## Arteriovenous Nicking in Hypertensive Retinopathy **Key Point:** Arteriovenous (AV) nicking, also called Salus sign, is a Grade 1–2 finding in hypertensive retinopathy caused by structural changes in the arteriole, not the venule. ### Pathophysiology of AV Nicking 1. **Chronic hypertension** → sustained elevation of blood pressure 2. **Arteriolar hyalinization** → thickening of the arteriolar wall (hyaline deposition in media and adventitia) 3. **Loss of arteriolar compliance** → rigid, narrowed arteriole 4. **Mechanical compression** → at the arteriovenous crossing, the thickened arteriole physically compresses and obscures the venule 5. **Appearance of "nicking"** → the venule appears to be pinched or interrupted where it crosses the arteriole **High-Yield:** AV nicking is a sign of *chronic* hypertensive vascular disease and indicates structural remodeling of the arteriole. It is NOT an acute phenomenon and does NOT indicate acute bleeding or thrombosis. **Clinical Pearl:** The Salus sign (AV nicking) is one of the earliest and most specific signs of hypertensive retinopathy. It reflects the arteriole's structural rigidity and narrowing — the venule is actually patent but appears interrupted because the thickened arteriole obscures it at the crossing. **Mnemonic:** **THICK** arteriole → **NICKING** - **T**hickened arteriolar wall (hyalinization) - **H**ypertension (chronic) - **I**ncreased stiffness - **C**ompression at AV crossing - **K**inked appearance of venule 
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