Amalric choroidal infarction, retinal artery occlusion, and ischemic optic neuropathy: Delayed presentations of traumatic internal carotid artery dissection

Abstract

Purpose: This case report describes the delayed, uncommon ophthalmic presentations of monocular choroidal ischemia (Amalric triangular sign), ischemic optic neuropathy, central retinal artery occlusion (CRAO), and extraocular motility restriction caused by traumatic internal carotid artery dissection (ICAD) in a young individual.

Observations: A 29-year-old man presented with sudden vision loss in his left eye which had started 7 h earlier. His medical history included a motorcycle accident six months prior, where he struck his chin on the ground and lost consciousness. At that time, he had completely recovered with no complications. On the day the patient reported with vision problem, an ophthalmic examination of the affected eye revealed visual acuity of no perception of light (NPL), restriction of extraocular movement, and relative afferent pupillary defect. Fundus examination showed slightly pale optic disc swelling, macular whitening with a cherry red spot appearance indicating the presence of CRAO, and several whitish triangular patches in the peripheral retina. Fundus fluorescein angiography revealed delayed arm to choroidal and retinal circulations in the early phase, with hyperfluorescence and hyperfluorescent staining along the areas of whitening triangular patches in the later phase. Carotid doppler ultrasonography and magnetic resonance angiography confirmed an extracranial left ICAD. After the 3-month follow up, the patient's vision remained NPL with hypo/hyperpigmentation changes along the previous whitish patches in the peripheral retina.

Conclusion and importance: This case underscores the delayed onset of ocular ischemic symptoms associated with ICAD following head and neck trauma in young individuals. Despite the low risk, patients may need to be informed about the possibility of these late occurring ophthalmic complications and physicians need to stay vigilant for these conditions, which may arise months after the initial trauma.

Keywords: Amalric choroidal infarction; Carotid artery dissection; Ischemic optic neuropathy; Retinal artery occlusion; Trauma.

Fig. 1

On presentation, ocular motility showing limitation in almost all directions in the left eye.

Fig. 2

On presentation, a color fundus photograph illustrating multiple whitish triangular patches in the peripheral retina corresponding to choroidal infarction and retinal whitening over posterior pole corresponding to retinal artery occlusion (A). Optical coherence tomography demonstraing diffuse retinal thickening and loss of entire retinal layer boundaries (B). (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Fig. 3

Fundus fluorescein angiography showing a delayed in choroidal and retinal filling time in an early phase taken at 26 seconds (A) hyperfluorescence of the choroid in the corresponding triangular whitening area on fundus examination and retinal vasuclar filling defect over the macular area taken at 1.05 minutes (B) and 1.43 minutes (C) hyperfluorescent staining of the choroidal infarction area and disc leakage in late phase taken at 10.18 minutes (D).

Fig. 4

Carotid doppler ultrasound displaying intraluminal echogenicity within the proximal ICA (arrow) (A) and an absence of flow in the remaining ICA (arrow head) (B).

Fig. 5

Magnetic resonance imaging showing an eccentric filling defect along anterior wall of left carotid bulb extending to bifurcation (yellow arrow head) (A) T2-hypointense image showing acute intramural hematoma (arrow) (B) and Diffusion-weighted magnetic resonance imaging (DWI) showing restricted diffusion of the left optic nerve (white arrow head) (C). (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Fig. 6

At three-month follow-up, a color fundus photograph presenting hyperpigmentation in the preceding choroidal ischemic area and optic disc atrophy (A). Optical coherence tomography showing generalized thinning and disorganization of all retinal layers (B). (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)