Download Central Retinal Artery Occlusion From Carotid Dissection

1271
Central Retinal Artery Occlusion From
Carotid Dissection Diagnosed by
Cervical Computed Tomography
T. Hemanth Rao, MD; Lori B. Schneider, MD;
Mahendra Patel, MD, FRCR; Richard B. Libman, MD, FRCPC
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Background Carotid dissection may lead to many different
types of neurological deficits, both transient and permanent.
Case Description We present a patient with an isolated
central retinal artery occlusion who was found to have an
ipsilateral carotid dissection by neck computed tomographic
scan, later confirmed by angiography.
Conclusions This is the first reported case of carotid dissection causing central retinal artery occlusion without any
other neurological deficits. It demonstrates the diagnostic
usefulness of computed tomographic imaging in such cases.
(Stroke. 1994;25:1271-1272.)
Key Words • blindness • dissection • tomography
C
red spot. The remainder of the neurological examination was normal.
Computed tomographic (CT) scan of the neck done
with contrast revealed an intimal thrombus and narrowing of the cervical portion of the right ICA (Figure).
This was confirmed by carotid angiography, which demonstrated diffuse narrowing of the cervical ICA. CT
scan of the brain was negative.
The patient was anticoagulated with heparin, then
discharged to his home on warfarin. After 6 months
there had been no improvement in his vision and no new
neurological symptoms.
arotid artery disease is known to cause a variety
of ischemic ocular syndromes1 secondary to
embolism or perfusion failure.2 Dissection of
the internal carotid artery (ICA) is known to cause
amaurosis fugax2 and other ocular ischemic syndromes
with a good functional outcome.3 There has been one
report of central retinal artery occlusion as a sequela of
ICA dissection,4 but the two patients involved had other
neurological deficits as well. We describe a patient with
traumatic ICA dissection who developed an ipsilateral
isolated central retinal artery occlusion.
Case Report
A previously healthy 36-year-old man was involved in
a motor vehicle accident and sustained head trauma;
the right side of his head hit the windshield. There was
no loss of consciousness. Immediately after the accident, the patient reported pain in his right eye, without
visual symptoms. A few days later he developed pain in
his neck and increasing pain in the right eye, which was
not relieved with nonsteroidal anti-inflammatory
agents. The day before presentation he complained of a
severe headache and right eye pain, which was associated with the impression of a shade coming down over
the right eye that progressed to complete blindness.
On examination the patient had scalp tenderness over
the right side of his head. His neck was supple without
tenderness or bruits. Neurological examination was
significant for an afferent pupillary defect and light
perception only in the right eye. Funduscopic examination revealed opacification of the retina with a cherry
Received January 3, 1994; final revision received March 22,
1994; accepted March 22, 1994.
From the Departments of Neurology (T.H.R., L.B.S., R.B.L.)
and Radiology (M.P.), Long Island Jewish Medical Center, The
Long Island Campus for The Albert Einstein College of Medicine,
New Hyde Park, NY.
Correspondence to Richard B. Libman, MD, Department of
Neurology, Long Island Jewish Medical Center, New Hyde Park,
NY 11042.
Discussion
Spontaneous and traumatic dissections of the ICA
have been well described in the literature.2-3 Carotid
artery dissection most commonly presents with the
abrupt onset of unilateral headache followed, at times,
by vascular events that can be transient or permanent.
Forty percent to 50% of patients have an ipsilateral
Horner's syndrome. Transient monocular visual loss
and neck pain are a common occurrence.5 The extracranial segment is the most commonly involved portion
of the ICA. Motor vehicle accidents are thought to be
the most common causative factor.5 Patients who sustain combinations of head, facial, and cervical injuries
are at greatest risk. As a rule, patients with traumatic
extracranial carotid dissections have a "lucid interval"
of hours to days before the abrupt onset of symptoms.56
This interval is most likely due to delayed thrombus
formation and embolism, leading to cerebral and ocular
ischemia.5 Ocular strokes due to carotid artery dissection are exceedingly rare. The literature contains only
one other case of an isolated permanent monocular
visual loss related to carotid dissection, and this was a
case of posterior ischemic optic neuropathy.7 Two cases
of central retinal artery occlusion secondary to carotid
dissection were associated with other neurological deficits. Another case of permanent monocular blindness
caused by carotid dissection was due to ophthalmic
artery occlusion, but this case was also associated with
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Stroke
Vol 25, No 6 June 1994
magnetic resonance imaging may prove quite useful,9
CT scans are noninvasive and may reveal persistent
dissections even after the angiogram appears normal.
Therefore, it has been proposed that CT scans are a
useful means of following the progression of a dissection
and determining when anticoagulation can be safely
discontinued. They may also be useful for delineating
the full extent of a pseudoaneurysm before surgical
repair.10-11
In conclusion, ocular strokes are a rare but serious
complication of carotid artery dissection. Carotid dissection should be considered in the differential diagnosis of patients who present with acute monocular visual
loss, especially in the setting of recent trauma or unilateral head and neck pain. Neck CT scans with contrast
can serve as an important diagnostic tool in suspected
carotid artery dissection.
Acknowledgment
We thank Ronald Kanner, MD, for his helpful review of the
manuscript.
References
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Neck computed tomographic scan with contrast shows an
intimal thrombus and narrowing of the lumen of the right internal
carotid artery due to dissection (arrows).
ophthalmoparesis.8 To our knowledge, this is the first
case of a carotid dissection resulting in an isolated
central retinal artery occlusion. Early diagnosis is important because conservative treatment with anticoagulants may prevent future ischemic events.
Our patient's presentation with right neck pain, scalp
tenderness, and monocular blindness after a motor
vehicle accident was highly suggestive of a traumatic
carotid artery dissection. In this case the dissection was
demonstrated on CT scan of the neck with contrast,
which revealed narrowing of the lumen and an intramural hematoma in the right cervical ICA. This was
confirmed by angiography. The CT scan enables the
physician to examine not only the lumen of the carotid
artery but also the vessel wall, revealing hematomas and
pseudoaneurysms. While angiography remains the
"gold standard" for the diagnosis of dissection and
1. Fischer CM. Observation of the fundus oculi in transient
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10. Hodge CJ, Leeson M, Cacayorin E, Petro G, Celebras A, Iliya A.
Computed tomographic evaluation of extracranial carotid artery
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Central retinal artery occlusion from carotid dissection diagnosed by cervical computed
tomography.
T H Rao, L B Schneider, M Patel and R B Libman
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Stroke. 1994;25:1271-1272
doi: 10.1161/01.STR.25.6.1271
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Copyright © 1994 American Heart Association, Inc. All rights reserved.
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