AHA: Central Retinal Artery Occlusion Requires Immediate Treatment, Can Signal Future Vascular Events

March 9, 2021

A new scientific statement from the American Heart Association, published in the journal Stroke, states that central retinal artery occlusion (CRAO) is a medical emergency and systems of care should evolve to prioritise early recognition and triage of CRAO to emergency medical attention.

The American Association of Neurological Surgeons/Congress of Neurological Surgeons Cerebrovascular Section affirms the educational benefit of the scientific statement, and it has been endorsed by the North American Neuro-Ophthalmology Society, the American Academy of Ophthalmology Quality of Care Secretariat and the American Academy of Optometry.

“Central retinal artery occlusion is a cardiovascular problem disguised as an eye problem,” said Brian C. Mac Grory, MD, Duke Comprehensive Stroke Center, Durham, North Carolina. “It is less common than stroke affecting the brain but is a critical sign of ill health and requires immediate medical attention. Unfortunately, a CRAO is a warning sign of other vascular issues, so ongoing follow-up is critical to prevent a future stroke or heart attack.”

In a comprehensive review of the world literature, committee members from the specialties of neurology, ophthalmology, cardiology, interventional neuroradiology, neurosurgery, and vitreoretinal surgery summarised the state of the science in this condition. They found indications that this type of stroke can be caused by problems with carotid arteries, but there is also evidence CRAOs could be caused by problems with the heart, such as atrial fibrillation. The risk of having a CRAO increases with age and in the presence of cardiovascular risk factors such as hypertension, hyperlipidaemia, type 2 diabetes, smoking, and obesity.

The new scientific statement notes the lack of large clinical trials on CRAOs leads to uncertainty within the medical community of exactly what causes them or the best way to treat them. As a result, there is wide variability in diagnosis and treatment methods. Most concerning is that many practitioners may not recognise CRAO as a form of stroke resulting in patients receiving delayed testing and treatment, often in the outpatient clinic instead of the emergency department.

“There is a narrow time window for effective treatment of CRAO and a high rate of serious related illness,” said Dr. Mac Grory. “So, if a person is diagnosed in a doctor’s office or other outpatient clinic, they should be immediately sent to a hospital emergency department for further evaluation and treatment.”

Current literature suggests that treatment with intravenous tissue plasminogen activator (tPA) may be effective, but the treatment must be administered within 4.5 hours of the first sign of symptoms to be most effective and safe.

The writing committee also noted that emerging treatments, such as hyperbaric oxygen and intra-arterial alteplase, show promise but require further study. Other potential treatments that require further research and evaluation include novel thrombolytics and novel neuroprotectants for use in tandem with other therapies to restore blood flow in the blocked artery.

Reference: https://www.ahajournals.org/doi/10.1161/STR.0000000000000366

SOURCE: American Heart Association