Ocular involvement in primary antiphospholipid syndrome: results of an extensive ophthalmological evaluation performed in the APS-Rio cohort.

OBJECTIVE: To study ophthalmological manifestations in a well-characterized primary antiphospholipid syndrome (PAPS) cohort (APS-Rio) and compare them with a healthy control group. METHODS: We examined PAPS patients and controls with an extensive ophthalmological evaluation, which included anamnesis, visual acuity, slit-lamp biomicroscopy, binocular indirect ophthalmoscopy, and retinography of the anterior and posterior segments of the eye. PAPS group also underwent angiography exam and optical coherence tomography using spectral domain technology (SD-OCT). RESULTS: 98 PAPS patients and 102 controls were included. The most common symptom in PAPS was amaurosis fugax (34.7% vs. 6.9%; p = .001). In the multivariate analyses, Raynaud's phenomenon was associated with amaurosis fugax (OR 3.71, CI:1.33-10.32; p = .012), and livedo correlated with hemianopia (OR 6.96, CI:1.11-43.72, p = .038) and diplopia (OR 3.49, CI:1.02-11.53, p = .047). After ophthalmological evaluation, 84 PAPS patients had ocular involvement (1.0% glaucoma, 94.0% posterior findings, 62.7% anterior findings, and 56.6% both posterior and anterior findings). Vascular tortuosity was more frequent in the PAPS group (63.2% vs. 42.2%; p = .002), as well as peripheral tortuosity (29.6% vs. 7.8%; p < .001). After excluding patients with atherosclerotic risk factors, peripheral vascular tortuosity was still statistically associated with PAPS (35.0 vs. 7.8%, p < .001). Triple positivity was more frequent in PAPS patients with peripheral vascular tortuosity than in those without this ocular finding (34.5% vs. 15.9%, p = .041). CONCLUSION: Vasomotor phenomena are importantly related to ocular symptoms in PAPS. Vascular tortuosity was a frequent finding in PAPS patients. Peripheral vascular tortuosity was associated with triple positivity and might be a biomarker of ischemic microvascular retinopathy due to PAPS.

[Amaurosis fugax in inferior wall myocardial infarction with ST segment elevation].

The patient, a fifty nine year old male, was admitted to the ward with symptoms of inferior wall myocardial infarction with ST segment elevation combined with intermittent right side sight loss. Despite typical resting stenocardial chest pain, ST segment elevation in ECG, transient symptoms of acute heart failure and slightly elevated myocardial necrosis biomarkers, coronarography did not reveal obvious source of myocardial ischemia. Moreover, echocardiography did not confirm decreased ejection fraction. However further research confirmed critical stenosis of the left internal carotid artery and chronic occlusion of the right internal carotid artery. Several questions were raised during diagnostic process including: the cause of cardiac ischemia and the cause of cerebral ischemia. Clinical data analysis and available literature allowed authors to exclude cerebral ischemia as a source of ECG ischemic changes and to establish transient myocardial ischemia causing circulatory decompensation amplified by carotid arteries atherosclerosis as the source of neurological symptoms.

Transient monocular blindness and the risk of vascular complications according to subtype: a prospective cohort study.

Patients with transient monocular blindness (TMB) can present with many different symptoms, and diagnosis is usually based on the history alone. In this study, we assessed the risk of vascular complications according to different characteristics of TMB. We prospectively studied 341 consecutive patients with TMB. All patients were interviewed by a single investigator with a standardized questionnaire; reported symptoms were classified into predefined categories. We performed Cox regression analyses with adjustment for baseline vascular risk factors. During a mean follow-up of 4.0 years, the primary outcome event of vascular death, stroke, myocardial infarction, or retinal infarction occurred in 60 patients (annual incidence 4.4 %, 95 % confidence interval (CI) 3.4-5.7). An ipsilateral ischemic stroke occurred in 14 patients; an ipsilateral retinal infarct in six. Characteristics of TMB independently associated with subsequent vascular events were: involvement of only the peripheral part of the visual field (hazard ratio (HR) 6.5, 95 % CI 3.0-14.1), constricting onset of loss of vision (HR 3.5, 95 % CI 1.0-12.1), downward onset of loss of vision (HR 1.9, 95 % CI 1.0-3.5), upward resolution of loss of vision (HR 2.0, 95 % CI 1.0-4.0), and the occurrence of more than three attacks (HR 1.7, 95 % CI 1.0-2.9). We could not identify characteristics of TMB that predicted a low risk of vascular complications. In conclusion, careful recording the features of the attack in patients with TMB can provide important information about the risk of future vascular events.

Ceguera y sordera como manifestación inicial de un cáncer de pulmón no microcítico / Blindness and Deafness as Initial Manifestation of Non-small Cell Lung Cancer

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Risk of recurrent stroke before carotid endarterectomy: the ANSYSCAP study.

BACKGROUND: Carotid endarterectomy yields greater risk reduction for ipsilateral ischemic stroke when performed within two-weeks of the last cerebrovascular symptom than when performed two-weeks or more after the last symptom. However, additional benefit might be gained if carotid endarterectomy is performed earlier than within two-weeks. AIMS: To investigate the 90-day risk of ipsilateral ischemic stroke recurrence after amaurosis fugax, retinal artery occlusion, transient ischemic attack, or minor ischemic stroke in patients with 50-99% carotid stenosis before carotid endarterectomy, with emphasis on the first 14 days. METHODS: Prospective cohort study. 230 consecutive patients with symptomatic 50-99% carotid stenosis (North American Symptomatic Carotid Endarterectomy Trial grading method) who underwent evaluation before carotid endarterectomy. Of these, 183 underwent carotid endarterectomy; the median delay to carotid endarterectomy was 29 days. Blood pressure lowering medication was used by 93% and lipid-lowering medication by 90%. RESULTS: The risk of ipsilateral ischemic stroke recurrence before carotid endarterectomy was 5·2% (n = 12) within two-days, 7·9% (n = 18) within seven-days, 11·2% (n = 25) within 14 days, and 18·6% (n = 33) within 90 days of the presenting event. The risk of ipsilateral ischemic stroke recurrence was higher if the presenting event was a stroke (adjusted hazard ratio 12·4, P = 0·015) or transient ischemic attack (adjusted hazard ratio 10·2, P = 0·026) compared with an amaurosis fugax. DISCUSSION: The risk of recurrent ipsilateral ischemic stroke was high within the first days of the presenting event. Many recurrences would likely have been avoided if carotid endarterectomy had been performed within the first days of the presenting event.

Tratamiento endovascular de la estenosis de la arteria carótida externaen un paciente con amaurosis fugaz / Endovascular treatment of stenosis of the external carotid artery in a patient with amaurosis fugax

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Oculo-pyramidal crossed syndrome heralded by seizure: a case report.

Ischemic oculo-pyramidal crossed syndrome, i.e. amaurosis fugax contralateral to hemiparesis, is caused by an embolus from internal carotid artery occluding the retinal or the ophthalmic artery as well as the middle cerebral artery. We report on a patient with an oculopyramidal crossed syndrome due to internal carotid artery dissection and clinically manifesting with amaurosis fugax and seizure. Ischemic lesions can present with symptomatic seizures and, conversely, seizures may precede ischemic strokes, thus being a warning sign of a cerebrovascular event.

Determinants of embolic risk during angioplasty and stenting: neurologic symptoms and coronary artery disease increase embolic risk.

BACKGROUND: Carotid angioplasty and stenting (CAS) has proven to be a potential alternative to carotid endarterectomy in the treatment of severe carotid disease. Patient selection has emerged as a means of optimizing the outcomes of CAS. OBJECTIVE: To determine whether the presence of preprocedural neurologic symptoms and having a history of coronary artery disease (CAD) are associated with greater embolic risk during CAS through analysis of the embolic debris captured within protective filters. METHODS: A total of 233 consecutive CAS procedures were performed between 2003 and 2009. Particles of embolic debris within the filters were quantified by photomicroscopy and video imaging software. Particulate size was determined by measuring the length along the longest axis. Preprocedural neurologic symptoms included transient ischemic attack, cerebrovascular accident, and amaurosis fugax. History of CAD included prior myocardial infarction, coronary artery bypass grafting, congestive heart failure, or abnormal stress test. RESULTS: Of the 137 (58.8%) filters that were analyzed (mean age, 71.3 ± 9.1 years, 56.9% male), 52 (38.0%) and 80 (58.4%) filters were from symptomatic and CAD patients, respectively. Filters of symptomatic (S) patients contained both a greater number and larger mean particle size compared with those of asymptomatic (AS) patients (S: 15.8 ± 13.5 particles vs. AS: 9.8 ± 8.7 particles, P = 0.002; S: 507 ± 389 µm vs. AS: 398 ± 181 µm, P = 0.03; respectively). Filters from CAD patients also had a greater number of particles, but trended toward smaller minimum size than those in non-CAD patients (CAD: 14.4 ± 12.8 particles vs. non-CAD: 8.8 ± 7.4 particles, P = 0.002; CAD: 167 ± 172 µm vs. 228 ± 203 µm, P = 0.06). CONCLUSIONS: These findings suggest that the presence of preprocedural neurologic symptoms and a history of CAD are associated with increased embolization during CAS. Therefore, the benefit of carotid stenting should be tempered by the potential for increased perioperative events in both symptomatic and CAD patients.

Coagulation activation and ultrasound characteristics in patients with carotid artery disease.

INTRODUCTION: Elevated levels of markers for thrombin activation are associated with plaque echogenicity and degree of stenosis in patients with carotid artery stenosis. The Activated Protein C-Protein C Inhibitor (APC-PCI) complex reflects activation of the Protein C system and is a measure of thrombin generation. The aim of the present study was to examine APC-PCI complex in patients undergoing thrombendartherectomy for carotid artery stenosis, and to relate the findings to clinical characteristics and plaque morphology as determined by ultrasound. MATERIALS AND METHODS: Blood was obtained from 125 patients (39 female, median age 71 years) with carotid artery stenosis admitted from September 2005 to May 2007. The APC-PCI complex was measured using a sandwich immunofluorometric method and compared to an age- and sex-matched healthy control-group. Clinical and demographic characteristics, routine laboratory markers and ultrasound characteristics were analysed using univariate and multivariate analysis. RESULTS: APC-PCI complex concentration was significantly increased in patients with carotid artery stenosis (median 0.21 microg/L; 10th to 90th percentile 0.15-0.36) compared to a healthy control-group (0.19 microg/L; 0.11-0.31; P=.009). There was no significant difference in APC-PCI-values between asymptomatic (n=48) and symptomatic (n=77) patients with carotid artery stenosis (0.22 vs. 0.20 microg/L; p=0.626). Patients with minor stroke (n=31) had a higher median APC-PCI-concentration (0.27 microg/L; 0.15-0.63) than patients with amaurosis fugax (0.19 microg/L; 0.15-0.36) or transient ischemic attack (0.21 microg/L; 0.12-0.36) (p=0.016). No association was found between APC-PCI-values and the degrees of carotid artery stenosis or the time from the latest neurological symptoms to blood sampling. Patients with echolucent plaques had significantly lower APC-PCI concentrations (0.20 microg/L; 0.14-0.35 vs. 0.24 microg/L; 0.15-0.60; p=0.043), according to the Gray-Weale classification. CONCLUSIONS: Patients with carotid artery disease exhibit increased concentrations of APC-PCI compared to a healthy control-group, particularly those patients with echogenic plaques, who have significantly higher APC-PCI levels than patients with echolucent plaques.

Correlation of calcified carotid plaques detected by panoramic radiograph with risk factors for stroke development.

OBJECTIVES: The aim was to evaluate whether patients with calcifications in the carotid region detectable by panoramic radiograph differ in the prevalence of risk factors for stroke development compared with those without calcifications. STUDY DESIGN: Forty consecutive individuals suffering from proven carotid artery atherosclerotic occlusive disease were submitted to carotid endarterectomy. Seventeen patients were symptomatic at the time of referral, having suffered at least 1 episode of ischemic cerebral event during the preceding 6 months, mainly transient ischemic attacks or amaurosis fugax, and the remaining 23 patients were asymptomatic and the diagnosis was reached during a thorough investigation of coexisting coronary or peripheral vascular disease. Preoperatively, all patients had undergone panoramic radiograph examination, as the presurgical protocol commanded. Based on the panoramic radiograph results, patients in whom calcifications were detected either unilaterally (n = 10) or bilaterally (n = 18) constituted group A (n = 28) and patients in whom no calcifications were detected constituted group B (n = 12) of this study. RESULTS: Univariate analysis among several risk factors for stroke development between the 2 groups of patients disclosed a stastistically significant lower incidence of diabetes mellitus (P = .005) but a higher incidence of symptomatic plaques (P < .030) in the group of patients with detectable calcifications in the panoramic radiograph. CONCLUSION: Patients with calcified carotid plaques detectable by panoramic radiography are more likely to have suffered cerebrovascular events. Therefore, patients with detectable carotid plaque in panoramic radiographs require referral to their physician for further investigation.

Elicited repetitive daily blindness: a new phenotype associated with hemiplegic migraine and SCN1A mutations.

OBJECTIVE: Familial hemiplegic migraine (FHM) is a genetically heterogeneous disorder in which three genes, CACNA1A, ATP1A2, and SCN1A, are currently known to be involved. FHM is occasionally associated with other neurologic symptoms such as cerebellar ataxia or epileptic seizures. A unique eye phenotype of elicited repetitive daily blindness (ERDB) has also been reported to be cosegregating with FHM in a single Swiss family. METHODS: We report an additional family in whom the proband had, in addition to FHM, typical ERDB. In this family and the previously reported Swiss family, the whole coding region of the SCN1A gene was screened after exclusion of mutation in CACNA1A and ATP1A2 genes. RESULTS: We identified two novel SCN1A mutations (c.4495T>C/p.Phe1499Leu and c.4467G>C/p.Gln1489His missense substitutions) in exons 24 and 23, respectively, segregating with the disease in all living affected members. Both mutations were absent from 180 healthy Caucasian controls and were located in an intracellular loop highly conserved throughout evolution. CONCLUSION: We report new clinical data supporting cosegregation of familial hemiplegic migraine and the new eye phenotype of elicited repetitive daily blindness and two novel SCN1A mutations as the underlying genetic defect in two unrelated families. SCN1A encodes the voltage-gated sodium channel Nav1.1 that is highly expressed in the CNS including the retina. This remarkably stereotyped new eye phenotype has clinical characteristics of abnormal propagation of the retinal electrical signal that may be a retinal spreading depression. These results suggest that SCN1A mutations, which alter neuronal brain excitability, may occasionally alter retinal cell excitability.

From amaurosis fugax to asymptomatic bithalamic infarct.

Bilateral paramedian thalamic infarctions are usually associated with impaired consciousness, oculomotor disturbances and neuropsychological changes. A 44-year-old healthy woman presented with amaurosis fugax of the right eye immediately after a Valsalva maneuver. Neurological examination, in particular visual acuity, vigilance and ocular movements, was normal. Blood pressure, ECG and angio-CT of the neck and head vessels were normal, but MRI/DWI and T2 sequences showed recent bi-thalamic ischemic lesions in the paramedian territories. Doppler sonography and transesophageal echocardiography showed a large right-to-left shunt due to an atrial communication, with septum aneurysm. Twenty-four-hours cardiac monitoring was normal but prior to an eventual closure of the cardiac defect she underwent an ambulatory 7-day ECG monitoring which revealed several paroxystic short lasting passages into atrial fibrillation, unnoticed by the patient. The interest in this case is threefold: (1) bilateral paramedian thalamic infarction which usually presents with a devastating clinical picture may occur clinically silent; (2) monocular amaurosis fugax which is usually associated with ipsilateral carotid disease may be the consequence of cardiac embolism, and (3) atrial fibrillation is never completely ruled out, here it was caught only in a 7-days ambulatory R-test, and consequently prevented closure of a possibly asymptomatic patent foramen ovale.

Do temporal artery duplex ultrasound findings correlate with ophthalmic complications in giant cell arteritis?

OBJECTIVE: Ophthalmic complications are common in acute GCA. Do temporal artery ultrasound and clinical parameters correlate with the occurrence and severity of ophthalmic complications? METHODS: The results of temporal artery ultrasound examinations are compared with the occurrence of anterior ischaemic optic neuropathy (AION), central retinal artery occlusion (CRAO), branch retinal artery occlusion (BRAO), diplopia and amaurosis fugax in 222 consecutive patients with newly diagnosed, active GCA. RESULTS: Temporal artery ultrasound displayed vasculitic wall swelling (halo), stenoses and/or acute occlusions in 84% (58% in 67 large-vessel GCA patients and 95% in 155 patients without proximal arm vasculitis). Ophthalmic complications occurred in 64 (29%), AION in 30 (14%), CRAO in 7 (3%), BRAO in 2 (1%), amaurosis fugax in 16 (7%) and diplopia in 9 patients (4%). Ophthalmic complications were insignificantly more common if temporal artery ultrasound was positive (31 vs 17%; P = 0.11) as a greater number of patients without arm vasculitis showed eye involvement (34 vs 18%; P = 0.02). The number of pathological temporal artery segments, presence of stenoses or bilateral findings did not correlate with ophthalmic complications. Age >or= 72 yrs at diagnosis correlated with a higher incidence of ophthalmic complications. CONCLUSION: Ophthalmic complications occurred less frequently if proximal arm vasculitis was present. Findings of temporal artery ultrasound did not correlate with eye complications.

Rare manifestations of Churg-Strauss syndrome: coronary artery vasospasm, temporal artery vasculitis, and reversible monocular blindness-a case report.

Churg-Strauss syndrome (CSS) is a rare illness with clinical findings characterized by asthma, eosinophilia, and vasculitis affecting medium and small-sized arteries and veins in a variety of organs. Involvement of the temporal arteries by non-giant cell eosinophilic vasculitis in CSS is quite rare and has only been published as isolated case reports or small patient series. Myocardial infarction due to coronary artery vasospasm is an unusual manifestation of CSS. We describe a case of a 39-year-old woman who had two myocardial infarctions due to severe coronary artery vasospasm and was diagnosed with CSS based on a temporal artery biopsy. During the course of her treatment, she also had another rare manifestation of CSS, monocular blindness reversible with immunosuppressive therapy.

Manifestaciones oftalmológicas de la enfermedad cerebrovascular / Ophthalmological manifestations of cerebrovascular disease

El ojo constituye una diana para la enfermedadvascular. El estudio de la microcirculación retinianaconstituye una oportunidad muy interesante para lavaloración del riesgo vascular al conocer la relaciónexistente entre los cambios vasculares en la retina y elriesgo de padecer un ictus. Es además una ventanaexcepcional para conocer mejor la fisiopatología de lamicrocirculación.La arteria oftálmica es la primera rama de la arteriacarótida interna. La afectación ocular puede ser uni obilateral. Los síntomas oculares o neuro-oftalmológicosson transitorios o persistentes y sus manifestaciones sonmuy heterogéneas abarcando alteraciones de la agudezavisual, trastornos de los campos visuales, síndromesoculomotores y manifestaciones clínicas corticales ysubcorticales complejas. Su conocimiento puede resultarclave para instaurar las medidas preventivas pertinenteso establecer el correcto diagnóstico y la aproximacióndiagnóstica inmediata, tan importante en la atenciónde los procesos vasculares cerebrales

Transient or persistent loss of vision in one eyeis a common and distinctive manifestation ofocclusive vascular disease. Occasionally, both eyesare involved together or sequentially, with temporaryor even permanent blindness. The internal carotidarteries supply blood to the organ of vision; thereforepathologies of those arteries caused byarteriosclerosis may have a direct influence on itsfunctioning. The most common syndromes aretemporary (amaurosis fugax) or constant reductionof visual acuity. In fundus examination central retinalartery occlusion and branch retinal artery occlusionare the most common diagnosis, while retinal veinocclusion, anterior ischemic optic neuropathy,ocular ischemic syndrome are less common. Thereare many clinical ophtlamological manifestations dueto vascular brain damage. Proper recognition anddiagnosis of the disease may protect the patientagainst serious life-threatening complications suchas stroke

Systemic diseases in non-inflammatory branch and central retinal artery occlusion--an overview of 416 patients.

BACKGROUND: To determine the frequency of essential cardiovascular risk factors in different vascular ocular diseases. - METHODS: We compiled cardiovascular risk factor findings (RFs) from 416 patients with non-inflammatory ocular vascular occlusions in a retrospective study: 134 patients with BRAO, 253 patients with CRAO, and 29 patients with hemi-CRAO. 274 (65.9 %) male and 142 (34.1 %) female patients were examined. Mean age of all patients was 66 years (range: 18-90). The right eye was involved in 221 (53.1 %), left eye in 193 (46.4 %), and both eyes in 2 patients (0.5 %). - RESULTS: Cardiovascular risk factors (RFs) were found in 243 patients. Three hundred and eight (308) out of 406 patients (75.9 %) presented with arterial hypertension. Hypertension was present in 96 patients with BRAO (73.8 %), in 197 patients with CRAO (79.8 %), and in 15 patients with hemi-CRAO (78.9 %). - RFs such as arterial hypertension, carotid artery diseases, diabetes mellitus, hyperlipidemia, hyperuricemia, and chronic smoking did not differ statistically between patients with BRAO, CRAO or hemi--CRAO. But visible emboli in retinal arteries were observed in patients with BRAO (47 %,), or hemi-CRAO (41.4 %), much more often than in patients with CRAO (11.1 %). - CONCLUSIONS: No statistical differences between the RFs of patients with BRAO, CRAO, or hemi-CRAO were noted. We maintain that every patient with retinal arterial obstruction should undergo extensive examination of essential RFs.

Type of stroke after transient monocular blindness or retinal infarction of presumed arterial origin.

BACKGROUND: Retinal infarction and transient monocular blindness (TMB) are associated with an increased risk of future ischaemic stroke. Little information is available on the type of subsequent ischaemic strokes that may occur (anterior or posterior circulation and small vessel or large vessel). AIM: To analyse the type of stroke after TMB. METHODS: Patients with transient or permanent retinal ischaemia were selected from three prospective studies: the Dutch TIA Trial, the Dutch Amaurosis Fugax Study and the European/Australian Stroke Prevention in Reversible Ischaemia Trial. On follow-up the type of stroke was classified according to the supply territory and the type of vessel involved. RESULTS: 654 patients were included. During a mean follow-up of 5.2 years, 42 patients were found to have had a cerebral or retinal infarct, of which 27 occurred in the carotid territory ipsilateral to the symptomatic eye, 9 in the territory of the contralateral carotid artery and 6 were infratentorial strokes. Thirty patients had a large-vessel infarct, four had a small-vessel infarct and eight had a retinal infarct. Characteristics associated with a notable increased risk for subsequent stroke or retinal infarction were age > or = 65 years, a history of stroke, a history of intermittent claudication, diabetes mellitus, Rankin score > or = 3, more than three attacks of retinal ischaemia and any degree of ipsilateral carotid stenosis on duplex ultrasonography observation. CONCLUSION: Ischaemic strokes after TMB or retinal infarction were found to be mainly large-vessel infarcts in the territory of the ipsilateral carotid artery. TMB and retinal infarction are probably manifestations of large-vessel disease.

Outcomes among valvular heart disease patients experiencing ischemic stroke or transient ischemic attack in Olmsted County, Minnesota.

OBJECTIVE: To estimate the rates and predictors of survival and recurrence among residents of Olmsted County, Minnesota, who received an Initial diagnosis based on 2-dimensional color Doppler echocardiography of moderate or severe mitral or aortic stenosis or regurgitation and who experienced a first ischemic stroke, transient ischemic attack (TIA), or amaurosis fugax. PATIENTS AND METHODS: At the Mayo Clinic in Rochester, Minn, we used the resources of the Rochester Epidemiology Project to identify Individuals who met the criteria for inclusion in the study and to verify exclusion criteria. The study included all residents of Olmsted County, Minnesota, who experienced a first Ischemic stroke, TIA, or amaurosis fugax within 30 days of or subsequent to receiving a first-time 2-dimensional color Doppler echocardlography-based diagnosis of moderate or severe mitral or aortic stenosis or regurgitation between January 1, 1985, and December 31, 1992. The Kaplan-Meier product-limit method was used to estimate the rates of subsequent stroke and death after the ischemic stroke, TIA, or amaurosis fugax. The Cox proportional hazards model was used to assess the effect of several potential risk factors on subsequent stroke occurrence and death. RESULTS: For the 125 patients in the study, the Kaplan-Meier estimates of the risk of death and the risk of stroke at 2-year follow-up were 38.6% (95% confidence interval [CI], 29.9%-47.5%) and 18.5% (95% CI, 10.0%-27.0%), respectively. Compared with the general population, death rates were significantly Increased (standardized mortality ratio = 1.75; 95% CI, 1.38-2.19; P < .001) but rates of subsequent stroke occurrence were not (standardized morbidity ratio = 1.20; 95% CI, 0.75-1.84; P = .40). After adjustment for age, sex, and cardiac comorbidity, neither the type nor severity of valvular heart disease was an independent determinant of survival or subsequent stroke occurrence. CONCLUSIONS: Patients with mitral or aortic valvular heart disease who experience Ischemic stroke, TIA, or amaurosis fugax have Increased rates of death, but not recurrent stroke, compared with expected rates. Other cardiovascular risk factors are more important determinants of survival In these patients than the type or echocardiographic severity of the valvular heart disease.