Acquired Visual Deficits Independent of Lesion Site in Acute Stroke

Abstract

Most clinical diagnoses of stroke are based on the persistence of symptoms relating to consciousness, language, visual-field loss, extraocular movement, neglect (visual), motor strength, and sensory loss following acute cerebral infarction. Yet despite the fact that most motor actions and cognition are driven by vision, functional vision per se is seldom tested rigorously during hospitalization. Hence we set out to determine the effects of acute stroke on functional vision, using an iPad application (Melbourne Rapid Field-Neural) that can be used to assess vision (visual acuity and visual field sensitivity) at the bedside or in the emergency ward in about 6 min per eye. Our convenience sample comprised 60 (29-88 years, 65 ± 14 years, 33 males) of 160 sequentially presenting first episode, acute (<7 days) ischemic stroke patients at Sunshine Hospital, Melbourne. One hundred patients were excluded due to existing eye disease, inadequate radiological confirmation, inability to comply with English directions or too ill to participate. Stroke cases were compared with 37 (29-85 years, 64 ± 12 years,14 males) similaraged controls using a Mann-Whitney U-test. A significant loss in visual field sensitivity was measured in 68% of stroke cases (41/60, Mean Deviation: Stroke: −5.39 ± 6.26 dB, Control: 0.30 ± 0.60 dB, MWU = 246, p < 0.0001). Surprisingly, 44% (18/41) of these patients were unaware of their field loss. Although high contrast visual acuity was unaffected in most (55/60) patients, visual acuity-in-noise was reduced in 62% (37/60, Stroke: mean 6/12−2, log MAR 0.34 ± 0.21 vs. Control: mean 6/7•5-2, log MAR 0.14 ± 0.10; MWU = 470, p < 0.0001). Visual field defects were associated with all occipital, parietal and posterior cerebellar artery strokes while 9/15 middle cerebral artery lesions and 11 lesions in other brain regions were also associated with visual field defects. Our findings demonstrate that ∼2/3 of acute first episode ischemic stroke patients experience acquired vision deficits, often unrelated to the confirmed lesion site. Our results also imply that visual dysfunction may be associated with a more generalized cerebral dysfunction while highlighting the need for bedside testing of vision for every stroke patient and demonstrating the translational clinical value of the "Melbourne Rapid Field-Neural" iPad application.

COVID-19 Pathophysiology Predicts That Ischemic Stroke Occurrence Is an Expectation, Not an Exception—A Systematic Review

“…Currently, there are little reliable data about how well individuals with severe respiratory system and lung damage will recover or whether scarring will make such patients vulnerable to other viral infections ( 31 ). Furthermore, questions remain regarding whether the hypoxia engendered during the acute hospitalization phase will have lasting effects on the brain and nerve tissue especially on high metabolic demand areas including the sympathetic system and the fast visual attention and eye movements pathways ( 112 ) and long motor pathways.…”

“…For further details, see Mantovani et al and the 29 recommendations on evidence-based cognitive rehabilitation in the context of stroke and TBI nominated by the Cognitive Rehabilitation Task Force (CRTF), which suggests that a more comprehensive biological understanding of the various systems affected by TBI should lead to more collaborative translational research utilizing artificial intelligence and novel technology to find better individually designed precision solutions (e.g., video-consults, tablet-based measurements, and use of wearable devices). Lastly, the integration of services, including private and public partnerships such as university–public hospital partnerships and partnerships with community organizations and volunteers, are likely to create excellent opportunities for the future ( 112 , 154 , 155 ) and better evidence-based neurorehabilitation pathways.…”

“…• COVID-19 induced decrease in the amounts of physiological anticoagulants and increased levels of coagulant factors and antiphospholipid antibodies (26, 109, 110) Endotheliopathy Endothelium-driven activation of the extrinsic coagulation system• Imbalance in the ACE2 and angiotension II (AT-II) receptors leads to the upregulation of tissue factor (27, 28) • Tissue factor interacts with Factor VII to activate the • Promotes organ damaging effects of the classical RAAS pathway(112) • Promotes overactivity of the sympathetic nervous system resulting in the exacerbation of traditional stroke risk factors(113) …”

Acute Ischemic Stroke in COVID-19: A Case-Based Systematic Review

“…Thus, these circumstances argue a strong case for converting the catastrophe [Complex rearrangement of hospital facilities as part of the preparation for the pandemic has also occasioned significant problems and added resource problems for health care systems across the world (44)(45)(46)(47)(48)(49)(50) into an opportunity for revamping of rehabilitation protocols]. Currently evidence is emerging for further expansion of telemedicine type paradigms, with incorporation of tablet based remote monitoring technology (Melbourne Rapid Field visual fields, wearable devices and artificial intelligence) suggesting as the way forward in neurorehabilitation of AIS in COVID19 pandemic era, at least for the foreseeable future (43,(51)(52)(53).…”

Vision and Visuomotor Performance Following Acute Ischemic Stroke

“…Clinical trials have reported that ∼70% of referred stroke survivors posthospitalization have ipsilaterally derived eye movement disorders (12)(13)(14)(15) and reduced amplitude in micro-saccades which may affect visual sensitivity (16). We have also recently reported that ∼2/3 of mild-moderate severity first episode acute ischemic stroke (AIS) patients with no previous history of impaired vision, experience deteriorated visual acuity-in-noise (VAn) with contralateral visual field defects immediately (i.e., within 7 days) after stroke (17). Given the ubiquity of motor involvement in stroke, we set out to examine and quantify visuomotor performance in the same group of hospitalized AIS cases whose sensory visual capacity was reported in the past (17), and for this study, we added a motor eye-hand coordination task.…”