Ischemic Neuropathy Research Articles

Impaired Visual Function

As an ophthalmologist specializing in neuro-ophthalmology, I welcome the wonderfully systematic article about gait disturbances, and especially the mention of bilateral vestibulopathy which is often overlooked. Such patients often present first to their ophthalmologist because they interpret the accompanying oscillopsia as an eye disorder. Examining the different directions of gaze is important in this setting, so as not to overlook nystagmus, which is often hardly noticeable when looking straight ahead. The authors in their Table 3 list common gait disorders and their causes; under “Sensory deficits,” however, they mention only “loss of visual acuity”. Visual acuity is defined as spatial resolution capacity of the central retina. In elderly people, visual acuity is most often impaired as a result of age related macular degeneration. If – typically – the visual field is intact, then loss of visual acuity is only rarely the decisive criterion for gait disturbances. Additionally, partial visual rehabilitation by prescribing magnifying visual aids (example under “Therapeutic options”) is of value primarily for near distances because of the massive reduction in the width of the visual field and the change in the perceived distance to the viewed object; it cannot improve spatial orientation and consequently not gait disturbances either. The term “impaired visual function” would have been more appropriate in table 3 to describe the situations that typically lead to difficulties in orientation in elderly people: primarily, bilateral visual field defects (which cannot always be properly evaluated by a neurologist’ perimetry) owing to chronic glaucoma, bilateral ischemic neuropathy of the optic nerve, and ischemic retinal diseases; further, localization impairments because of eye muscle paresis in the dominant eye; eventually double vision and loss of stereoscopic vision for various reasons—for example, in pathologies also with intact oculomotor function, such as decompensated phorias, suppression loss in congenital strabismus, and involutive divergence paresis. All these are most likely to be diagnosed and treated by ophthalmologists, possibly in collaboration with an orthoptist.

A Case of Craniofacial Polyostotic Fibrous Dysplasia

We present the case of a patient with craniofacial polyostotic fibrous dysplasia. Polyostotic fibrous dysplasia is relatively rare and usually presents in late childhood/early adulthood. It is occasionally associated with endocrine disorders such as McCune-Albright syndrome. The benign pathology of this bone tumor belies its implications in the region of the skull base. Craniofacial polyostotic fibrous dysplasia can have devastating complications depending on which ostia are involved, including vision loss. Our patient was already beginning to experience visual field deficits from ischemic neuropathy. He was treated surgically with optic nerve decompression; however, the efficacy of this approach is currently being debated.

Tibial ischemic neuropathy as an unusual complication of interventional radiology

Ischemia can be a rare cause of focal neuropathy. We report an 83-year-old man with right tibial ischemic neuropathy after a catheterization and embolization procedure to treat recurrent hemarthrosis of the right knee. The electrophysiological study confirmed a conduction block at the right tibial nerve (between the ankle and knee), without local compression.

Ischemic Monomelic Neuropathy: An Underappreciated Cause of Pain and Disability following Vascular Access Surgery

The establishment and maintenance of a functioning arteriovenous access site is essential for the care of the hemodialysis (HD) patient. Ischemic monomelic neuropathy (IMN) represents an underappreciated complication and an unrecognized source of short- and long-term disability because of its protean manifestations in the post-operative period. Delayed diagnosis of IMN greatly reduces the chance of avoiding irreversible disability. Prompt diagnosis and early management of IMN can avoid morbidity for the patient, diminish healthcare costs for the system and avoid medical liability for care providers. A multidisciplinary awareness of the symptoms of IMN is essential to permit prompt diagnosis and management.

Effect of Diabetes Mellitus on Protein–Energy Wasting and Protein Wasting in End‐Stage Renal Disease

Protein wasting (PW) or protein-energy wasting (PEW) occurs commonly in patients with diabetes mellitus who have end-stage renal disease (ESRD) and are undergoing maintenance dialysis (MD) therapy. Some but not all studies indicate that PW or PEW is more prevalent in diabetic when compared with nondiabetic MD patients and that diabetic patients commencing maintenance hemodialysis (MHD) are more likely to lose fat-free, edema-free weight than are incident nondiabetic MHD patients. The causes of PW and PEW in diabetic MD patients are probably largely similar to those of nondiabetic MD patients. These causes include anorexia, reduced food intake, concurrent illnesses particularly when associated with inflammatory processes, physical or mental debility, removal of nutrients by dialysis procedure, acidemia, possibly physical deconditioning, and oxidant and carbonyl stress. However, diabetic MD patients are also at greater risk for PW or PEW from comorbidities related to diabetes per se. These disorders include ischemic vascular disease, hypertension, gastrointestinal dysfunction, and neuropathy. Metabolic disorders such as insulin deficiency or resistance to the actions of insulin, and elevated levels of counterregulatory hormones may also contribute to PW or PEW in diabetic MD patients. Mechanisms by which these metabolic disorders in diabetic ESRD patients may cause PW or PEW are discussed.

Optic nerve MRI enhancement in posterior ischaemic optic neuropathy due to internal carotid artery dissection

Posterior ischaemic neuropathy (PION) is characterized by infarction in the retrobulbar optic nerve. A 73-year-old man suddenly experienced blurred vision in his left eye and intermittent weakness in his right hand. He had visual defects of superior lateral quarter and inferior medial quarter areas in the left eye. Gadolinium-enhanced magnetic resonance imaging (MRI) revealed segmental enhancement in the left optic nerve. A cerebral angiogram showed a left internal carotid dissection (ICD). He did not have fever, and his laboratory and cerebrospinal fluid tests were normal. These findings were suggestive of PION associated with ICD. No reports of PION caused by ICD has been reported and his is the first case in which MRI showed optic nerve enhancement due to ICD.

Health-related quality of life in diabetes: The associations of complications with EQ-5D scores

BackgroundThe aim of this study was to describe how diabetes complications influence the health-related quality of life of individuals with diabetes using the individual EQ-5D dimensions and the EQ-5D index.MethodsWe mailed a questionnaire to 1,000 individuals with diabetes type 1 and 2 in Norway. The questionnaire had questions about socio-demographic characteristics, use of health care, diabetes complications and finally the EQ-5D descriptive system. Logistic regressions were used to explore determinants of responses in the EQ-5D dimensions, and robust linear regression was used to explore determinants of the EQ-5D index.ResultsIn multivariate analyses the strongest determinants of reduced MOBILITY were neuropathy and ischemic heart disease. In the ANXIETY/DEPRESSION dimension of the EQ-5D, "fear of hypoglycaemia" was a strong determinant. For those without complications, the EQ-5D index was 0.90 (type 1 diabetes) and 0.85 (type 2 diabetes). For those with complications, the EQ-5D index was 0.68 (type 1 diabetes) and 0.73 (type 2 diabetes). In the linear regression the factors with the greatest negative impact on the EQ-5D index were ischemic heart disease (type 1 diabetes), stroke (both diabetes types), neuropathy (both diabetes types), and fear of hypoglycaemia (type 2 diabetes).ConclusionsThe EQ-5D dimensions and the EQ-5D seem capable of capturing the consequences of diabetes-related complications, and such complications may have substantial impact on several dimensions of health-related quality of life (HRQoL). The strongest determinants of reduced HRQoL in people with diabetes were ischemic heart disease, stroke and neuropathy.

A Case of Ischemic Neuropathy after Brachial Artery Puncture for Arterial Blood Sampling

A Case of Ischemic Neuropathy after Brachial Artery Puncture for Arterial Blood Sampling

The diagnostic dilemma of neuro-imaging in acute isolated sixth nerve palsy

Microvascular ischemia is a frequent cause of acute isolated cranial nerve six (CN VI) palsy. Alternative etiologies of CN VI palsy with grave neurological implications often cannot be excluded without neuroimaging. However, the practice of obtaining neuro-imaging for every patient presenting with an acute, isolated CN VI palsy is a costly diagnostic paradigm. Recent studies have sought to delineate the risk factors for microvascular ischemic ocular motor cranial neuropathies and to investigate the utility of neuroimaging in the initial evaluation of such cases. The aim of this review is to provide an update on the issues and controversies of neuroimaging in the initial evaluation of an acute isolated CN VI palsy. Diabetes mellitus, but not hypertension alone, is a risk factor for microvascular ischemic ocular motor cranial neuropathies. Small-scale prospective studies have suggested that immediate neuroimaging should be considered in the initial evaluation of all patients with CN VI palsy, regardless of the presence of microvascular ischemic risk factors. There remains a lack of large-scale, prospective, age-specific studies to indicate the diagnostic yield of immediate neuroimaging in the setting of acute isolated CN VI palsy. An algorithm is offered for the evaluation of acute isolated CN VI palsy, which allows for initial expectant observation and re-consideration of obtaining neuroimaging upon follow-up if the ophthalmoplegia does not improve, progresses, or becomes nonisolated.

AION and glaucoma: similarities and difference

Abstract Purpose Anterior ischemic neuropathy (AION) and glaucomatous optic neuropathy (GON) are two distinct clinical entities, but share some striking similarities. Methods These similarities between AION and GON are highly suggestive of a common mechanism for the development of the two diseases. Evidence has gradually emerged that there is vascular insufficiency in the optic nerve head (ONH) in both anterior ischemic optic neuropathy and glaucomatous optic neuropathy; thus both represent ischemic disorders of the ONH. Conclusion During this lecture, the clinical similarities and differences between AOIN and GON will be highlighted, and their potential common pathogenetic mechanisms will be discussed.

Neuropatía óptica isquémica anterior migrañosa

We report the case of a 22-year-old man who presented with headache and blurred vision which had started four days previous. A periventricular lesion was found in the magnetic resonance imaging. The patient was diagnosed with demyelinating neuritis and treated with intravenous methylprednisolone. After six months visual function had not improved, so the initial diagnosis was probably erroneous. It is likely that the patient suffered from migraineous optic ischemic neuropathy. In this paper we review the scarce literature about this topic, and the role of migraine as a cardiovascular risk factor.

A phase II trial of first-line bevacizumab in combination with pemetrexed and carboplatin in advanced nonsquamous non-small cell lung cancer (NSCLC)

e19091 Background: Combining bevacizumab (Bev) with platinum doublet yields a survival benefit in previously untreated patients with advanced nonsquamous non-small cell lung cancer. Carboplatin with pemetrexed is an efficient combination that is potentially less toxic. This phase II trial evaluates the efficacy and the safety of adding bevacizumab to carboplatin and pemetrexed in advanced non-small cell lung cancer. Methods: This is a single arm, open-label phase II trial. Eligibility stipulated enrollment of patients with stage IIIB/IV non-squamous non-small cell lung cancer with an ECOG PS 0–1 and no other contraindications to Bev. Treatment consisted of pemetrexed 500 mg/m2, carbo AUC 6 and Bev 15mg/kg on day 1, repeated every 3 weeks. If clinical benefit was proven, patients received Bev maintenance until progression. The response was evaluated every two cycles. The primary endpoint was time to progression (TTP); secondary endpoints included overall survival, response rate (RR) and grade 3–4 toxicities. Results: As of September 2008, 27 out of 42 projected patients were enrolled of which, 14 were males and 13 females; median age 68 (72% older than 60); IIIB/IV 5/22; median number of cycles 9 (range 2–33). At the time of analysis, 25 patients were evaluable. Preliminary results show a median time to progression of 7.25 months (95% CI, 6.4 to 8.2). 23 patients (92%) had disease control (95%, CI 82–96%) with an overall response rate of 36% (95%, CI 25–47%).14 patients had stable disease (56%), 8 had partial response (32%) and one achieved a complete response (4 %). Median survival has not yet been reached. Grade 3/4 adverse events include: Cerebral ischemic event (N=1), Anorexia (Gr 3: N= 5/ Gr 4: N= 4), gastrointestinal fistula (N=1), hypertension (Gr3: N=3), epistaxis (Gr 3 N=1), vomiting (Gr 3; N= 3), fever (Gr 4: N=1) and neuropathy (Gr 3: N=2). Conclusion: The addition of bevacizumab to carboplatin and pemetrexed appears to be an active first line treatment with a high disease control rate and an acceptable toxicity profile in the setting of advanced non-small cell lung cancer. No significant financial relationships to disclose.

Les neuropathies optiques au cours de la maladie de Behçet : à propos de 18 cas

Introduction The objective of this study was to analyse the incidence and the main characteristics of optic neuropathy in Behçet's disease. Methods A retrospective review of a well-documented population of 376 Tunisian patients with Behçet's disease was performed. All patients fulfilled three or more criteria defined by the International Study Group for Behçet's Disease. The diagnosis of optic neuropathy was based on the clinical examination, visual field, visual evoked potentials and retinal angiography. Results Eighteen patients (4.7 %) presented an optic nerve involvement. The mean age at presentation of these patients (10 men and nine women) was 39.11 ± 12.9 years (range 17 to 73). The mean vision at presentation was 4.2/10 ± 2.9, the vision was less than 1/10 in 34.5 % of eyes. The optic neuropathy was anterior in 89 % cases (26 eyes, 90 %), posterior in one case (2 eyes, 7 %); one patient (1 eye, 3 %) presented an optic atrophy. The optic neuropathy was associated with other ocular lesions in 13 cases (72.2 %). It was an inflammatory neuropathy in four cases (22.3 %) and a stasis papilledema complicating a benign intracranial hypertension in five cases (27.8 %). Corticosteroids were administrated in 17 cases (94.4 %), cyclophosphamide in six cases (33.3 %) and anticoagulant therapy in one patient (5.6 %). After a mean duration of 79 months (range: three months to 12 years), a third of the patients (8 eyes, 27.5 %) have a visual loss. Conclusion Optic neuropathy is a rare ocular involvement in Behçet's disease. It can be related to an inflammatory neuropathy, a stasis papilledema complicating a benign intracranial hypertension or an ischemic neuropathy. The association of optic neuropathy with other ocular lesions could be responsible for a diagnostic delay. Its treatment relies on systemic corticosteroids and immunosuppressive drugs. The prognosis remained poor, with a third of the patients having lost their sight.

Complications of arteriovenous hemodialysis access: Recognition and management

English language citations reporting complications of arteriovenous access for hemodialysis are critically reviewed and discussed. Venous hypertension, arterial steal syndrome, and high-output cardiac failure occur as a result of hemodynamic alterations potentiated by access flow. Uremic and diabetic neuropathies are common but may obfuscate recognition of potentially correctable problems such as compression or ischemic neuropathy. Mechanical complications include pseudoaneurysm, which may develop from a puncture hematoma, degeneration of the wall, or infection. Dysfunctional hemostasis, hemorrhage, noninfectious fluid collections, and access-related infections are, in part, manifestations of the adverse effects of uremia on the function of circulating hematologic elements. Impaired erythropoiesis is successfully managed with hormonal stimulation; perhaps, similar therapies can be devised to reverse platelet and leukocyte dysfunction and reduce bleeding and infectious complications.

Ischemic Optic Neuropathies

Anterior ischemic optic neuropathy (AION) is the most common cause of acute optic neuropathy after age 50, but may also occur in younger patients. The diagnosis is clinical and includes painless visual loss associated with a relative afferent pupillary defect and disc edema. In almost all cases, there is an underlying crowded optic nerve with a small cup-to-disc ratio. The visual prognosis is usually poor, although up to 43% of patients may improve over time. The fellow eye is involved in up to 15% of patients within 5 years, but the risk of recurrence in the same eye is less than 5%. There is no treatment for acute nonarteritic AION but it is essential to evaluate these patients for underlying treatable atheromatous vascular risk factors. A coagulation workup should also be considered in younger patients. It is essential to rule out giant cell arteritis in all patients over the age of 50 with ischemic optic neuropathies. Posterior ischemic neuropathy (in which the optic nerve is normal acutely) is rare and should be considered a diagnosis of exclusion.

Postoperative pain and vomiting after orbital wall surgery in trauma

Postoperative pain and vomiting after orbital wall surgery in trauma

Ischemic neuropathy and rhabdomyolysis as presenting symptoms of postpartum cardiomyopathy

Rhabdomyolysis and peripheral neuropathy are two distinct disease entities which are rarely encountered in combination. We present a woman with rhabdomyolysis and peripheral neuropathy 3 weeks postpartum. Her symptoms were caused by bilateral femoral artery thrombosis due to postpartum cardiomyopathy (PPCM). This demonstrates that PPCM may present with predominantly non-cardial symptoms and underscores the importance of rapidly recognizing this disorder.

Kombinierte Nervenschäden und Embolia cutis medicamentosa nach intraglutäaler Fehlinjektion

Injection-induced palsy of the ischiatic nerve with concomitant damage of other peripheral nerves occurred in two patients following intramuscular injection in the upper outer quarter of the large gluteal muscle. In close chronological connection skin changes developed in both cases representing drug-induced cutaneous embolism, and in one case extensive muscular necrosis was observed. In both cases the cause may be assumed to be ischaemic neuropathy following embolic occlusion of the vasa nervorum as a result of accidental intraarterial injection.

Painless Acute Aortic Dissection Presenting as Left Lower Extremity Weakness and Numbness

Acute aortic dissection usually presents with a sudden, painful, tearing sensation in the chest or back. However, acute aortic dissection may also present atypically without pain and with solely neurological symptoms. We describe a case of painless acute aortic dissection which presented as acute left lower extremity weakness and numbness. These neurological symptoms are due to vascular occlusion causing peripheral ischaemic neuropathy. It is imperative to consider acute aortic dissection in the differential diagnosis of acute neurological syndromes.

Manifestaciones oftalmológicas de la hipertensión arterial

Systemic Arterial hypertension (AHT) is one of the most frequent diseases in the industrialised countries, with an incidence reaching 30%, a figure that is rising due to the greater life expectancy of the population. This rise in arterial tension causes, or accelerates, changes in the vascular wall of the target organs such as the kidney, brain, heart and eye. At the ocular level, AHT produces lesions in the retina, the choroids and optic nerve head; this can include a wide range of lesions, from slight vascular narrowing to severe visual loss due to ischaemic optical neuropathy. The primary response of the retinal arteries to systemic arterial hypertension is vascular narrowing and the manifestations that appear at the back of the eye in hypertensive retinopathy are diffuse or focal vasoconstriction, extravasation due to increased vascular permeability and arteriosclerosis with swelling of the wall of the vessels. These three entities are responsible for the appearance of different lesions that characterise the stages of the retinal disease, which are: arteriovenous crossings, hard and cotton-like exudates, thrombosis, embolisms, haemorrhages in the retinal parenchyma, vitreous detachment from the retina, papilla edema and ischaemic optical neuropathy in the more severe cases, such as in case malign arterial hypertension.