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Medawar NG, Dorweiler TF, Abela GS, Busik JV, Grant MB. The role of cholesterol crystals and ocular crystal emboli in retinal pathology. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 47:100475. [PMID: 39493444 PMCID: PMC11530860 DOI: 10.1016/j.ahjo.2024.100475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2024] [Accepted: 10/06/2024] [Indexed: 11/05/2024]
Abstract
Cholesterol crystals (CC) can be responsible for a range of clinical syndromes in the retina from asymptomatic plaques to retinal artery occlusion with clinical trials providing evidence for the efficacy in lipid lowering therapies in preventing ocular pathology. Much of the literature has focused on CC in retinal circulation as a marker of poor systemic health and have attempted to use them to categorize risk of mortality and stroke. More recently cholesterol accumulation and CC formation have been linked to development of diabetic retinopathy with CC formation in the retina due to aberrant retinal cholesterol homeostasis and not simply systemic dyslipidemia.
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Affiliation(s)
- Nicholas G. Medawar
- University of Alabama at Birmingham, Department of Visual Sciences and Ophthalmology, Birmingham, AL, United States of America
| | - Tim F. Dorweiler
- Boston Children's Hospital, Department of Surgery, Cambridge, MA, United States of America
| | - George S. Abela
- Michigan State University, Department of Medicine, College of Human Medicine, East Lansing, MI, United States of America
| | - Julia V. Busik
- University of Oklahoma, Department of Biochemistry and Physiology, Oklahoma City, OK, United States of America
| | - Maria B. Grant
- University of Alabama at Birmingham, Department of Visual Sciences and Ophthalmology, Birmingham, AL, United States of America
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2
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Pacchiarini MC, Di Mario F, Greco P, Fiaccadori E, Rossi GM. The Controversial Role of Glucocorticoids in Atheroembolic Renal Disease: A Narrative Review. J Clin Med 2024; 13:6441. [PMID: 39518580 PMCID: PMC11546646 DOI: 10.3390/jcm13216441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2024] [Revised: 10/20/2024] [Accepted: 10/22/2024] [Indexed: 11/16/2024] Open
Abstract
Cholesterol crystal embolism (CCE) is an underrecognized multisystemic disease caused by the displacement of cholesterol crystals from atheromatous aortic plaques to distal vascular beds, leading to ischemic injury of target organs, particularly the kidneys, i.e., atheroembolic renal disease (ARD). According to recent research, cellular necrosis, induced by crystal-induced cytotoxicity, enhances the autoinflammatory cascade of the NLPR3 inflammasome, leading in turn to the so-called "necroinflammation". The purported involvement of the latter in CCE offers a rationale for the therapeutic approach with anti-inflammatory drugs such as glucocorticoids, the use of which has long been a matter of debate in CCE. Diagnostic delay and no consistent evidence regarding efficacious treatment, leading to inconsistency in clinical practice, may worsen the already poor prognosis of ARD. The possible role of glucocorticoids in the treatment of ARD is thereby herein explored in a narrative fashion, analyzing the limited data from case reports and clinical trials.
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Affiliation(s)
- Maria Chiara Pacchiarini
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Nephrology Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Francesca Di Mario
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Nephrology Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Paolo Greco
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Nephrology Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Enrico Fiaccadori
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Nephrology Unit, University Hospital of Parma, 43126 Parma, Italy
- Laboratorio di Immunopatologia Renale “Luigi Migone”, University of Parma, 43126 Parma, Italy
| | - Giovanni Maria Rossi
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Nephrology Unit, University Hospital of Parma, 43126 Parma, Italy
- Laboratorio di Immunopatologia Renale “Luigi Migone”, University of Parma, 43126 Parma, Italy
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Ghoneim BM, Westby D, Elsharkawi M, Said M, Walsh SR. Systematic review of the relationship between Hollenhorst plaques and cerebrovascular events. Vascular 2024; 32:784-791. [PMID: 36914563 DOI: 10.1177/17085381231163339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Few studies have evaluated the association between asymptomatic cholesterol emboli on fundoscopy (known as Hollenhorst plaque) and the subsequent risk of stroke or death.1. AIM To evaluate the association between the presence of asymptomatic cholesterol retinal emboli and the risk of cerebrovascular events, with assessment of the need for carotid intervention. METHODS PubMed, Embase, and Cochrane Library databases were searched using appropriate terms. The systematic review was conducted according to PRISMA guidelines. RESULTS Initial search revealed 43 in Medline and 46 in Embase databases. Twenty-four potentially eligible studies were included after duplicate and non-related studies were excluded based on title and abstract. Three more studies were identified from reference lists. Seventeen studies were included in the final analysis. Asymptomatic cholesterol emboli were present in 1343 patients. Approximately 17.8% (n = 181) had history of either cerebro-vascular Accident (CVA) or transient ischaemic attacks (TIAs) at presentation (more than 6 months). Nine studies mentioned the incidence of cerebrovascular events during follow-up. Of 780 patients, 93 evolved to stroke, TIAs, or death from a major carotid event during the follow-up period (6-86 m), an incidence of about 12%. Death due to stroke was documented in 3 studies (n = 12). CONCLUSION The presence of asymptomatic retinal emboli indicates a risk of a cerebrovascular event when compared to patients with no plaques seen on fundoscopy. The evidence suggests that these patients warrant referral for medical optimization of cardiovascular risk factors. Currently, there is no recommendation to support carotid endarterectomy in patients with Hollenhorst plaques, or retinal emboli, and further studies are needed to assess this.
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Affiliation(s)
- Baker Moustafa Ghoneim
- Vascular Surgery Department, Galway University Hospital, Cairo, Egypt
- Vascular Surgery Department, Cairo University Hospital, Giza, Egypt
| | - Daniel Westby
- Vascular Surgery Department, Galway University Hospital, Cairo, Egypt
| | | | - Marwa Said
- Vascular Surgery Department, Cairo University Hospital, Giza, Egypt
| | - Stewart R Walsh
- Vascular Surgery Department, Galway University Hospital, Cairo, Egypt
- National University of Ireland Galway NUIG, Galway, Ireland
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Teebagy S, Jastrzembski BG, Oke I. Factors Associated With Incidental Retinal Emboli in the U.S. Adult Population. Am J Ophthalmol 2024; 257:34-37. [PMID: 37582466 DOI: 10.1016/j.ajo.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/01/2023] [Accepted: 08/09/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE We sought to estimate the prevalence of incidental retinal emboli and identify associated factors using a nationally representative sample of the U.S. POPULATION DESIGN Cross-sectional study. METHODS We included adult (age ≥40 years) participants of the 2005-2008 National Health and Nutrition Examination Survey (NHANES). Incidental retinal emboli were identified through retinal fundus photography. Multivariable logistic regression was used to determine the association between the presence of retinal emboli and sociodemographic, lifestyle, and clinical factors (age, sex, race/ethnicity, education, income, smoking, alcohol use, body mass index [BMI], hypertension, diabetes, hypercholesterolemia, and history of cardiovascular disease). RESULTS This study included 5,764 adults (53% female). Incidental retinal emboli were identified in 0.7% (39/5764) of individuals. The survey-weighted prevalence of retinal emboli increased with age, from 0.1% in participants 40-49 years of age to 1.4% in participants≥70 years of age. The prevalence did not differ by sex or race/ethnicity. Factors associated with retinal emboli after adjusting for age and sex included underweight BMI (odds ratio [OR] 7.24 [95% confidence interval {CI} 1.06-49.3]), current smoking (OR 6.16 [95% CI 1.49-25.5]), low household income (OR 4.41 [95% CI 1.3-15.0]), and hypertension (OR 2.67 [95% CI 1.31-5.44]). CONCLUSIONS In a cohort representative of the U.S. adult population, the prevalence of incidental retinal emboli increased with age but did not differ by sex, race, or ethnicity. Further investigation into the potential association of socioeconomic and nutritional status with retinal emboli may enable opportunities to identify individuals with underlying cardiovascular risk.
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Affiliation(s)
- Sean Teebagy
- From the Department of Ophthalmology and Visual Sciences (S.T.), University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Benjamin G Jastrzembski
- Department of Ophthalmology and Vision Science (B.G.J.), University of California Davis Eye Center, Sacramento, California, USA
| | - Isdin Oke
- Department of Ophthalmology (I.O.), Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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Rockman CB, Garg K. Contemporary Treatment of the Asymptomatic Carotid Patient. Surg Clin North Am 2023; 103:629-644. [PMID: 37455029 DOI: 10.1016/j.suc.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Stroke is a persistent leading cause of morbidity and mortality, and carotid artery atherosclerosis remains a treatable cause of future stroke. Although most patients with asymptomatic carotid artery disease may be at a relatively low risk for future stroke, most completed strokes are unheralded; thus, the identification and appropriate treatment of patients with asymptomatic carotid artery disease remains a critical part of overall stroke prevention. Select patients with asymptomatic carotid artery stenosis with an increased risk of future stroke based on the degree of stenosis and other imaging or patient-related characteristics are appropriate to consider for carotid artery intervention.
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Affiliation(s)
- Caron B Rockman
- Florence and Joseph Ritorto Professor of Surgery, Division of Vascular Surgery, NYU Langone Medical Center, NYU Grossman School of Medicine, 530 1st Avenue, 11th Floor, New York, NY 10016, USA.
| | - Karan Garg
- Division of Vascular Surgery, NYU Langone Medical Center, 530 1st Avenue, 11th Floor, New York, NY 10016, USA
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Marta A, Abreu AC, Gonçalves N, Miranda V. RETINAL EMBOLIZATION AFTER CAROTID ECHO DOPPLER: A CASE REPORT. Retin Cases Brief Rep 2022; 16:649-652. [PMID: 32969980 DOI: 10.1097/icb.0000000000001052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE To report a case of symptomatic multiple retinal emboli during a carotid Doppler ultrasonography (CDU) procedure. METHODS Case report documented with clinical records, fundus photography, optical coherence tomography angiography of the retina, and computed tomography angiography of the supraaortic vessels. RESULTS A 60-year-old male patient presented to the emergency department with sudden vision loss in the left eye and pain in the left upper eyelid noticed during a CDU procedure. On the left eye, the best-corrected visual acuity was 20/200, and fundus observation revealed retinal arteriolar attenuation, retinal whitening with cherry point, and multiple intraarterial emboli in all arcades of the central retinal artery. Computed tomography angiography of the supraaortic vessels revealed an absence of filling throughout the cervical, petrous, and cavernous segment of the left internal carotid artery, resuming only in the ophthalmic segment and an important stenosis of the left external carotid artery. He had no indication to be submitted to left carotid endarterectomy and began ocular massage and oral anticoagulant. Four months later, ptosis was no longer present, best-corrected visual acuity improved to 20/20 with a residual scotoma, and emboli disappeared on fundus photography. CONCLUSION Embolic occlusion of retinal arteries may be an extremely rare but serious complication associated with CDU, and patients and clinicians should be aware of it.
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Affiliation(s)
- Ana Marta
- Department of Ophthalmology, Porto Hospital and University Center, Oporto, Portugal
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Rockman C, Jacobowitz GR. Role of Duplex Ultrasound in Carotid Screening. NONINVASIVE VASCULAR DIAGNOSIS 2022:211-230. [DOI: 10.1007/978-3-030-60626-8_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
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Cicinelli MV, Sadiq SA, Mishra S, Jampol LM, Mirza RG. Multimodal Imaging Characterization of Arteriolosclerotic Plaques in Retinal Vein Occlusion. Ophthalmic Surg Lasers Imaging Retina 2021; 52:650-657. [PMID: 34908486 DOI: 10.3928/23258160-20211118-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES To investigate the multimodal imaging features and the clinical associations of arteriolosclerotic plaques in patients with retinal vein occlusion (RVO). MATERIALS AND METHODS This was a retrospective case series of patients with RVO. Demographic and clinical characteristics were recorded at the time of RVO for each participant. Best-corrected visual acuity and central macular thickness were collected at baseline and observed for 1 year. Arteriolosclerotic plaques were identified on multimodal imaging, and their imaging features were summarized. Differences in demographic and clinical characteristics between eyes with arteriolosclerotic plaques and those with no arteriolosclerotic plaques were reported. RESULTS Seventy-five eyes of 75 patients (39 males; mean age, 72.5 years) were included. Arteriolosclerotic plaques were identified in nine eyes (12%) as segmental, yellow, ill-defined creamy lesions in the arterioles' walls. Baseline macular edema was worse in eyes with arteriolosclerotic plaques than in eyes with no plaques (716.5 μm vs 539.7 μm). Arteriolosclerotic plaques did not interfere with blood flow and regressed in three eyes (33%). Eyes with plaques had worse best-corrected visual acuity (P < .001) and lower central macular thickness (P = .02) at 12 months than did eyes with RVO and no plaques. CONCLUSIONS Arteriolosclerotic plaques suggest an ischemic or inflammatory involvement of the arteriolar branches in eyes with RVO and are associated with severe macular damage. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:650-657.].
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Baumer Y, McCurdy SG, Boisvert WA. Formation and Cellular Impact of Cholesterol Crystals in Health and Disease. Adv Biol (Weinh) 2021; 5:e2100638. [PMID: 34590446 PMCID: PMC11055929 DOI: 10.1002/adbi.202100638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 08/20/2021] [Indexed: 11/10/2022]
Abstract
Cholesterol crystals (CCs) were first discovered in atherosclerotic plaque tissue in the early 1900 and have since been observed and implicated in many diseases and conditions, including myocardial infarction, abdominal aortic aneurism, kidney disease, ocular diseases, and even central nervous system anomalies. Despite the widespread involvement of CCs in many pathologies, the mechanisms involved in their formation and their role in various diseases are still not fully understood. Current knowledge concerning the formation of CCs, as well as the molecular pathways activated upon cellular exposure to CCs, will be explored in this review. As CC formation is tightly associated with lipid metabolism, the role of cellular lipid homeostasis in the formation of CCs is highlighted, including the role of lysosomes. In addition, cellular pathways and processes known to be affected by CCs are described. In particular, CC-induced activation of the inflammasome and production of reactive oxygen species, along with the role of CCs in complement-mediated inflammation is discussed. Moreover, the clinical manifestation of embolized CCs is described with a focus on renal and skin diseases associated with CC embolism. Lastly, potential therapeutic measures that target either the formation of CCs or their impact on different cell types and tissues are highlighted.
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Affiliation(s)
- Yvonne Baumer
- Social Determinants of Obesity and Cardiovascular Risk Laboratory, National Heart, Lung, and Blood Institute, Building 10, 10 Center Drive, Bethesda, MD 20814, USA
| | - Sara G. McCurdy
- Dept. of Medicine, University of California San Diego, 9500 Gilman Street, La Jolla, CA 92093, USA
| | - William A. Boisvert
- Center for Cardiovascular Research, University of Hawaii, 651 Ilalo Street, Honolulu, HI 96813, USA
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10
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Retinal Fundus Multi-Disease Image Dataset (RFMiD): A Dataset for Multi-Disease Detection Research. DATA 2021. [DOI: 10.3390/data6020014] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The world faces difficulties in terms of eye care, including treatment, quality of prevention, vision rehabilitation services, and scarcity of trained eye care experts. Early detection and diagnosis of ocular pathologies would enable forestall of visual impairment. One challenge that limits the adoption of computer-aided diagnosis tool by ophthalmologists is the number of sight-threatening rare pathologies, such as central retinal artery occlusion or anterior ischemic optic neuropathy, and others are usually ignored. In the past two decades, many publicly available datasets of color fundus images have been collected with a primary focus on diabetic retinopathy, glaucoma, age-related macular degeneration and few other frequent pathologies. To enable development of methods for automatic ocular disease classification of frequent diseases along with the rare pathologies, we have created a new Retinal Fundus Multi-disease Image Dataset (RFMiD). It consists of 3200 fundus images captured using three different fundus cameras with 46 conditions annotated through adjudicated consensus of two senior retinal experts. To the best of our knowledge, our dataset, RFMiD, is the only publicly available dataset that constitutes such a wide variety of diseases that appear in routine clinical settings. This dataset will enable the development of generalizable models for retinal screening.
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11
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Chen SN, Hwang JF, Huang J, Wu SL. Retinal arterial occlusion with multiple retinal emboli and carotid artery occlusion disease. Haemodynamic changes and pathways of embolism. BMJ Open Ophthalmol 2020; 5:e000467. [PMID: 32789185 PMCID: PMC7390230 DOI: 10.1136/bmjophth-2020-000467] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/22/2020] [Accepted: 07/10/2020] [Indexed: 11/25/2022] Open
Abstract
Objective To introduce a special subgroup, retinal artery occlusion (RAO) with multiple emboli, which is highly associated with ipsilateral carotid artery occlusion disease (CAOD). Methods and analysis This is a cohort study. Cases of RAO with multiple retinal emboli were consecutively enrolled. All patients underwent at least one of the carotid/cerebral evaluations: carotid arteriography, orbital/carotid colour Doppler ultrasonography and CT angiography to demonstrate haemodynamic changes and to discuss possible mechanisms and pathways of the emboli. Results Among 208 RAO eyes, 12 eyes (5.7%) in 11 patients had multiple emboli were recruited in this study. Eleven eyes (91.6%) had ipsilateral carotid plaques and atherosclerosis with high-grade stenosis; among them, five were total carotid occlusion. Haemodynamic changes were found in nine patients with RAO (81.8%) with carotid stenosis 60% or greater. Most compensatory intracranial circulations were re-established via the circle of Willi with antegrade ophthalmic flows, but the direction of ophthalmic flow reversed in three eyes indicating the recruitment of external collaterals. Two cases underwent carotid stent successfully. Conclusion RAOs with multiple emboli are rare but highly associated with severe CAOD with haemodynamic flow changes, warning critical condition in carotid/cerebral circulations. Either direct embolism from the carotid or cardiac lesions or indirect embolism via the collateral pathways is the mechanism of pathogenesis. Immediate action should start to manage these patients to prevent further deterioration.
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Affiliation(s)
- San-Ni Chen
- Department of Ophthalmology, Changhua Christian Medical Foundation Changhua Christian Hospital, Changhua, Taiwan.,School of Medicine, Chung Shan Medical University, Changhua, Taiwan.,Department of Optometry, College of Nursing and Health Sciences, Da-Yeh University, Changhua, Taiwan
| | - Jiunn-Feng Hwang
- Department of Ophthalmology, Changhua Christian Medical Foundation Changhua Christian Hospital, Changhua, Taiwan
| | - Jeff Huang
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario, Canada
| | - Shey-Lin Wu
- Department of Neurology, Changhua Christian Medical Foundation Changhua Christian Hospital, Changhua City, Taiwan
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MicroRNAs as sentinels and protagonists of carotid artery thromboembolism. Clin Sci (Lond) 2020; 134:169-192. [PMID: 31971230 DOI: 10.1042/cs20190651] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/12/2019] [Accepted: 01/03/2020] [Indexed: 02/06/2023]
Abstract
Stroke is the leading cause of serious disability in the world and a large number of ischemic strokes are due to thromboembolism from unstable carotid artery atherosclerotic plaque. As it is difficult to predict plaque rupture and surgical treatment of asymptomatic disease carries a risk of stroke, carotid disease continues to present major challenges with regard to clinical decision-making and revascularization. There is therefore an imminent need to better understand the molecular mechanisms governing plaque instability and rupture, as this would allow for the development of biomarkers to identify at-risk asymptomatic carotid plaque prior to disease progression and stroke. Further, it would aid in creation of therapeutics to stabilize carotid plaque. MicroRNAs (miRNAs) have been implicated as key protagonists in various stages of atherosclerotic plaque initiation, development and rupture. Notably, they appear to play a crucial role in carotid artery thromboembolism. As the molecular pathways governing the role of miRNAs are being uncovered, we are learning that their involvement is complex, tissue- and stage-specific, and highly selective. Notably, miRNAs can be packaged and secreted in extracellular vesicles (EVs), where they participate in cell-cell communication. The measurement of EV-encapsulated miRNAs in the circulation may inform disease mechanisms occurring in the plaque itself, and therefore may serve as sentinels of unstable plaque as well as therapeutic targets.
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Denis Le Seve J, Gourraud Vercel C, Connault J, Artifoni M. [Update on cholesterol crystal embolism]. Rev Med Interne 2020; 41:250-257. [PMID: 32088097 DOI: 10.1016/j.revmed.2020.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 12/19/2019] [Accepted: 02/01/2020] [Indexed: 10/25/2022]
Abstract
Cholesterol crystal embolism is a systemic pathology associated with diffuse atherosclerosis. Pathophysiology corresponds to tissue necro-inflammation secondary to arteriolar occlusion associated with microembolism from atherosclerotic plaques of large diameter arteries. The clinical presentation is heterogeneous and polymorphic. Multiple organs may be the targets, but preferential damage is skin, kidneys and digestive system. It is a serious pathology, underdiagnosed, with a poor prognosis. The risk factors for developing the disease remain the same risk factors as atheroma. The factors favouring migration of microembolism remain mainly vascular interventional procedures; easy to diagnose, they oppose spontaneous embolic migrations or secondary to the introduction of antithrombotic treatment, whose diagnosis is more difficult and the prognosis more severe. The diagnosis of the disease remains mostly a diagnosis of elimination and often refers to a bundle of clinical, biological, morphological and histologic arguments. The treatment is poorly codified and the subject of few publications. It will favour both symptomatic treatment (and mainly that of pain) and complications (high blood pressure, renal insufficiency). The aetiological support remains less consensual. The treatment of atherosclerotic plaques consists, of course, in the correction of classical cardiovascular risk factors, the introduction of a statin. It will be discussed in the implementation of surgery or angioplasty to exclude potentially responsible atherosclerotic lesions. Eviction of antithrombotic therapy should be considered in terms of the benefit-risk balance, but often in favour of maintaining it. Finally, other treatments may be proposed in a case-by-case basis, such as oral or intravenous corticosteroid therapy, colchicine or LDL aphaeresis.
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Affiliation(s)
- J Denis Le Seve
- Service de médecine interne-vasculaire, centre hospitalier universitaire de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France.
| | - C Gourraud Vercel
- Service de néphrologie et immunologie clinique, centre hospitalier universitaire de Nantes, 30, boulevard Jean-Monnet, immeuble Jean-Monnet, 44093 Nantes cedex 1, France
| | - J Connault
- Service de médecine interne-vasculaire, centre hospitalier universitaire de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - M Artifoni
- Service de médecine interne-vasculaire, centre hospitalier universitaire de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
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14
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Leisser C, Zandieh S, Hirnschall N, Findl O. [Reduced Caliber of the Ophthalmic Artery in Magnetic Resonance Angiography in Patients after Retinal Artery Occlusion]. Klin Monbl Augenheilkd 2019; 237:972-975. [PMID: 31652483 DOI: 10.1055/a-0972-9886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Retinal artery occlusion (RAO) is caused by embolic occlusion of retinal arteries. Previous strokes in the medical history were reported in up to 20% of patients. According to data from a computational blood flow analysis based on magnetic resonance imaging of a patient with RAO, about 90% of ascending emboli are washed into the brain, leaving speculations about further embolic sources for RAO, such as plaques or stenosis of the ophthalmic artery. The aim of this study was to examine the reduced caliber of the ophthalmic artery in magnetic resonance angiography (MRA). PATIENTS AND METHODS An analysis of a prospective case series of 9 patients with newly diagnosed RAO, presenting at the outpatient department. Magnetic resonance angiography of the brain, including the ophthalmic artery and carotid siphon was performed in all patients and evaluated by an experienced radiologist also specialised in neuroradiology. Outcomes were compared to an age-matched control group of 9 patients without RAO. RESULTS Four of 9 patients (44.4%) had a reduced caliber of the ophthalmic artery, two only at the side of RAO and another two bilateral. One of these cases also had a severe steno-occlusive disease of the internal carotid artery in the MRA, being in accordance with the results from duplex-sonography of the internal carotid artery. None of the patients in the control group had any signs of stenosis of the ophthalmic artery. CONCLUSIONS Reduced caliber of the ophthalmic artery in MRA is present in almost half of patients with RAO and indicates that steno-occlusive disease of the ophthalmic artery could be a possible source of emboli, causing RAO.
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Affiliation(s)
- Christoph Leisser
- Vienna Institute of Research in Ocular Surgery, Hanusch-Krankenhaus, Wien, Österreich
| | - Shahin Zandieh
- Abteilung für Radiologie und Nuklearmedizin, Hanusch-Krankenhaus, Wien, Österreich.,Abteilung für Radiologie, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | - Nino Hirnschall
- Vienna Institute of Research in Ocular Surgery, Hanusch-Krankenhaus, Wien, Österreich
| | - Oliver Findl
- Vienna Institute of Research in Ocular Surgery, Hanusch-Krankenhaus, Wien, Österreich
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15
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Ozkok A. Cholesterol-embolization syndrome: current perspectives. Vasc Health Risk Manag 2019; 15:209-220. [PMID: 31371977 PMCID: PMC6626893 DOI: 10.2147/vhrm.s175150] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 05/10/2019] [Indexed: 12/16/2022] Open
Abstract
Cholesterol-embolization syndrome (CES) is a multisystemic disease with various clinical manifestations. CES is caused by embolization of cholesterol crystals (CCs) from atherosclerotic plaques located in the major arteries, and is induced mostly iatrogenically by interventional and surgical procedures; however, it may also occur spontaneously. Embolized CCs lead to both ischemic and inflammatory damage to the target organ. Therefore, anti-inflammatory agents, such as corticosteroids and cyclophosphamide, have been investigated as treatment for CES in several studies, with conflicting results. Recent research has revealed that CES is actually a kind of autoinflammatory disease in which inflammasome pathways, such as NLRP3 and IL1, are induced by CCs. These recent findings may have clinical implications such that colchicine and IL1 inhibitors, namely canakinumab, may be beneficial in the early stages of CES.
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Affiliation(s)
- Abdullah Ozkok
- Department of Internal Medicine and Nephrology, Memorial Şişli Hospital, Istanbul, Turkey
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Leisser C, Findl O. Rate of strokes 1 year after retinal artery occlusion with analysis of risk groups. Eur J Ophthalmol 2019; 30:360-362. [PMID: 30782009 DOI: 10.1177/1120672119830925] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The risk of developing stroke after retinal artery occlusion was reported to be increased. The aim of our study was to assess the rate of strokes/transitory ischemic attacks after retinal artery occlusion in a European population and to identify the risk groups. METHODS All patients, diagnosed with branch or central retinal artery occlusion at our outpatient department since 2014, were asked to participate in this prospective case-control study. At the initial examination, the medical history was documented and 1 year after retinal artery occlusion, patients were called by telephone interview for assessment of the rate of strokes/transitory ischemic attack in the follow-up period. RESULTS In all, 30 eyes of 30 patients could be included. Among these, six patients had a stroke, one a transitory ischemic attack, and one an amaurosis fugax in the medical history before retinal artery occlusion. In the period 1 year after retinal artery occlusion, one patient had a re-stroke and one patient had a transitory ischemic attack, with amaurosis fugax in the medical history. Rates of strokes/transitory ischemic attack before and after retinal artery occlusion did not show significant differences between branch and central artery occlusion. CONCLUSION The number of strokes/transitory ischemic attacks within the first year is relatively low after retinal artery occlusion and patients that already had a previous stroke, transitory ischemic attack, and/or amaurosis fugax before retinal artery occlusion seem to have a higher risk for a cerebrovascular event after retinal artery occlusion.
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Affiliation(s)
- Christoph Leisser
- VIROS-Vienna Institute for Research in Ocular Surgery, A Karl Landsteiner Institute, Hanusch Hospital, Vienna, Austria
| | - Oliver Findl
- VIROS-Vienna Institute for Research in Ocular Surgery, A Karl Landsteiner Institute, Hanusch Hospital, Vienna, Austria
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17
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Affiliation(s)
- Reginald S. A. Lord
- Surgical Professorial Unit, St Vincent's Hospital, Sydney, and the University of New South Wales
- Surgical Professorial Unit, St Vincent's HospitalDarlinghurstN.S.W.2010
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Kim H, Kim HK, Yang JY, Kim SS. Optical Coherence Tomography Measurement and Visual Outcome in Acute Central Retinal Artery Occlusion. KOREAN JOURNAL OF OPHTHALMOLOGY 2018; 32:303-311. [PMID: 30091309 PMCID: PMC6085189 DOI: 10.3341/kjo.2017.0093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 11/29/2017] [Indexed: 11/23/2022] Open
Abstract
Purpose This study investigated visual acuity (VA) values and differences depending on optical coherence tomography (OCT) findings in patients with acute central retinal artery occlusion (CRAO). Methods A retrospective chart review was performed on patients with acute CRAO who underwent macular and disc OCT. We evaluated changes in macular thickness and retinal nerve fiber layer (RNFL) thickness after acute CRAO onset based on OCT. We also determined the association of thickness changes with VA improvement. Results This study involved both eyes in a total of 12 patients with acute CRAO. A significant increase was observed in foveal (1 mm) thickness (p = 0.002), parafoveal (3 mm) thickness (p = 0.002), and peripapillary RNFL thickness (p = 0.005) in affected eyes with CRAO, but not in central foveal thickness (p = 0.266). A significant small difference in both eyes (affected eye – fellow eye) was shown in foveal (1 mm) and mean parafoveal (3 mm) thickness in the improved VA group (p = 0.008 and p = 0.004, respectively), but not in central foveal or peripapillary RNFL thickness (both p = 0.283). Conclusions Both macular and RNFL thickness increased in patients with acute CRAO. RNFL thickness decreased over time with progression of RNFL atrophy. Less macular damage caused by acute CRAO could be predicted by a small difference in macular thickness between eyes (affected eye – fellow eye). In such cases, patients had a greater chance of VA improvement.
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Affiliation(s)
- Heesuk Kim
- Institute of Vision Research, Department of Ophthalmology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hong Kyu Kim
- Department of Ophthalmology, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | | | - Sung Soo Kim
- Institute of Vision Research, Department of Ophthalmology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Is Management of Central Retinal Artery Occlusion the Next Frontier in Cerebrovascular Diseases? J Stroke Cerebrovasc Dis 2018; 27:2781-2791. [PMID: 30060907 DOI: 10.1016/j.jstrokecerebrovasdis.2018.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 05/30/2018] [Accepted: 06/05/2018] [Indexed: 01/19/2023] Open
Abstract
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!
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Male With Sudden Left Eye Vision Loss. Ann Emerg Med 2017; 70:921-935. [DOI: 10.1016/j.annemergmed.2017.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Indexed: 11/23/2022]
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Kalavakunta JK, Mittal MK, Janoudi A, Abela OG, Alreefi F, Abela GS. Role of Cholesterol Crystals During Acute Myocardial Infarction and Cerebrovascular Accident. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2017. [DOI: 10.15212/cvia.2017.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
Atheromatous embolization is a multisystem disease complicating advanced atherosclerosis. It occurs most often as a complication of angiography, an endovascular procedure or cardiovascular surgery. Atheromatous embolization can present in a subtle manner where it is often under-recognized, or with catastrophic results including myocardial infarction, strake or acute renal failure. It may mimic other disease processes and often goes underdiagnosed and undertreated. A high clinical suspicion is the key to diagnosis. Atheromatous embolization results in significant morbidity and mortality; therefore, early recognition followed by aggressive management may help to prevent end-organ damage and improve overall clinical outcomes. Management strategies should include risk factor modification, prevention of further insults by discontinuing or avoiding predisposing factors, supportive treatment and interventional or surgical approaches to remove the atheroembolic source. Atheromatous embolization is expected to increase as our population ages and the epidemics of diabetes mellitus and obesity increase.
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Affiliation(s)
- Yin Ping Liew
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Abstract
Four case reports are presented, followed by a discussion of the acute, potentially life-threatening manifestations of the cholesterol embolism syndromes. Every major organ system except the lungs may be directly affected by cholesterol emboli; devastating consequences encompass cerebral, myocardial, spinal cord, intestinal, renal, and other visceral organ infarction, as well as peripheral and perineal gangrene. Additional complications include severe hypertension, gastrointestinal bleeding, and hemodynamic instability. Anticoagulants and thrombolytic therapy may exacerbate atheromatous embolism and are relatively contraindicated. Aggressive supportive therapy may improve chances of survival, but long-term prognosis is poor. Prevention remains the most important aspect in this devastating disorder.
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Affiliation(s)
- Lisa L. Kirkland
- From the Intensive Care Units, St John's Mercy Medical Center, and St Louis University Medical Center, St. Louis, MO
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Friedlander AH, Giaconi JA, Tsui I, Aghazadehsanai N, Chang TI, Garrett NR. Meaningful correlation between asymptomatic retinal arteriole emboli and calcified carotid plaque found on panoramic dental imaging of males with diabetes. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 121:434-40. [PMID: 26972542 DOI: 10.1016/j.oooo.2015.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 12/01/2015] [Accepted: 12/14/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE There is ongoing controversy with regard to the stability of calcified carotid artery plaques (CCAPs) seen in the bifurcation area on panoramic images (PIs). Therefore, we sought to evaluate the possibility of these plaques shedding emboli by observing their relationship with ipsilateral retinal emboli. STUDY DESIGN The study group included 50 neurologically and visually asymptomatic males with diabetes, with PIs that incidentally demonstrated CCAPs (CCAP+) and contemporaneous digital retinal images that had been obtained for evaluation of diabetic retinopathy. The control group consisted of 50 males with diabetes who were matched for age and body mass index and had undergone both imaging studies and whose PIs were devoid of carotid plaques (CCAP-). The presence of retinal emboli was determined by two ophthalmologists blinded to the patients' medical histories, and the prevalence rates for the two groups were calculated. RESULTS The presence of asymptomatic retinal arteriolar emboli was found in the eye ipsilateral to the radiographically observed carotid atheroma in 10 of 50 (20%) of the patients in the CCAP+ group, compared with 2 of 50 (4%) in the CCAP- group, and this difference was statistically significant (Fisher's exact P < .03). CONCLUSIONS Some male patients with diabetes mellitus type II having calcified carotid artery atheromas in the bifurcation area, as visualized on PIs, may have significant sequelae as evidenced by retinal artery emboli.
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Affiliation(s)
- Arthur H Friedlander
- Associate Chief of Staff and Director of Graduate Medical Education, Veterans Affairs Greater Los Angeles Healthcare System; Director of Quality Assurance, Hospital Dental Service, Ronald Reagan UCLA Medical Center; Professor-in-Residence of Oral and Maxillofacial Surgery, School of Dentistry, University of California, Los Angeles, CA, USA.
| | - JoAnn A Giaconi
- Chief of Ophthalmology, Veterans Affairs Greater Los Angeles Healthcare System; Associate Clinical Professor at the UCLA Jules Stein Eye Institute, Los Angeles, CA, USA
| | - Irena Tsui
- Staff Ophthalmologist, Veterans Affairs Greater Los Angeles Healthcare System and Assistant Professor at the UCLA Jules Stein Eye Institute, Los Angeles, CA, USA
| | - Nona Aghazadehsanai
- Oral and Maxillofacial Surgery Research Fellow, Veterans Affairs, Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Tina I Chang
- Director of the Research Fellowship and Inpatient Oral and Maxillofacial Surgery, Veterans Affairs Greater Los Angeles Healthcare System; Instructor of Oral and Maxillofacial Surgery, School of Dentistry, University of California, Los Angeles, CA, USA
| | - Neal R Garrett
- Professor Emeritus, School of Dentistry, University of California, Los Angeles, CA, USA
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Rim TH, Han J, Choi YS, Hwang SS, Lee CS, Lee SC, Kim SS. Retinal Artery Occlusion and the Risk of Stroke Development: Twelve-Year Nationwide Cohort Study. Stroke 2016; 47:376-82. [PMID: 26742801 DOI: 10.1161/strokeaha.115.010828] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 12/08/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND PURPOSE Our aim was to evaluate the risk of subsequent stroke development after retinal artery occlusion (RAO). METHODS National registry data were collected from the Korean National Health Insurance Service, comprised 1 025 340 random subjects. Patients diagnosed with RAO in 2002 and 2003 were excluded. The RAO group was composed of patients with an initial diagnosis of either central or other RAO between January 2004 and December 2013 (n=401). The comparison group was composed of randomly selected patients (5 per RAO patient; n=2003) who were matched to the RAO group according to sociodemographic factors and year of RAO diagnosis. Each sampled patient was tracked until 2013. Cox proportional hazard regression was used. RESULTS Stroke occurred in 15.0% of the RAO group and in 8.0% of the comparison group (P < 0.001). RAO was associated with an increased risk of stroke occurrence (hazard ratio, 1.78; 95% confidence interval, 1.32-2.41). The magnitude of the RAO effect for stroke was larger among younger adults aged <65 years (hazard ratio, 3.11) than older adults aged ≥65 years (hazard ratio, 1.26). However, the risk of subsequent stroke was significantly increased in older adults aged ≥65 years at the 4-year follow-up (hazard ratio, 1.58; 95% confidence interval, 1.01-2.48). CONCLUSIONS RAO was significantly associated with subsequent stroke after adjusting for comorbidities and sociodemographic factors. These findings are limited by uncontrolled confounding factors and need to be replicated by other observational studies.
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Affiliation(s)
- Tyler Hyungtaek Rim
- From the Department of Ophthalmology, Severance Hospital, Institute of Vision Research (T.H.R., J.H., C.S.L., S.C.L., S.S.K.), Department of Radiology, Severance Hospital (Y.S.C.), and Yonsei Healthcare Big Data Based Knowledge Integration System Research Center and Institute of Convergence Science (S.S.K.), Yonsei University College of Medicine, Seoul, Korea; and Department of Social and Preventive Medicine, Inha University School of Medicine, Epidemiology, Incheon, South Korea (S.-s.H.)
| | - Jinu Han
- From the Department of Ophthalmology, Severance Hospital, Institute of Vision Research (T.H.R., J.H., C.S.L., S.C.L., S.S.K.), Department of Radiology, Severance Hospital (Y.S.C.), and Yonsei Healthcare Big Data Based Knowledge Integration System Research Center and Institute of Convergence Science (S.S.K.), Yonsei University College of Medicine, Seoul, Korea; and Department of Social and Preventive Medicine, Inha University School of Medicine, Epidemiology, Incheon, South Korea (S.-s.H.)
| | - Yoon Seong Choi
- From the Department of Ophthalmology, Severance Hospital, Institute of Vision Research (T.H.R., J.H., C.S.L., S.C.L., S.S.K.), Department of Radiology, Severance Hospital (Y.S.C.), and Yonsei Healthcare Big Data Based Knowledge Integration System Research Center and Institute of Convergence Science (S.S.K.), Yonsei University College of Medicine, Seoul, Korea; and Department of Social and Preventive Medicine, Inha University School of Medicine, Epidemiology, Incheon, South Korea (S.-s.H.)
| | - Seung-sik Hwang
- From the Department of Ophthalmology, Severance Hospital, Institute of Vision Research (T.H.R., J.H., C.S.L., S.C.L., S.S.K.), Department of Radiology, Severance Hospital (Y.S.C.), and Yonsei Healthcare Big Data Based Knowledge Integration System Research Center and Institute of Convergence Science (S.S.K.), Yonsei University College of Medicine, Seoul, Korea; and Department of Social and Preventive Medicine, Inha University School of Medicine, Epidemiology, Incheon, South Korea (S.-s.H.)
| | - Christopher Seungkyu Lee
- From the Department of Ophthalmology, Severance Hospital, Institute of Vision Research (T.H.R., J.H., C.S.L., S.C.L., S.S.K.), Department of Radiology, Severance Hospital (Y.S.C.), and Yonsei Healthcare Big Data Based Knowledge Integration System Research Center and Institute of Convergence Science (S.S.K.), Yonsei University College of Medicine, Seoul, Korea; and Department of Social and Preventive Medicine, Inha University School of Medicine, Epidemiology, Incheon, South Korea (S.-s.H.)
| | - Sung Chul Lee
- From the Department of Ophthalmology, Severance Hospital, Institute of Vision Research (T.H.R., J.H., C.S.L., S.C.L., S.S.K.), Department of Radiology, Severance Hospital (Y.S.C.), and Yonsei Healthcare Big Data Based Knowledge Integration System Research Center and Institute of Convergence Science (S.S.K.), Yonsei University College of Medicine, Seoul, Korea; and Department of Social and Preventive Medicine, Inha University School of Medicine, Epidemiology, Incheon, South Korea (S.-s.H.)
| | - Sung Soo Kim
- From the Department of Ophthalmology, Severance Hospital, Institute of Vision Research (T.H.R., J.H., C.S.L., S.C.L., S.S.K.), Department of Radiology, Severance Hospital (Y.S.C.), and Yonsei Healthcare Big Data Based Knowledge Integration System Research Center and Institute of Convergence Science (S.S.K.), Yonsei University College of Medicine, Seoul, Korea; and Department of Social and Preventive Medicine, Inha University School of Medicine, Epidemiology, Incheon, South Korea (S.-s.H.).
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Affiliation(s)
| | | | - Robert D Brown
- From the Department of Neurology, Mayo Clinic, Rochester, MN.
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Abstract
Retinal emboli are opacities identified in retinal arterioles and are often incidental findings on ophthalmic examination. They are generally composed of cholesterol, platelet-fibrin, or calcium and are thought to arise from carotid arteries, coronary arteries, or cardiac valves. In the general population, the estimated prevalence is 0.2% to 1.3%, and the estimated incidence is 0.9% to 2.9%. The transient nature of retinal emboli likely explains the variations between and within these reported figures. The strongest risk factor for retinal emboli is smoking, which has been reported consistently across many studies. Other likely risk factors include older age, hypertension, male sex, total cholesterol, coronary artery disease, and history of coronary artery bypass grafting. The presence of multiple risk factors, as is common in many patients, confers a higher risk for retinal emboli. Several studies suggest that retinal emboli predict an increase in stroke-related, all-cause, and possibly cardiovascular mortality. Due to these sequelae, patients often undergo further workup, most commonly carotid ultrasonography. However, given the low prevalence of significant carotid disease in patients with retinal emboli, further workup, such as carotid ultrasound, should be reserved for those with risk factors for carotid disease. All patients would benefit from medical optimization and coordinated care with the primary care physician.
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Leisser C. Risk factor analysis in patients with retinal artery occlusion with respect to transesophageal echocardiography. SPEKTRUM DER AUGENHEILKUNDE 2014. [DOI: 10.1007/s00717-014-0218-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Retinal emboli in cholesterol crystal embolism. Case Rep Ophthalmol Med 2013; 2013:421352. [PMID: 24396621 PMCID: PMC3874346 DOI: 10.1155/2013/421352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 11/25/2013] [Indexed: 11/18/2022] Open
Abstract
Cholesterol crystal embolism (CCE) is a rare and severe multisystemic disorder. It results from a massive release of cholesterol crystals from widespread atherosclerotic disease. The main difference with atherosclerosis is the severity and the quantity of the embolic events that occur during the course of the disease, eventually leading to multivisceral failure and death. The symptoms are multiple and make it a diagnostic challenge. Fundoscopic examination can be of great help, showing retinal emboli in up to 25% of the cases, and has been rarely described in the ophthalmologic literature. We report the case of a 77-year-old man with acute renal failure after coronarography. Retinal emboli seen in the fundus confirmed the diagnosis of cholesterol crystal embolism and thus prevented any further invasive investigations. In this case, anticoagulants must be stopped and any further endovascular procedure proscribed. Although impossible for this patient, peritoneal dialysis should be preferred to hemodialysis because it does not need any anticoagulation. Systemic corticosteroid can be used in the acute phase.
Fundoscopic examination should be performed each time cholesterol crystal embolism is suspected. When typical emboli are seen in the retina, it permits avoiding invasive investigations and saving precious time for the management of this potentially lethal disease.
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Gonzalez-Castellon M, Kadakia P, Willey J, Rudich DS, Odel J. Teaching video neuroimages: Hollenhorst plaque. Neurology 2013; 81:e60. [PMID: 23978727 DOI: 10.1212/wnl.0b013e3182a2ce2b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
Cholesterol emboli syndrome is a relatively rare, but potentially devastating, manifestation of atherosclerotic disease. Cholesterol emboli syndrome is characterized by waves of arterio-arterial embolization of cholesterol crystals and atheroma debris from atherosclerotic plaques in the aorta or its large branches to small or medium caliber arteries (100-200 μm in diameter) that frequently occur after invasive arterial procedures. End-organ damage is due to mechanical occlusion and inflammatory response in the destination arteries. Clinical manifestations may include renal failure, blue toe syndrome, global neurologic deficits and a variety of gastrointestinal, ocular and constitutional signs and symptoms. There is no specific therapy for cholesterol emboli syndrome. Supportive measures include modifications of risk factors, use of statins and antiplatelet agents, avoidance of anticoagulation and thrombolytic agents, and utilization of surgical and endovascular techniques to exclude sources of cholesterol emboli.
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Affiliation(s)
- Adriana Quinones
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, 560 First Avenue, New York, NY 10016, USA.
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Chang YS, Jan RL, Weng SF, Wang JJ, Chio CC, Wei FT, Chu CC. Retinal artery occlusion and the 3-year risk of stroke in Taiwan: a nationwide population-based study. Am J Ophthalmol 2012; 154:645-652.e1. [PMID: 22809785 DOI: 10.1016/j.ajo.2012.03.046] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 03/29/2012] [Accepted: 03/30/2012] [Indexed: 11/15/2022]
Abstract
PURPOSE To verify the association between retinal artery occlusion (RAO) and stroke with a large-scale nationwide study. DESIGN Retrospective nationwide population-based administrative database study. METHODS Data were collected from the Longitudinal Health Insurance Database 2000 (LHID2000), which contains claim data from 1 million randomly selected beneficiaries among Taiwan's 23 million residents. The study cohort consisted of all patients with a diagnosis of RAO from January 1999 through December 2006 (n = 464). The control group consisted of randomly selected patients (n = 2748) matched with the study group by age, sex, date of index medical care, and comorbid hypertension. Patients were tracked from their index date for 3 years. The Kaplan-Meier method was used to compute the stroke-free survival rate. Cox proportional hazard regressions were used to compute the adjusted stroke-free survival rate after adjusting for possible confounding factors. RESULTS Ninety-one RAO patients (19.61%) and 280 controls (10.05%) had a stroke (P < .0001) during the 3-year follow-up period. Compared with the controls, the incidence rate ratios of stroke in RAO patients were 9.46 at 0-1 month, 5.57 at 1-6 months, and 2.16 at 0-3 years after RAO (P < .0001). After adjusting for age, sex, and selected comorbid disorders, the hazard ratio of having a stroke for RAO patients was still 2.07 times higher than that of controls and 3.34 times higher in the ≤60-year-old subgroup. CONCLUSIONS RAO increases the risk for subsequent stroke. Early neurologic evaluation and secondary prevention for stroke are recommended for RAO patients.
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Affiliation(s)
- Yuh-Shin Chang
- Department of Ophthalmology, Chi Mei Medical Center, Tainan, Taiwan
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Tokoyoda T, Tsujimoto I, Sugiura Y, Sezaki R. A hollenhorst plaque in cholesterol crystal embolism. Intern Med 2012; 51:223. [PMID: 22246495 DOI: 10.2169/internalmedicine.51.6710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Mohr J, Mast H. Carotid Artery Disease. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10022-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Steigerwalt RD, Belcaro G, Cesarone MR, De Angelis M, Florio FR, Gattegna R, Pascarella A. Branch retinal arterial occlusion treated with intravenous prostaglandin e1 and steroids. Retin Cases Brief Rep 2011; 5:355-357. [PMID: 25390434 DOI: 10.1097/icb.0b013e3182051de9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE To present the use of 6-methylprednisolone IV and prostaglandin E1 IV, a powerful vasodilator of the microcirculation, in the treatment of a branch retinal arterial occlusion. METHODS A 63-year-old man presented with a 3-hour history of a sudden loss of vision in the right eye. On ophthalmic examination, the diagnosis of a superior temporal branch retinal arterial occlusion was made. The patient was immediately given 40 mg of 6-methylprednisolone IV for more than 5 minutes followed by 80 μg of prostaglandin E1 with 2 milliequivalents of potassium IV for more than 3 hours. The same treatment was repeated the following morning. RESULTS The visual acuity in the right eye improved from 2/10 at presentation to 7/10 at the end of the second day of treatment. Clinically, there was a reduction of the posterior pole edema. Eleven days after treatment, the visual acuity was 9/10 with no retinal edema. CONCLUSION Immediate prostaglandin E1 IV and steroids should be considered in cases of recent-onset branch retinal arterial occlusion to restore retinal blood flow and improve visual acuity.
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Affiliation(s)
- Robert D Steigerwalt
- From *Via A. Brofferio, 6, Rome, Italy; †University of Chieti, Department of Angiology, Chieti, Italy; ‡Irvine Vascular Labs, San Valentino, Pescara, Italy; §Department of Medical Retina, Ophthalmic Hospital, Rome, Italy; and ¶Via Grazioli Lante, 16, Rome, Italy
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Affiliation(s)
- Itzhak Kronzon
- From the Department of Medicine, New York University Langone Medical Center, New York, NY
| | - Muhamed Saric
- From the Department of Medicine, New York University Langone Medical Center, New York, NY
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Abstract
Atheroembolic renal disease develops when atheromatous aortic plaques rupture, releasing cholesterol crystals into the small renal arteries. Embolisation often affects other organs, such as the skin, gastrointestinal system, and brain. Although the disease can develop spontaneously, it usually develops after vascular surgery, catheterisation, or anticoagulation. The systemic nature of atheroembolism makes diagnosis difficult. The classic triad of a precipitating event, acute or subacute renal failure, and skin lesions, are strongly suggestive of the disorder. Eosinophilia further supports the diagnosis, usually confirmed by biopsy of an affected organ or by the fundoscopic finding of cholesterol crystals in the retinal circulation. Renal and patient prognosis are poor. Treatment is mostly preventive, based on avoidance of further precipitating factors, and symptomatic, aimed to the optimum treatment of hypertension and cardiac and renal failure. Statins, which stabilise atherosclerotic plaques, should be offered to all patients. Steroids might have a role in acute or subacute progressive forms with systemic inflammation.
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Liu GT, Volpe NJ, Galetta SL. Vision loss. Neuroophthalmology 2010. [DOI: 10.1016/b978-1-4160-2311-1.00004-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Alp BN, Bozbuğa N, Alp M. Risk factors for retinal arteriolar emboli in coronary artery disease. J Int Med Res 2009; 37:1301-10. [PMID: 19930835 DOI: 10.1177/147323000903700505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study determined the prevalence of retinal arteriolar emboli risk factors in 148 patients (86 males) diagnosed with coronary artery disease who required coronary artery bypass graft surgery (mean +/- SD age 59.1 +/- 12.9 years). The prevalence of smoking was 50.7%, hypertension was 49.3%, diabetes mellitus was 27.0% and obesity was 31.1%. Retinal arteriolar emboli were detected using binocular indirect ophthalmoscopy of both eyes. They were found in 10 patients (6.8%) and identified as the cholesterol type. Patients were divided according to their baseline low-density lipoprotein cholesterol (LDL-C) serum level; retinal arteriolar emboli were significantly more frequent in patients with LDL-C levels > 100 mg/dl. These results demonstrate that the prevalence of hypercholesterolaemia and high LDL-C were increased in patients with retinal arteriolar emboli. Identification and treatment of modifiable risk factors, such as high LDL-C and hypercholesterolaemia, might be beneficial in these individuals.
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Affiliation(s)
- B N Alp
- Department of Health Education Faculty, Marmara University, Istanbul, Turkey
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Irefin SA, Selhorst JB. The carotid origin of retinal emboli Evidence by manual manipulation. Neuroophthalmology 2009. [DOI: 10.3109/01658108808996048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Hirschmann JV, Raugi GJ. Blue (or purple) toe syndrome. J Am Acad Dermatol 2009; 60:1-20; quiz 21-2. [DOI: 10.1016/j.jaad.2008.09.038] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 08/26/2008] [Accepted: 09/03/2008] [Indexed: 01/19/2023]
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Ahmed R, Khetpal V, Merin LM, Chomsky AS. Case Series: Retrospective Review of Incidental Retinal Emboli Found on Diabetic Retinopathy Screening: Is There a Benefit to Referral for Work-Up and Possible Management? Clin Diabetes 2008; 26:179. [PMID: 20107523 PMCID: PMC2811382 DOI: 10.2337/diaclin.26.4.179] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Rehan Ahmed
- Rehan Ahmed, BA, is a medical student; Vijay Khetpal, MD, is a research assistant; Lawrence M. Merin, RBP, FIMI, is an assistant professor of ophthalmology and director of the Vanderbilt Ophthalmic Imaging Center; and Amy S. Chomsky, MD, is an assistant professor of ophthalmology at the Vanderbilt Eye Institute at Vanderbilt University Medical Center in Nashville, Tenn. Mr. Merin is also director of the Vanderbilt Ophthalmic Imaging Center, and Dr. Chomsky is chief of ophthalmology at the Veterans Administration Tennessee Valley Healthcare System, both in Nashville
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Rapp JH, Pan XM, Neumann M, Hong M, Hollenbeck K, Liu J. Microemboli composed of cholesterol crystals disrupt the blood-brain barrier and reduce cognition. Stroke 2008; 39:2354-61. [PMID: 18566307 DOI: 10.1161/strokeaha.107.496737] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Microemboli occur frequently in patients with asymptomatic carotid atherosclerosis. In other vascular beds, microemboli are known to initiate an inflammatory response, causing organ dysfunction. In the current study, we investigated whether emboli composed of cholesterol crystals, a component of human atherosclerotic plaque, could also cause inflammation and brain dysfunction demonstrated by cognitive impairment. METHODS Cholesterol crystals of 60 to 100 microm were injected via the rat internal carotid artery. T2-weighted magnetic resonance imaging was conducted after 3 days to estimate infarct volume. Brains were examined for matrix metalloproteinase activation at 24 hours and for albumin leakage and microglia and astrocyte activation at 4 days and 1, 2, and 4 weeks after embolization. To determine changes in cognition, behavioral tests including open field, motor learning, and Barnes Maze tests were conducted on young adult and middle-aged rats 4 weeks after either a single injection or after repeated, bilateral injections given at an interval of 2 weeks. RESULTS Matrix metalloproteinase activation was detected in 50% of the animals examined. Perivascular albumin staining was found at 4 days but rarely persisted beyond 1 week. Activation of microglia and astrocytes occurred in all animals and persisted for up to 8 weeks. Cognitive impairment was observed in middle-aged rats after repeated, bilateral injections but not after single injections. In these animals, areas of inflammation were small and scattered but often involved the striatum and hippocampus. CONCLUSIONS Cholesterol embolization caused an inflammatory response in the brain with persistent activation of microglia and astrocytes and led to cognitive impairment after repeated injections in middle-aged animals with only small foci of neural injury. These data indicate that microembolization causes inflammation and that minimal neuronal injury can cause cognitive impairment in older animals.
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Affiliation(s)
- Joseph H Rapp
- Department of Surgery, University of California, San Francisco, and the San Francisco Department of Veterans Affairs Medical Center, San Francisco, Calif 94121, USA.
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Hoki SL, Varma R, Lai MY, Azen SP, Klein R. Prevalence and associations of asymptomatic retinal emboli in Latinos: the Los Angeles Latino Eye Study (LALES). Am J Ophthalmol 2008; 145:143-8. [PMID: 17981255 PMCID: PMC2219465 DOI: 10.1016/j.ajo.2007.08.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2007] [Revised: 08/21/2007] [Accepted: 08/22/2007] [Indexed: 12/17/2022]
Abstract
PURPOSE To study the prevalence and associations of asymptomatic retinal emboli in a cohort of Latinos and to compare these findings with those of previous population studies. DESIGN Population-based cross-sectional study. METHODS All participants in this study underwent a comprehensive eye examination, including fundus photography. Photographs were graded by trained masked graders. Lifestyle factors and medical history were obtained during extensive interviews. Blood pressure, serum glucose, and glycosylated hemoglobin were measured. Age- and gender-specific prevalence rates were calculated. Odds ratios (ORs) were calculated using stepwise logistic regression analyses to identify independent risk factor associated with asymptomatic retinal emboli. RESULTS Photographs gradable for retinal emboli were obtained from 5,959 participants. For all participants, the prevalence of definite asymptomatic retinal emboli was 0.4% (n = 26). Stepwise logistic regression analyses identified smoking (> five pack years; OR, 4.3) and history of coronary artery disease (OR, 2.8) to be associated independently with retinal emboli (P < .05). CONCLUSIONS We found a lower prevalence of asymptomatic retinal emboli compared with previous population-based studies. This could be secondary to the Los Angeles Latino Eye Study (LALES) population being younger, having lower blood pressure, and having fewer smokers than other studies. As in other studies, smoking emerges as the strongest association with retinal emboli.
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Affiliation(s)
- Susan Liu Hoki
- Doheny Eye Institute and the Department of Ophthalmology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Rohit Varma
- Doheny Eye Institute and the Department of Ophthalmology, Keck School of Medicine of the University of Southern California, Los Angeles, California
- Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Mei Ying Lai
- Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Stanley P Azen
- Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Ronald Klein
- Department of Ophthalmology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Dunlap AB, Kosmorsky GS, Kashyap VS. The fate of patients with retinal artery occlusion and Hollenhorst plaque. J Vasc Surg 2007; 46:1125-9. [PMID: 17950567 DOI: 10.1016/j.jvs.2007.07.054] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2007] [Revised: 07/24/2007] [Accepted: 07/28/2007] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Ocular symptoms and signs often herald hemispheric neurological events associated with extracranial cerebrovascular disease. However, the presence of a Hollenhorst plaque (HP) or retinal artery occlusion (RAO) and the risk of stroke is unclear. The purpose of this study was to review the outcomes of all patients who presented with a HP or RAO at a single institution. METHODS Between 2000 and 2005, the management and outcome of 130 consecutive patients with a diagnosis of HP, central RAO, or branch RAO (ICD-9 codes 362.30 to 362.33) were reviewed. Patients with transient monocular visual loss (amaurosis fugax), retinal venous occlusion, and other ocular pathologies were excluded. Electronic and hardcopy medical records were reviewed for demographic data, clinical variables, radiological, and noninvasive vascular lab testing. Duplex and magnetic resonance angiography (MRA) of the carotid arteries were reviewed to confirm the presence of a lesion and quantify the degree of stenosis. RESULTS During the study interval, 70 males and 60 females, with a mean age of 68 +/- 16 (+/-SD) years underwent ophthalmologic evaluation. Symptoms were present in 61% of patients and included eye pain, blurred vision, or atypical visual symptoms, while 39% were asymptomatic. Atherosclerotic risk factors in this population included the presence of hypertension (73%), diabetes (33%), hyperlipidemia (75%), and tobacco use (38%). A majority of patients underwent carotid interrogation via Duplex imaging (68%). Carotid bifurcation stenoses ipsilateral to the ocular findings were <30% in 68% of the patients, between 30 and 60% in 22% and >60% in only 8% of patients. Six patients with lesions greater than 60% went on to have either a carotid endarterectomy or carotid stenting. Follow-up data on this group ranged from 1 to 49 months (median, 22 months), with no stroke or transient ischemic attack identified. There were five deaths during follow-up; none related to stroke. Serial carotid Duplex examinations failed to identify progression of carotid stenoses in this group of patients. Overall survival was 94% at 36 months for this cohort. CONCLUSION The presence of a HP or RAO is associated with a low prevalence of extracranial cerebrovascular disease that requires intervention. Furthermore, in contradistinction to amaurosis fugax, these ocular findings are not associated with a high risk for hemispheric neurological events.
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Affiliation(s)
- Allan B Dunlap
- Department of Vascular Surgery, The Cleveland Clinic, Cleveland, Ohio 44195, USA
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