Immediate Stroke Risk Evaluation in Patients with Transient Monocular Vision Loss

Introduction to TMVL and Stroke Risk

The American Heart Association and the American Stroke Association recommend that patients with transient monocular vision loss (TMVL) undergo immediate evaluation for stroke risk within 24-48 hours, regardless of symptom resolution, due to the high risk of stroke, with up to 10% risk of stroke within 90 days and half of those strokes occurring within the first 48 hours 1, 2
The International Journal of Stroke guidelines state that TMVL is a retinal transient ischemic attack that demands urgent stroke workup, with the highest stroke risk occurring within the first 7 days after the event 1, 4

The American Academy of Ophthalmology recommends brain MRI with diffusion-weighted imaging (DWI-MRI) to identify silent cerebral infarctions, found in 11.8-30.8% of TMVL patients, and vascular imaging from aortic arch to vertex (CTA or MRA) to identify carotid stenosis, present in up to 70% of retinal arterial occlusion patients 2
The American College of Cardiology recommends continuous cardiac monitoring and echocardiography to identify atrial fibrillation or other cardioembolic sources, with approximately 20% of TMVL patients having a major embolic source requiring urgent anticoagulation 1, 5

The Canadian guidelines specify that TMVL within 48 hours requires same-day assessment at a stroke center, with immediate transfer to ED or stroke center with capacity for advanced imaging, and brain MRI with DWI and vascular imaging (CTA/MRA) within 24 hours 1, 2
The American Heart Association recommends initiating antiplatelet therapy, such as aspirin 325mg loading dose, unless contraindicated, and admitting or placing in observation unit for rapid diagnostic protocol completion 5