Implementation of a Retinal Stroke-code Protocol Results in Visual Recovery in Patients Receiving Reperfusion Therapies

Overview

Journal Eur Stroke J

Specialties Cardiology & Vascular Diseases
Neurology

Date 2024 Jan 8

PMID 38189284

Authors

Alejandro Bustamante

Marta Balboa

Garbine Ezcurra

Adrian Sanchez-Fortun

Judith Ruiz

Jordi Castellvi

Susana Castillo-Acedo

Eric Matas

Rachid Bouchikh

Marina Martinez-Sanchez

Carlos Castano

Sebastia Remollo

Mariano Werner

Maria Carmen Salgado

Samuel Villodres

Mireia Gea

Monica Millan

Natalia Perez de la Ossa

Susana Ruiz-Bilbao

Affiliations

Soon will be listed here.

Abstract

Introduction: Reperfusion therapies represent promising treatments for patients with Central Retinal Artery Occlusion (CRAO), but access is limited due to low incidence and lack of protocols. We aimed to describe the benefit of implementing a Retinal Stroke-Code protocol regarding access to reperfusion, visual acuity and aetiological assessment.

Patients And Methods: Prospective cohort study performed at a Comprehensive Stroke Centre. Criteria for activation were sudden monocular, painless vision loss within 6 h from onset. Eligible patients received IAT when immediately available and IVT otherwise. All patients were followed by ophthalmologists to assess best-corrected visual acuity (BCVA) and visual complications, and by neurologists for aetiological workup. Visual amelioration was defined as improvement of at least one Early Treatment Diabetic Retinopathy Study (ETDRS) letter from baseline to 1 week.

Results: Of 49 patients with CRAO, 15 (30.6%) received reperfusion therapies (12 IVT, 3 IAT). Presentation beyond 6 h was the main contraindication. Patients receiving reperfusion therapies had better rates of visual improvement (33.3% vs 5.9%, = 0.022). There were no complications related to reperfusion therapies. Rates of neovascular glaucoma were non-significantly lower in patients receiving reperfusion therapies (13.3% vs 20.6%, = 0.701). Similar rates of atherosclerotic, cardioembolic and undetermined aetiologies were observed, leading to 10 new diagnosed atrial fibrillation and five carotid revascularizations.

Conclusion: A comprehensive acute management of CRAO is feasible despite low incidence. In our study, reperfusion therapies were safe and associated with higher rates of visual recovery. A similar etiological workup than ischemic stroke led to of high proportion of underlying aetiologies.

References

Kewcharoen J, Tom E, Wiboonchutikula C, Trongtorsak A, Wittayalikit C, Vutthikraivit W . Prevalence of Atrial Fibrillation in Patients with Retinal Vessel Occlusion and Its Association: A Systematic Review and Meta-Analysis. Curr Eye Res. 2019; 44(12):1337-1344. DOI: 10.1080/02713683.2019.1641826. View

Baumgartner P, Kook L, Altersberger V, Gensicke H, Ardila-Jurado E, Kagi G . Safety and effectiveness of IV Thrombolysis in retinal artery occlusion: A multicenter retrospective cohort study. Eur Stroke J. 2023; 8(4):966-973. PMC: 10683723. DOI: 10.1177/23969873231185895. View

Mason 3rd J, Patel S, Feist R, Albert Jr M, Huisingh C, McGwin Jr G . Ocular neovascularization in eyes with a central retinal artery occlusion or a branch retinal artery occlusion. Clin Ophthalmol. 2015; 9:995-1000. PMC: 4467756. DOI: 10.2147/OPTH.S82796. View

Flowers A, Chan W, Meyer B, Bruce B, Newman N, Biousse V . Referral Patterns of Central Retinal Artery Occlusion to an Academic Center Affiliated With a Stroke Center. J Neuroophthalmol. 2021; 41(4):480-487. PMC: 9546636. DOI: 10.1097/WNO.0000000000001409. View

Rumelt S, Dorenboim Y, Rehany U . Aggressive systematic treatment for central retinal artery occlusion. Am J Ophthalmol. 1999; 128(6):733-8. DOI: 10.1016/s0002-9394(99)00359-1. View

Babikian V, Wijman C, Koleini B, Malik S, Goyal N, Matjucha I . Retinal ischemia and embolism. Etiologies and outcomes based on a prospective study. Cerebrovasc Dis. 2001; 12(2):108-13. DOI: 10.1159/000047689. View

Wong T, Klein R . Retinal arteriolar emboli: epidemiology and risk of stroke. Curr Opin Ophthalmol. 2002; 13(3):142-6. DOI: 10.1097/00055735-200206000-00002. View

Fallico M, Lotery A, Longo A, Avitabile T, Bonfiglio V, Russo A . Risk of acute stroke in patients with retinal artery occlusion: a systematic review and meta-analysis. Eye (Lond). 2019; 34(4):683-689. PMC: 7093449. DOI: 10.1038/s41433-019-0576-y. View

Schulze-Bonsel K, Feltgen N, Burau H, Hansen L, Bach M . Visual acuities "hand motion" and "counting fingers" can be quantified with the freiburg visual acuity test. Invest Ophthalmol Vis Sci. 2006; 47(3):1236-40. DOI: 10.1167/iovs.05-0981. View

10.

Leavitt J, Larson T, Hodge D, Gullerud R . The incidence of central retinal artery occlusion in Olmsted County, Minnesota. Am J Ophthalmol. 2011; 152(5):820-3.e2. PMC: 3326414. DOI: 10.1016/j.ajo.2011.05.005. View

11.

Mac Grory B, Landman S, Ziegler P, Boisvert C, Flood S, Stretz C . Detection of Atrial Fibrillation After Central Retinal Artery Occlusion. Stroke. 2021; 52(9):2773-2781. DOI: 10.1161/STROKEAHA.120.033934. View

12.

Hong J, Sohn S, Kwak J, Yoo J, Ahn S, Woo S . Retinal artery occlusion and associated recurrent vascular risk with underlying etiologies. PLoS One. 2017; 12(6):e0177663. PMC: 5453434. DOI: 10.1371/journal.pone.0177663. View

13.

Huang L, Wang Y, Zhang R . Efficacy and safety of intra-arterial thrombolysis in patients with central retinal artery occlusion: a systematic review and meta-analysis. Graefes Arch Clin Exp Ophthalmol. 2022; 261(1):103-113. DOI: 10.1007/s00417-022-05797-1. View

14.

Schumacher M, Schmidt D, Jurklies B, Gall C, Wanke I, Schmoor C . Central retinal artery occlusion: local intra-arterial fibrinolysis versus conservative treatment, a multicenter randomized trial. Ophthalmology. 2010; 117(7):1367-75.e1. DOI: 10.1016/j.ophtha.2010.03.061. View

15.

Schrag M, Youn T, Schindler J, Kirshner H, Greer D . Intravenous Fibrinolytic Therapy in Central Retinal Artery Occlusion: A Patient-Level Meta-analysis. JAMA Neurol. 2015; 72(10):1148-54. DOI: 10.1001/jamaneurol.2015.1578. View

16.

Pick J, Nickels S, Saalmann F, Finger R, Schuster A . Incidence of retinal artery occlusion in Germany. Acta Ophthalmol. 2020; 98(5):e656-e657. DOI: 10.1111/aos.14369. View

17.

Rudkin A, Lee A, Chen C . Ocular neovascularization following central retinal artery occlusion: prevalence and timing of onset. Eur J Ophthalmol. 2010; 20(6):1042-6. DOI: 10.1177/112067211002000603. View

18.

Aroor S, Singh R, Goldstein L . BE-FAST (Balance, Eyes, Face, Arm, Speech, Time): Reducing the Proportion of Strokes Missed Using the FAST Mnemonic. Stroke. 2017; 48(2):479-481. DOI: 10.1161/STROKEAHA.116.015169. View

19.

Mac Grory B, Schrag M, Biousse V, Furie K, Gerhard-Herman M, Lavin P . Management of Central Retinal Artery Occlusion: A Scientific Statement From the American Heart Association. Stroke. 2021; 52(6):e282-e294. DOI: 10.1161/STR.0000000000000366. View

20.

Adams Jr H, Bendixen B, Kappelle L, Biller J, Love B, Gordon D . Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993; 24(1):35-41. DOI: 10.1161/01.str.24.1.35. View