PATENT FORAMEN OVALE, MIGRAINE AND STROKE

M. Del Sette
Dept. of Neuroscience
University of Genova – Italy

MIGRAINE AND PFO: COLLABORATORS

S. Angeli
G. L. Bruzzone
S. Cultrera
C. Finocchi
M. Leandri
C. Gandolfo

Dept. of Neuroscience
University of Genova - Italy

QUESTIONS

• IS MIGRAINE A RISK FACTOR FOR ISCHEMIC STROKE?
• IS MIGRAINE ASSOCIATED TO ISCHEMIC LESIONS ON CT OR MRI?
• IS MIGRAINE ASSOCIATED TO OTHER CONDITIONS POTENTIALLY CAUSES OF STROKE?

MIGRAINE AND STROKE

• Tzourio 212 stroke Vs 212 contr.OR:4.3(1.2-16.3) women<45
• et al., ‘93
• Lidegaard 692 women (registry)OR:2.8 (p<.001)
• ‘95
• Tzourio 72 stroke vs.173 contOR:3.0 (1.5-5.8) MO
• et al., ‘95OR:6.2 (2.1-18.0) MA
• Carolei308 Tia or strokeOR:3.7(1.5-9) women<35
• et al., ’96 vs.591 contr.OR:8.6 (1-75) MA

MIGRAINE AND STROKE

• stroke with clinical features of migraine
• migraine-induced stroke
• coexistence of migraine and stroke

Is migraine correlated to ischemic lesions on CT or MRI?

• White matter disease on MRI (Frazekas et al., ‘92; De Benedittis et al., ‘95)
• Ischemic lesions on posterior circulation (Hoeckstra van Dalen et al., ‘96)
• Association in diseases causing ischemic lesions:

- MELAS; MERRF
- familial hemiplegic migraine
- CADASIL

 

• Direct risk : changes in blood flow during attacks (Larsen et al., ‘90)
• Medications for migraine can cause stroke
• Failure in migraineur to seek medical attention for TIA
• Indirect risk: associated conditions

Risky conditions associated with migraine

• aPL (Silvestrini et al., ‘93)
• aCL (Tetjen et al., ‘98)
• platelets hyperaggregability (Couch et al., ‘77)
• mitral valve prolapse (Petty et al., ‘94)

Migraine and Patent Foramen Ovale (PFO)

• PFO is a well-recognized risk factor for ischemic stroke in the young (Di Tullio et al., 1992)
• Patients with transient global amnesia have high prevalence of PFO (Klotzsch et al., 1996)
• Case reports of stroke with coexistence of migraine and PFO (Ries et al., 1996)

• 80 consecutive patients diagnosed as having migraine with or without aura (mean age 32.7±11)
• 73 consecutive patients without migraine, younger than 45 admitted to our stroke unit for ischemic stroke (mean age 35.3±8.9)
• 76 age- and sex matched controls, asymptomatic for cerebrovascular disease, and without migraine (mean age 34.4±9)

METHOD – I

• Bilateral simultaneous transcranial doppler monitoring (Multidop DWL X Sipplingen, Germany) of middle cerebral arteries (MCA)
• Injection of 10 ml glucose 10% mixed with 1 ml of air
• Test performed with patient at rest, and during Valsalva manouvre
• Same protocol recording on basilar artery (BA)

 

METHOD – II

• Diagnosis of right to lef shunt (RLS) when at least 3 microbubbles were recorded on MCA or BA within 10 seconds from injection

Diagnosis of RLS on transcranial doppler

 

Accuracy of cTCD in RLS detection (in comparison to cTEE)