Disease of the Year: Cerebrovascular Disorders

Editorial Disease of the Year: Cerebrovascular Disorders Koto Ishida, MD, Valérie Biousse, MD A lthough the global incidence, prevalence, and mortality of stroke are decreasing, given the growing and aging population, the overall burden of stroke remains exceptionally high and the absolute number of people affected by stroke is on the rise. Worldwide, 80 million people were estimated to have been survivors of stroke in 2016 (1). This global burden of stroke highlights the need for supplementation of traditional cardiovascular screening methods for identifying those at highest risk of stroke and, ultimately, decreasing morbidity and mortality from this disabling disease. The past 20 years have revolutionized the diagnosis and management of stroke making it challenging for neuroophthalmologists to stay up to date in this ever changing field (2,3). Cerebrovascular disorders are the Journal of Neuro-Ophthalmology’s Disease of the Year 2020, emphasizing the close relationship between ischemia of the eye and brain. Developmentally, the brain and retina share a close embryological connection in addition to a common vascular supply. The monikers for arterial ischemia vary based on anatomical localization, ranging from myocardial infarction to ischemic stroke, and although not classically referred to as “stroke,” retinal arterial occlusions share both similar risk factors and mechanisms. Consequently, up to 50% of patients with acute retinal artery occlusions or transient monocular vision loss were noted to have concurrent acute cerebral infarctions on diffusion-weighted MRI (4). Given this intimate link, retinal vascular disease has been proposed as a useful surrogate in screening for cerebrovascular risk which may aid in long-term management. Neuro-ophthalmologic presentations of acute ischemic stroke are also common providing an opportunity for neuro-ophthalmologists to guide early expedited accurate management of acute stroke. Specifically, both clinical and subclinical retinal vascular signs have been associated with cerebrovascular disease including stroke. Broadly, these may encompass hypertensive or diabetic retinopathy, retinal vein or artery occlusion, and retinal vascular imaging measures including vessel caliber and branching patterns. A comprehensive review of the close link between these retinal vascular abnormalities and cerebrovascular disease is presented by Hyungtaek et al (5). In addition, differentiating stroke mechanism has become more nuanced over time. It is more important than ever to determine the etiology of stroke given recent data supporting distinct treatments based on specific mechanism. Despite comprehensive evaluation, cryptogenic stroke remains common, accounting for up to 25% of presentations. Several recent studies have demonstrated a benefit of percutaneous patent foramen ovale closure over medical management alone in a subset of these patients. Wilson et al (6) provide an overview of cryptogenic stroke and review these data in detail in this issue. Subsequent issues of the Journal of Neuro-Ophthalmology will highlight various aspects of ocular and cerebral vascular diseases, including central venous hypertension-related complications in patients receiving hemodialysis, the spectrum of hereditary cerebroretinal vasculopathies, and various aspects of acute treatment and secondary prevention of stroke. The last few years have really seen a complete paradigm shift in the management of stroke, both with treatment in the acute and hyperacute settings as well as for secondary prevention (2,3). The old mantra “time is brain” is only a part of the story now, and new surrogate markers for salvageable brain tissue have created incredible opportunities for effective treatment even in historically very delayed time windows. In addition, the medical and endovascular arsenals for secondary prevention of stroke have greatly expanded, and the body of both existing literature and upcoming studies on these topics has grown exponentially (2,3). Department of Neurology (KI), New York University School of Medicine, New York, New York; and Departments of Ophthalmology and Neurology (VB), Emory University School of Medicine, Atlanta, Georgia. The authors report no conflicts of interest. Address correspondence to Valérie Biousse, MD, 1365-B Clifton Road NE, Atlanta, GA 30322; E-mail: [e-mail] Ishida and Biousse: J Neuro-Ophthalmol 2020; 40: 1-2 1 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Editorial These recent developments reinforce the need for neuroophthalmologists to appropriately refer patients with suspected ischemic stroke to certified stroke centers. It is our hope that the articles relating to cerebrovascular, this year’s Disease of the Year, will galvanize our readers to learn more about the many recent revolutionary advances in the diagnosis and management of this all too common disease. 3. 4. REFERENCES 1. GBD 2016 Neurology Collaborators. Global, regional, and national burden of neurological disorders, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019;18:459–480. 2. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, 2 5. 6. Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke. Stroke. 2019;50:e344–e408. Wu S, Cheng Y, Wu B, Liu M. Stroke research in 2019: towards optimizing treatment and prevention. Lancet Neurol. 2020;19:2–3. Biousse V, Nahab F, Newman NJ. Acute retinal ischemia: follow the guidelines. Ophthalmology. 2018;125:1597–1607. Hyungtaek T, Jun AW, Seung HC, Cheung CY, Wong TY. Retinal vascular signs and cerebrovascular diseases. J Neuroophthalmol. 2020;40:44–59. Wilson CA, Stone DK, Buchwald N. Updates in the management of cryptogenic stroke and patent foramen ovale. J Neuroophthalmol. 2020;40:60–66. Ishida and Biousse: J Neuro-Ophthalmol 2020; 40: 1-2 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.