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Concept: Amaurosis fugax

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Background Previous clinical trials have suggested that carotid-artery stenting with a device to capture and remove emboli (“embolic protection”) is an effective alternative to carotid endarterectomy in patients at average or high risk for surgical complications. Methods In this trial, we compared carotid-artery stenting with embolic protection and carotid endarterectomy in patients 79 years of age or younger who had severe carotid stenosis and were asymptomatic (i.e., had not had a stroke, transient ischemic attack, or amaurosis fugax in the 180 days before enrollment) and were not considered to be at high risk for surgical complications. The trial was designed to enroll 1658 patients but was halted early, after 1453 patients underwent randomization, because of slow enrollment. Patients were followed for up to 5 years. The primary composite end point of death, stroke, or myocardial infarction within 30 days after the procedure or ipsilateral stroke within 1 year was tested at a noninferiority margin of 3 percentage points. Results Stenting was noninferior to endarterectomy with regard to the primary composite end point (event rate, 3.8% and 3.4%, respectively; P=0.01 for noninferiority). The rate of stroke or death within 30 days was 2.9% in the stenting group and 1.7% in the endarterectomy group (P=0.33). From 30 days to 5 years after the procedure, the rate of freedom from ipsilateral stroke was 97.8% in the stenting group and 97.3% in the endarterectomy group (P=0.51), and the overall survival rates were 87.1% and 89.4%, respectively (P=0.21). The cumulative 5-year rate of stroke-free survival was 93.1% in the stenting group and 94.7% in the endarterectomy group (P=0.44). Conclusions In this trial involving asymptomatic patients with severe carotid stenosis who were not at high risk for surgical complications, stenting was noninferior to endarterectomy with regard to the rate of the primary composite end point at 1 year. In analyses that included up to 5 years of follow-up, there were no significant differences between the study groups in the rates of non-procedure-related stroke, all stroke, and survival. (Funded by Abbott Vascular; ACT I ClinicalTrials.gov number, NCT00106938 .).

Concepts: Myocardial infarction, Atherosclerosis, Stroke, Transient ischemic attack, Ischemia, Embolism, Carotid endarterectomy, Amaurosis fugax

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A 77-year-old man presented to the ophthalmology clinic reporting three episodes of blurred vision in his right eye, each lasting approximately 5 minutes, during the past hour. A dilated fundus examination revealed a visible motile embolus, shown in a video.

Concepts: Retina, Eye, Visual perception, Ophthalmology, Optometry, Dilated fundus examination, Amaurosis fugax

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Transient monocular blindness and amaurosis fugax are umbrella terms describing a range of patterns of transient monocular visual field loss (TMVL). The incidence rises from ≈1.5/100,000 in the third decade of life to ≈32/100,000 in the seventh decade of life. We review the vascular supply of the retina that provides an anatomical basis for the types of TMVL and discuss the importance of collaterals between the external and internal carotid artery territories and related blood flow phenomena. Next, we address the semiology of TMVL, focusing on onset, pattern, trigger factors, duration, recovery, frequency-associated features such as headaches, and on tests that help with the important differential between embolic and non-embolic etiologies.

Concepts: Internal carotid artery, Common carotid artery, External carotid artery, Blindness, Visual field, Amaurosis fugax

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: During evaluation for monocular visual loss, a 48-year-old woman was found to have a posttraumatic paraophthalmic internal carotid artery (ICA) pseudoaneurysm. She underwent reconstruction of the ophthalmic segment of the right ICA with a Pipeline embolization device but her vision did not return.

Concepts: Internal carotid artery, Common carotid artery, External carotid artery, Ophthalmology, Carotid sinus, Internal jugular vein, Ophthalmic artery, Amaurosis fugax

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The prevalence and etiology of neovascular glaucoma (NVG) as a complication of central retinal artery occlusion (CRAO) is a debated issue. According to some authors, NVG associated with CRAO always involves underlying chronic ocular ischemic syndrome (COIS) as a primum movens for CRAO. However, we describe 5 cases of NVG following CRAO with no underlying COIS, confirmed by carotid Doppler studies and ultrasound color Doppler imaging (USCDI) of the ophthalmic artery (OA).

Concepts: Retina, Ophthalmology, Arteries of the head and neck, Central retinal artery, Ocular ischemic syndrome, Ophthalmic artery, Amaurosis fugax

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A 61-year-old woman visited us with recent onset right-side weakness. Magnetic resonance imaging showed ischemic changes at the left internal border zone due to occlusive disease affecting the left proximal internal carotid artery. Prompt oral dual antiplatelet therapy and intravenous fluid were administered with subsequent induced hypertension and without reperfusion therapy. Although the hemiparesis was improved, she complained of a new-onset transient left-side monocular visual loss. Fluorescein angiography confirmed delayed perfusion in the left eye. We performed extracranial-intracranial bypass for flow augmentation. After bypass, the amaurosis fugax resolved. Follow-up retinal fluorescein angiography also showed improved retinal perfusion.

Concepts: Blood, Magnetic resonance imaging, Internal carotid artery, Common carotid artery, External carotid artery, Ophthalmic artery, Amaurosis fugax

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An 87-year-old woman presented 1 month after uneventful cataract surgery with ipsilateral corneal edema. She was diagnosed with pseudophakic bullous keratopathy and scheduled for endothelial transplantation. However, a few days later, she presented with bilateral corneal edema, dilated pupils and further reduction of visual acuity. Neuro-Ophthalmic evaluation disclosed a bilateral ocular ischemic syndrome causing complete visual loss. Temporal artery biopsy was consistent with GCA. Corneal decompensation should be considered as a rare presentation of GCA, that ophthalmologists should suspect in any case of unilateral or bilateral ocular ischemic syndrome.

Concepts: Blood vessel, Eye, Visual acuity, Cornea, Ophthalmology, Cataract, Pupil, Amaurosis fugax

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With the increase in popularity of the use of cosmetic fillers in plastic and esthetic surgery, the possibility of severe ocular complications should not be neglected. Of the fillers used, autologous fat is the most common to cause permanent visual deterioration, one of the most severe complications associated with the use of cosmetic fillers. Here we present the first report of a complete recovery of visual acuity from an instance of visual loss with no light perception caused by ophthalmic artery occlusion of the right eye following autologous fat injection in the facial area. Immediate ophthalmological intervention and comprehensive therapy with prostaglandins and vinpocetine made it possible to restore retinal perfusion and achieve complete recovery of visual acuity. Awareness of the iatrogenic artery occlusions associated with facial fillers and the need for immediate treatment should be popularized among injectors to prevent devastating consequences, such as permanent vision loss. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Concepts: Evidence-based medicine, Visual perception, Visual acuity, Ophthalmology, Blindness, Cataract, Vision loss, Amaurosis fugax

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Carotid artery dissection is an uncommon entity associated with head and neck pain, partial Horner’s syndrome, amaurosis fugax, and brain ischemia, which may all occur in isolation or in combination. Herein, we report a rare case of cervical artery dissection in which pulsatile tinnitus was the only reported symptom. A 38-years-old man attended our hospital with a 4-days history of left side pulsatile tinnitus which began after stumbling. He had no other symptom. MRA showed luminal stenosis with pseudo lumen of the internal carotid artery. The patient was diagnosed with left internal carotid artery dissection and treated with antihypertensive therapy accordingly. After 2 months, the stenosis and tinnitus spontaneously resolved.

Concepts: Neurology, Internal carotid artery, Common carotid artery, External carotid artery, Internal jugular vein, Carotid artery dissection, Amaurosis fugax

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We report a modified operative technique termed partial eversion carotid endarterectomy (PECE). During a 9-year period (2006-2015), 352 patients underwent PECE. Indications for surgery, intraoperative details, and outcomes were recorded. The initial 185 patients had carotid duplex ultrasound imaging at 6 weeks and then at 6, 12, and 24 months. Subsequent patients had carotid imaging at 4 to 6 weeks. Indications included stroke (76), transient ischemic attack (153), and amaurosis fugax (33); 58 patients were asymptomatic, and 32 patients had surgery before cardiac surgery. Median clamp time was 14 minutes (interquartile range, 11.5-17 minutes). Median total operation time was 41 minutes (interquartile range, 31-72 minutes). Outcomes included four transient ischemic attacks (1.2%), five strokes (1.4%), and two deaths at 30 days (0.5%). No significant cranial nerve injuries or carotid restenosis was detected during follow-up. PECE is technically straightforward, with outcomes comparable to those of current operative techniques. Its advantages included reduced operative and carotid clamping time.

Concepts: Stroke, Transient ischemic attack, Interquartile range, Cranial nerves, Medical ultrasonography, Nerve, Carotid endarterectomy, Amaurosis fugax