal vascular occlusions is advised.


Assuntos
Fibrilação Atrial/epidemiologia , Oclusão da Artéria Retiniana/epidemiologia , Oclusão da Veia Retiniana/epidemiologia , Idoso , Fibrilação Atrial/diagnóstico , Estudos de Casos e Controles , Dinamarca/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Oclusão da Artéria Retiniana/diagnóstico , Oclusão da Veia Retiniana/diagnóstico , Medição de Risco , Fatores de Risco
15.
JAMA Intern Med ; 178(4): 502-510, 2018 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-29459947

RESUMO

Importance: Infective endocarditis is a life-threating condition with annual mortality of as much as 40% and is associated with embolic events in as many as 80% of cases. These embolic events have notable prognostic implications and have been linked to increased length of stay in intensive care units and mortality. A vegetation size greater than 10 mm has often been suggested as an optimal cutoff to estimate the risk of embolism, but the evidence is based largely on small observational studies. Objective: To study the association of vegetation size greater than 10 mm with embolic events using meta-analytic techniques. Data Sources: A computerized literature search of all publications in the PubMed and EMBASE databases from inception to May 1, 2017, was performed with search terms including varying combinations of infective endocarditis, emboli, vegetation size, pulmonary infarct, stroke, splenic emboli, renal emboli, retinal emboli, and mesenteric emboli. This search was last assessed as being up to date on May 1, 2017. Study Selection: Observational studies or randomized clinical trials that evaluated the association of vegetation size greater than 10 mm with embolic events in adult patients with infective endocarditis were included. Conference abstracts and non-English language literature were excluded. The search was conducted by 2 independent reviewers blinded to the other's work. Data Extraction and Synthesis: Following PRISMA guidelines, the 2 reviewers independently extracted data; disputes were resolved with consensus or by a third investigator. Categorical dichotomous data were summarized across treatment arms using Mantel-Haenszel odds ratios (ORs) with 95% CIs. Heterogeneity of effects was evaluated using the Higgins I2 statistic. Results: The search yielded 21 unique studies published from 1983 to 2016 with a total of 6646 unique patients with infective endocarditis and 5116 vegetations with available dimensions. Patients with a vegetation size greater than 10 mm had increased odds of embolic events (OR, 2.28; 95% CI, 1.71-3.05; P < .001) and mortality (OR, 1.63; 95% CI, 1.13-2.35; P = .009) compared with those with a vegetation size less than 10 mm. Conclusions and Relevance: In this meta-analysis of 21 studies, patients with vegetation size greater than 10 mm had significantly increased odds of embolism and mortality. Understanding the risk of embolization will allow clinicians to adequately risk stratify patients and will also help facilitate discussions regarding surgery in patients with a vegetation size greater than 10 mm.


Assuntos
Embolia/epidemiologia , Endocardite/diagnóstico por imagem , Humanos , Isquemia Mesentérica/epidemiologia , Razão de Chances , Infarto Pulmonar/epidemiologia , Oclusão da Artéria Retiniana/epidemiologia , Fatores de Risco , Infarto do Baço/epidemiologia , Acidente Vascular Cerebral/epidemiologia
16.
J Neuroophthalmol ; 38(1): 36-41, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-28665867

RESUMO

BACKGROUND: Retinal artery occlusion (RAO) is a rare but devastating complication of spinal fusion surgery. We aimed to determine its incidence and associated risk factors. METHODS: Hospitalizations involving spinal fusion surgery were identified by searching the National Inpatient Sample, a database of hospital discharges, from 1998 to 2013. RAO cases were identified using ICD-9-CM codes. Using the STROBE guidelines, postulated risk factors were chosen based on literature review and identified using ICD-9-CM codes. Multivariate logistic models with RAO as outcome, and risk factors, race, age, admission, and surgery type evaluated associations. RESULTS: Of an estimated 4,784,275 spine fusions in the United States from 1998 to 2013, there were 363 (CI: 291-460) instances of RAO (0.76/10,000 spine fusions, CI: 0.61-0.96). Incidence ranged from 0.35/10,000 (CI: 0.11-1.73) in 2001-2002 to 1.29 (CI: 0.85-2.08) in 2012-2013, with no significant trend over time (P = 0.39). Most strongly associated with RAO were stroke, unidentified type (odds ratio, OR: 14.33, CI: 4.54-45.28, P < 0.001), diabetic retinopathy (DR) (OR: 7.00, CI: 1.18-41.66, P = 0.032), carotid stenosis (OR: 4.94, CI: 1.22-19.94, P = 0.025), aging (OR for age 71-80 years vs 41-50 years referent: 4.07, CI: 1.69-10.84, P = 0.002), and hyperlipidemia (OR: 2.96, CI: 1.85-4.73, P < 0.001). There was an association between RAO and transforaminal lumbar interbody fusion (OR: 2.95, CI: 1.29-6.75, P = 0.010). RAO was more likely to occur with spinal surgery performed urgently or emergently compared with being done electively (OR: 0.40, CI: 0.23-0.68, P < 0.001). CONCLUSIONS: Patient-specific associations with RAO in spinal fusion include aging, carotid stenosis, DR, hyperlipidemia, stroke, and specific types of surgery. DR may serve as an observable biomarker of heightened risk of RAO in patients undergoing spine fusion.


Assuntos
Oclusão da Artéria Retiniana/epidemiologia , Fusão Vertebral/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Humanos , Incidência , Pacientes Internados/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Período Perioperatório , Oclusão da Artéria Retiniana/etiologia , Fatores de Risco , Fusão Vertebral/efeitos adversos , Estados Unidos/epidemiologia
17.
J Neurol ; 265(2): 330-335, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29236169

RESUMO

BACKGROUND: Central retinal artery occlusion (CRAO) is an ophthalmological emergency, the retinal analog of a stroke. To date there is no consensus or national guidelines on how this disorder should be managed. As academic neurologists and ophthalmologists treat CRAO frequently, we set out to understand how these clinicians approach patients with CRAO with a national survey. METHODS: We identified university-associated teaching hospitals offering vascular neurology, neuro-ophthalmology and/or retina fellowships in the US and asked the directors of the programs to respond to questions in an open response format to profile the acute management of CRAO at their institution. RESULTS: We found remarkable heterogeneity in the approach to acute treatment of patients with CRAO among the 45 institutions that responded to the survey. Only 20% had a formal policy, guideline or white paper to standardize the approach to treatment. The primary treating physician was an ophthalmologist, neurologist, or neuro-ophthalmologist 44, 27, and 4% of the time, respectively; 24% were co-managed acutely by neurology and ophthalmology. Intravenous fibrinolysis was offered to selected patients in 53% of institutions, and was the preferred initial treatment in 36%. When the acute treatment team involved a vascular neurologist, fibrinolysis was more likely to be considered a first-line treatment (p < 0.05). Anterior chamber paracentesis, ocular massage and hyperbaric oxygen therapy were offered 42, 66 and 7% of the time, respectively, while 9% of institutions offered no treatment. Anterior chamber paracentesis was more likely to be offered at programs where neurologists were not involved in treating CRAOs (p < 0.001). At 35% of institutions, patients with acute CRAO were not routinely referred to a general emergency room for initial evaluation and treatment. Carotid imaging was routinely obtained by 89% of programs, magnetic resonance imaging of the brain by 69%, echocardiogram by 62%, laboratory screening for an inflammatory state by 27% and retinal angiography by 30%. The thoroughness of vascular risk factors' screening was greater in programs that routinely referred acute CRAO cases to the emergency department. CONCLUSIONS: This survey shows that there is significant variability in treatment practices for acute CRAO in the US. Because of the high cerebrovascular and cardiovascular risk reported in this population of patients, it is notable that the approach to risk factor screening is also highly variable and many programs do not routinely refer patients to an emergency department for urgent evaluation. Finally, there appears to be equipoise among treatment teams regarding the efficacy of systemic fibrinolysis, as 53% of programs report a willingness to treat at least some patients with this modality.


Assuntos
Oclusão da Artéria Retiniana/terapia , Terapia Trombolítica/métodos , Terapia Trombolítica/normas , Gerenciamento Clínico , Feminino , Hemodiluição/métodos , Hospitais de Ensino , Humanos , Masculino , Neuroimagem , Oclusão da Artéria Retiniana/diagnóstico por imagem , Oclusão da Artéria Retiniana/epidemiologia , Fatores de Risco , Inquéritos e Questionários , Estados Unidos
18.
Ophthalmic Epidemiol ; 25(3): 220-226, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29190171

RESUMO

PURPOSE: Retinal vascular occlusions can lead to sudden and permanent visual impairment or blindness. Few epidemiological studies on retinal vascular occlusions have been conducted, especially on diverse populations. METHODS: This is a retrospective case-control study of all incident retinal vascular occlusions occurring during a three and one-half year study period at Montefiore Medical Center, capturing all potential cases by diagnosis codes. Patients with retinal venous occlusions (RVO) and retinal arterial occlusions (RAO) were analyzed separately and compared to age-matched control groups. RESULTS: All potential charts (n = 700) were reviewed, confirming 214 RVO and 35 RAO incident cases. In multivariable analyses, RVO was associated with type 2 diabetes mellitus (OR 2.41, p < 0.001), history of cerebrovascular accident (OR 2.14, p = 0.011), hypertension (OR 1.83, p = 0.004), glaucoma (OR 6.91, p < 0.001), black race (OR 3.72, p < 0.001), and male gender (OR 2.19 p < 0.001). RAO was significantly associated with current and former smoking combined (OR 8.95, p = 0.021) and male gender (OR 2.56, p = 0.038). CONCLUSION: Cardiovascular risk factors and glaucoma are reaffirmed as significant predictors of retinal vascular occlusions in a diverse patient population. Retinal vascular occlusions are more common in certain races and ethnicities, and further study into this may help identify high-risk individuals based on demographics.


Assuntos
Oclusão da Artéria Retiniana/epidemiologia , Oclusão da Veia Retiniana/epidemiologia , Medição de Risco , População Urbana , Fatores Etários , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Estados Unidos/epidemiologia
19.
Stroke ; 48(5): 1392-1396, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28386036

RESUMO

BACKGROUND AND PURPOSE: We aimed to determine the incidence of co-occurring cerebral ischemia, extent of cerebral small vessel disease, and vascular risk profile of patients with acute retinal ischemia. METHODS: RETIS (Frequency of Acute Silent Brain Infarction and Systematic Evaluation of Stroke Risk in Retinal Ischemia) was a single-center, prospective, observational study comprising ophthalmologic examination, brain magnetic resonance imaging, and extensive diagnostic work-up of vascular risk factors and stroke cause. Silent brain infarctions were identified on diffusion-weighted imaging, leukoaraiosis was quantified on fluid-attenuated inversion recovery sequences, and carotid artery stenosis was assessed by carotid ultrasound. RESULTS: Of 112 patients with retinal ischemia, 77 (68.8%) had retinal arterial occlusion, and 35 (31.3%) presented with amaurosis fugax. Silent brain infarctions were found in 17 (15.1%) patients. Internal carotid artery stenosis was present in 19 (17.0%) and severe leukoaraiosis in 29 (25.9%) patients. Atrial fibrillation was detected in 14 (12.5%) patients. Patients with silent brain infarctions had higher rates of internal carotid artery stenosis (35.3% versus 13.7%; P=0.029) than those without, whereas leukoaraiosis and vascular risk factors were comparable between groups. Internal carotid artery stenosis was the only significant predictor of silent brain infarctions in multivariate analysis (odds ratio, 4.27; 95% confidence interval, 1.06-17.23). CONCLUSIONS: Silent cerebral ischemia is present in about 1 in 7 patients with retinal ischemia. The high rate of symptomatic internal carotid artery stenosis suggests that large artery atherosclerosis plays a major role in the pathogenesis of acute retinal ischemia.


Assuntos
Amaurose Fugaz/diagnóstico , Estenose das Carótidas/diagnóstico por imagem , Infarto Cerebral/diagnóstico por imagem , Leucoaraiose/diagnóstico por imagem , Oclusão da Artéria Retiniana/diagnóstico , Idoso , Amaurose Fugaz/epidemiologia , Estenose das Carótidas/complicações , Estenose das Carótidas/epidemiologia , Infarto Cerebral/epidemiologia , Comorbidade , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Incidência , Leucoaraiose/epidemiologia , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Oclusão da Artéria Retiniana/epidemiologia , Oclusão da Artéria Retiniana/etiologia , Ultrassonografia
20.
Scand J Rheumatol ; 46(6): 484-489, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28276953

RESUMO

OBJECTIVE: No large-scale nationwide study has determined the risk of ocular manifestations in patients with giant cell arteritis (GCA). The aim was to study the incidence and risk factors of ocular manifestations in patients with GCA in Sweden. METHOD: A national cohort was created by linking Swedish nationwide registers. GCA patients were identified from the Swedish Hospital Inpatient and Outpatient Registers between 2002 and 2010, and were followed until the development of ocular manifestations. Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated for ocular manifestations in patients with GCA compared to those without GCA. RESULTS: We identified 3737 males and 8311 females with GCA. A total of 1618 individuals had subsequent ocular manifestations, representing 13.4% of the GCA patients. The overall SIR of ocular manifestations was 6.96 (95% CI 6.63-7.31). The risk for disorders of the optic nerve or visual tract was particularly high (SIR = 51.68, 95% CI 46.12-57.73). Men with GCA had a higher risk than women, and GCA patients without polymyalgia rheumatica (PMR) symptoms had a higher risk than those with PMR symptoms. Living outside big cities was negatively associated with ocular manifestations in GCA patients, whereas hypertension and diabetes were associated with an increased risk of ocular manifestations. CONCLUSION: The overall risk of ocular manifestations was higher in GCA patients than in the general population, especially for men and for those without PMR symptoms.


Assuntos
Oftalmopatias/epidemiologia , Arterite de Células Gigantes/epidemiologia , Polimialgia Reumática/epidemiologia , Idoso , Amaurose Fugaz/epidemiologia , Cegueira/epidemiologia , Cidades , Estudos de Coortes , Diabetes Mellitus/epidemiologia , Diplopia/epidemiologia , Dor Ocular/epidemiologia , Feminino , Humanos , Hipertensão/epidemiologia , Incidência , Masculino , Características de Residência , Oclusão da Artéria Retiniana/epidemiologia , Oclusão da Veia Retiniana/epidemiologia , Fatores de Risco , Fatores Sexuais , Suécia , Baixa Visão/epidemiologia
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...