Saad Umar1, Carlos Santos2, Jason Schick3, Muhammad Farooq4, Aileen Antonio5, Ronel Santos6
1Ross School of Business, University of Michigan, 2Biomedical Engineering, Wayne State University, 3Trinity Health Grand Rapids, 4Neuroscience Program,Saint Mary'S Health, 5Trinity Health Saint Mary's Hauenstein Neurosciences, 6Hauenstein Neurosciences Trinity Health Grand Rapids
Objective:
To describe a rare case of carotid dissection manifesting as junctional scotoma, emphasizing the role of neuro-ophthalmologic evaluation in localization and guiding timely, life-saving management.
Background:
Junctional scotomas, though rare, are classic visual field defects enabling precise localization to the optic chiasm and its adjacent vascular structures.
Design/Methods:
Not applicable
Results:
A 51-year-old man with an acute painless right eye vision loss presented to the Emergency Department, where he was diagnosed with a right central retinal artery occlusion. CT angiogram revealed a right internal carotid artery (ICA) dissection with near-complete thrombosis. The vascular team deemed this to be nonsurgical, and aspirin and ticagrelor were initiated.
2 months later, he developed painless superior left eye vision loss and worsening vision in the right. Neuro-ophthalmologic evaluation revealed generalized constriction and a central scotoma for the right eye, along with a superior temporal arcuate scotoma of the left eye. These findings localized to the junction of the right optic nerve and the optic chiasm, confirmed by MRI. Repeat CTA showed right ICA dissection extension to the skull base. Connective tissue disease workup was negative. He was transitioned to apixaban for long-term anticoagulation.
Conclusions:
Neuro-ophthalmologic evaluation is essential in critical care and vascular neurology, particularly for identifying life-threatening conditions like carotid artery dissection. A central scotoma in one eye and a superotemporal scotoma in the other is classic for a junctional scotoma, localizing to the optic chiasm and the optic nerve ipsilateral to the central scotoma. Early recognition of these subtle visual field deficits in our case led to prompt diagnosis of the right ICA dissection extension, timely initiation of apixaban, and likely prevention of further neurological deterioration. This highlights the importance of vigilant visual assessment in improving outcomes and reducing disability.
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