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  • Thrombolysis for Central Retinal Artery Occlusion

    By Lynda Seminara
    Selected By: Prem S. Subramanian, MD, PhD
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    Journal Highlights

    Journal of Neuro-Ophthalmology
    2020;40:333-345

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    Acute nonarteritic central retinal artery occlusion (CRAO) is an ophthalmo­logic and neurologic emergency with poor visual prognosis and no proven therapies. Although retinal infarction is regarded as comparable to brain in­farction, and thrombolysis is a standard therapy for brain acute ischemic stroke syndromes, reperfusion therapies for acute CRAO are still controversial. Dumitrascu et al. reviewed published evidence for IV and intra-arterial (IA) tissue plasminogen activator (tPA) in CRAO management. They found that patients with nonarteritic CRAO often did not present within the currently accepted time window for IV or IA thrombolysis, leading to poor visual outcomes.

    For this study, the researchers in­cluded all reports since 1960 found in three online databases of acute IV or IA therapy with alteplase in patients with nonarteritic CRAO. Use of IV throm­bolysis was reported in seven articles, involving 111 patients. Of these, 54% received IV alteplase within 4.5 hours of symptom onset.

    Most patients were treated at the dose currently recommended for acute cerebral ischemia (0.9 mg/kg), with IV heparin administered concomitantly at 1,200 units per hour over five days. No hemorrhagic complications were noted when the current cerebral ischemic protocol was followed; however, symp­tomatic intracranial hemorrhage (ICH) occurred in one patient for whom heparin was initiated immediately after alteplase administration. Two patients had asymptomatic ICH, and another had hematuria.

    Use of IA alteplase was reported in six studies, with only 13.4% of 134 pa­tients treated within the first six hours of visual loss. Alteplase was infused continuously or in aliquots, with the dosage ranging from 8.8 mg to 80 mg. Most of these studies involved heparin administration in addition to tPA. Ad­verse events for IA thrombolysis were minimal and included two transient ischemic attacks, two cases of ICH, one hypertensive crisis, two groin hemato­mas, and 12 minor side effects that may have been unrelated to tPA treatment.

    The authors emphasize that eye stroke encounters must involve expert ophthalmologic evaluation to deter­mine the correct diagnosis and to look for ocular signs that could guide tPA administration or IA management. They also recommend that future work include investigating the effect of thrombolysis on visual outcomes, as the currently unfavorable view of the outcomes of CRAO treatment may be related to delayed time to intervention.

    The original article can be found here.