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KOR J CEREBROVASCULAR SURGERY
December 2011 Vol. 13 No 4, page 291-296
Central Retinal Artery Occlusion After Carotid Artery Angioplasty
and Stenting in an Elderly Patient - A Case Report Department of Neurosurgery Soonchunhyang University Bucheon Hospital, Bucheon, Korea
Dong-Seong Shin, M.D. · Bum-Tae Kim, M.D.
ABSTRACT
Carotid artery angioplasty and stenting (CAS) has become increasingly accepted as an alternative therapy to carotid endarterectomy for treatment of carotid artery stenosis. Central retinal artery occlusion (CRAO) is one of the diseases presented due to
carotid artery stenosis. But CRAO without cerebral ischemia after CAS is uncommon. An 80-year-old man was admitted to the
hospital with the right centrum ovale ischemic stroke and right proximal carotid artery stenosis. We performed CAS with a distal
protection device after pre-ballooning 3 times, without post-ballooning. Then, 12 hours after the CAS, the patient complained of
blindness in the right eye and was diagnosed with CRAO. However, Diffusion weighted magnetic resonance imaging (DW-MRI)
showed no significant findings in the brain. CRAO after CAS without intracranial infarction is a rare complication.
(Kor J Cerebrovascular Surgery 13(4):291-296, 2011)
KEY WORDS : Stents・Central retinal artery occlusion・Carotid artery stenosis
weakness and slurred speech, was admitted to the
Introduction
hospital. He had been diagnosed with and treated for hypertension for 10 years. Diffusion weighted magnetic res-
Complications associated with carotid artery angioplasty
onance imaging (DW-MRI) showed a high signal lesion
and stenting (CAS) may occur during or after the proce-
on his right centrum ovale, and a neck magnetic reso-
dure and generally present as neurological symptoms due
nance angiogram (MRA) showed a right proximal carotid
to an embolism or thrombus.4) Physicians can prevent
artery stenosis (Fig. 1). Single-photon emission computed
Cerebral
tomography (SPECT) showed a decreasing perfusion in
infarction is a well-known CAS complication. However,
right fronto-parietal lobe under the non-acetazolamide
without intracranial infarction, central retinal artery occlu-
challenge. Conventional angiography showed severe steno-
sion (CRAO) after CAS is not a common complication.
sis in the proximal part of right internal carotid artery
11)
these complications by using protective filters.
(ICA). Normal ICA diameter was 4.52 mm. However,
Case Report
An 80-year-old man, who complained of left side
stenotic lesion was 1.78 mm. According to the North
American Symptomatic Carotid Endarterectomy Trial (NASCET),
60% stenosis was shown (Fig. 2).
The patient underwent carotid angioplasty and CAS
twenty days after ischemic attack, receiving an antiplatelet
논문접수일 : 2011년 9월 10일
심사완료일 : 2011년 11월 2일
교신저자 : Bum-Tae Kim, M.D. Department of Neurosurgery, Soonchunhyang
University Bucheon Hospital 1174, Jung-dong, Wonmi-gu, Bucheon-si,
Gyeonggi-do, 420-767, South Korea
∙ Fax : (032) 621-5662
Tel : (032) 621-5289
Email : [email protected]
agent for one week. After inserting an 8Fr sheath via
right femoral puncture, the physician used an exchange
technique to place an 8Fr guiding catheter (Mach 1,
Boston Scientific, Fremont, CA, USA) in the patient's
291
Retinal artery occlusion after carotid stenting
A
B
C
Fig. 1. A: Diffusion-weighted magnetic resonance image (DW-MRI) shows multiple small infarctions on the centrum ovale
of the right hemisphere. B: Magnetic resonance angiography(MRI) shows proximal internal carotid artery (ICA) stenosis. C:
Single-photon emission computed tomography (SPECT) without acetazolamide challenge shows a decreasing perfusion
with right fronto-parietal lobe.
A
Fig. 2. Measurements of ICA. ICA stenosis is 60% in the
NASECT index.
B
Fig. 3. A : Right common carotid artery (CCA) angiogram
after took the third balloon angioplasty. Stenosis of ICA is
relief about a half diameter. B : ICA stenosis is relieved after
carotid artery stenting (CAS).
right common carotid artery and placed an embolic protection device (FilterWire EZTM 190 cm, Boston Scientific)
in the petrous portion of the internal carotid artery (ICA),
carotid artery, which effectively covered the ICA stenosis
followed by a balloon catheter (Ultrasoft SV 4.0/2.0 cm,
lesion (Fig. 3. B). There was no further balloon angio-
Boston Scientific) on the stenosis lesion of the right
plasty after applying the stent.
proximal ICA. The patient underwent balloon angioplasty
The angiography after the CAS revealed increasing in-
three times because the result of carotid angioplasty was
tracranial cerebral flow and no significant abnormal find-
not satisfactory in spite of two time trials (Fig. 3. A).
ings (Fig. 4). However, the patient complained of blurred
After angioplasty, a carotid stent (Carotid Wallstent TM
vision in his right eye three hours after the CAS and of
Monorail TM diameter 10.0 mm, length 30 mm, Boston
blindness in the right eye 12 hours after CAS. DW MRI
Scientific) was applied, from the ICA to the common
was shown no significant findings in the cerebrum (Fig.
292
Kor J Cerebrovascular Surgery 13(4):291-296, 2011
Dong-Seong Shin・Bum-Tae Kim
A
B
Fig. 4. Comparison of intracranial flow (both angiography show Rt. ICA with delayed arterial phage). A : Decreasing of intracranial flow is revealed on the pre-procedural angiogram. B : Intracranial flow is increasing after CAS. Ophthalmic artery
flow is increasing without flow cutoff.
A
B
Fig. 5. A, B : DW-MRI obtained when blindness occurred. These images show no newly-developed acute infarction in the
cerebral hemisphere.
5). Right eye fundus photography revealed a cherry-red
rescein angiogram (FAG) of the right eye showed de-
spot on the macula, the retina's white ground-glass ap-
layed filling of the superior temporal and inferior nasal
pearance and attenuated arterioles (Fig. 6. A). A fluo-
arteries, and a filling defect of the inferior temporal ar-
Kor J Cerebrovascular Surgery 13(4):291-296, 2011
293
Retinal artery occlusion after carotid stenting
A
B
Fig. 6. Fundus photography and fluorescein angiogram obtained immediately. A, B : Right eye fundus photography (A)
shows a cherry-red spot on the macula and also ischemic retina whitening. The fluorescein angiogram (B) at 42 seconds
after dye injection shows delayed filling of the superior temporal and inferior nasal arteries, and a filling defect of the inferior temporal artery.
Fig. 7. Follow up fluorescein angiogram obtained fifth procedural day. Right eye fluorescein angiogram at 27 seconds after dye injection shows recovery of the retinal artery
filling defect.
Fig. 8. Follow up Fundus photograph obtained 30th procedural day. Right eye fundus photography after one month
shows resolution of ischemic retinal whitening and generalized arterial attenuation.
tery (Fig. 6. B). After five days, Patient’s visual acuity
Discussion
was improved to 0.02 on the standard Korean eye
chart(logarithm of the minimum angle of resolution scale)
CAS can be a preferred treatment method for certain
and a follow-up FAG revealed recovery of the filling de-
patients who are not good candidates for carotid endarter-
fect of the central retinal artery (Fig. 7). After one
ectomy, such as patients who experienced recurrent steno-
month, fundus photography showed resolution of the reti-
sis after a previous endarterectomy, who have medical
na edema and generalized arterial attenuation (Fig. 8).
problems, and suffer from an anatomically inaccessible le1-3)8)
sion above the C2 level or radiation-induced stenosis.
294
Kor J Cerebrovascular Surgery 13(4):291-296, 2011
Dong-Seong Shin・Bum-Tae Kim
Complications associated with CAS are major or minor
tion, a dynamic change in ICA blood flow might have
stroke, TIA, seizure, bradycardia, vasospasm, dissection
influenced the atherosclerotic ophthalmic artery after the
10)11)14)
Embolic protection devices are
CAS. We have usually been carrying out balloon angio-
useful for preventing CAS-induced thromboembolic in-
plasty procedure once for extra-cranial carotid stenosis.
farctions, but several studies showed this is not a perfect
However, we performed a balloon angioplasty 3 times be-
and hypotension.
7)
reported detecting a new, high sig-
fore applying the stent. Repeated procedure might have
nal intensity lesion on DW-MRI in about 39% of their
worsened the unstable atherosclerosis of an ICA stenotic
CAS procedures with protection devices, with no apparent
lesion. If we had performed angioplasty just once before
6)
major arterial or territorial infarctions. du Mesnil et al.
applying the stent, we could have reduced this complica-
documented that 19 of 50 cases treated with CAS, in-
tion risk. Another possible cause of CRAO is external
cluding protection devices, showed punctuated new DW
carotid artery (ECA) to ophthalmic artery anastomosis. A
MRI lesions. These lesions have been detected in vas-
number of extra-orbital branches arise from the oph-
cular territories independent of the stented carotid artery.
thalmic artery. Such extra-orbital ophthalmic branches
In particular, filter-type protection devices cannot prevent
have extensive anastomosis with the ECA.
the transportation of embolic particles smaller than the
mosis might have offered an embolic route from the ECA
filter pores, and the filter retrieval process itself might
to the ophthalmic artery, and we did not use an ECA
solution. Kim et al.
7)
9)
This anasto-
Another possible reason of
protection device in this case. In our case, it was thought
thromboembolic infarction caused by CAS is post-proce-
that the origin of CRAO was unstable in situ embolus in
dural transport of in situ embolus on the carotid stent
the carotid stenosis caused by multiple angioplasties. If
lesion.
cause distal embolization.
Embolic protection device can protect acute is-
CRAO had come from ophthalmic artery, angiography
chemia during CAS, but stent can’t cover in situ embolus
would have shown atherosclerosis of ophthalmic artery.
after CAS. According to the above studies, such embolic
Moreover, embolus might have passed ECA route.
events are probably correlated with certain catheterization
Because if embolus had passed ICA, DW-MRI would
procedures and the placement of large-caliber guiding
have shown new develop lesion.
Patients can undergo treatment modalities that lower intra-
catheters.
Regarding the etiology of CRAO, procedure like car-
ocular pressure and enhance retinal oxygenation, such as an-
otid angiography or intravitreal steroid injection can result
terior chamber paracentesis, ocular massage, systemic aceta-
12)13)
Sudden and profound vis-
zolamide, topical timolol maleate, and 5% carbon diox-
ual loss is a disease presentation. After a retinal in-
ide/95% oxygen inhalation. Despite these treatments, the
farction, the patient's prognosis is poor.
prognosis of retinal infraction due to CRAO is poor and ret-
in retinal artery occlusions.
Even though DW-MRI after CAS did not show a new-
inal cloudiness can become a continuing process. Currently,
ly developed ischemic lesion on the cerebrum, CRAO
physicians sometimes try intravenous or intraarterial throm-
may have been an embolic complication in our case. The
bolysis treatment for CRAO. The results of thrombolysis for
patient had some risk factors for CRAO or ischemic
CRAO appear to be better than either the natural history of
stroke. He had suffered from hypertension for 10 years,
CRAO or conservative treatment,
had carotid artery atherosclerotic disease, and was elderly.
treatment for CRAO requires further studies.
5)
but thrombolysis as a
Therefore, we hypothesized that an embolus had ob-
Embolism due to carotid atherosclerotic disease has
structed the retinal artery, as the symptoms occurred just
been described as the most common cause of CRAO.
12 hours after his CAS. Atherosclerosis of the ophthalmic
Endovascular surgeons should keep in mind the risk of
artery is another possible cause of CRAO. Even though
permanent vision loss because of carotid CAS.
we did not find a severe ophthalmic artery stenosis on
our patient's angiography, he might have suffered an
Conclusion
atherosclerotic change in the ophthalmic artery due to hypertension, old age, or systemic atherosclerosis. In addi-
CRAO after CAS without intracranial infarction is a
Kor J Cerebrovascular Surgery 13(4):291-296, 2011
295
Retinal artery occlusion after carotid stenting
rare complication. We here report a case in an elderly
7) Kim SJ, Roh HG, Jeon P, Kim KH, Lee KH, Byun HS et al.
Cerebral ischemia detected with diffusion-weighted MR imaging
patient.
after protected carotid artery stenting: comparison of distal balloon and filter device. Korean J Radiol 8:276-85, 2007
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