Binocular Visual Loss Caused by Acute Cardioembolic Stroke(4)

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Binocular visual loss, acute visual loss, cardioembolic stroke, cerebral angiography, DSA, selective intra-arterial thrombolysis, visual pathway infarction, posterior circulation stroke, occipital lobe infarction, cortical blindness, visual pathway ischemia, neuro-ophthalmology, emergency stroke imaging, interventional neuroradiology


PART 4 — ADVANCED TREATMENT STRATEGIES, NEUROCRITICAL CARE & PROGNOSIS

Binocular Visual Loss Caused by Acute Cardioembolic Stroke
State-of-the-Art Therapeutic Framework & Evidence-Based Outcome Prediction

SECTION 24 — THERAPEUTIC PRINCIPLES IN ACUTE BINOCULAR VISUAL LOSS

Acute binocular visual loss due to ischemic stroke constitutes a neuro-ophthalmologic catastrophe. Management must be:

  • Immediate
  • Multidisciplinary
  • Evidence-based
  • Time-critical

Core Therapeutic Objectives:

  1. Rapid reperfusion
  2. Salvage of ischemic penumbra
  3. Prevention of infarct expansion
  4. Reduction of cerebral edema
  5. Prevention of secondary complications
  6. Maximization of visual recovery

SECTION 25 — HYPERACUTE STROKE MANAGEMENT PROTOCOL

25.1 Prehospital Management

  • Oxygen supplementation
  • Blood pressure stabilization
  • Blood glucose correction
  • Rapid transport to a comprehensive stroke center

25.2 Emergency Department Management

Step

Action

1

Stroke code activation

2

Noncontrast CT

3

CTA + CTP

4

IV thrombolysis screening

5

Emergency DSA

SECTION 26 — INTRAVENOUS THROMBOLYSIS (IVT)

Standard Agent: Recombinant Tissue Plasminogen Activator (rtPA)

Parameter

Value

Time window

≤ 4.5 hours

Dose

0.9 mg/kg

Goal

Microvascular reperfusion

Limitations in PCA Stroke:

  • Low recanalization rate
  • High distal embolic burden
  • Delayed visual recovery

SECTION 27 — SELECTIVE INTRA-ARTERIAL THROMBOLYSIS (IAT)

27.1 Rationale

Selective intra-arterial thrombolysis offers:

  • Direct clot targeting
  • Higher recanalization rates
  • Lower systemic bleeding risk
  • Superior distal branch reperfusion

27.2 Procedural Technique

  1. Femoral artery puncture
  2. Guide the catheter into the vertebral artery
  3. Microcatheter navigation into the PCA
  4. Local thrombolytic infusion
  5. Continuous angiographic monitoring

27.3 Pharmacologic Agents

Agent

Mechanism

Urokinase

Plasminogen activation

Alteplase

Fibrin clot lysis

Tenecteplase

Long-acting thrombolysis

27.4 Clinical Outcomes

  • Recanalization rates: 70–85%
  • Visual recovery: 40–65%
  • Functional independence: 55–75%

SECTION 28 — MECHANICAL THROMBECTOMY IN POSTERIOR CIRCULATION

28.1 Indications

  • Large clot burden
  • Basilar artery occlusion
  • Proximal PCA occlusion

28.2 Devices

Device

Function

Stent retrievers

Clot capture

Aspiration catheters

Direct suction

Combined technique

Maximal efficacy

28.3 Procedural Success Metrics

Parameter

Target

TICI score

≥ 2b

Time to reperfusion

< 60 min

Complication rate

< 5%

SECTION 29 — NEUROCRITICAL CARE MANAGEMENT

29.1 Cerebral Edema Control

  • Osmotic therapy (mannitol, hypertonic saline)
  • Head elevation
  • Normocapnia

29.2 Secondary Stroke Prevention

  • Anticoagulation (cardioembolic)
  • Antiplatelet therapy
  • Statin therapy
  • Blood pressure optimization

29.3 Visual Rehabilitation Therapy

  • Neurovisual stimulation
  • Prism adaptation
  • Visual scanning training
  • Occupational therapy

SECTION 30 — PROGNOSIS & VISUAL RECOVERY PREDICTION

30.1 Determinants of Visual Recovery

Factor

Impact

Time to reperfusion

  Most critical

Collateral flow

  Major

Infarct volume

  Major

Age 

  Moderate

Comorbidities 

  Moderate

30.2 Prognostic Stratification Model

Category

Expected Outcome

Early reperfusion (<2h)

Excellent recovery

2–6 hours

Partial recovery

>6 hours

Poor recovery

30.3 Long-Term Outcomes

Outcome

Frequency

Full visual recovery

30–45%

Partial improvement

30–40%

Permanent blindness

15–25%

SECTION 31 — LONG-TERM NEUROVISUAL REHABILITATION

Visual neuroplasticity allows partial recovery through:

  • Cortical reorganization
  • Adjacent cortical recruitment
  • Visual perceptual training

REFERENCES

  1. Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke. Stroke, 2019;50(12):e344–e418.
  2. Powers WJ, et al. 2018 Guidelines for the early management of acute ischemic stroke. Stroke, 2018;49:e46–e110.
  3. Saver JL. Time is brain—quantified. Stroke, 2006;37:263–266.
  4. Rizzo JF, Lessell S. Cortical blindness. Ophthalmology, 1994;101(10):1778–1783.
  5. Broderick JP, et al. Endovascular therapy after intravenous t-PA versus t-PA alone. N Engl J Med, 2013;368:893–903.
  6. Goyal M, et al. Endovascular thrombectomy after large-vessel ischemic stroke. Lancet, 2016;387:1723–1731.
  7. Biousse V, Newman NJ. Neuro-ophthalmology of stroke. Lancet Neurol, 2015;14:1168–1180.
  8. Campbell BCV, et al. Imaging selection in ischemic stroke. N Engl J Med, 2015;372:1009–1018.


To be continued.

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