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Chronic occlusive disease of the carotid arteries with nondiagnostic or misleading pressures on the retinal arteries
Chronic Occlusive Disease of the Carotid Arteries with Nondiagnostic or Misleading Pressures on the Retinal Arteries MAURICE C. SMITH, M.D.
From tbe Division oJ Neurological Surgery and tbe Department of Opbtbalmology, University of Calijornia School of Medicine, San Francisco, California.
measurement of pressures on the retinal arteries with the ophthaImodynamometer has been reported to be of value in the diagnosis of occlusive disease of the carotid arteries [r,6_8,r2,24,r~~19,21,22,24,2$]. It k generaIIy agreed that ophthalmodynamometry is valuable in the diagnosis of acute thrombosis of carotid arteries. Recently, much attention has been focused on the numerous patients with chronic or slowly progressive occlusions of the carotid arteries, and ophthaImodynamometry has been recommended for the evaluation of their condition. Some investigators have been enthusiastic about the reIiability of this procedure [6,14,15,17,18,22,24,25] and others have not been [3,5,9]. We have reviewed twenty-two case reports of occIusive disease of the carotid arteries, studied both by angiography and by ophthaImodynamometry, from the Neurosurgery Service at the H. C. MoffItt HospitaI. In twelve of these cases, the results of ophthalmodynamometric examination* were either nondiagnostic or misleading. The foIIowing seven case reports have been seIected to iIIustrate this problem.
T
HE
* Rleasurements of pressures on the retina1 arteries were performed with the BaiIIiart ophthalmodynamometer. OnIy diastohc readings were reported. Examination was performed with the patient in the supine position. The “posture test,” suggested by Smith and Cogan [IS], was used as was the comparison of systolic readings with the ophthaImodynamometer. In our experience, these additiona maneuvers did not change the concIusions indicated by the comparison of the diastolic readings alone. The resuIts of ophthalmodynamometry were considered to be nondiagnostic
AND
U:ILLIAM F. HOYT,
M.D.
REPORTS
CASE
Unilateral Subtotal Carotid Artery. CASE I. Slowly progressive hemiplegia on the right side is exemplified in this case. A fifty-three year old left-handed man was hospitalized. He had an eight week history of a defect in the right visual field associated with hemiplegia of the right side (more sevcrc in the Icg than the arm) which \vas slow in onset but was progressive. had become confused and mildly Th c patient aphasic. His blood pressure was equal in the two arms (r4oi90 mm. Hg). He had an aphasic expression, a right homonymous hemianopsia and a right hcmiparesis. Compression of the right common carotid artery produced syncope. Ophthalmodynamometry revealed equal diastolic readings in both eyes. Bilateral arteriograms of the carotid arteries showed almost complete obstruction of the left internal carotid artery. (Fig. IA and B.) Comments: suggest
the
the
internal
the
bifurcation
Ophthalmodynamometry presence carotid
of near artery
of the
on the
carotid
did
tota
occIusion left
side
not of near
artery.
CASE II. Intermittent neurologic symptoms, incIuding blurring of vision is exemplified in this case. A sixty-two year old white man entered the hospital \vith a one year history of intermittent numbness in the left arm associated with blurred vision which was more noticeable in the right eye than in the left.
(for practica1 purposes, equal) when the difference in the two rcndings was Iess than 5 mm. for readings below 50 mm. and less than IO mm. for readings above 60 mm. (such criteria were suggested by HoIIenhorst because of the variations found in norma persons and the inaccuracies inherent in the technic [7].
Smith and Hoyt
IB
IA
FIG. I. Case I. A, Injection of radiopaque materia1 into the Ieft common carotid artery. There is a stenotic Iesion of the internal carotid artery at the bifurcation. B, Injection into the right common carotid artery.
Ieft carotid artery. Pulsation was diminished. The patient had mild hemiparesis of the right side and aphasia. EIectroencephaIography demonstrated a dysrhythmia in the right side of the temporal Iobe which was exaggerated by compression of the right common carotid artery. OphthaImodynamometry revealed equa1 diastolic readings of 55 mm. BiIateraI arteriograms of the carotid arteries showed a marked stenotic lesion in the Ieft interna carotid artery. (Fig. 2A and B.)
One month before admission, he experienced a sudden attack of nausea and dizziness associated with blurring of vision in both eyes. The next morning he had total Ioss of vision in the right eye. He noted flashing Iights and coIored “snowflakes” in this eye. The vision returned shortIy with subsequent awareness of a sector-like visua1 Ioss in the upper nasal field. The bIood pressure was equal in the two arms (170/100 mm. Hg). The resuIts of neuroIogic examination were within norma limits. Ophthalmodynamometry reveaIed a diastolic reading of 75 mm. in the right eye and 69 mm. in the Ieft eye. Bilateral arteriograms of the carotid arteries disclosed partial occIusion of the right internal carotid artery.
Comments: The pressures on the retina1 arteries in this patient were equa1 one year after onset of hemiparesis on the right side. Arteriography showed a marked stenosis of the Ieft interna carotid artery.
had a Comments: AIthough the patient history of retina1 artery insuffIciency on the right side, and the findings verified this, a diagnostic difference in pressure in the retina1 arteries was Iacking. The measured diastolic reading was higher on the side in which the interna carotid artery was occIuded.
Unilateral Total Occlusion of the Internal Carotid Artery. CASE IV. Sudden severe hemiparesis developed in the right side of a sixty-five year oId right-handed white woman. The hemiparesis, associated with mutism and stupor, occurred during hospitalization; the patient was recovering from amputation of a left lower extremity performed for vascuIar occIusive disease. Her bIood pressure was 160/90 mm. Hg in the right arm and 140/80 mm. Hg in the Ieft arm. PuIsation in the Ieft carotid artery was diminished and a bruit was heard. A hemiparesis of the right side was noted; this was associated with hyperrehexia and Babinski reffex on the right side. The patient had hypesthesia in the right side of her face and the cornea1 reflex in the right eye was absent.
CASE III. Sudden hemiparesis of the right side with slow improvement occurred in this patient. A forty-eight year old right-handed white man suddenIy experienced hemiparesis of the right side with aphasia one year before admission to the hospital. Improvement was sIow but definite. His bIood pressure was equa1 in the two arms (12080 mm. Hg.) A bruit was audible over the
662
OccIusive
Disease
of Carotid
FIG. zA. Case 111.Injection of radiopaquc mat&al into the Icft common car<~tid artery, Stenosis of the intern;ll carotid artery is demonstrated.
Arteries
Pulsation in the left carotid nrtcry \\;Is diminished; no bruit was audible. Ophthalmodynamometry revealed a pressure of 90 mm. diastolic in the right eye and 90 mm. diastolic in the left eye. Bilateral percutaneous artrriograms of the carotid arteries showctl cornplete occlusion in the left internal carotid artery.
Ophthalmodynamometry revealed a diastolic reading of 60 mm. in the right eye and 65 mm. in the left. A percutaneous arteriogram of the left carotid artery revealed compIete obstruction of the artery intracraniaily, above the point from which the ophthalmic artery branches. (Fig. 3.)
(Fig. 4.)
OccIusion of the left internal Comments: carotid artery was compIete. Ophtha[moclyn:~mometry was not diagnostic.
The occlusion of the internal Comments: carotid artery in this patient was located above the cavernous sinus. The pressure on the retinal artery was sIightIy higher on the side in which the carotid artery was occluded. Cask v. A sIo\+ly progressive neurologic deficit is exemplified in this case. A fifty-nine year old white man had a four year history of difficulty in reading, a three year history of gradual loss of USC of the right hand (spastic hemiparesis) and a two year history of expressive aphasia. One year beforc admission, the patient had a Jacksonian seizure which started on the right side and progressed to a generalized seizure. Another such seizure occurred just before admission to the hospital. His bIood pressure was equal in the two arms (r4o/84 mm. Hg). The patient flad both expressive and receptive aphasia. A right central facial palsy was present with a right hemiparesis. The deep tendon reflexes on the right side were increased and visua1 inattention was present on the right side.
663
Rilated Total Occlusion of the /nter?lal Carotid Artery. &SE VI. Transient attacks leading to permanent neurologic deficit is presented in this case report. A fifty-nine year old right-handed man had a history of syncopal episodes for many years. These attacks became more frequent seven months before acfmission and were associated n-ith numbness in the left cheek. Six months bcforc admissinn, weakness of the left part of his fact and hand, associated with sturrcd speech, developed. llis blood pressure was 180 IIO mm. I-lg in tflc right arm and 210. IIO mm. Hg in the left arm. The patient had slurred speech but no evidence of true aphasia. The left corncal refles and the gag rctlex were depressed. His strength \vas diminished in the left arm and hand. The patient had hyperreflexia in the left arm, but the rctlcxcs in the lower extremities were equal. Pulsation in the right carotid artery \vas diminishctl hut no bruit was heard.
Smith
and Hoyt
3B
3A
FIG. 3. Case IV. Injection of radiopaque material into the Ieft common carotid artery cavernous sinus with fiIIing of the ophthaImic artery is apparent.
(A and B). Obstruction
at the
A biIatera1 percutaneous angiogram of the carotid arteries and a transsterna1 aortogram were obtained which reveaIed compIete biIatera1 obstruction of the internal carotid artery. (Fig. 5A and B.) The intracrania1 portion of the left carotid artery fiIIed from the externa1 carotid artery via the left ophthaImic artery. (Fig. 5C.)
The results of electroencephaIography with compression of the carotid arteries were within norma limits. Ophthalmodynamometry readings were 50 mm. on the right and 45 mm. on the left.
Comments: OphthaImodynamometry in this case suggested a Iesion of the Ieft carotid artery. The resuhs of arteriography showed biIatera1 compIete occlusion of the internal carotid artery. The symptoms and neuroIogic findings for this patient suggested vertebral basiIar artery disease.
Unilateral
Artery.
Total Occlusion of tbe Common Carotid
CASEVII.
Exemplified in this case report are transient neuroIogic and visua1 symptoms suggesting vertebral basiIar insuffIciency. A sixty-one year old right-handed white man entered the hospital; he had a two week history of transient attacks of dizziness associated with bIurring of the left visua1 fieId. The carotid and superficia1 temporal pulses were diminished on the right side. A bruit was heard over the left carotid and the Ieft subcIavian arteries. Manual occlusion of the right carotid artery had no effect, but pressure on the Ieft carotid artery caused paresthesia in the right arm and Ieg and a hemianopsia in the Ieft eye which
FIG. 4. Case v. Injection of radiopaque materia1 into the Ieft common carotid artery demonstrating complete occlusion of the interna carotid artery.
664
Occhsive
Disease
of Carotid
Arteries
jC
FIG. 5. Case VI. A, Injection of radiopaque carotid artery could be demonstrated. B, radlopaque material Into the Ieft common stratcd after injection into the left common
material into the right common carotid artery. No filling of the internal there is no filling of the intcrna1 carotid artery following injection of carotrd artcry. C, cxtern;ll to Internal carotrd :~nast:lmosrs arc drmoncarotid :rrtery.
was more dense in the lower quadrant. His blood pressure was go/80 mm. Hg in the right arm and I IO :70 mm. Hg in the left arm. Neurologic examination revealed decreased perception of skin writing over the left side of the body and inferior quadrantanopsia in the left eye. Ophthalmodynamometry readings were equal (60 mm.). The results of angiography by the left carotid and right subclavian percutaneous routes showed total obstruction of the right common carotid
artery. The intracranial portion of the right carotid artery filled as a result of injection of the radiopaque material into the left common carotid artery. Comments: The patient’s symptoms and the defect in his visual field suggested vertebral hasiIar disease. The resuks of arteriography reveaIed tota obstruction of the right common carotid artery. Pressures on the retina1 arteries were equal. The coIIatera1 circuIation to the 6%
Smith and Hoyt right ophthaImic artery apparently the left interna carotid artery.
came from
COMMENTS
The cIinica1 correIation of symptoms, physicaI findings, pressures on the retina1 arteries and angiographic hndings is generalIy not diffrcuIt in patients with acute thrombosis of the carotid artery. OphthaImodynametric examination in such patients usuahy reflects a general reduction in bIood pressure in the invoIved carotid system [2-4~0, I 1,13,20,23]. The correIation of symptoms and findings in patients with chronic occIusive disease is more diffmuIt. The adaptabiIity of the cerebra1 vascuIar system to sIowIy progressive 0ccIusion of a major extracrania artery by the deveIopment of colIatera1 circuIation is common knowIedge. The retina1 artery may be suppIied by the externa1 carotid artery of either side as we11 as by retrograde flow in the interna carotid artery of the same side. Symptoms exhibited by such patients may in no way suggest that a carotid artery is occluded. Angiographic studies carried out in such patients often revea1 unexpected occIusion of a carotid artery. The cIinica1 usefulness of ophthaImodynamometry in the evaIuation of patients with Iong-standing occlusion of a carotid artery seems doubtfu1 to us. Certainly the finding of equa1 pressures on the retina1 arteries gives no assurance that occlusion of a common or an internal carotid artery does not exist; the finding of unequa1 pressures may be equaIIy misIeading. OphthaImodynamometric readings, therefore, cannot be used to the excIusion of angiography. SUMMARY
OphthaImodynamometry has been nondiagnostic or misIeading in tweIve out of twentytwo cases of angiographicahy verified occIusion of a carotid artery. Seven iIIustrative case reports are presented. The diagnostic vaIue of routine measurement of pressures on the retina1 arteries in patients with chronic cerebra1 vascuIar insufficiency is questioned. REFERENCES I. BAURMANN, M. Druckmessungen
au der NetzhautzentraIarterie. Ber. Versamml. deutsch. ophth. GeseIIsch., 51: 228, 1936. 2. BOSSI. R. and PISANI. C. Collateral cerebra1 circuIation through the ophthalmic artery and its efhciency in interna carotid occtusion. &it. J. Radiol., 28: 462, 1955.
3. CKOLL, nl., IIAKDY, W. G., LINDNEK, D. W., WEBSTER, J. E. and GURDJIAN, E. S. EvaIuation of ophthalmodynamometric and angiographic findings in patients with internal carotid artery thrombosis. J. Neurosurg., 17: 394, 1960. 4. ELSCHNIG, A. Uber den EinIIuss des VerschIusses der Arteria OpthaImica und der Carotis auf das Schorgan, von Graefes. Arch. Opbtb., 39: 151, 1893. 5. FIELDS, W. S., CRAWFORD, E. S., and DEBAKEY, M. E. Surgical considerations in cerebral arteria1 insufficiency. Neurology, 8: I I : 801, 1958. 6. HEYMAN, A., KARP, H. R. and BLOOR, B. M. Determination of retinal artery pressures in diagnosis of carotid artery occlusion. Neurology, 7: I: 97, ‘957. 7. HOLLENHORST, R. W. Ocular manifestations of insuffciency of thrombosis of the internal carotid artery. Tr. Am. Opbtb. Sot., 56: 474, 1958. 8. HOLLENHORST.R. W. OohthaImodvnamometrv and intracranial’ vascula; disease. “M. Clin. kortb America, 42: 4: 95 I, 1958. 9. HOYT, W. F. Some neuro-ophthalmological considerations in cerebral vascuIar insufficiency. Arch. Opbtb., 62: 26o0, 1959. IO. LIN, P. M. and SCOTT, M. CoIIateraI circuIation of the externa1 carotid artery and the interna carotid artery through the ophthalmic artery in cases of interna carotid artery thrombosis: report of hve cases. Radiology, 65: 5: 755, 1955. II. MARX, F. An arteriographic demonstration of I . collaterals between interna and externa1 carotid arteries. Acta Radiol., 31 : 2: 155, 1949. 12. MILETTI, M. Le diagnostic de Ia thrombose primitive de Ia carotide interne daus Ia region cervicale au moyen de Ia determination des vaIeues de Ia pression systolique de I’artere centraIe de la retine. Presse m&d., 54: 655, 1946. 13. SACHS. E.. JR. Arterioaraphic demonstration of coIIatera1 circuIation through ophthalmic artery in interna carotid artery thrombosis: report of two cases. J. Neurosurg., I : 4: 405, 1954. 14. SMITH, J. L., ZIEPER, I. H. and COGAN, D. G. Observations on ophthaImodynamometry. J. A. M. A., 170: 1403, 1959. 15. SMITH, J. L. and COCAN, D. G. The ophthatmodynamometric posture test. Am. J. Opbtb., 48: 6: Y
.
735, 1959. 16. SPALTER, H. F. OphthaImodynamometry and carotid artery thrombosis. Am. J. Opbtb., 47: 453, 1959. 17. SVIEN, H. J. and HOLLENHORST,R. W. Pressure in retinaI arteries after ligation or occlusion of the carotid artery. Proc. Staff Meet. Mayo Clin., 31: 684, 1956. 18. THOMAS, M. H. and PETROHELOS,M. A. Diagnostic significance of retinal artery pressure in interna carotid involvement; hndings in 8 cases with carotid artery lesions compared to 50 controls and 210 cases from the literature. Am. J. Oabtb.. A
36: 335. ‘953. 19. TINDALL, G. T., DUKES, H. T., CUPP, H. B., JR. and DAVID, N. J. SimuItaneous determinations of retina1 and carotid artery pressures. Neurology, IO: 623, 1960. 20. VAERNET, K. CoIIateraI ophthaImic artery circu-
Occhsive
Disease
of Carotid
I;ltion in thrombot ic wrotid occlusion. Neurolrq4: 605, 1954. 2~. VAU ALLEN, M. W. wd BLODI, F. C. Kc&al xtery blood pressure changes; with compression or ligntion of the wrotid :wtcrics. Am. J. O&b.. 45: 364, 1958. 22. VAN ALLEN. ht. W.. BLODI. F. C. and BRINTNALL. 17. S. Re&al n&y blood pressure measurements in diqnosis :tnd surgery of spontaneous carotid occlusions. J. Neurosur~., I$: rg, 1958. 23. \V\I.SII, I;. B. :~ntl KIUC, A. B. Ocular signs of
Arteries
RECKMAU~, P. nnd OSSESDOI~I+, I. Htwrtr~ilurlg der dcs intracraniellen Krcislaufs mit lfilti Netzh;tut;~rtcricndruckm~ssung. Dot. ophth. I>carl llx1g. 7: 183, 8: 264, ‘954. 25. WOOD, F. A. nnd Too~.e, J. I;. <:;rrotid ;wtcr? occlusion :~ncl its di:rgnosis by ol~llt[l;lllll(ldVI1:,momctry. J. A. ,kf. A., 16:: 1264, fc)j-.
667
From tbe Division oJ Neurological Surgery and tbe Department of Opbtbalmology, University of Calijornia School of Medicine, San Francisco, California.
measurement of pressures on the retinal arteries with the ophthaImodynamometer has been reported to be of value in the diagnosis of occlusive disease of the carotid arteries [r,6_8,r2,24,r~~19,21,22,24,2$]. It k generaIIy agreed that ophthalmodynamometry is valuable in the diagnosis of acute thrombosis of carotid arteries. Recently, much attention has been focused on the numerous patients with chronic or slowly progressive occlusions of the carotid arteries, and ophthaImodynamometry has been recommended for the evaluation of their condition. Some investigators have been enthusiastic about the reIiability of this procedure [6,14,15,17,18,22,24,25] and others have not been [3,5,9]. We have reviewed twenty-two case reports of occIusive disease of the carotid arteries, studied both by angiography and by ophthaImodynamometry, from the Neurosurgery Service at the H. C. MoffItt HospitaI. In twelve of these cases, the results of ophthalmodynamometric examination* were either nondiagnostic or misleading. The foIIowing seven case reports have been seIected to iIIustrate this problem.
T
HE
* Rleasurements of pressures on the retina1 arteries were performed with the BaiIIiart ophthalmodynamometer. OnIy diastohc readings were reported. Examination was performed with the patient in the supine position. The “posture test,” suggested by Smith and Cogan [IS], was used as was the comparison of systolic readings with the ophthaImodynamometer. In our experience, these additiona maneuvers did not change the concIusions indicated by the comparison of the diastolic readings alone. The resuIts of ophthalmodynamometry were considered to be nondiagnostic
AND
U:ILLIAM F. HOYT,
M.D.
REPORTS
CASE
Unilateral Subtotal Carotid Artery. CASE I. Slowly progressive hemiplegia on the right side is exemplified in this case. A fifty-three year old left-handed man was hospitalized. He had an eight week history of a defect in the right visual field associated with hemiplegia of the right side (more sevcrc in the Icg than the arm) which \vas slow in onset but was progressive. had become confused and mildly Th c patient aphasic. His blood pressure was equal in the two arms (r4oi90 mm. Hg). He had an aphasic expression, a right homonymous hemianopsia and a right hcmiparesis. Compression of the right common carotid artery produced syncope. Ophthalmodynamometry revealed equal diastolic readings in both eyes. Bilateral arteriograms of the carotid arteries showed almost complete obstruction of the left internal carotid artery. (Fig. IA and B.) Comments: suggest
the
the
internal
the
bifurcation
Ophthalmodynamometry presence carotid
of near artery
of the
on the
carotid
did
tota
occIusion left
side
not of near
artery.
CASE II. Intermittent neurologic symptoms, incIuding blurring of vision is exemplified in this case. A sixty-two year old white man entered the hospital \vith a one year history of intermittent numbness in the left arm associated with blurred vision which was more noticeable in the right eye than in the left.
(for practica1 purposes, equal) when the difference in the two rcndings was Iess than 5 mm. for readings below 50 mm. and less than IO mm. for readings above 60 mm. (such criteria were suggested by HoIIenhorst because of the variations found in norma persons and the inaccuracies inherent in the technic [7].
Smith and Hoyt
IB
IA
FIG. I. Case I. A, Injection of radiopaque materia1 into the Ieft common carotid artery. There is a stenotic Iesion of the internal carotid artery at the bifurcation. B, Injection into the right common carotid artery.
Ieft carotid artery. Pulsation was diminished. The patient had mild hemiparesis of the right side and aphasia. EIectroencephaIography demonstrated a dysrhythmia in the right side of the temporal Iobe which was exaggerated by compression of the right common carotid artery. OphthaImodynamometry revealed equa1 diastolic readings of 55 mm. BiIateraI arteriograms of the carotid arteries showed a marked stenotic lesion in the Ieft interna carotid artery. (Fig. 2A and B.)
One month before admission, he experienced a sudden attack of nausea and dizziness associated with blurring of vision in both eyes. The next morning he had total Ioss of vision in the right eye. He noted flashing Iights and coIored “snowflakes” in this eye. The vision returned shortIy with subsequent awareness of a sector-like visua1 Ioss in the upper nasal field. The bIood pressure was equal in the two arms (170/100 mm. Hg). The resuIts of neuroIogic examination were within norma limits. Ophthalmodynamometry reveaIed a diastolic reading of 75 mm. in the right eye and 69 mm. in the Ieft eye. Bilateral arteriograms of the carotid arteries disclosed partial occIusion of the right internal carotid artery.
Comments: The pressures on the retina1 arteries in this patient were equa1 one year after onset of hemiparesis on the right side. Arteriography showed a marked stenosis of the Ieft interna carotid artery.
had a Comments: AIthough the patient history of retina1 artery insuffIciency on the right side, and the findings verified this, a diagnostic difference in pressure in the retina1 arteries was Iacking. The measured diastolic reading was higher on the side in which the interna carotid artery was occIuded.
Unilateral Total Occlusion of the Internal Carotid Artery. CASE IV. Sudden severe hemiparesis developed in the right side of a sixty-five year oId right-handed white woman. The hemiparesis, associated with mutism and stupor, occurred during hospitalization; the patient was recovering from amputation of a left lower extremity performed for vascuIar occIusive disease. Her bIood pressure was 160/90 mm. Hg in the right arm and 140/80 mm. Hg in the Ieft arm. PuIsation in the Ieft carotid artery was diminished and a bruit was heard. A hemiparesis of the right side was noted; this was associated with hyperrehexia and Babinski reffex on the right side. The patient had hypesthesia in the right side of her face and the cornea1 reflex in the right eye was absent.
CASE III. Sudden hemiparesis of the right side with slow improvement occurred in this patient. A forty-eight year old right-handed white man suddenIy experienced hemiparesis of the right side with aphasia one year before admission to the hospital. Improvement was sIow but definite. His bIood pressure was equa1 in the two arms (12080 mm. Hg.) A bruit was audible over the
662
OccIusive
Disease
of Carotid
FIG. zA. Case 111.Injection of radiopaquc mat&al into the Icft common car<~tid artery, Stenosis of the intern;ll carotid artery is demonstrated.
Arteries
Pulsation in the left carotid nrtcry \\;Is diminished; no bruit was audible. Ophthalmodynamometry revealed a pressure of 90 mm. diastolic in the right eye and 90 mm. diastolic in the left eye. Bilateral percutaneous artrriograms of the carotid arteries showctl cornplete occlusion in the left internal carotid artery.
Ophthalmodynamometry revealed a diastolic reading of 60 mm. in the right eye and 65 mm. in the left. A percutaneous arteriogram of the left carotid artery revealed compIete obstruction of the artery intracraniaily, above the point from which the ophthalmic artery branches. (Fig. 3.)
(Fig. 4.)
OccIusion of the left internal Comments: carotid artery was compIete. Ophtha[moclyn:~mometry was not diagnostic.
The occlusion of the internal Comments: carotid artery in this patient was located above the cavernous sinus. The pressure on the retinal artery was sIightIy higher on the side in which the carotid artery was occluded. Cask v. A sIo\+ly progressive neurologic deficit is exemplified in this case. A fifty-nine year old white man had a four year history of difficulty in reading, a three year history of gradual loss of USC of the right hand (spastic hemiparesis) and a two year history of expressive aphasia. One year beforc admission, the patient had a Jacksonian seizure which started on the right side and progressed to a generalized seizure. Another such seizure occurred just before admission to the hospital. His bIood pressure was equal in the two arms (r4o/84 mm. Hg). The patient flad both expressive and receptive aphasia. A right central facial palsy was present with a right hemiparesis. The deep tendon reflexes on the right side were increased and visua1 inattention was present on the right side.
663
Rilated Total Occlusion of the /nter?lal Carotid Artery. &SE VI. Transient attacks leading to permanent neurologic deficit is presented in this case report. A fifty-nine year old right-handed man had a history of syncopal episodes for many years. These attacks became more frequent seven months before acfmission and were associated n-ith numbness in the left cheek. Six months bcforc admissinn, weakness of the left part of his fact and hand, associated with sturrcd speech, developed. llis blood pressure was 180 IIO mm. I-lg in tflc right arm and 210. IIO mm. Hg in the left arm. The patient had slurred speech but no evidence of true aphasia. The left corncal refles and the gag rctlex were depressed. His strength \vas diminished in the left arm and hand. The patient had hyperreflexia in the left arm, but the rctlcxcs in the lower extremities were equal. Pulsation in the right carotid artery \vas diminishctl hut no bruit was heard.
Smith
and Hoyt
3B
3A
FIG. 3. Case IV. Injection of radiopaque material into the Ieft common carotid artery cavernous sinus with fiIIing of the ophthaImic artery is apparent.
(A and B). Obstruction
at the
A biIatera1 percutaneous angiogram of the carotid arteries and a transsterna1 aortogram were obtained which reveaIed compIete biIatera1 obstruction of the internal carotid artery. (Fig. 5A and B.) The intracrania1 portion of the left carotid artery fiIIed from the externa1 carotid artery via the left ophthaImic artery. (Fig. 5C.)
The results of electroencephaIography with compression of the carotid arteries were within norma limits. Ophthalmodynamometry readings were 50 mm. on the right and 45 mm. on the left.
Comments: OphthaImodynamometry in this case suggested a Iesion of the Ieft carotid artery. The resuhs of arteriography showed biIatera1 compIete occlusion of the internal carotid artery. The symptoms and neuroIogic findings for this patient suggested vertebral basiIar artery disease.
Unilateral
Artery.
Total Occlusion of tbe Common Carotid
CASEVII.
Exemplified in this case report are transient neuroIogic and visua1 symptoms suggesting vertebral basiIar insuffIciency. A sixty-one year old right-handed white man entered the hospital; he had a two week history of transient attacks of dizziness associated with bIurring of the left visua1 fieId. The carotid and superficia1 temporal pulses were diminished on the right side. A bruit was heard over the left carotid and the Ieft subcIavian arteries. Manual occlusion of the right carotid artery had no effect, but pressure on the Ieft carotid artery caused paresthesia in the right arm and Ieg and a hemianopsia in the Ieft eye which
FIG. 4. Case v. Injection of radiopaque materia1 into the Ieft common carotid artery demonstrating complete occlusion of the interna carotid artery.
664
Occhsive
Disease
of Carotid
Arteries
jC
FIG. 5. Case VI. A, Injection of radiopaque carotid artery could be demonstrated. B, radlopaque material Into the Ieft common stratcd after injection into the left common
material into the right common carotid artery. No filling of the internal there is no filling of the intcrna1 carotid artery following injection of carotrd artcry. C, cxtern;ll to Internal carotrd :~nast:lmosrs arc drmoncarotid :rrtery.
was more dense in the lower quadrant. His blood pressure was go/80 mm. Hg in the right arm and I IO :70 mm. Hg in the left arm. Neurologic examination revealed decreased perception of skin writing over the left side of the body and inferior quadrantanopsia in the left eye. Ophthalmodynamometry readings were equal (60 mm.). The results of angiography by the left carotid and right subclavian percutaneous routes showed total obstruction of the right common carotid
artery. The intracranial portion of the right carotid artery filled as a result of injection of the radiopaque material into the left common carotid artery. Comments: The patient’s symptoms and the defect in his visual field suggested vertebral hasiIar disease. The resuks of arteriography reveaIed tota obstruction of the right common carotid artery. Pressures on the retina1 arteries were equal. The coIIatera1 circuIation to the 6%
Smith and Hoyt right ophthaImic artery apparently the left interna carotid artery.
came from
COMMENTS
The cIinica1 correIation of symptoms, physicaI findings, pressures on the retina1 arteries and angiographic hndings is generalIy not diffrcuIt in patients with acute thrombosis of the carotid artery. OphthaImodynametric examination in such patients usuahy reflects a general reduction in bIood pressure in the invoIved carotid system [2-4~0, I 1,13,20,23]. The correIation of symptoms and findings in patients with chronic occIusive disease is more diffmuIt. The adaptabiIity of the cerebra1 vascuIar system to sIowIy progressive 0ccIusion of a major extracrania artery by the deveIopment of colIatera1 circuIation is common knowIedge. The retina1 artery may be suppIied by the externa1 carotid artery of either side as we11 as by retrograde flow in the interna carotid artery of the same side. Symptoms exhibited by such patients may in no way suggest that a carotid artery is occluded. Angiographic studies carried out in such patients often revea1 unexpected occIusion of a carotid artery. The cIinica1 usefulness of ophthaImodynamometry in the evaIuation of patients with Iong-standing occlusion of a carotid artery seems doubtfu1 to us. Certainly the finding of equa1 pressures on the retina1 arteries gives no assurance that occlusion of a common or an internal carotid artery does not exist; the finding of unequa1 pressures may be equaIIy misIeading. OphthaImodynamometric readings, therefore, cannot be used to the excIusion of angiography. SUMMARY
OphthaImodynamometry has been nondiagnostic or misIeading in tweIve out of twentytwo cases of angiographicahy verified occIusion of a carotid artery. Seven iIIustrative case reports are presented. The diagnostic vaIue of routine measurement of pressures on the retina1 arteries in patients with chronic cerebra1 vascuIar insufficiency is questioned. REFERENCES I. BAURMANN, M. Druckmessungen
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3. CKOLL, nl., IIAKDY, W. G., LINDNEK, D. W., WEBSTER, J. E. and GURDJIAN, E. S. EvaIuation of ophthalmodynamometric and angiographic findings in patients with internal carotid artery thrombosis. J. Neurosurg., 17: 394, 1960. 4. ELSCHNIG, A. Uber den EinIIuss des VerschIusses der Arteria OpthaImica und der Carotis auf das Schorgan, von Graefes. Arch. Opbtb., 39: 151, 1893. 5. FIELDS, W. S., CRAWFORD, E. S., and DEBAKEY, M. E. Surgical considerations in cerebral arteria1 insufficiency. Neurology, 8: I I : 801, 1958. 6. HEYMAN, A., KARP, H. R. and BLOOR, B. M. Determination of retinal artery pressures in diagnosis of carotid artery occlusion. Neurology, 7: I: 97, ‘957. 7. HOLLENHORST, R. W. Ocular manifestations of insuffciency of thrombosis of the internal carotid artery. Tr. Am. Opbtb. Sot., 56: 474, 1958. 8. HOLLENHORST.R. W. OohthaImodvnamometrv and intracranial’ vascula; disease. “M. Clin. kortb America, 42: 4: 95 I, 1958. 9. HOYT, W. F. Some neuro-ophthalmological considerations in cerebral vascuIar insufficiency. Arch. Opbtb., 62: 26o0, 1959. IO. LIN, P. M. and SCOTT, M. CoIIateraI circuIation of the externa1 carotid artery and the interna carotid artery through the ophthalmic artery in cases of interna carotid artery thrombosis: report of hve cases. Radiology, 65: 5: 755, 1955. II. MARX, F. An arteriographic demonstration of I . collaterals between interna and externa1 carotid arteries. Acta Radiol., 31 : 2: 155, 1949. 12. MILETTI, M. Le diagnostic de Ia thrombose primitive de Ia carotide interne daus Ia region cervicale au moyen de Ia determination des vaIeues de Ia pression systolique de I’artere centraIe de la retine. Presse m&d., 54: 655, 1946. 13. SACHS. E.. JR. Arterioaraphic demonstration of coIIatera1 circuIation through ophthalmic artery in interna carotid artery thrombosis: report of two cases. J. Neurosurg., I : 4: 405, 1954. 14. SMITH, J. L., ZIEPER, I. H. and COGAN, D. G. Observations on ophthaImodynamometry. J. A. M. A., 170: 1403, 1959. 15. SMITH, J. L. and COCAN, D. G. The ophthatmodynamometric posture test. Am. J. Opbtb., 48: 6: Y
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735, 1959. 16. SPALTER, H. F. OphthaImodynamometry and carotid artery thrombosis. Am. J. Opbtb., 47: 453, 1959. 17. SVIEN, H. J. and HOLLENHORST,R. W. Pressure in retinaI arteries after ligation or occlusion of the carotid artery. Proc. Staff Meet. Mayo Clin., 31: 684, 1956. 18. THOMAS, M. H. and PETROHELOS,M. A. Diagnostic significance of retinal artery pressure in interna carotid involvement; hndings in 8 cases with carotid artery lesions compared to 50 controls and 210 cases from the literature. Am. J. Oabtb.. A
36: 335. ‘953. 19. TINDALL, G. T., DUKES, H. T., CUPP, H. B., JR. and DAVID, N. J. SimuItaneous determinations of retina1 and carotid artery pressures. Neurology, IO: 623, 1960. 20. VAERNET, K. CoIIateraI ophthaImic artery circu-
Occhsive
Disease
of Carotid
I;ltion in thrombot ic wrotid occlusion. Neurolrq4: 605, 1954. 2~. VAU ALLEN, M. W. wd BLODI, F. C. Kc&al xtery blood pressure changes; with compression or ligntion of the wrotid :wtcrics. Am. J. O&b.. 45: 364, 1958. 22. VAN ALLEN. ht. W.. BLODI. F. C. and BRINTNALL. 17. S. Re&al n&y blood pressure measurements in diqnosis :tnd surgery of spontaneous carotid occlusions. J. Neurosur~., I$: rg, 1958. 23. \V\I.SII, I;. B. :~ntl KIUC, A. B. Ocular signs of
Arteries
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