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Thrombolysis for Central Retinal Artery Occlusion in 2020: Time Is Vision!
Oana M Dumitrascu1, Nancy J Newman, Valérie Biousse
1Department of Neurology (OMD), Cedars-Sinai Medical Center, Los Angeles, California; and Departments of Ophthalmology (NJN, VB), Neurology (NJN, VB), and Neurological Surgery (NJN), Emory University School of Medicine, Atlanta, Georgia.
Insights
Thrombolysis with tissue plasminogen activator (tPA) may improve vision in acute central retinal artery occlusion (CRAO) when given early. Further research is needed for optimal treatment strategies in this eye stroke condition.
Area of Science:
- Ophthalmology
- Neurology
- Vascular Medicine
Background:
- Acute nonarteritic central retinal artery occlusion (CRAO) is an eye stroke with poor visual prognosis.
- Current therapies for CRAO are limited, prompting a re-evaluation of thrombolysis.
- Advances in acute stroke care necessitate a critical review of thrombolysis for CRAO.
Purpose of the Study:
- To review evidence for intravenous (IV) and intra-arterial (IA) tissue plasminogen activator (tPA) in managing acute nonarteritic CRAO.
- To assess the efficacy and safety of thrombolytic therapies in CRAO patients.
Main Methods:
- Systematic search of MEDLINE, Scopus, and Cochrane databases from 1960 to present.
- Inclusion of English language case reports, case series, interventional studies, and randomized controlled trials.
- Analysis of study type, patient demographics, treatment regimens, timing, visual outcomes, and safety reports.
Main Results:
- IV alteplase (tPA) was reported in 7 articles (111 patients), with 54% treated within 4.5 hours; no intracranial/ocular hemorrhage reported.
- IA alteplase (tPA) was described in 6 studies (134 patients), with only 13.4% treated within 6 hours; minimal adverse events.
- Visual outcomes were variable, but most studies indicated benefits from early reperfusion therapies; no tenecteplase reports found.
Conclusions:
- Nonarteritic CRAO patients should ideally receive thrombolytic therapies within the same time window as acute cerebral ischemia.
- Ophthalmologic evaluation is crucial for accurate diagnosis and guiding thrombolysis decisions in CRAO.
- Future research should explore retinal imaging techniques to aid thrombolysis decision-making in CRAO.
Background:
Acute nonarteritic central retinal artery occlusion (CRAO) is an eye stroke with poor visual prognosis and no proven effective therapies. Given advances in acute stroke care, thrombolysis in CRAO merits critical re-examination. We review the evidence for intravenous (IV) and intra-arterial (IA) tissue plasminogen activator (tPA) in CRAO management.
Evidence Acquisition:
MEDLINE, Scopus, and Cochrane online databases were systematically searched from 1960 to present, for reports of acute IV or IA therapy with alteplase or tenecteplase in nonarteritic CRAO patients. English language case reports, case series, interventional studies, or randomized controlled trials were included. The study type, age and number of subjects, the regimen administered, the time since symptoms' onset, visual outcome, and safety reports were noted.
Results:
Use of IV thrombolysis with alteplase was reported in 7 articles encompassing 111 patients, with 54% of them receiving IV tPA within 4.5 hours of symptom onset, and none developing symptomatic intracranial or ocular hemorrhage. Six studies described IA alteplase administration, with only 18 of a total of 134 patients (13.4%) treated within the first 6 hours after visual loss. The reported adverse events were minimal. Visual outcomes post-IV and IA thrombolysis were heterogeneously reported; however, most studies demonstrated benefit of the respective reperfusion therapies when administered very early. We found no reports of tenecteplase administration in CRAO.
Conclusions:
In 2020, nonarteritic CRAO patients should theoretically receive the same thrombolytic therapies, in the same time window, as patients with acute cerebral ischemia. Eye stroke and teleeye stroke code encounters must include an expert ophthalmologic evaluation to confirm the correct diagnosis and to evaluate for ocular signs that may help guide IV tPA administration or IA management. Future research should focus on developing feasible retinal penumbra imaging studies that, similar to cerebral tissue viability or perfusion imaging, can be incorporated into the thrombolysis decision-making algorithm.
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