Amaurosis Fugax Research Articles

Intraplaque hemorrhage in carotid atherosclerotic plaques is associated with a local increase in inflammatory cytokines

Abstract Background One of the main features of vulnerability in atherosclerotic carotid plaques is intraplaque hemorrhage (IPH), which is related to a higher incidence of cerebrovascular events in patients with carotid artery disease. Additionally, inflammation plays a pivotal role in the progression of atherosclerotic disease. Purpose We aimed to determine plasma and tissue levels of inflammatory cytokines in patients with carotid artery disease hypothesizing that plaques with IPH are characterized by the presence of a more inflamed environment. Methods We retrospectively enrolled 104 consecutive patients undergoing carotid endarterectomy (CEA) with symptomatic (ischemic stroke, TIA, amaurosis fugax) or asymptomatic ipsilateral carotid artery disease. Plasma and carotid plaque specimens were collected at CEA. The tissue samples were stained with H&E to identify IPH and classified as specimens with and without IPH. Frozen homogenates of both plasma and tissue were analyzed using a customized 10-plex Luminex assay to determine the levels of inflammatory cytokines such as MCP-1/CCL2, IL-8/CXCL8, IFN-gamma, IL-10, IL-1beta/IL-1F2, IL-6, PDGF-AA, PDGF-AB/BB, TNF-alpha, and VEGF. Results IPH was identified in 53 patients (51.0 %). Cytokine levels in plasma and tissue from patients with and without IPH are reported in Table 1. In the univariate logistic regression MCP-1/CCL2, IL-8/CXCL8, IFN-gamma, IL-10, IL6, PDGF-AA, and PDGF-AB/BB were associated with IPH (Table 2). In the multivariate logistic regression, IL-6 was an independent predictor of IPH (HR 1.026 [95% CI 1.005-1.047]; p=0.014) after adjusting for cardiovascular risk factors such as age, BMI, sex, hypertension, diabetes mellitus, hyperlipidemia, ipsilateral carotid stenosis %. Conclusions Carotid plaques with IPH have an elevated inflammatory burden, potentially impacting adverse outcomes in this patient cohort. The local inflammatory cytokines in carotid plaques with IPH might serve as biomarkers and therapeutic targets in patients with carotid artery disease.

Plasma cytokines are associated with major adverse cardiovascular events in follow-up of patients undergoing carotid endarterectomy

Abstract Background Patients with carotid artery disease undergoing carotid endarterectomy (CEA) have a high risk of experiencing Major Adverse Cardiovascular Events (MACE) after surgery. The occurrence of MACE in CEA-treated patients is not predicted by common cardiovascular (CV) risk factors. Purpose We aimed to identify the association between plasma and plaque inflammatory cytokines and the incidence of MACE in the follow-up after CEA. We hypothesized that MACE is related to a higher level of circulating inflammatory cytokines at the time of surgery. Methods We prospectively enrolled patients with carotid artery disease undergoing CEA. Plasma and carotid plaques were collected during the surgery. Inflammatory cytokines (MCP-1/CCL2, IL-8/CXCL8, IFN-gamma, IL-10, IL-1beta/IL-1F2, IL-6, PDGF-AA, PDGF-AB/BB, TNF-alpha, VEGF) were measured in plasma and tissue homogenates using a customized 10-plex Luminex assay. Baseline demographics and clinical data for all the patients were extracted from electronic health records. MACE after CEA was defined as a composite measure of nonfatal cardiac events such as myocardial infarction with or without revascularization, cerebrovascular events (ischemic stroke, TIA, and amaurosis fugax), and all-cause mortality. Results Of 107 patients who underwent CEA with a median age of 73 (67-78) years, 57 (53.2%) experienced MACE during a median follow-up of 5.2 [2.2-9.3] years: 23 (40.3%) cardiac events, 9 (15.7%) CVA, and 25 (43.8%) all-cause mortality. Plaque cytokines levels did not differ between the groups with and without MACE in the follow-up after CEA. Instead, plasma cytokines were associated with MACE in the follow-up after CEA, as summarized in Figure 1. In the logistic regression analysis, plasma levels of MCP-1/CCL2, IFN-gamma, and TNF-alpha were independent predictors of MACE in follow-up post-CEA in univariate and multivariable models adjusted for CV risk factors such as age, BMI, systolic and diastolic blood pressure, low-density lipoprotein, high-density lipoprotein, and glucose level: MCP1/CCL2 (HR 1.009 [1.002-1.015]; p=0.007), IFN-gamma (HR 1.368 [1.014-1.845]; p=0.040), and TNF-alpha (HR 1.121 [1.022-1.228]; p=0.015) (Table 1). Conclusions Plasma levels of CCL2, IFN-gamma, and TNF-alpha are associated with the high incidence of MACE in the follow-up after CEA, indicating that these are potential biomarkers of MACE in this patient population and potential therapeutic targets in patients' progression of systemic atherosclerosis.Plasma cytokines and MACE after CEACytokines logistic regression analysis

Recurrent Ischemic Stroke/Transient Ischemic Attack After Patent Foramen Ovale Closure: A cohort study.

Patent foramen ovale (PFO) has been associated with ischemic stroke and transient ischemic attack (TIA). Guidelines recommend PFO closure for stroke prevention in selected patients, but the risk of recurrent stroke remains high compared to the background population. We aimed to evaluate the causes of recurrent stroke/TIA and post-interventional complications in patients after PFO closure. Patients from the Central Denmark Region who underwent PFO closure at Aarhus University Hospital between November 5, 2018, and May 12, 2023, following an ischemic stroke, TIA, amaurosis fugax or retinal emboli were included. Data on patient demographics, risk factors, procedural details, post-interventional complications and recurrent stroke/TIA were collected from electronic medical records. PFO closure was performed in 310 patients (median age: 49 years). During a median follow-up of 2.6 years (interquartile range: 1.5-3.6, 814 total patient years), recurrent stroke/TIA was observed in 8 patients (2.6%) or 0.98 recurrent strokes per 100 patient years. Recurrent stroke/TIA was more frequent in patients with hypertension (50.0% vs 16.9%, p = 0.039). Recurrent stroke/TIA was related to thrombophilia or haematological conditions entailing hypercoagulability in 62.5% of patients. New-onset atrial fibrillation was observed in 9.4% of patients within 45 days after the procedure. None of these patients subsequently developed an ischemic event. Other adverse outcomes were uncommon. Rates of recurrent ischaemic stroke/TIA after PFO closure were comparable to findings in previous trials. Pre-existing vascular risk factors (hypertension), and a hypercoagulable state were associated with recurrent ischaemic stroke/TIA.

Prolonged and repeated microemboli detection in acute ischemic stroke – The Norwegian Microemboli in Acute Stroke Study (NOR-MASS)

ObjectivesCerebral microemboli can be detected by transcranial Doppler monitoring (TCDM) and may elucidate stroke etiology, the effect of preventive therapy, and the risk of stroke recurrence. Microemboli detection is usually performed for up to 60 minutes, but due to temporal variability, microembolization may be missed if the monitoring time is too short. We aimed to assess the time course of microembolization in acute ischemic stroke and explore the utility of prolonged and repeated microemboli detection. Materials and MethodsPatients with suspected ischemic stroke and symptom onset within 24 hours were examined with bilateral, stationary TCDM for one hour followed by unilateral, ambulatory TCDM for two hours. Unilateral TCDM was repeated for the following two days and after three months. ResultsWe included 47 patients, of which 41 had ischemic stroke, five had transient ischemic attack, and one had amaurosis fugax. Microemboli were detected in 60 % of patients. The occurrence was highest within 24 hours after onset and significantly lower at three months. Prolonged and repeated microemboli detection yielded only one additional microemboli-positive patient. Hence, patients who initially were microemboli negative tended to remain negative. We could not demonstrate an association between microemboli occurrence and clinical outcome or stroke recurrence. ConclusionsMicroembolic signals are frequent within 24 hours after ischemic stroke onset, but prolonged and repeated microemboli detection did not increase the yield of MES positive patients. Clinical Trial Registration-URLhttp://www.clinicaltrials.gov. Unique identifier: NCT03543319.

Determinants of prehospital and in-hospital delay in patients with symptomatic carotid stenosis and their influence on the outcome after elective carotid endarterectomy

BackgroundThis study analyses the determinants of prehospital (index event to admission) and in-hospital delay (admission to carotid endarterectomy (CEA)). In addition, the analysis addresses the association between prehospital or in-hospital...

Amaurosis fugax due to internal carotid artery dissection during carotid chemodectoma resection

The article presents a clinical observation of carotid chemodectoma resection, which was complicated by amaurosis fugax and left-sided hemianopia due to dissection of internal carotid artery during surgery. The clinical symptoms manifested on 3rd day after surgery and totally resolved after internal carotid artery reconstruction also on the 3rd day. Treatment of carotid chemodectoma requires a multidisciplinary approach involving a neurosurgeon who has the skills of reconstructive operations on brachiocephalic arteries, a radiologist, and an endovascular surgeon. Determining the tactics and stages of treatment requires an individual approach, depending on the size of the tumor, the degree of invasion into the carotid arteries and cranial nerves. В данной статье приводится описание клинического наблюдения удаления каротидной хемодектомы, ослож- нившейся развитием преходящего амавроза со стороны операции и левосторонней гемианопсии. Данное осложнение стало следствием диссекции внутренней сонной артерии (ВСА) после удаления опухоли с мани- фестацией клинических симптомов на 3-и сутки после операции. У пациента острота зрения восстановилась на 1-е сутки после операции до 1,0, гемианопсия регрессировала на 3-и сутки после реконструкции ВСА. Лечение каротидных хемодектом требует полидисциплинарного подхода с участием нейрохирурга, владею- щего навыками реконструктивных операций на брахиоцефальных артериях, радиолога, эндоваскулярного хирурга. Определение тактики и этапности лечения требует индивидуального подхода в зависимости от размеров опухоли, степени инвазии в сонные артерии и черепные нервы.

Comparison of vascular risk profile and clinical outcomes among patients with central (branch) retinal artery occlusion versus amaurosis fugax

BackgroundRetinal artery occlusions lead to sudden, painless vision loss, affecting millions globally. Despite their significance, treatment strategies remain unestablished, contrasting with acute ischemic stroke (AIS), where IVT has proven efficacy. Similar to AIS, retinal artery occlusions demand urgent evaluation and treatment, reflecting the principle "time is retina". Even for patients with transient monocular vision loss, also known as amaurosis fugax (AF), pertinent guidelines meanwhile recommend immediate emergency assessment in a specialized facility. However, data on the clinical benefit and comparability with persistent occlusions are missing. This study aimed to compare the results of a comprehensive stroke-workup among patients with persistent retinal artery occlusions (RAO), including both central retinal (CRAO) and branch retinal artery occlusion (BRAO) and those with AF.MethodsConducted at the University Hospital Giessen, Germany, this exploratory cross-sectional study enrolled patients with transient or permanent unilateral vision loss of non-arteritic origin. The primary outcome were differences between the two groups RAO and AF with regard to cardiovascular risk profiles and comorbidities, vascular and pharmacological interventions and clinical neurological and ophthalmological outcomes. Secondary outcome was a sub-group analysis of patients receiving IVT.ResultsOut of 166 patients assessed, 76 with RAO and 40 with AF met the inclusion criteria. Both groups exhibited comparable age, gender distribution, and cardiovascular risk profiles. Notably, RAO patients did not show significantly more severe vascular comorbidities than AF patients. However, AF patients received vascular interventions more frequently. Pharmacological intervention rates were similar across groups. RAO patients had slightly worse neurological outcomes, and IVT did not yield favorable ophthalmological outcomes within any observed patients.ConclusionThe study found similar vascular burden and risk factors in patients with RAO and AF, with implications for clinical workflows. IVT for RAO may only be effective in very early treatment windows. This emphasizes the need for public awareness and collaborative protocols between ophthalmologists and neurologists to improve outcomes.

Giant Cell Arteritis.

Giant cell arteritis (GCA) is the most common primary vasculitis and is associated with potential bilateral blindness. Neither clinical nor laboratory evidence is simple and unequivocal for this disease, which usually requires rapid and reliable diagnosis and therapy. The ophthalmologist should consider GCA with the following ocular symptoms: visual loss or visual field defects, transient visual disturbances (amaurosis fugax), diplopia, eye pain, or new onset head or jaw claudication. An immediate ophthalmological examination with slit lamp, ophthalmoscopy, and visual field, as well as color duplex ultrasound of the temporal artery should be performed. If there is sufficient clinical suspicion of GCA, corticosteroid therapy should be initiated immediately, with prompt referral to a rheumatologist/internist and, if necessary, temporal artery biopsy should be arranged. Numerous developments in modern imaging with colour duplex ultrasonography, MRI, and PET-CT have the potential to compete with the classical, well-established biopsy of a temporal artery. Early determination of ESR and CRP may support RZA diagnosis. Therapeutically, steroid-sparing immunosuppression with IL-6 blockade or methotrexate can be considered. These developments have led to a revision of both the classification criteria and the diagnostic and therapeutic recommendations of the American College of Rheumatologists and the European League against Rheumatism, which are summarised here for ophthalmology.

Light-induced Amaurosis Fugax (P10-5.020)

Light-induced Amaurosis Fugax (P10-5.020)

Transient Monocular Visual Loss (Amaurosis Fugax): How Does Age Impact Diagnosis?

Transient monocular visual loss (TMVL), also known as transient monocular blindness or amaurosis fugax ("fleeting blindness"), is a temporary loss of vision often due to ischemia to the retina. While acute TMVL should be considered an emergency that further requires exhaustive investigation, there are some cases in which TMVL arises secondary to benign causes. Age has a major impact in the diagnosis of ischemia and although the differential diagnosis of TMVL can be broad, timely and appropriate history, examination, diagnostic testing, and treatment can be vision- or life-saving. We review the causes of TMVL and the impact of age on the differential diagnoses and management.

Bailout Distal Internal Carotid Artery Stenting after Carotid Endarterectomy: Indications, Technique, and Outcomes

Distal internal carotid artery (ICA) stenting may be employed as a bailout maneuver when an inadequate end point or clamp injury is encountered at the time of carotid endarterectomy (CEA) in a surgically inaccessible region of the distal ICA. We sought to characterize the indications, technique, and outcomes for this infrequently encountered clinical scenario. We performed a retrospective review of all patients who underwent distal ICA stenting at the time of CEA at our institution between September 2008 and July 2022. Procedural details and postoperative follow-up were reviewed for each patient. Six patients were identified during the study period. All were male with an age range of 63 to 82years. Five underwent carotid revascularization for asymptomatic carotid artery stenosis, and one patient was treated for amaurosis fugax. Three patients were on dual antiplatelet therapy preoperatively, whereas 2 were on aspirin monotherapy, and one was on aspirin and low-dose rivaroxaban. Five patients underwent CEA with patch angioplasty, and one underwent eversion CEA. The indication for stenting was distal ICA dissection due to clamp or shunt injury in 2 patients and an inadequate distal ICA end point in 4 patients. In all cases, access for stenting was obtained under direct visualization within the common carotid artery, and a standard carotid stent was deployed with its proximal aspect landing within the endarterectomized site. Embolic protection was typically achieved via proximal common carotid artery and external carotid artery clamping for flow arrest with aspiration of debris before restoration of antegrade flow. There was 100% technical success. Postoperatively, 2 patients were found to have a cranial nerve injury, likely occurring due to the need for high ICA exposure. Median length of stay was 2days (range 1-7days) with no instances of perioperative stroke or myocardial infarction. All patients were discharged on dual antiplatelet therapy with no further occurrence of stroke, carotid restenosis, or reintervention through a median follow-up of 17months. Distal ICA stenting is a useful adjunct in the setting of CEA complicated by inadequate end point or vessel dissection in a surgically inaccessible region of the ICA and can minimize the need for high-risk extensive distal dissection of the ICA in this situation.

Thrombosis Tendency After Splenectomy in a Danish Family With Hemoglobin Volga, and a Literature Review

Hemoglobin (Hb) Volga is a rare, unstable β-chain hemoglobin variant (β27 Ala→Asp), causing chronic hemolytic anemia. This study presents two members of a Danish family, splenectomized due to Hb Volga at and with multiple thrombotic events. The proband was diagnosed with Hb Volga 9 years old and splenectomy was performed as a part of treatment. Throughout his life, he experienced multiple superficial thrombophlebitis, two episodes of distal deep venous thrombosis (DVT) on lower extremities (age 32 and 33) and a transient ischemic attack (TIA) presented as amaurosis fugax (age 51). Thrombophilia investigation was normal. The proband’s son was diagnosed with Hb Volga and underwent splenectomy at the age of 6. Despite anticoagulation therapy, he suffered from multiple venous thromboembolic events in his youth and died of chronic pulmonary embolism (PE)/pulmonary hypertension combined with infection. Given the observed propensity for multiple thromboses in these two patients, a literature review was conducted investigating reported occurrence of thrombotic events in individuals with Hb Volga. Currently 25 cases of Hb Volga are reported worldwide. The clinical symptoms primarily described are related to hemolytic anemia. Splenectomy is reported in 15 patients. Thromboses have previously been reported in only three patients who were also splenectomized. These cases involved DVT and PE, myocardial infarction, and an unspecified thrombotic event. The proband represents the first reported Hb Volga case with both venous and arterial thrombotic disorders. The exact mechanism underlying thrombotic tendency in patients with Hb Volga remains unknown, but it is probably associated with splenectomy.

Full sample analysis of cerebral venous sinus thrombosis in ophthalmology inpatients

We hope that by analyzing the clinical features of cerebral venous sinus thrombosis (CVST), we can help ophthalmologists reduce misdiagnosis or delayed diagnosis. We evaluated 47 patients with CVST in terms of clinical manifestations. All cases were analyzed in terms of risk factors, clinical symptoms, ophthalmic examination, imaging examination and lumbar puncture. The body mass indices (BMIs) of 41 patients (87.2%; 95% CI, 77.7-96.8%) were≥24, which is overweight by Chinese standards. There were 22 patients (46.8%; 95% CI, 32.5-61.1%) with BMIs≥28, who were considered obese. Thirteen were hypertensive (27.7%; 95% CI, 14.9-40.5%). The initial symptoms included blurred vision (23, 48.9%; 95% CI, 34.6-63.2%), amaurosis fugax (13, 27.7%; 95% CI, 14.9-40.5%), headache (11 patients, 23.4%; 95% CI, 11.3-35.5%), dizziness (3, 6.4%; 95% CI, -0.6-13.4%), and bilateral diplopia (3, 6.4%; 95% CI, -0.6-13.4%). There were 9 patients (9, 19.2%; 95% CI, 7.9-30.4%) with blindness, 23 patients (48.9%; 95% CI, 34.6-63.2%) with pupillary abnormalities, and 40 patients (85.1%; 95% CI, 74.9-95.2%) with papilledema. Forty-three of the 45 patients who successfully underwent a routine lumbar puncture showed high intracranial pressure (91.7%; 95.6% CI, 89.6-101.6%). Finally, two cases are reported in greater detail for illustrative purposes. The main reasons interfering with the diagnosis of CVST might be its nonspecific ocular symptoms and the physicians' clinical thought process being limited to the scope of common ophthalmological diseases.

RDH12-associated retinal degeneration caused by a homozygous pathogenic variant of 146C>T and literature review.

To describe the clinical, electrophysiological, and genetic features of an unusual case with an RDH12 homozygous pathogenic variant and reviewed the characteristics of the patients reported with the same variant. The patient underwent a complete ophthalmologic examination including best-corrected visual acuity, anterior segment and dilated fundus, visual field, spectral-domain optical coherence tomography (OCT) and electroretinogram (ERG). The retinal disease panel genes were sequenced through chip capture high-throughput sequencing and Sanger sequencing was used to confirm the result. Then we reviewed the characteristics of the patients reported with the same variant. A 30-year male presented with severe early retinal degeneration who complained night blindness, decreased visual acuity, vitreous floaters and amaurosis fugax. The best corrected vision was 0.04 OD and 0.12 OS, respectively. The fundus photo and OCT showed bilateral macular atrophy but larger areas of macular atrophy in the left eye. Autofluorescence shows bilateral symmetrical hypo-autofluorescence. ERG revealed that the amplitudes of a- and b-wave were severely decreased. Multifocal ERG showed decreased amplitudes in the local macular area. A homozygous missense variant c.146C>T (chr14:68191267) was found. The clinical characteristics of a total of 13 patients reported with the same pathologic variant varied. An unusual patient with a homozygous pathogenic variant in the c.146C>T of RDH12 which causes late-onset and asymmetric retinal degeneration are reported. The clinical manifestations of the patient with multimodal retinal imaging and functional examinations have enriched our understanding of this disease.

Amaurosis Fugax Due to Radiation-induced Carotid Stenosis Treated by Carotid Artery Stenting

59-year-old male had four episodes of transient, painless vision loss in right eye in the last 20 days which had resolved spontaneously. Three years ago, patient had been diagnosed with oropharyngeal squamous cell carcinoma, which had been treated with six cycles of chemotherapy and radiotherapy. MRI brain angiogram showed diffuse long segment wall thickening of Right Internal Carotid Artery with luminal narrowing with no acute infarct or haemorrhage; which was later confirmed by four vessel DSA. He was treated with Right Carotid Artery angioplasty with a cutting balloon while using a distal protection device, followed up by stenting. The patient recovered well on follow-up and there were no further episodes. Thus, amaurosis fugax may be a presentation of carotid artery stenosis, especially after radiotherapy and such patients can be treated by carotid angioplasty and stenting.

Study protocol - Prospective case-control trial - Impact of significant carotid stenosis on retinal perfusion measured with automated retinal oximetry.

Large vessel carotid stenosis is a significant cause of ischaemic stroke. Indications for surgical revascularisation depend on the severity of the stenosis and clinical symptoms. However, mild symptoms such as TIA (Transient ischaemic attack), amaurosis fugax or minor stroke precede large strokes in only 15% of cases. The aim of this prospective study is to evaluate whether retinal perfusion is impacted in significant carotid stenosis. Automated retinal oximetry will be used to better assess perfusion in the post-stenotic basin. We presume the more stenotic the blood vessel, the more reduced the retinal perfusion is, resulting in adaptive changes such as greater arteriovenous saturation difference due to greater oxygen extraction. This could broaden the indication spectrum for revascularisation for carotid stenosis. We plan to enroll yearly 50 patients with significant carotid stenosis and cross-examine them with retinal oximetry. The study group will provide stenotic vessels and, non-stenotic vessels will form the control group. Patients with significant carotid stenosis will undergo an MRI (Magnetic Resonnance imaging) examination to determine the presence of asymptomatic recent ischaemic lesions in the stenotic basin, and the correlation to oximetry parameters. The stenosis severity and retinal oximetry parameters will be compared for study and control groups with a threshold of 70%, respectively 80% and 90% stenosis. Results will be then reevaluated with emphasis on MRI findings in the carotid basin. This prospective case control study protocol will be used to launch a multicentre trial assessing the relationship between significant carotid stenosis and retinal perfusion measured with automated retinal oximetry. Despite these differences, the findings indicate the potential of retinal oximetry for noninvasive real-time measurements of oxyhaemoglobin saturation in central nervous system vessels. Following calibration upgrade and technological improvement, verification retinal oximetry may potentially be applied to critically ill and anaesthesia care patients. The study on combined scanning laser ophthalmoscope and retinal oximetry supports the feasibility of the technique for oximetry analysis in newly born babies. ClinicalTrials.gov, ID: NCT06085612.

Amaurosis fugax in Marfan syndrome with myxomatous degeneration

A 28-year-old male presented with a sudden, transient visual impairment in the right eye. Brain MRI revealed no obvious ischemic lesions, and he was diagnosed with amaurosis fugax. Physical examination revealed characteristic features of Marfan syndrome, along with a family history of tall stature and valvular heart disease. Further investigation revealed: 1) an ascending aortic aneurysm, 2) a bicuspid aortic valve with fenestration and regurgitation, and 3) a mitral valve prolapse with regurgitation. Genetic testing identified a heterozygous variant c.6905G>A of FBN1, confirming the diagnosis of Marfan syndrome. Bentall operation and mitral valve replacement were performed, resulting in a favorable outcome. Pathological examination showed extensive myxomatous degeneration with thickening of the aortic and mitral valves, suggesting a potential source of embolism.

Impact of Vascular Service Centralization on the Carotid Endarterectomy Pathway: A Study at the Bedfordshire, Luton, and Milton Keynes Vascular Network.

Introduction Carotid endarterectomy (CEA) is the gold standard intervention for patients experiencing transient ischemic attacks (TIAs) or embolic strokes with >50% internal carotid artery (ICA) stenosis supplying index hemispheric territory. The recommended period for CEA is 14 days post-index event; this period carries a heightened risk for second ischemic events. However, implementation of this stringent timeline often encounters delays stemming from multifaceted factors. The centralization of vascular services, designed to enhance patient care, introduces a paradigm shift. Centralization's efficacy in improving patient outcomes, particularly in the CEA pathway, is a subject of ongoing investigation. Our study aims to discern the impact of centralized services on the timeliness of CEA for symptomatic carotid artery stenosis, shedding light on this complex interplay of factors. Methods This retrospective study analyzed CEA data at the Bedfordshire, Luton, and Milton Keynes Vascular Network between January 2021 and June 2023. Eligible patients exhibited symptomatic carotid artery stenosis, with asymptomatic cases; those unfit for surgery or receiving best medical therapy only were excluded. Patients were categorized by their primary referral location: Hub, Spoke-1, or Spoke-2. Demographic and referral data were collected, and timelines from symptom onset to surgery were recorded. Continuous variables were expressed as means and standard deviations, and categorical variables as counts and percentages. Box plots illustrated the relationship between referral origin and surgery timing, and the Classification and Regression Tree (CART) assessed second events. Statistical significance was determined using Fisher's exact and chi-square tests, with p<0.05 indicating significance. Results A total of 148 patients underwent CEA after implementing exclusion criteria. 35.5% (n=53)of patients were referred from the Hub, while 45.6% (n=67)and 18.8% (n=28)were from Spoke-1 and Spoke-2, respectively. 40% (n=59) received CEA within the recommended timeframe, and 15.4% (n=23) experienced a second ischemic event pre-surgery. Time from TIA clinic review to referral was 5.5±8 days and 16.4±20 days from vascular referral to surgery. Patterns of delays were observed, with Spoke-2 exhibiting the most significant delays. Notably, amaurosis fugax and embolic stroke correlated with recurrent ischemic events, emphasizing the importance of timely care in CEA. Conclusion Our study underscores the significant benefits and challenges of the Hub and Spoke model in vascular surgery. The growing referral delays from Spoke sites are concerning, emphasizing the need for a multi-disciplinary team approach within Spoke sites to ensure efficient and standardized care delivery.

Abstract 17381: Relationship Between Amaurosis Fugax and Intraplaque Hemorrhage in Patient With Carotid Plaques

Introduction: The term amaurosis fugax is often used interchangeably to describe transient visual loss. However, it is employed widely in medicine to refer to any cause of transient monocular visual loss. Amaurosis fugax is associated with an imminent stroke and it could be linked to vascular thromboembolic events arising from the internal carotid arterial system. The aims of the study are to determine the plaque characteristics of patients who underwent carotid artery revascularization and the relationship of plaque characteristics with amaurosis fugax. Methods: Before elective carotid revascularization 44 patients (mean age 72±8 years; 25 males, 19 females) underwent 3-T MRI. After localization of the carotid bifurcation using phase contrast imaging, Time-of-Flight, 3D T1 weighting, transverse T1 and T2 weightings and proton density sequences were acquired. The different plaque components: lipid rich core, intraplaque hemorrhage, calcification and the characterization of the fibrous cap were assessed. Results: Carotid plaque samples had the following characteristics: Intraplaque hemorrhage (59%), surface defects (38.6%), stable fibrous cap (27.3%), lipid rich necrotic core (18%), and calcifications (11.4%). Amaurosis fugax history was identified in 7 patients (15.9%). Plaque samples from all 7 patients who had experienced amaurosis fugax revealed intraplaque hemorrhage. MRI revealed intraplaque hemorrhage in 19 (51%) patients without history of amaurosis fugax (p=0.016). The rest of the plaque characteristics did not show any statistically significant relationship with history of amaurosis fugax. Conclusions: This study demonstrated that intraplaque hemorrhage may be correlated to amaurosis fugax.

Abstract 12214: Large Left Atrial Infected Myxoma in a Healthy Patient With Intermittent Fever

Introduction: Infected myxomas represent a rare subset of cardiac myxomas. The diagnosis is classified as definite, probable, or possible based on microbiological and pathological findings. Prognosis is often favorable with early diagnosis and intervention. Case description: A 39-year-old female with a history of iron-deficiency anemia presented with three months of fever, poor exercise tolerance, 15-lb unintentional weight loss, and episodes of amaurosis fugax associated with upper extremity paresthesias. Her physical exam revealed tachycardia and a grade 3/6 apical holosystolic murmur. Her laboratory workup was notable for microcytic anemia, elevated inflammatory markers, and Streptococcus sanguinis bacteremia . Echocardiography showed left ventricular and left atrial dilation with normal systolic function and a 6.4x4.3 cm heterogenous left atrial mass adherent to the interatrial septum with prolapse across the mitral valve plane (Figure 1, panel A-B) associated with eccentric mitral regurgitation. She was managed with surgical resection and antibiotics. Pathology revealed myxomatous tissue and prominent plasma cell infiltrates, confirmatory of definite infected cardiac myxoma. Follow-up echocardiography showed residual mitral regurgitation due to mitral annular stretch from myxoma for which surgical intervention was deferred in the acute setting. Discussion: A definite diagnosis of infected myxoma is established with biopsy-proven myxoma, along with microorganism visualization or positive blood cultures with inflammatory cells on histopathology. Rare in occurrence, infected myxomas have been associated with a higher incidence of embolic events, sepsis, and shock compared to uninfected myxomas. Prognosis is favorable with prompt intervention. Increased awareness leading to earlier diagnosis and management is a priority for this subset of patients.