Synchronous subarachnoid haemorrhage and ischaemic stroke as a result of complete internal carotid artery occlusion

A previously healthy man in his 60s presents with a one-day history of insidious onset headache and 'walking into doors'. He reported transient right arm pain and tingling but no weakness. A CT brain showed a right middle cerebral artery (MCA) infarct as well as a synchronous right frontal lobe convexal subarachnoid haemorrhage (cSAH). An arch to vertex CT angiogram demonstrated right MCA occlusion and complete right internal carotid artery (ICA) occlusion from its origin. Reconstitution of flow was seen within the distal right ICA at the level of the distal foramen lacerum. A repeat CT of the brain after one week showed a stable appearance of the bleeding and infarct. He was commenced on antiplatelet therapy for the treatment of the ischaemic stroke as well as secondary prevention.This is a rare case of synchronous right MCA infarct as well as a right frontal cSAH secondary to ipsilateral carotid artery occlusion.

Immediate implantable loop recorder implantation for detecting atrial fibrillation in cryptogenic stroke

INTRODUCTION

Atrial fibrillation (AF) is suspected as the main cause of stroke in the majority of patients presenting with cryptogenic stroke (CS). Implantable loop recorders (ILR's) are indicated for detecting AF in these patients. The short term (<1 month) and long-term AF detection rates in patients inserted with an ILR immediately after CS is reported. Secondly, we compare the safety of nurse led vs physician led ILR implantation in these patients.

METHODS

This is a retrospective review of all patients who underwent inpatient ILR implantation (Medtronic Linq) between May 2020 and May 2022 at East Sussex Healthcare NHS trust. All patients were remotely monitored via the FOCUSON^TM monitoring and triage service.

RESULTS

A total of 186 subjects were included in the study and were followed up for a mean period of 363.0 +/- 222.6 days. The mean time between stroke and ILR was 7.0 +/- 5.5 days. The mean time between referral and ILR was 1.0 +/- 2.0 days. AF was detected in 25 (13.4%) patients. During the first 30 days of monitoring, AF was detected in 9 (4.8%) patients. The number of ILR implants performed by the specialist nurse was 107 (57.5%). There was no significant difference in the major complication rate (requiring device removal) between nurse and physician led implant (1 (0.95%) vs 0 (0%), p value = 0.389).

CONCLUSION

Inpatient ILR for cryptogenic stroke is feasible. The rate of AF detection in the first month post CS is 4.8% however, more AF was detected up to one year post implant, suggesting rationale for proceeding directly to ILR implant in these patients before discharge to not delay treatment. A nurse led service is also viable with no significant difference in the major complication rate compared to physician led implants.

Sagittal sinus thrombosis with subarachnoid haemorrhage in a patient with COVID-19 infection

A man in his late 50s was admitted with a 10-day history of right frontotemporal headache, left arm and leg weakness, and a sudden decline in visual acuity in the right eye. The patient had recent exposure to COVID-19 infection and tested positive for the same on admission. A CT scan of the head done on arrival demonstrated a subarachnoid haemorrhage in the right central sulcus with an underlying superior sagittal sinus thrombosis. No other known risk factors for central venous sinus thrombosis could be identified. The patient had a normal level of consciousness on admission clinically; however, he was in severe pain. A collective decision was made to administer anticoagulants to the patient with heparin after carefully deliberating the risk-to-benefit ratio of a superior sagittal thrombus with an associated subarachnoid haemorrhage. Our patient recovered and was discharged after 2 weeks on warfarin. We present this case to highlight the potential risks of hypercoagulable and neurotropic complications of COVID-19 infections, with special emphasis on cerebral venous thrombosis.

AB1512 CENTRAL RETINAL ARTERY OCCLUSION (CRAO) LEADING TO BILATERAL BLINDNESS; DUE TO BOTH ARTERITIC AND NON-ARTERITIC ISCHEMIC OPTIC NEUROPATHY

Background

Giant cell arteritis (GCA) is a large vessel vasculitis which is common in the elderly. It affects the cranial branches of the aorta, commonly superficial temporal, posterior ciliary and retinal arteries. Hence blindness can be one of the dreaded complications of the disease which makes prompt diagnosis and treatment of utmost importance. Sometimes atypical presentations and concurrent pathologies can make the timely diagnosis of the disease difficult. Therefore it is very important for clinicians to be vigilant of the varied presentations of the GCA and coexisting vascular risk factors.

Objectives

A 78-year-old Caucasian male was presented with acute onset blindness of the left eye. It started as few blotchy patches in the peripheral visual field and gradually became diffuse visual loss over a few days. He denied any headache, temporal tenderness, tongue or jaw claudication or symptoms of polymyalgia rheumatica. Following ophthalmology review he was diagnosed to have CRAO with marked disc pallor without any evidence of retinal emboli. He was in sinus rhythm, no carotid bruits or cardiac murmurs were noted. His comorbidities were hypertension and hypercholesterolemia. He was assessed in the transient ischemic attack clinic for screening for vascular risk factors and started on anti platelets.

Methods

Three months later he re-presented with visual loss in the right eye. Apart from the mild tenderness of the right temporal region noticed when trimming his hair he had no symptoms of GCA. He was started on dual antiplatelets and urgently referred to ophthalmologist who diagnosed central retinal artery occlusion of right eye with clear demonstration of emboli in all the arcades of the central retinal artery. A temporal arterial biopsy was performed.

Results

His CRP was 19mg/l & ESR was 18mm/hr initially. During the second presentation both ESR (35) and CRP (40) were further elevated. His carotid doppler did not show significant stenosis in internal carotid arteries. ECG at presentation was in sinus rhythm however 24 hour holter monitoring after involvement of both eyes showed paroxysmal atrial fibrillation (PAF). Transthoracic echocardiogram was normal. His temporal arterial biopsy showed destruction of the internal elastic lamina with lymphohistiocytic infiltration and occasional giant cells in keeping with a diagnosis of GCA.

Patient was started on prednisolone 60 mg daily followed by a tailing off regime and antiplatelets were changed to anticoagulation due to PAF. His vision improved mildly, only in the right eye in the way of perception of hand movements.

Conclusion

CRAO is an ocular emergency and is the ocular manifestation of a stroke. The usual presentation is a painless unilateral visual loss leading to profound blindness and is commonly due to non arteritic causes like carotid artery stenosis, cardiogenic embolism, small vessel disease and rarely due to arteritic causes like GCA. Accurate identification of the aetiology is very important to avoid further recurrence.

By consensus multiple retinal emboli usually excludes a diagnosis of GCA(1). However considering, the patient’s age and recurrence of CRAO while on antiplatelets led us to consider occult GCA. 21.2% of patients with GCA induced vision loss do not have any systemic symptoms of the disease(2). Hence there should be a high index of suspicion when an elderly person presents with ischaemic ocular manifestations especially optic nerve and retinal ischaemia even in the presence of another plausible explanation like PAF.

References

[1]Hedges, TR. (2018) Central and branch retinal artery occlusion (internet) (Accessed 22 Jan 2022). Available at https://www.uptodate.com/contents/central-and-branch-retinal-artery-occlusion?search=central%20retinal%20artery%20occlusion&source=search_result&selectedTitle=1~28&usage_type=default&display_rank=1

[2]Sane, M. et al. (2014) Transient visual loss due to reversible ‘pending’ central retinal artery occlusion in occult giant cell arteritis. Eye (Lond),28(11),1387–1390.

Disclosure of Interests

None declared