A recent article in BMJ Case Reports provides us with a fascinating glimpse into the complex pathology of ocular ischemia caused by spontaneous internal carotid artery dissection (ICAD). The paper, titled “Ocular ischemia due to a spontaneous carotid artery dissection,” was authored by Frazão Sara and colleagues and details the case of an otherwise healthy middle-aged patient who developed central retinal artery occlusion (CRAO) secondary to ICAD. This unusual case provides insight into a rare but serious condition, shedding light on possible diagnoses and treatment strategies for similar cases.
The case report, published on May 6, 2019, with DOI number 10.1136/bcr-2018-227952, outlines the sequence of events leading up to the diagnosis of CRAO in a patient with no underlying health conditions that would commonly predispose them to vascular disorders. ICAD occurs when there is a disruption to the tunica intima – one of the layers of an artery wall – causing an intramural hematoma. This can severely restrict or even occlude the lumen of the artery, which compromises blood flow and can lead to thrombus formation. The ophthalmological signs, such as those seen in this patient, are often the first indicators of ICAD and can precede neurological symptoms, such as those related to cerebral infarction, by several weeks.
In turn, CRAO can develop as a complication of ICAD triggered either by hemodynamic changes, leading to reduced ocular perfusion and a reversed ophthalmic artery flow, or by thromboembolic events, which are less common. The report underscores the necessity for clinicians to consider the possibility of ICAD in patients presenting with CRAO, even in the absence of other risk factors or symptoms.
The publication of this case study is not only of clinical importance but also serves as a foundation for broader discussions within the medical community.
Keywords
1. Ocular ischemia
2. Spontaneous carotid artery dissection
3. Central retinal artery occlusion
4. ICAD diagnosis
5. CRAO treatment
References
1. Frazão, S., Perry da Câmara, C., Pinto Proença, R., Tavares Ferreira, J., & BMJ Case Reports. (2019). Ocular ischaemia due to a spontaneous carotid artery dissection. e227952. DOI: 10.1136/bcr-2018-227952
2. Abed, K., Misra, A., & Vankawala, V. (2015). Spontaneous internal carotid dissection in a 38-year-old woman: a case report. J Community Hosp Intern Med Perspect, 5:28844. DOI: 10.3402/jchimp.v5.28844
3. Butterworth, R.J., Thomas, D.J., Wolfe, J.H., et al. (1999). Endovascular treatment of carotid dissecting aneurysms. Cerebrovasc Dis, 9:242–7. DOI: 10.1159/000015963
4. McDonough, R.L., Forteza, A.M., & Flynn, H.W. (1998). Internal carotid artery dissection causing a branch retinal artery occlusion in a young adult. Am J Ophthalmol, 125:706–8. DOI: 10.1016/S0002-9394(98)00034-8
5. Biousse, V., Touboul, P.J., D’Anglejan-Chatillon, J., et al. (1998). Ophthalmologic manifestations of internal carotid artery dissection. Am J Ophthalmol, 126:565–77. DOI: 10.1016/S0002-9394(98)00136-6
The case report by Frazão and colleagues brings awareness to the fact that there is still much to learn about the relationship between ICAD and ocular manifestations such as CRAO. The rarity of such presentations highlights the need for continued vigilance among clinicians for signs that could indicate underlying vascular pathologies. Such awareness is crucial, as early diagnosis and intervention can significantly alter the trajectory of these conditions, potentially averting catastrophic outcomes such as stroke or severe vision loss.
If the medical community takes note of this report and incorporates its findings into practice, it may lead to a heightened index of suspicion among physicians when encountering patients with unexplained ocular symptoms. In conclusion, this case emphasizes the importance of considering a broad differential diagnosis, which may include vascular causes like ICAD, in patients presenting with acute ocular conditions such as CRAO.
The report also underscores the need for swift referral to appropriate specialists, such as neurologists and ophthalmologists, to ensure multidisciplinary collaboration in diagnosis, treatment, and management of this complex interplay between neurovascular and ocular pathologies.
The patient’s journey from the onset of symptoms to final diagnosis also highlights areas where the healthcare system can improve in its responsiveness to atypical presentations of common conditions. Streamlining processes for rapid imaging, applying advanced diagnostic techniques, and fostering communication between various medical disciplines are just some of the ways that the prognosis for similar cases can be improved.
For patients and clinicians alike, the story told by this case report serves as a powerful reminder: ocular symptoms should not always be viewed in isolation, as they may be the window to deeper, more threatening vascular conditions. Proper recognition and management of these symptoms, guided by studies such as the one published in BMJ Case Reports, have the potential to preserve vision and, more importantly, save lives.