Acute unilateral visual loss as the first symptom of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy.
BACKGROUND
Although cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is considered a cerebrovascular disorder with almost exclusively neurological symptoms, the arteriopathy is generalized and involves choroidal and retinal vasculature as demonstrated by fluorescein angiographic and ocular electrophysiological abnormalities. The occurrence of acute visual loss due to nonarteritic anterior ischemic optic neuropathy (NAION) has not previously been reported in CADASIL.


OBJECTIVE
To describe acute visual loss due to NAION as a possible manifestation of CADASIL.


METHODS
The patient was a 60-year-old man with subcortical diffuse leukoencephalopathy, multi-infarct dementia, tetraparesis, visual loss, and a family history of stroke. We performed clinical and neuro-ophthalmological evaluation, electrophysiological assessment, brain magnetic resonance imaging, and genetic screening for mutations or small deletions of the Notch3 gene, (causing CADASIL).


RESULTS
The patient's first symptom was acute visual loss in the right eye due to NAION at age 27 years, in absence of the common cardiovascular risk factors and before any neurological impairment. The patient was reevaluated at age 60 years, and neuro-ophthalmological examination showed optic disc atrophy in the right eye with arteriolar narrowing and a reduction in visual acuity in the left eye. Fluorescein angiography of the right eye showed evidence of persistent peripapillary hypofluorescence with a retinal pigment epithelial windows defect in the inferior temporal area. Pattern reversal visual evoked potentials were abolished in the right eye. The P100 latency of the left eye was delayed and reduced in amplitude. The diagnosis of CADASIL was confirmed by molecular analysis (heterozygotes for the C406T mutation on exon 3 of the Notch3 gene). There was a family history of cerebrovascular disorders and ocular impairment.


CONCLUSIONS
Visual loss due to transient or stable ischemic events involving the optic nerve head should be considered in the CADASIL phenotype. The possibility of CADASIL should also be evaluated in patients with NAION who do not have cardiovascular risk factors but do have a family history of stroke.
Rufa
Alessandra
A
Neurology and Neurometabolic Disease Unit, Center for the Diagnosis, Prevention, and Therapy of Neurological Handicap, Department of Behavioral and Neurological Sciences, University of Siena Medical School, Siena, Italy.
De Stefano
Nicola
N
Dotti
Maria Teresa
MT
Bianchi
Silvia
S
Sicurelli
Francesco
F
Stromillo
Maria Laura
ML
D'Aniello
Bruno
B
Federico
Antonio
A
D001766:Blindness / Q000175:diagnosis* / Q000235:genetics; D002888:Chromosomes, Human, Pair 19; D004252:DNA Mutational Analysis; D015161:Dementia, Multi-Infarct / Q000175:diagnosis* / Q000235:genetics; D018450:Disease Progression; D005074:Evoked Potentials, Visual / Q000235:genetics / Q000502:physiology; D005091:Exons; D005451:Fluorescein Angiography; D007839:Functional Laterality / Q000235:genetics / Q000502:physiology; D006580:Genetic Carrier Screening; D020022:Genetic Predisposition to Disease; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009896:Optic Atrophy / Q000175:diagnosis / Q000235:genetics; D018917:Optic Neuropathy, Ischemic / Q000175:diagnosis* / Q000235:genetics; D010641:Phenotype; D011518:Proto-Oncogene Proteins / Q000235:genetics*; D000071656:Receptor, Notch3; D011956:Receptors, Cell Surface; D051880:Receptors, Notch; D014793:Visual Cortex / Q000473:pathology / Q000503:physiopathology
C499374:NOTCH3 protein, human; D011518:Proto-Oncogene Proteins; D000071656:Receptor, Notch3; D011956:Receptors, Cell Surface; D051880:Receptors, Notch