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Show Photo and Video Essay Section Editors: Kimberly M. Winges, MD Michael J. Gilhooley, MA, MB, BChir, DPhil MR Restricted Diffusion in Anterior Ischemic Optic Neuropathy in Giant Cell Arteritis Pasquale F. Finelli, MD, Amre H. Nouh, MD, FAHA, MBA FIG. 1. MR diffusion-weighted image showing bilateral restricted diffusion of anterior optic nerve (A, arrows) with corresponding ADC map (B, arrows). A n 81-year-old patient with a history of atrial fibrillation treated with apixaban awoke with painless loss of vision. Visual acuity was reduced to hand motion from either eye, and fundoscopy showed swollen pale optic discs consistent with anterior ischemic optic neuropathy. The sedimentation rate was 129 mm/hour (N = ,30), and C-reactive protein was 8.48 mg/dL (N = 0–0.49). Carotid ultrasound showed no significant occlusive or atherosclerotic disease, and transthoracic echocardiogram showed biatrial enlargement with no bubble study reported. Bilateral temporal artery biopsy specimen was reported as inadequate for interpretation. MR imaging showed restricted diffusion of both optic nerves, anteriorly (Fig. 1A, B). Vision remained unchanged after 1 month following 10 days highdose intravenous Solu-Medrol and subsequent oral prednisone of 60 mg daily. The absence of temporal artery biopsy Department of Neurology (PFF), Hartford Hospital and University of Connecticut School of Medicine, Hartford, Connecticut; and Cleveland Clinic Florida (AN), Department of Neurology, Cleveland Clinic Neurologic Institute, Weston, Florida. The authors report no conflicts of interest. Address correspondence to Pasquale F. Finelli, MD, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102-5037; E-mail: pasquale. finelli@hhchealth.org e176 evidence notwithstanding our patient was clinically determined to have giant cell arteritis (GCA) and treated as such. Various MR features involving the orbital contents including enhancement of optic nerve sheath, optic nerve/ head, and orbit have been described with GCA.1–3 MR restricted diffusion of the optic nerve with GCA is limited to 2 cases reported with posterior ischemic optic neuropathy, one unilateral4 and the other (Case 7) bilateral.1 Restricted diffusion on MR related to arteritic anterior ischemic optic neuropathy (AAION) in association with GCA has not previously been described. The absence of previous reports of anterior optic nerve diffusion-weighted imaging changes with AAION in GCA may relate to the fact that orbital MR imaging is not routinely included in head MR, particularly when such patients present to other than an ophthalmologist. The results of our case should encourage a lower threshold for orbital MR imaging in patients suspected of ischemic optic neuropathy. AAION, the most common cause of vision loss in GCA, involves the short posterior ciliary arteries that supply the anterior portion of the optic nerve by way of the circle of Zinn–Haller.5,6 Our case with bilateral restricted diffusion of the anterior optic nerves broadens the imaging spectrum associated with an important treatable cause of vision loss in GCA. Finelli and Nouh: J Neuro-Ophthalmol 2024; 44: e176-e177 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Photo and Video Essay STATEMENT OF AUTHORSHIP Conception and design: P. F. Finelli, A. H. Nouh; Acquisition of data: P. F. Finelli, A. H. Nouh; Analysis and interpretation of data: P. F. Finelli, A. H. Nouh. Drafting the manuscript: P. F. Finelli, A. H. Nouh; Revising the manuscript for intellectual content: P. F. Finelli, A. H. Nouh. Final approval of the completed manuscript: P. F. Finelli, A. H. Nouh. REFERENCES 1. Bender B. Diffusion restriction of the optic nerve in patients with acute visual loss. J Mag Reason Image. 2014;40:334–340. Finelli and Nouh: J Neuro-Ophthalmol 2024; 44: e176-e177 2. D’Souza NM, Morgan ML, Almarzouqi SJ, Lee AG. Magnetic resonance imaging findings in giant cell arteritis. Eye. 2016;30:758–762. 3. Remond P, Attye A, Lecler A, et al. The central bright spot sign: a potential new MR imaging sign for the early diagnosis of anterior ischemic optic neuropathy due to giant cell arteritis. Am J Neuroradiol. 2017;38:1411–1415. 4. Albarrak AM, Mohammad Y, Hussain S, Muayqil T. Simultaneous bilateral posterior ischemic optic neuropathy secondary to giant cell arteritis: a case presentation and review of the literature. BMC Ophthalmol. 2018;18:317–321. 5. Donaldson L, Margolin E. Vision loss in giant cell arteritis. Pract Neurol. 2022;22:138–140. 6. Vodopivec I, Rizzo JF. Ophthalmic manifestations of giant cell arteritis. Rheumatology. 2018;57:ii63–ii72. e177 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. |
