Intracranial fibromuscular dysplasia presenting as various ocular manifestations

Yield of Investigations in Young Patients Presenting With Transient Monocular Vision Loss: A Prospective Study

PURPOSE

It is unclear whether transient monocular vision loss (TMVL) warrants the same thorough systemic evaluation for potential embolic sources in young adults as it does in older adults. The objective of the present study was to evaluate the yield of investigations in patients under 45 years of age presenting with TMVL.

DESIGN

Prospective cohort study.

METHODS

Young adult patients with TMVL presenting to a university-affiliated neuro-ophthalmology clinic were included. All included patients were referred for neuroimaging (computed tomography or magnetic resonance angiography of entire carotid tree and magnetic resonance imaging of the brain) and cardiac investigations (transesophageal echocardiography and 2 weeks of Holter monitoring).

RESULTS

A total of 20 participants with TMVL were included in the study. The mean age was 33.1 ± 8.2 years, and 16 of the 20 participants were women. The most common finding on past medical history was migraines, in 5 of 20 cases (25%), and 25% of patients had headaches during their visual loss. Of 17 participants who completed neuroimaging, 1 had fibromuscular dysplasia (this patient also experienced headaches during their symptoms). Two of 13 patients who completed echocardiography had patent foramen ovale. Overall, 3 of 20 participants (15%, 95% CI 3%-38%) had abnormal findings associated with their TMVL. Aspirin treatment was initiated in 2 of 3 patients following investigations.

CONCLUSION

In our cohort of young patients presenting with TMVL, 15% of patients had abnormal findings on further investigations. We recommend that young patients presenting with TMVL be referred for neuroimaging and cardiac workup so that appropriate treatments can be initiated to prevent future complications. Headaches during vision loss may not always indicate a benign cause, and retinal migraine should be a diagnosis of exclusion.

Ocular ischemic manifestations in fibromuscular dysplasia

PURPOSE

To report visual, clinical and radiological outcomes of three patients with fibromuscular dysplasia (FMD) that presented different ocular ischemic events, supported by different multimodal imaging.

METHODS

A retrospective study including patients who attended a tertiary referral hospital from July 2016 to June 2019 referring acute visual loss and later diagnosed of FMD. Ophthalmological examination included best corrected visual acuity (BCVA), biomicroscopy, fundoscopy, fluorescein angiography (FA), and macular and retinal nerve fiber layer spectral domain optic coherence tomography (SD-OCT). Patients were admitted by the Neurology service, completing the study with blood and cerebrospinal fluid (CSF) test, serology and cultures, cerebral magnetic resonance angiography (angioMRI), and arteriography.

RESULTS

Three patients were included; one male and second females. All referred unilateral acute visual loss, with BCVA of counting fingers or hand-motion. Relative afferent pupilar defect was present in all patients. Two patients associated neurological focal signs and one had chronic hypertension. Fundoscopy revealed hemorrhages and exudates in all patients, and the typical sign of "string-of-beads" in one. FA showed dye filling delay and macular and peripheral hypofluorescence. SD-OCT revealed acute and chronic retinal ischemic signs. Blood and CSF tests, serologies and cultures resulted negative. All presented cerebral vascular involvement, objectified in the cerebral angioMRI or arteriography.

CONCLUSIONS

FMD should be considered in cases with unilateral sudden visual loss associated to neurological focal deficits in young patients. The typical "string-of-beads" image is rare in small arteries such as the retinal vasculature. When suspected, a complete ophthalmological examination and cerebral vascular imaging is essential to confirm the diagnosis.

A Case of Isolated Intracranial Fibromuscular Dysplasia

Fibromuscular dysplasia (FMD) is a non-inflammatory, non-atherosclerotic disease resulting in stenosis and arterial wall weakening of typically medium-sized arteries. Intracranial aneurysm is an uncommon presentation of FMD, with a significant proportion presenting in the posterior circulation. Presented is the rare case of an adult female with left-sided stroke with angiographically-confirmed left middle cerebral artery FMD, with pan-scanning unremarkable for other demonstrable evidence of FMD. The patient's neurological deficits completely resolved. The patient was stable for discharge home on antiplatelet therapy. Appropriate imaging and screening should be performed to ensure FMD is localized versus systemic. Patients with intracranial FMD should be protected from cerebrovascular events with antiplatelet therapy.