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Orbital bruits and retinal artery pressure in internal carotid artery occlusion
ORBITAL BRUITS AND RETINAL ARTERY PRESSURE IN INTERNAL CAROTID ARTERY OCCLUSION
M. Lauritzen*, J. A lving and O.B. Paulson
SUMMARY Four patients are reported with orbital bruits. They had minor neurological deficits and all proved to have occlusion of the contralateral internal carotid artery. In three of the patients the retinal artery pressures were normal with no side to side difference, whereas pressure was slightly reduced on the occluded side in one patient. These observations give further evidence that an orbital bruit may indicate occlusion of the contralateral carotid artery with good collateral circulation.
INTRODUCTION
Decreased pressure in the central retinal artery is a common feature in occlusion of the internal carotid artery, especially in patients with marked neurological deficits (PAULSON, 1976). An unreduced retinal artery pressure ipsilateral to a symptomatic occlusion of the carotid artery is considered uncommon. If present, it indicates an effective collateral flow, either through the external carotid artery or through the circle of Willis. Orbital bruits occur in cerebrovascular diseases and suggest an occlusion of the contralateral internal or common carotid artery (DALSGAARD-NIELSEN, 1939; MACKENZIE, 1955; FISHER, 1957). The orbital bruit is explained by an increased flow rate in the internal carotid artery (due to occlusion of the contralateral carotid artery) giving rise to turbulence and a vascular murmur which becomes audible on auscultation of the orbit. An orbital bruit might therefore be a sign of good collateral circulation. The present study deals with the various aspects of collateral circulation and describes four patients with internal carotid artery occlusion, orbital bruits, and normal or near normal pressure in the central retinal arteries. MATERIALAND METHODS Four patients with orbital bruits were studied. All had minor neurological deficits
* Department of Neurology. Rigshospitalet, State University Hospital, Blegdamsvej 9, DLK-2100 Copenhagen. Denmark Clin. Neurol. Neurosurg. 1981. Vol. 83-1. (accepted 30.1.81).
and angiography subsequently demonstrated an occlusion in the extracranial portion of one of the internal carotid arteries. Retinal artery pressure was measured by an ordinary ophthalmodynamometer ad m o d u m Baillard as gram pressure which had to be applied to the ocular bulb to collapse the retinal arteries in the diastole. Systolic pressure was only measured in one of the patients. All patients were studied supine as well as erect. The material was selected over a period of a few years among patients submitted for cerebrovascular diseases at the department of neurology at Rigshospitalet. In many of the patients auscultation of the orbits was performed routinely. In cases 1 to 3 the orbital bruit, among other clinical signs, was the indication for the angiogram, while cerebral infarction was the indication in case 4.
CASE l
A 59-year-old woman experienced an attack of transient blurred vision of both eyes, remitting after half an hour and followed by a diffuse headache. There was no accompanying nausea or vomiting. Six weeks later she experienced left-sided hemiparaesthesia and heaviness in the limbs of the left side. The symptoms subsided gradually but incompletely during the following days. Examination revealed no detectable pulse in the fight carotid artery. There were bilateral orbital bruits, most pronounced on the left side and a systolic bruit over the left common carotid artery, but no cardiac murmurs. Retinal artery pressure measurement on both sides showed no differences, measurements being -/42 gram on both sides in the supine position and 108/37 gram on both sides in the sitting position. The patient had slight hypaesthesia over the left side of the face and the tendon jerks were more brisk on the left side. Otherwise the neurological examination was normal. Aortic arch angiography showed occlusion of the fight common carotid artery and a stenosis of the left common carotid artery. EEG and isotope brain scan were normal.
CASE 2
A 65-year-old man had for I I/z year complained of clumsiness of the left hand, difficulty in controlling the left arm and slight left-sided numbness. Examination revealed pulsation of both carotids in the neck, no carotid or cardiac bruits, but a clear left-sided orbital bruit. Retinal artery pressures were: in the supine-position -/25 gram on both sides and erect -/20 gram on both sides. The patient suffered from slight incoordination on the left side, with an impaired joint position sense, graphaesthesia in the left palm and discrete constructional apraxia. Apart from this the neurological examination was normal. Right-sided carotid angiography showed occlusion of the right internal carotid artery. Left-sided angiography was not performed. EEG was normal.
CASE 3
A 41-year-old man had for several months complained of slight left-sided paraesthesia and weakness. In addition he complained of a persistent pulsesynchronous headache which was most pronounced over the left ear. Examination revealed pulsation of both carotid arteries in the neck. A systolic bruit was present over the upper part of the left carotid artery and the left side of the forehead, being at its maximum over the orbit. There were no cardiac murmurs. The retinal artery pressures were -/22, -/34 gram (right and left side, respectively) in the supine position. The patient had a slight left-sided weakness with slightly hyperactive tendon reflexes and an atypical left-sided plantar response and left-sided dysaesthesia. Otherwise the neurological examination was normal. Angiography showed an occlusion of the right internal carotid artery and severe stenosis of the left internal carotid corresponding to the carotid siphon. CASE 4
A 62-year-old man with pulmonary fibrosis was referred to our hospital because of partial seizures in the left extremities. Examination revealed pulsation of both carotid arteries in the neck with a bruit over the left orbit and the left common carotid artery. Retinal artery pressures were -/25 gram in the supine position and -/23 gram in the erect position on both sides. The patient suffered from lack of co-ordination on the left side, slight paresis of the left leg while the tendon reflexes were more brisk on the left side. Angiography showed an occlusion of the right internal carotid artery and a moderate stenosis of the left carotid artery. Isotope brain scan showed infarction in the right hemisphere. DISCUSSION
In all patients the carotid artery occlusion was radiographically verified. The orbital bruits were most pronounced or only audible on the non-occluded side. Retinal artery pressure was the same (and within normal range) on both eyes in case 1, 2 and 4, while in case 3 it was slightly lower on the occluded side. Neurological deficits were minor. The slight reduction of the retinal artery pressure is in accordance with previous findings in occlusive carotid disease, in patients with minor deficits or transient ischemic attacks (PAULSON, 1976; VUSON and "rOOLE, 1976). Orbital bruits in patients with internal carotid artery occlusion have been attributed to increased blood supply to the affected territory from other parts of the vascular tree (FISCHER, 1957; WADIA and MONCKTON, 1957; ALLAN and MUSTIAN, 1962; RENNIE el al., 1964). The correlation in our patients between normal or near-normal central retinal artery pressure, minor neurological deficits and orbital bruits makes this explanation most likely. These observations emphasize the valuable information which can be obtained by combining auscultation of the skull with ophthalmodynamometry.
10 REFERENCES ALLEN, N. and v. MUSTXAN(1962) Origin and significance of vascular m u r m u r s in the head and neck. Medicine 41:227. DALSGAARD-t~IELSEt~,T. (1939) Studies on intracranial vascular sounds. Acta Psychiat. (Kbh.) 14:69. FISHER, ¢.M. (1957) Cranial bruits associated with occlusion of the internal carotid artery. Neurology 7:299. MACKENZIE, I. (1955) The intracranial bruit. Brain 78:350. PAULSON, O.B. (1976) O p h t h a l m o d y n a m o m e t r y in internal carotid artery occlusion. Stroke 7:564. RENNIE, L., B. EJRUP, and F.H. MCDOWELL (1964) Arterial bruits in cerebrovascular disease. Neurology 14:751. WADIA, N.H. and G. MONCKTON(1957) Intracranial bruits in health and disease. Brain 80:492. YUSON, C.P. and J.F. TOOLE (1976) Bruits, o p h t h a l m o d y n a m o m e t r y and rectilinear scanning on transient ischemic attachs. Stroke 7:541.
M. Lauritzen*, J. A lving and O.B. Paulson
SUMMARY Four patients are reported with orbital bruits. They had minor neurological deficits and all proved to have occlusion of the contralateral internal carotid artery. In three of the patients the retinal artery pressures were normal with no side to side difference, whereas pressure was slightly reduced on the occluded side in one patient. These observations give further evidence that an orbital bruit may indicate occlusion of the contralateral carotid artery with good collateral circulation.
INTRODUCTION
Decreased pressure in the central retinal artery is a common feature in occlusion of the internal carotid artery, especially in patients with marked neurological deficits (PAULSON, 1976). An unreduced retinal artery pressure ipsilateral to a symptomatic occlusion of the carotid artery is considered uncommon. If present, it indicates an effective collateral flow, either through the external carotid artery or through the circle of Willis. Orbital bruits occur in cerebrovascular diseases and suggest an occlusion of the contralateral internal or common carotid artery (DALSGAARD-NIELSEN, 1939; MACKENZIE, 1955; FISHER, 1957). The orbital bruit is explained by an increased flow rate in the internal carotid artery (due to occlusion of the contralateral carotid artery) giving rise to turbulence and a vascular murmur which becomes audible on auscultation of the orbit. An orbital bruit might therefore be a sign of good collateral circulation. The present study deals with the various aspects of collateral circulation and describes four patients with internal carotid artery occlusion, orbital bruits, and normal or near normal pressure in the central retinal arteries. MATERIALAND METHODS Four patients with orbital bruits were studied. All had minor neurological deficits
* Department of Neurology. Rigshospitalet, State University Hospital, Blegdamsvej 9, DLK-2100 Copenhagen. Denmark Clin. Neurol. Neurosurg. 1981. Vol. 83-1. (accepted 30.1.81).
and angiography subsequently demonstrated an occlusion in the extracranial portion of one of the internal carotid arteries. Retinal artery pressure was measured by an ordinary ophthalmodynamometer ad m o d u m Baillard as gram pressure which had to be applied to the ocular bulb to collapse the retinal arteries in the diastole. Systolic pressure was only measured in one of the patients. All patients were studied supine as well as erect. The material was selected over a period of a few years among patients submitted for cerebrovascular diseases at the department of neurology at Rigshospitalet. In many of the patients auscultation of the orbits was performed routinely. In cases 1 to 3 the orbital bruit, among other clinical signs, was the indication for the angiogram, while cerebral infarction was the indication in case 4.
CASE l
A 59-year-old woman experienced an attack of transient blurred vision of both eyes, remitting after half an hour and followed by a diffuse headache. There was no accompanying nausea or vomiting. Six weeks later she experienced left-sided hemiparaesthesia and heaviness in the limbs of the left side. The symptoms subsided gradually but incompletely during the following days. Examination revealed no detectable pulse in the fight carotid artery. There were bilateral orbital bruits, most pronounced on the left side and a systolic bruit over the left common carotid artery, but no cardiac murmurs. Retinal artery pressure measurement on both sides showed no differences, measurements being -/42 gram on both sides in the supine position and 108/37 gram on both sides in the sitting position. The patient had slight hypaesthesia over the left side of the face and the tendon jerks were more brisk on the left side. Otherwise the neurological examination was normal. Aortic arch angiography showed occlusion of the fight common carotid artery and a stenosis of the left common carotid artery. EEG and isotope brain scan were normal.
CASE 2
A 65-year-old man had for I I/z year complained of clumsiness of the left hand, difficulty in controlling the left arm and slight left-sided numbness. Examination revealed pulsation of both carotids in the neck, no carotid or cardiac bruits, but a clear left-sided orbital bruit. Retinal artery pressures were: in the supine-position -/25 gram on both sides and erect -/20 gram on both sides. The patient suffered from slight incoordination on the left side, with an impaired joint position sense, graphaesthesia in the left palm and discrete constructional apraxia. Apart from this the neurological examination was normal. Right-sided carotid angiography showed occlusion of the right internal carotid artery. Left-sided angiography was not performed. EEG was normal.
CASE 3
A 41-year-old man had for several months complained of slight left-sided paraesthesia and weakness. In addition he complained of a persistent pulsesynchronous headache which was most pronounced over the left ear. Examination revealed pulsation of both carotid arteries in the neck. A systolic bruit was present over the upper part of the left carotid artery and the left side of the forehead, being at its maximum over the orbit. There were no cardiac murmurs. The retinal artery pressures were -/22, -/34 gram (right and left side, respectively) in the supine position. The patient had a slight left-sided weakness with slightly hyperactive tendon reflexes and an atypical left-sided plantar response and left-sided dysaesthesia. Otherwise the neurological examination was normal. Angiography showed an occlusion of the right internal carotid artery and severe stenosis of the left internal carotid corresponding to the carotid siphon. CASE 4
A 62-year-old man with pulmonary fibrosis was referred to our hospital because of partial seizures in the left extremities. Examination revealed pulsation of both carotid arteries in the neck with a bruit over the left orbit and the left common carotid artery. Retinal artery pressures were -/25 gram in the supine position and -/23 gram in the erect position on both sides. The patient suffered from lack of co-ordination on the left side, slight paresis of the left leg while the tendon reflexes were more brisk on the left side. Angiography showed an occlusion of the right internal carotid artery and a moderate stenosis of the left carotid artery. Isotope brain scan showed infarction in the right hemisphere. DISCUSSION
In all patients the carotid artery occlusion was radiographically verified. The orbital bruits were most pronounced or only audible on the non-occluded side. Retinal artery pressure was the same (and within normal range) on both eyes in case 1, 2 and 4, while in case 3 it was slightly lower on the occluded side. Neurological deficits were minor. The slight reduction of the retinal artery pressure is in accordance with previous findings in occlusive carotid disease, in patients with minor deficits or transient ischemic attacks (PAULSON, 1976; VUSON and "rOOLE, 1976). Orbital bruits in patients with internal carotid artery occlusion have been attributed to increased blood supply to the affected territory from other parts of the vascular tree (FISCHER, 1957; WADIA and MONCKTON, 1957; ALLAN and MUSTIAN, 1962; RENNIE el al., 1964). The correlation in our patients between normal or near-normal central retinal artery pressure, minor neurological deficits and orbital bruits makes this explanation most likely. These observations emphasize the valuable information which can be obtained by combining auscultation of the skull with ophthalmodynamometry.
10 REFERENCES ALLEN, N. and v. MUSTXAN(1962) Origin and significance of vascular m u r m u r s in the head and neck. Medicine 41:227. DALSGAARD-t~IELSEt~,T. (1939) Studies on intracranial vascular sounds. Acta Psychiat. (Kbh.) 14:69. FISHER, ¢.M. (1957) Cranial bruits associated with occlusion of the internal carotid artery. Neurology 7:299. MACKENZIE, I. (1955) The intracranial bruit. Brain 78:350. PAULSON, O.B. (1976) O p h t h a l m o d y n a m o m e t r y in internal carotid artery occlusion. Stroke 7:564. RENNIE, L., B. EJRUP, and F.H. MCDOWELL (1964) Arterial bruits in cerebrovascular disease. Neurology 14:751. WADIA, N.H. and G. MONCKTON(1957) Intracranial bruits in health and disease. Brain 80:492. YUSON, C.P. and J.F. TOOLE (1976) Bruits, o p h t h a l m o d y n a m o m e t r y and rectilinear scanning on transient ischemic attachs. Stroke 7:541.