A 67-year-old female with a history of hypertension, hyperlipidemia, diabetes mellitus, prior coiled right middle cerebral artery (MCA) aneurysm, and prior left internal carotid artery (ICA) stenosis status post carotid endarterectomy presents with painless left eye vision loss. Per hospital CRAO protocol, a stroke code was activated. Exam was notable for left eye afferent pupillary defect and visual acuity of light perception only. CT Head showed stable coiling artifact from prior right MCA aneurysm. CT Angiography revealed 55% stenosis at the right ICA origin and focal calcifications of the left ICA near the ostium of the ophthalmic artery. Optical coherence tomography identified ischemia of the inferior and center retina, confirming the diagnosis of a BRAO. The patient was taken for digital subtraction angiography which found decreased retinal blush on the left. A total of 22mg of intra-arterial tissue plasminogen activator was injected into the left ophthalmic artery via superselective microcatheterization in 5mg aliquots. Post-IAT angiography noted improvement in the retinal blush.
Visual acuity improved to hand motion on post-op day 1. She was discharged on a 90-day course of dual antiplatelet therapy for a presumed etiology of intracranial atherosclerotic disease with plans for outpatient holter monitor.