PMC4345628_01
Ophthalmological studies at the initial onset of blurred vision in the right. In fundus photograph ((a), left), the arteries are stenotic, however, an ischemic change such as cherry red spot is not detected on the retina. In optical coherence tomography ((b), right), cross-section of the macular is in normal configuration. At the lower left of the (b) retinal thickness around the macula is shown. The macular area is divided into 9 segments and the thickness of each segment is within normal limits and is painted as green (arrow)
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F1
The arteries of the retina were stenotic, however, the color of the retina was normal and an ischemic condition such as cherry red spot was not detected [Figure 1a (left)]. Optical coherence tomography demonstrated normal thickness of the retina [Figure 1b (right)].
Preoperative imaging studies. Initial diffusion-weighted images (DWI) magnetic resonance imaging (MRI) demonstrates no high intensity lesions (a). Head magnetic resonance angiography (MRA) shows occlusion of the right internal carotid artery (ICA) and the right ophthalmic artery (b). Neck MRA shows occlusion of the right common carotid artery (CCA) (c). Magnetization prepared rapid gradient echo (MPRAGE) image shows loss of black signal in the right CCA (d). No stenosis is seen 10 months prior on head and neck MRA (e and f)
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F2
Initial diffusion-weighted images (DWIs) magnetic resonance imaging (MRI) of the brain did not demonstrate any high intensity lesions [Figure 2a]. Magnetic resonance angiography (MRA) showed occlusion of the right internal/external carotid artery (ICA/ECA) and the right ophthalmic artery was not visualized [Figure 2b]. MRA did not show any signal intensity of the right ICA/ECA or of the right common carotid artery (CCA) [Figure 2c]. Magnetization prepared rapid gradient echo (MPRAGE) image showed loss of black signal in the right CCA with no obvious deposition of vulnerable plaque [Figure 2d]. Considering his past history of two embolic strokes attributable to chronic Af, the sudden-onset clinical course, and negative atherosclerotic arterial stenotic lesions in the MRA 10 months prior [Figure 2e and f], we inferred that cardiogenic emboli occluded both the right ECA and
Intraoperative images of the cervical embolectomy. An embolus is coming out from the incision (a). The embolus consists of two components, each of which is 1 cm in size, and is composed of simple violet thrombus at gross inspection (b). The arteriotomy is sutured with 6-0 nylon (c)
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F3
Linear longitudinal incision was made in the CCA, and bluish fresh large emboli came out of the incision spontaneously by back flow [Figure 3a]. Gross inspection of the emboli found simple bluish emboli rather than debris related to atherosclerotic plaque, suggesting cardiogenic embolism [Figure 3b]. The distal portion of the CCA was also clamped, and the arteriotomy was sutured with 6-0 nylon [Figure 3c].
Magnetic resonance angiography (MRA) image after the cervical embolectomy. Head MRA shows total recanalization of the right internal carotid artery (ICA), including the right ophthalmic artery (a). Neck MRA shows good patency of the ICA and consistent occlusion of the external carotid artery (ECA) (b). Follow-up MRA on postoperative date (POD) 7 demonstrates recanalization of the right ECA (c)
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F4
Postoperative DWI did not show any intracranial ischemic lesions, and MRA showed anterograde recanalization of the right cervical to intracranial ICA, including the right ophthalmic artery [Figure 4a]. Cervical MRA showed consistent occlusion of the ECA [Figure 4b]. However, follow-up MRA on postoperative day (POD) 7 demonstrated complete recanalization of the right ECA, suggesting that the occlusion was embolic in nature [Figure 4c].
Postoperative ophthalmological studies. Fundus fluorescein angiography (a) demonstrates recovery of blood flow of the retinal arteries. As a result of retinal ischemia caused by occlusion of the carotid arteries, cherry red spot is seen in fundus photograph (b)arrow. Optical coherence tomography (c) also shows thinning of the retina around the macular area as painted red (arrow)
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F5
On POD 2, the ophthalmologist reported improvement of blood flow to the right retina based on fundus fluorescein angiography [Figure 5a]. Although the retinal perfusion was recovered by the operation, the influence of retinal ischemia caused by occlusion of the carotid arteries still remained and therefore, cherry red spot was still seen [Figure 5b]. Optical coherence tomography on the same day showed thinning of the retina around the macular area [Figure 5c].