Thrombolysis in central retinal artery occlusion: a retrospective observational study

Abstract

Background There is no evidence-based therapy for non-arteritic central retinal artery occlusion (NA-CRAO). Intravenous thrombolysis (IVT) with alteplase in a time window < 4.5 h may lead to a favorable outcome. Purpose of this study was to investigate the feasibility, efficacy and safety of IVT in patients classified as functionally blind. Methods We conducted a retrospective observational study of NA-CRAO-patients. All patients underwent an ophthalmological and neurological examination including cerebral magnetic resonance imaging (MRI) for assessment of additional stroke lesions. Patients were treated either conservatively or with IVT within 4.5 h. Visual acuity (VA) was evaluated in logMAR and a categorical analysis was performed. Results Thirty-seven patients were included in the study, 21 patients in the conservative treatment group (CTG) and 16 patients in the IVT group. The median logMAR visual acuity at admission and discharge was similar in both groups. The medium symptom to treatment time in the IVT group was 158.0 min. 3 patients (19%) of the IVT group showed a favorable outcome, all CTG patients remained at the level of functional blindness. No serious adverse events were observed after IVT. MRI showed additional acute stroke in over one-third of the patients (n = 14). Conclusions Early intravenous thrombolysis therapy according to the current stroke protocol n a time window up to 4.5 h after the onset of symptoms was feasible and might be a potential treatment option for NA-CRAO. Patients with NA-CRAO are at very high risk of ischemic stroke and MRI should be done in all patients for optimized treatment and secondary stroke prevention. A prospective randomized study is required.

Thrombolysis for central retinal artery occlusion: An individual participant-level meta-analysis

“…AD sensitivity meta-analyses included CRAO patients with a baseline VA of 20/200 or worse, excluding two studies with a high risk of bias and substantial influence on outcomes (N = 602). 52,53…”

“…AD sensitivity meta-analyses included CRAO patients with a baseline VA of 20/200 or worse, excluding two studies with a high risk of bias and substantial influence on outcomes (N = 602). 52,53 International Journal of Stroke, 19 (1) In AD-Design 1, among patients who received IVT-tPA within 4.5 h (Figure 3), 80.9% (CI: 65.7-93.0%; unadjusted rate: 80.0%) had VA improvement by ⩾0.1 logMAR, 74.3% (CI: 60.9-86.0%; unadjusted rate: 73.2%) had ⩾0.3 logMAR VA improvement, and 39.0% (CI: 25.6-53.1%; unadjusted rate: 39.2%) had a final VA of ⩾20/100. SMCC of 77.1% logMAR (CI: 47.1-107.1%) was reported after receiving IVT-tPA within 4.5 h.…”

Is Erythrocyte Sedimentation Rate Necessary for the Initial Diagnosis of Giant Cell Arteritis?

“…The results of ESR did not change the likelihood of GCA or any decision made using the combination of platelet count and CRP. These results give rise to crucial considerations when pursuing a faster initial diagnosis for dubious cases to facilitate prompt glucocorticoid treatment for an atypical clinical presentation of GCA or treatment for relevant differential diagnoses e.g., non-arteritic CRAO and the ongoing studies of time-critical intravenous alteplase [ 10 , 11 ]. It should be noted that ultrasound examination of the extra-cranial arteries may enable a rapid and immediate diagnosis of GCA in a rheumatological setting [ 14 , 15 ].…”

“…Or do we have enough information to make decisions earlier? Second, current studies are exploring intravenous alteplase in non-arteritic CRAO within 4 to 5 h after symptom onset [ 10 , 11 ]. In that context, evaluation of whether a CRAO is arteritic or non-arteritic needs to be performed as fast as possible, and one can question how much more value we obtain by waiting for the ESR result?…”

VIsion Salvage Using Intra-Ophthalmic Arterial Alteplase Combine with Nimodipine in Central Retinal Artery Occlusion (VISION)

“…A meta-analysis of intravenous fibrinolytic therapy in CRAO found that the treatment can significantly improve vision (defined as the improvement of VA from 20/200 or worse at presentation to 20/100 or better) in up to 50% in patients presenting within 4.5 hours after the onset. 4 To lessen systemic side effects, intra-arterial thrombolytic therapy (IAT) with direct infusion and lowered total thrombolytic dose has been used with several studies showed promising results of IAT in terms of visual improvement 6,8,9,[11][12][13] , despite The European Assessment Group for Lysis in the Eye (EAGLE) trial, the only randomized control trial of IAT, was terminated before the study was completed, due to a higher rate of adverse events, although minor, in the IAT group, with similar efficacy in the IAT and conservative management groups. 14 Various vasodilators such as sublingual isosorbide dinitrate and intravenous glyceryl trinitrate have been used to increase retinal blood flow, to dislodge the embolus and allow it to migrate more peripherally.…”