1 - Transient Vision loss 2

bilateral vision loss/blur episodes with sudden onset that last 2-3min

+/- diplopia if brainstem involved

+/- dizziness

+/- HA

+/- drop spells

+/- ataxia

+/- bilateral numbness of face, mouth

+/- nystagmus

+/- Wallenberg's or Foville's

What are some symptoms of vertebral-basilar insufficiency?

same as amaurosis fugax from carotid artery disease

What factors of systemic health and vital statistics contribute to vertebral-basilar insufficiency?

normal

How does vertebral-basilar insufficiency appear upon examination?

atherosclerosis of the vertebral-basilar artery = lack of blood supply to the post cerebral artery = occipital cortex infarcts

What is the etiology of vertebral-basilar insufficiency?

thrombo-embolic process = something is blocking blood flow

hemodynamic process = blood from 2 ICAs and 2 vertebrals cannot access brain = anoxia

What are the 2 theories about TIAs in the posterior circulation via vertebral-basilar insufficiency?

CBC
2hr post-prandial BG
lipid profile
electrolytes
CT scan

What lab / non-invasive studies should we do in vertebral-basilar insufficiency?

aortich arch angiography

NOTE: invasive studies are NOT recommended

What invasive studies should we do in vertebral-basilar insufficiency?

medical tx (same as for carotid artery disease) = aspirin, persantine, coumadin

NOTE: surgical tx not recommended bc atherosclerosis is diffuse throughout vascular system

What are the 2 tx options for vertebral-basilar insufficiency?

no = VBI has less risk of stroke compared to carotid disease

Does vertebral-basilar insufficiency have the same risk of stroke as carotid artery disease?

PCP or neurologist

Who should we refer someone with vertebral-basilar insufficiency to for tx?

disseminated disease of the aged = beginning with low grade fever, anorexia, malaise, weight loss = 1-2wks later severe unilateral or bilateral fronto-temporal or occipital pains, scalp tenderness, bilateral visual loss

What occurs in GCA?

granulomatous inflammation = plasma cells, lymphocytes, giant cells infiltrate the temporal artery = acellular thickening of the tunica intima = destroys the inner elastic membrane and occludes the artery lumen = blocks off post ciliary arteries = infarcted ONH

What is the pathophysiology behind GCA?

painful, sudden, monocular vision loss that may be transient (2-3min) or permanent NLP

+/- scalp tenderness

+/- jaw claudication

pale, swollen ONH = AAION

+/- hemes at the disc

+/- CN III palsy with pupil involvement

What are some S/S of GCA?

NLP

amaurotic pupil and APD

altitudinal hemianopia if not NLP

AAION = disc edema, APD, vision loss, alitudinal scotoma

What main things will we see during our exam in GCA?

polymyalgia rheumatica = RA that affects axial skeleton = pain in shoulders and hips

malaise

weight loss

fever

What do pt's with GCA often have in their Hx?

age 65+

Caucasians

females

What demographics do we typically see GCA in?

bloodwork with Westergen ESR, CRP STAT

temporal artery biopsy to look for mast cells, giant cells and loss of inner elastic lamina

What tests do we run for pt's with GCA?

males = age / 2

females = (age + 10) / 2

Recall: what is the normal max value of ESR?

oral steroids STAT = 40-60mg of prednisone qday x 1 year

Actemra (tocilizumab) = IV administration of IL-6 blocker weekly with steroid taper

What is the tx for GCA?

chemical diabetes
osteoporosis
depression
psychosis

Recall: what are some side effects of oral steroids?

pale due to optic atrophy (C)

Acutely, a nerve in GCA and AAION will appear as swollen +/- hemes (B). How does it appear long term?

prevent involvement of the fellow eye in the coming hours or days = occurs in 25% of pt's

While we cannot recover vision in the affected eye, why do we tx GCA?

NORMAL

How does migraine typically occur on physical exam?

classic = pt has a visual prodrome, then the HA

common = HA and nausea but not prodrome

complicated = focal neuro deficit with the HA

What are 3 presentations of migraine?

bilateral flashing lights or teichopsias/jagged saw-tooth lines (positive scotoma) that starts in periphery then expands

then a negative scotoma (homo hemianopsia)

Describe the visual prodrome that pt's have during migraine.

20min

How long does the migraine prodrome occur for?

abortive migraine meds like ergotamine

pregnancy or menopause can make the pain go away

pt may forget HA if they are distracted by the photopsias

elderly pt

What are 4 situations in which a pt may have a prodrome without a HA?

< age 40

female >>> male

FHx of migraines

type A perfectionist

stress and major life events

Which demographics are most often affected by migraine?

< age 20 (esp onset of menarche) = classic migraine

age 20-40 = common migraine

age 40+ = simple HA

How does migraine presentation differ based on age?

homonymous hemianopsia opposite to the side of the HA

What VF defect is present DURING a migraine attack?

vasoconstriction = ischemia along the post cerebral arteries

What is the pathophysiology of migraine?

1/2 of the visual cortex is devoted to macula = 1/2 of the photopsia episode time (10min) occurs in central vision

How does the pattern of migraine prodrome correlated to occipital lobe anatomy?

ischemic process is traveling across remaining 50% of visual cortex

Why does the migraine prodrome appear to speed up in the periphery?

abortive tx (oral, injection, nasal sprays) = prevent migraine or stop it once it starts

prophylactic tx to prevent frequent migraines

surgery = peripheral nerve decompression for pt's who can identify a specific locus

What is the main tx for migraine?

triptans = target serotonin = sumatriptan, zolmitriptan, rizatriptan

ergotamine tartrate (cafergot)

anti-nausea medications = prochlorperazine, promethazine

weak narcotics for pain = butalbitol, acetaminophen with codein

OTC = aspirin, acetaminophen, ibuprofen; with caffeine

CGRP antagonists = blocks CGRP (often high in migraineur blood) = less vasodilation

5HT agonists = increase serotonin affinity without vasoconstriction (safe in cardio dz)

What are some examples of abortive tx for migraine?

beta-blockers = propranolol, timolol

Ca-channel blockers = verapamil

anti-depressants = amitriptyline

anti-seizure meds = gabapentin, topiramate, valproic acid

antihistamines and anti-allergy drugs = diphenhydramine

botox

CGRP anatognists

What are some examples of prophylactic tx for migraine?