RESUMEN
OBJECTIVES: To determine quantitative and qualitative hemodynamic alterations within the ophthalmic, central retinal, and short posterior ciliary arteries in patients with giant cell arteritis (GCA) proved by biopsy specimen. DESIGN, PATIENTS, AND SETTING: A consecutive case series of patients with GCA referred to an urban eye hospital who were evaluated with color Doppler imaging that was used to analyze orbital blood flow velocities and vascular resistance in 22 consecutive patients with GCA compared with age and sex-matched controls. RESULTS: Patients with GCA all demonstrated significantly reduced central retinal and short posterior ciliary arterial mean flow velocities as well as significantly increased vascular resistance compared with matched controls. Ophthalmic artery mean flow velocity demonstrated marked variation depending on the anatomic location studied. Other color Doppler imaging characteristics of GCA included the following: ophthalmic artery aliasing (high velocity and turbulent flow at presumed focal vasculitic stenoses), reversal of flow within the ophthalmic artery, reduced and truncated time-velocity waveforms of the central retinal and short posterior ciliary arteries, and absolute deficits of flow within the central retinal and short posterior ciliary arteries. Aliasing of flow velocity within the ophthalmic artery (two patients) was associated with clinical progression of GCA. CONCLUSIONS: These data support the concept that quantitative and qualitative alterations in blood flow or pathophysiologic mechanisms of visual loss in GCA. This technique may be useful in the diagnosis and management of GCA since some of the color Doppler waveforms observed in GCA have not been seen in non-arteritic optic neuropathy. Treatment with corticosteroids often appears to stop the progression of these hemodynamic abnormalities but generally does not improve preexisting vascular abnormalities.
Asunto(s)
Cuerpo Ciliar/irrigación sanguínea , Arteritis de Células Gigantes/fisiopatología , Arteria Oftálmica/fisiopatología , Arteria Retiniana/fisiopatología , Anciano , Anciano de 80 o más Años , Velocidad del Flujo Sanguíneo/fisiología , Femenino , Arteritis de Células Gigantes/tratamiento farmacológico , Humanos , Flujometría por Láser-Doppler , Masculino , Metilprednisolona/uso terapéutico , Persona de Mediana Edad , Flujo Sanguíneo Regional/fisiologíaRESUMEN
OBJECTIVE: To describe three patients with giant cell arteritis (GCA) who suffered profound, irreversible visual loss due to delayed initiation or discontinuation of corticosteroid therapy pending results of histopathologic examination of temporal artery biopsy specimens and to review the appropriate management of GCA once the clinical diagnosis is made. STUDY DESIGN: Case series. SETTING: University-affiliated eye hospital. PATIENTS: Three women with biopsy-proven GCA and bilateral visual loss due to delayed institution or discontinuation of corticosteroid therapy. MAIN OUTCOME MEASURES: Visual acuity and onset, and time course of corticosteroid therapy. RESULTS: Permanent visual loss resulted from delayed initiation of corticosteroid therapy in two patients and discontinuation of therapy in one patient with clinically suspected diagnosis of GCA. In two of these patients, visual loss was preceded by amaurosis fugax and other visual disturbances, although one patient did not volunteer this information to her physician. CONCLUSIONS: Giant cell arteritis may cause rapid and profound loss of vision bilaterally, often without warning. It is essential that systemic corticosteroid therapy be initiated as soon as the diagnosis of GCA is made clinically. Corticosteroid therapy should not be delayed until results of examination of the temporal artery biopsy specimen are obtained. Biopsy specimen interpretation will not be affected if the biopsy is performed within 7 to 10 days of starting therapy.
Asunto(s)
Corticoesteroides/uso terapéutico , Ceguera/etiología , Arteritis de Células Gigantes/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Biopsia , Femenino , Arteritis de Células Gigantes/complicaciones , Arteritis de Células Gigantes/patología , Humanos , Inyecciones Intravenosas , Hemisuccinato de Metilprednisolona/administración & dosificación , Hemisuccinato de Metilprednisolona/uso terapéutico , Arterias Temporales/patología , Factores de TiempoRESUMEN
PURPOSE: The purpose of this study is to examine changes in color Doppler imaging parameters before and after optic nerve sheath decompression (ONSD) for chronic papilledema caused by pseudotumor cerebri (PTC). METHODS: Color Doppler imaging was performed within 48 hours before surgery and within 48 hours after the procedure using a color Doppler unit with a 7.5-MHz phased linear transducer. Pulsed Doppler spectrum analyses were recorded digitally on videotape from the ophthalmic, central retinal, and short posterior ciliary arteries, using a 0.4 x 0.6-mm sample volume. RESULTS: Blood flow velocities in the ophthalmic, short posterior ciliary, and central retinal arteries of 24 eyes were significantly decreased compared with a healthy age-matched group. Eyes with visual acuities worse than 20/30 before surgery had significantly decreased velocities in the ophthalmic, short posterior ciliary, and retinal arteries, whereas in eyes with visual acuities better than 20/30, only the short posterior ciliary and central retinal arteries demonstrated decreased velocities. In addition, Gosling's pulsatility index was increased for the central retinal artery but not the ophthalmic or short posterior ciliary arteries. Thirteen eyes improving in visual acuity and field after ONSD demonstrated significant improvement in all color Doppler imaging parameters for the short posterior ciliary arteries. The ophthalmic artery diastolic velocity also increased significantly but the central retinal artery parameters did not change. The eyes that remained stable or worsened did not demonstrate significant postoperative changes. CONCLUSION: These results suggest that some of the visual loss from chronic papilledema may be due to ischemia, and worsening visual acuity correlates with greater impairment of the retrobulbar circulation. One of the mechanisms by which ONSD improves visual function may be reversal of this ischemic process.
Asunto(s)
Velocidad del Flujo Sanguíneo , Nervio Óptico/cirugía , Papiledema/fisiopatología , Arterias/diagnóstico por imagen , Arterias/fisiología , Velocidad del Flujo Sanguíneo/fisiología , Enfermedad Crónica , Cuerpo Ciliar/irrigación sanguínea , Femenino , Estudios de Seguimiento , Hemodinámica , Humanos , Estudios Longitudinales , Masculino , Arteria Oftálmica/diagnóstico por imagen , Arteria Oftálmica/fisiología , Papiledema/etiología , Papiledema/cirugía , Seudotumor Cerebral/complicaciones , Arteria Retiniana/diagnóstico por imagen , Arteria Retiniana/fisiología , Ultrasonografía , Agudeza VisualRESUMEN
We evaluated 37 patients with hemifacial spasm and 16 age-matched control patients with other neurological disorders using magnetic resonance (MR) imaging, MR angiography, and MR tomographic angiography. MR tomographic angiography is a new technique using computer reconstruction of MR angiographic images to create coronal angiotomes that display tissue and arterial structures on the same image. Twenty-four of 37 (64.9%) patients with hemifacial spasm had ipsilateral vascular compression of cranial nerve VII or the pons noted by this technique, whereas only 1 of 16 (6.3%) control patients had compression. MR imaging and MR angiography were less sensitive and less specific in evaluating for vascular compression. This study supports vascular compression of cranial nerve VII or the pons as a cause of hemifacial spasm, and demonstrates MR tomographic angiography's value as an excellent, noninvasive technique to demonstrate the compression.
Asunto(s)
Angiografía , Tronco Encefálico/patología , Músculos Faciales , Nervio Facial , Procesamiento de Imagen Asistido por Computador/métodos , Imagen por Resonancia Magnética , Síndromes de Compresión Nerviosa/diagnóstico , Espasmo/etiología , Adulto , Anciano , Anciano de 80 o más Años , Arteria Basilar/diagnóstico por imagen , Encefalopatías/diagnóstico , Cerebelo/irrigación sanguínea , Femenino , Lateralidad Funcional , Humanos , Masculino , Persona de Mediana Edad , Síndromes de Compresión Nerviosa/complicaciones , Arteria Vertebral/diagnóstico por imagenRESUMEN
PURPOSE: This study describes hemodynamic characteristics of the ophthalmic, central retinal, and posterior ciliary arteries in 16 eyes of 11 patients with the ocular ischemic syndrome. Understanding the hemodynamic characteristics of the retrobulbar circulation may elucidate the natural history and pathophysiology of the ocular ischemic syndrome and perhaps form the basis for rational treatment of this condition. METHODS: Color Doppler imaging, a procedure that permits rapid noninvasive imaging of the ophthalmic, central retinal, and posterior ciliary arteries, was used to quantitate peak systolic blood flow velocities and vascular resistance (pulsatility index) within these vessels in study group eyes and in an age-matched control population. RESULTS: We demonstrated markedly reduced ocular ischemic syndrome central retinal and posterior ciliary artery peak systolic velocities compared with control group eyes. Central retinal and posterior ciliary artery vascular resistance (pulsatility index) was greater in ocular ischemic eyes versus control group eyes. Reversal of ophthalmic artery blood flow was detected in 12 of 16 ocular ischemic syndrome eyes. Study group eyes with poor vision had no detectable posterior ciliary arterial blood flow. CONCLUSION: Color Doppler imaging quantitates hemodynamic characteristics of the retrobulbar circulation in the ocular ischemic syndrome. There is markedly reduced peak systolic velocity and increased vascular resistance in ocular end arteries such as the central retinal and posterior ciliary arteries. Ophthalmic artery reversal of flow seems to represent collateral blood flow to lower resistance vascular beds. Posterior ciliary artery hypoperfusion may correlate with poor vision in the ocular ischemic syndrome.
Asunto(s)
Ojo/irrigación sanguínea , Ojo/diagnóstico por imagen , Isquemia/diagnóstico por imagen , Isquemia/fisiopatología , Anciano , Anciano de 80 o más Años , Velocidad del Flujo Sanguíneo , Cuerpo Ciliar/diagnóstico por imagen , Ojo/fisiopatología , Femenino , Fondo de Ojo , Humanos , Masculino , Persona de Mediana Edad , Arteria Oftálmica/diagnóstico por imagen , Arteria Retiniana/diagnóstico por imagen , Síndrome , UltrasonografíaRESUMEN
BACKGROUND: Pituitary adenomas that arise from the gonadotroph cells are being recognized with increasing frequency in men, but they are still rarely recognized in women. This rarity could be the result of an actual difference in occurrence or of greater difficulty in recognition. The tumors are usually recognized in men more than 50 years old, but elevated serum gonadotropin levels in women of that age could be produced by normal gonadotroph cells. METHODS: Because the stimulation of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and the beta subunit of LH (LH beta) by thyrotropin-releasing hormone (TRH) is a characteristic of gonadotroph adenomas in men, we administered TRH to 16 women with apparently nonsecreting pituitary macroadenomas and measured serum FSH, LH, LH beta, and the glycoprotein hormone alpha subunit every 15 minutes for 90 minutes before and 90 minutes after. The results were compared with the responses in 16 healthy women matched for age and in 10 women with macroadenomas secreting prolactin, growth hormone, or corticotropin. The tumors from 12 of the women with nonsecreting adenomas were cultured, and the secretion of FSH, LH, and LH beta in culture was determined. RESULTS: Eleven of the 16 women with apparently nonsecreting adenomas had significant increases in serum LH beta in response to TRH, 3 had FSH responses, and 4 had LH responses. None of the 16 healthy women and none of the 10 women with secreting macroadenomas had LH beta, FSH, or LH responses to TRH. Ten of the 12 adenomas that were cultured secreted readily detectable amounts of FSH, LH, and LH beta, and their secretion in vitro correlated with the patients' responses to TRH in vivo. CONCLUSIONS: Most apparently nonsecreting pituitary macroadenomas in women arise from gonadotroph cells. The majority of these can be recognized, even in postmenopausal women, by the serum LH beta responses to TRH, and some can be recognized by the responses of serum FSH and LH.
Asunto(s)
Adenoma/diagnóstico , Neoplasias Hipofisarias/diagnóstico , Adenoma/metabolismo , Adulto , Anciano , Femenino , Hormona Folículo Estimulante/metabolismo , Humanos , Hormona Luteinizante/metabolismo , Menopausia , Persona de Mediana Edad , Adenohipófisis , Neoplasias Hipofisarias/metabolismo , Factores Sexuales , Hormona Liberadora de Tirotropina , Células Tumorales CultivadasRESUMEN
We observed seven patients with the unusual combination of a central retinal vein obstruction in conjunction with a simultaneous branch retinal artery obstruction. The patients presented with sectoral retinal whitening, as well as diffuse peripapillary and superficial retinal hemorrhages. In five of the seven patients, the retinal hemorrhages appeared most florid in the territory of the obstructed arteriole, resulting initially in the consideration that these cases represented a combined branch retinal artery and branch retinal vein obstruction. In all cases, however, the presence of dilated, tortuous veins with diffuse retinal hemorrhages, in addition to generalized delay in arteriovenous transit on fluorescein angiography, localized the venous blockage to the central retinal vein. No intra-arterial retinal emboli were visualized. Initially, five of the seven patients suffered markedly diminished visual function; although visual acuity returned to near normal in all but two patients. In the two patients with non-resolving, markedly impaired visual acuity, neovascularization of the iris complicated the clinical course. Both of these patients were treated with panretinal photocoagulation, with resolution of the iris neovascularization. These seven patients highlight another variation of combined arterial and venous retinal vascular disease.
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Oclusión de la Arteria Retiniana/complicaciones , Oclusión de la Vena Retiniana/complicaciones , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Angiografía con Fluoresceína , Fondo de Ojo , Humanos , Iris/irrigación sanguínea , Iris/cirugía , Fotocoagulación , Masculino , Persona de Mediana Edad , Neovascularización Patológica/patología , Oclusión de la Arteria Retiniana/patología , Hemorragia Retiniana/etiología , Oclusión de la Vena Retiniana/patología , Agudeza VisualRESUMEN
Between October, 1978 and August, 1986, 35 patients with thyroid ophthalmopathy were treated with radiotherapy. Twenty-eight patients had treatment with corticosteroids prior to radiotherapy and either progressed on steroids or relapsed during tapering. Seven patients with contraindications to steroids were treated primarily with radiotherapy. After radiotherapy, 25 patients (71%) did not require any further steroids or orbital decompression and ten (29%) failed. Patients who required steroids or decompression for active disease after radiotherapy were considered treatment failures. A total of 14 (40%) patients required eye muscle or lid surgery for correction of stable soft tissue defects after radiotherapy, more commonly in patients treated with radiotherapy after steroids or decompression than those irradiated primarily; the median time between radiotherapy and surgery was 8 months (range 1-48). Various factors were examined for prognostic significance in predicting radiotherapy failure. Review of the interval between onset of eye disease and radiotherapy demonstrated that six of ten (60%) failures versus only five of 25 (20%) successful treatments received radiotherapy within 6 months of onset of eye disease. No relation between outcome and sex, age or hyperthyroid versus euthyroid Graves' disease was apparent. Radiotherapy has been used for patients with thyroid ophthalmopathy who failed steroids, decompression, or had steroid contraindications. Morbidity of radiotherapy was minimal and most patients were spared the morbidity of continued steroid therapy.
Asunto(s)
Oftalmopatías/radioterapia , Enfermedad de Graves/complicaciones , Tiroiditis Autoinmune/complicaciones , Adulto , Anciano , Anciano de 80 o más Años , Oftalmopatías/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , PronósticoRESUMEN
Facial nerve paresis is rarely seen in dural cavernous sinus arteriovenous malformations or carotid-cavernous sinus fistulae. A patient with an otherwise typical presentation of a spontaneous carotid-cavernous sinus malformation was found to have ipsilateral infranuclear facial nerve paresis. Angiography revealed a dural arteriovenous malformation with early petrosal sinus filling. Possible mechanisms for the paresis include compression of the facial nerve by increased venous pressure and "stealing" of the arterial supply by the malformation.