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Images in Neurology
January 2019

Global Orbital Infarction Syndrome After a Carotid Artery Dissection

Author Affiliations
  • 1Service of Neurology, University Hospital “Central de Asturias,” Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
JAMA Neurol. 2019;76(1):111-112. doi:10.1001/jamaneurol.2018.2880

A 59-year-old man with a history of smoking and chronic bronchitis was admitted to the hospital with a sudden-onset episode of right oculocephalic deviation, homonymous hemianopsia, anosognosia, asomatognosia, hemihypoesthesia, and left-sided hemiplegia because of an ischemic stroke in the right middle cerebral artery. Angiographic imaging suggested a cervical internal carotid artery (ICA) dissection with tandem extracranial ICA–terminal ICA occlusion and ophthalmic artery (OA) compromise (Figure 1A). The patient was treated with emergency angioplasty and stenting of the cervical ICA and mechanical thrombectomy of the intracranial occlusion, which achieved a successful recanalization. At the end of procedure, a progressive visual acuity impairment, ophthalmoparesis, mydriasis, ptosis, proptosis, and chemosis on his right eye were noted (Figure 1B). A fundus examination showed macular edema and ischemic retinal signs without intravascular thrombosis, hemorrhage, exudates, dilation, nor tortuosity of vessels. Laboratory screening, including tests of thyrotropin level, autoantibodies, serum IG4 levels, and the erythrocyte sedimentation rate, as well as a second angiography, showed no abnormalities. Orbital computed tomographic and magnetic resonance imaging studies showed moderate proptosis because of extraocular muscle and orbital fat swelling (Figure 2B). A T2 diffusion-weighted magnetic resonance image revealed hyperintensity along the right optic nerve in the optic canal, eyelid elevator, and external and superior ocular muscles (Figure 2A). Antiedema treatment with mannitol and steroids was administered, leading to improvement of proptosis and ocular motility but persistence of amaurosis. Three months after discharge, the patient was fully independent, but the visual loss remained.