Challenges and Opportunities in Diagnosing CRAO/BRAO

Hello and welcome to The Neurology Minute. This is Dan Akerman and I have just had the absolute privilege of learning from Valerie Beos and Nancy Newman from Emory University. And we've been talking all about CRAO Central Retinal Artillery Occlusion and Branch Rational Artillery Occlusion on the full-length podcast. First of all, I would strongly encourage you to check out the full-length podcast because truly there is some crucial information for anyone who has care of stroke patients in that podcast. But just for the moment, tell us Nancy and Valerie for a patient who has a stroke alert for the eye, who has a stroke alert related to sudden painless loss of vision. What should we be doing differently compared to our usual stroke alert process? When I first started in this business, I was told as a neurologist, the most important question was where. And so I have made a mantra in my entire career of where? Then what? Then now what? So you never put the treatment until you know where? In this case, you have to be absolutely sure what it is that caused that vision loss in one eye. So you know it has to be on that eyeball or that optic nerve, but you are going to need help from an eye care specialist or from a non-midriotic fundus camera equipped with OCT to help you know where the pathology is. Once you figured out that indeed it is a central retinal artery occlusion, meaning occlusion of the blood supply to the inner retina of that eye. You then want to proceed to your what's. Your what's are, what's causing that? Is there an embolus there to suggest that it's an artery artery embolus? Is there other findings that make you worried about giant cell arteritis since you have to obviously in the right age group test for that? And then only then, once you have gone through the where and the what's, can you go on to the now what, which is the question of whether you would give thrombolysis if you are within the window of time presumably around 4.5 hours. Just highlighting the very important collaboration between emergency department eye care providers and stroke neurologist. Whether emergency department is on site, ophthalmology can be remote, stroke neurology can be remote if it's a needy using the telestroke network. The patient waxing complains of occured vision loss, the educated triage of staff, identifies it as a possible eye stroke alert. Immediately brings the patient to the non-mediatic ocular fundoscarma, ideally equipped with optical coherence tomography located in the ED. The picture is taken within two or three minutes. It takes about one minute to get the picture of both eyes. No need for pharmacologic dilation of the pupil. We don't need an eye exam. At the same time, the page the ophthalmologist on call who remotely confirms the diagnosis of occured CIO. I do that on my phone wherever I am and tells them it's a CIO. We are within whatever amount of time since onset of vision loss trigger the eye stroke protocols. Trophy neurology has been alerted. They are on their way. They arrive. They evaluate the patient for potential indication and contraindication for intravenous thrombolysis or intra-artial thrombolysis if it is what the people like to do at their respective institution. Paying particular attention to safety, the treatment either intravenous alteplase or tenecteplase is administered off-label after a solid discussion with the patient regarding benefits of potential recovery, especially in patients who only have one eye that's seeing and risk of complications, especially hemorrhagic complications. Once this is done, the ophthalmologist don't even have to come. The patient is scared for by the stroke team similar to any patient who receives thrombolysis for cerebral ischemia. This is not the future. This is happening routinely at many institutions and by implementing more cameras, we will be able to offer this type of treatment or any other acute treatment to these patients. Thank you so much for that. And again, I'd encourage everyone to take this advice to heart, check out the full-length podcast and take this opportunity to update our understanding of CRAO and BRAO both in the hyperacute setting in the workup with regard to etiology and ultimately in how we equip our emergency departments to be able to really take care of these patients appropriately and get them the treatment they need. Thank you so much again Nancy Ballard for joining us today.