Cinzia Finocchi

Migraine with Aura and Right-to-Left Shunt on Transcranial Doppler: A Case-Control Study

Right-to-left shunt (RLS), usually due to patent foramen ovale, is a well-established risk factor for ischemic stroke in young patients, while the role of migraine as an independent factor is still debated. We evaluated 44 patients suffering from migraine with aura, and compared them with 73 patients younger than 50 with focal cerebral ischemia, and 50 controls, asymptomatic for cerebrovascular disease, and without a history of migraine. All the subjects underwent bilateral transcranial Doppler with injection of contrast medium in an antecubital vein. The test was performed during normal ventilation and during Valsalva maneuver, recording both the middle cerebral arteries and the basilar artery. Criteria for diagnosing RLS was the presence of at least 3 microbubbles within 15 s from injection. Eighteen out of 44 migraine patients (41%) showed RLS, as opposed to 8 of 50 controls (16%) (p < 0.005). Twenty-six out of 73 patients with cerebral ischemia had RLS (35%). We conclude that the prevalence of RLS in patients with migraine with aura is significantly higher than in normal controls, and is similar to the prevalence of RLS in young patients with stroke. These findings could be helpful in understanding the relationship between migraine and stroke.

Right-to-left shunt does not increase white matter lesion load in migraine with aura patients

Background: White matter lesions (WMLs) are commonly found on brain MRI of migraine patients. Migraine with aura (MA+) is associated with an increased frequency of right-to-left shunt (RLS) mostly due to patent foramen ovale. The relationship between WML load and RLS in MA+ is currently unknown. Methods: MA+ patients were consecutively enrolled as part of the Shunt Associated Migraine (SAM) study. Patients underwent a standardized headache and vascular risk factors questionnaire, contrast-enhanced transcranial Doppler, blood coagulation tests, and brain MRI. RLS was categorized into four grades: no shunt, <10 microbubbles (mb), >10 mb single spikes pattern, and >10 mb shower/curtain pattern. Standard and fluid-attenuated inversion recovery T2-weighted MRI sequences were inspected for WMLs by three independent raters blinded to RLS grade. WML load was scored in the periventricular areas (PV-WMLs) with the Fazekas scale and in the deep white matter (D-WMLs) with the Scheltens scale. Interobserver agreement was good to excellent (κ = 0.64 to 0.96, p < 0.0001). WML load was then correlated between patients with and without RLS. Results: One hundred eighty-five patients (77% women) were included. PV-WML load was similar between patients with and without RLS. D-WML load decreased in patients with RLS (p = 0.045). On logistic regression analysis, only age was associated with WMLs (p < 0.001). Conclusions: The presence of right-to-left shunt does not increase white matter lesion load in patients who have migraine with aura.

Microembolic Signals With Serial Transcranial Doppler Monitoring in Acute Focal Ischemic Deficit A Local Phenomenon

BACKGROUND AND PURPOSE The occurrence of microembolic signals (MES) in patients with transient ischemic attack (TIA) or stroke has already been described, but the diagnostic and prognostic value of this finding is still debated. METHODS We evaluated 90 consecutive patients admitted for their first hemispheric TIA or ischemic stroke within 72 hours of onset. All of them underwent 30-minute bilateral transcranial Doppler monitoring of middle cerebral arteries, within 72 hours of onset. The monitoring was repeated after an additional 24 hours and after 7 days. We then classified the episodes in the following etiologic categories: cardioembolic, atherothrombotic, small-vessel disease, mixed cases, unknown origin, and other causes. RESULTS We included 75 patients, with a mean interval of registration of 32.04 +/- 19.39 hours. There were 9 patients with MES (12%). All MES were recorded only on the symptomatic middle cerebral artery, and the majority were recorded during the first or the second registration. No statistically significant difference was found in risk factors and hematologic parameters. Five patients (56%) had atherothrombotic episodes, 3 patients (33%) had cardioembolic episodes, and 1 patient (11%) had a protein S deficit. No patient with MES had small-vessel disease (P = .01). CONCLUSIONS MES are an infrequent finding in patients with TIA or ischemic stroke within 72 hours of onset, but they can be recorded more easily with serial registration. In our patients, MES were found only on the symptomatic middle cerebral artery and were present in atherothrombotic and cardioembolic episodes but not in small-vessel disease.

Role of Transcranial Doppler and Stump Pressure During Carotid Endarterectomy

BACKGROUND AND PURPOSE The aim of our study was to clarify the pathophysiology of perioperative cerebral complications during carotid endarterectomy in our series. METHODS By means of transcranial Doppler ultrasonography and stump pressure measurement, we monitored 112 patients who underwent carotid endarterectomy under general anesthesia for symptomatic or asymptomatic severe carotid stenosis. RESULTS Of 18 patients who underwent carotid endarterectomy with intra-arterial shunt, 2 (11.1%) developed an ischemic stroke. Of the other 94 patients, one suffered a nucleocapsular hemorrhage and 5 had cerebral ischemic complications. In these 5 patients, the duration of clamping was significantly longer (mean +/- SD, 16.4 +/- 1.1 versus 12.7 +/- 2.6 minutes; P = .0019), and the decrease of middle cerebral artery mean velocity on clamping was significantly greater (mean +/- SD, 56.4 +/- 4.9% versus 28.8 +/- 20.2%; P = .0031), while stump pressure was not significantly different. Microembolic signals were recorded in 70 patients (62.5%) and were not associated with cerebral ischemic complications. The 7 patients who developed cerebral ischemic complications had a significantly higher percentage of stenosis in the contralateral internal carotid artery (mean +/- SD, 82.0 +/- 17.8% versus 29.3 +/- 36.4%; P = .0018). CONCLUSIONS The results of our study suggest that the major complications of carotid endarterectomy may be due to hemodynamic factors. Stump pressure alone is not a reliable indicator of hemodynamic changes that predict cerebral ischemia. Particulate microembolism may cause more subtle changes in cerebral parenchyma, but further studies are needed to clarify this point.

White Matter Lesions Progression in Migraine with Aura: A Clinical and MRI Longitudinal Study

To prospectively evaluate longitudinal changes in white matter lesions (WMLs) in migraineurs with aura, by magnetic resonance imaging (MRI), and to correlate WMLs modifications with patients’ clinical characteristics.

Therapeutic strategies in migraine patients with mood and anxiety disorders: clinical evidence

Mood and anxiety disorders are comorbid with migraine. The coexistence of a psychiatric disorder alters the quality of life, the total disability, the course of migraine and the final prognosis; it increases the probability of central sensitization, other chronic pain conditions and the evolution to chronic migraine. All patients presenting with frequent episodic and chronic migraine should be screened for depression and anxiety. When these conditions are present, drugs for migraine prevention that may worsen the psychiatric comorbid disorder have to be avoided. When it is possible, both conditions should be treated with a single agent. Amitriptiline can be used both in mood disorders and migraine prevention. Flunarizine and beta-blockers may help if anxiety is present. Pregabalin has demonstrated efficacy in anxiety disorders and fibromyalgia. Divalproex sodium, topiramate and lamotrigine that have demonstrated efficacy in mood stabilization are also indicated in migraine without aura (divalproex sodium and topiramate) and with aura (lamotrigine). When a specific treatment for the comorbid psychiatric disorder is needed, the selective serotonin reuptake inhibitors or the serotonin norepinephrine reuptake inhibitors are the drugs of choice both in depression and anxiety, and the cognitive behavioural therapy has good evidence of efficacy in anxiety disorders. Vagal nerve stimulation may be an option in patients with refractory chronic migraine and depression.

Internal Borderzone Infarction in Patients with Ischemic Stroke

Objective: The mechanism underlying cerebral infarction in the borderzone between the territories of deep and superficial perforating arteries has not yet been clarified. This study was performed to investigate the prevalence, volume, site, and etiology of this type of subcortical infarction in a large unselected group of stroke patients. Methods and Patients: We analyzed a continuous series of 383 patients with recent cerebral infarction observed in our Stroke Unit. Patients underwent a complete clinical and instrumental workup. The subgroup of subjects with internal borderzone infarct alone were compared with the subgroups of patients with other types of cerebral infarcts by uni- and multivariate statistical tests. Results: There were 90 internal borderzone infarcts of 725 ischemic lesions (12% of the total), with a median volume of 0.32 ml (95% confidence interval 0.24–0.44; range: 0.012–20.2 ml). Internal borderzone infarcts alone occurred in only 13 of 383 (3.4%) patients. A comparison between patients with ‘pure’ internal borderzone infarction and patients with other types of cerebral infarcts by multiple logistic regression analysis demonstrated a significant independent causal role of carotid stenosis or occlusion. Conclusion: Our study suggests that ‘pure’ internal borderzone infarctions are quite rare findings in patients with ischemic stroke, and that the hemodynamic impairment due to atherosclerotic occlusion or stenosis of the carotid system could be the cause in the large majority of cases.

Sex-related differences in migraine

This paper reviews sex-related differences in migraine epidemiology, symptoms, natural history and co-morbid disorders. Migraine is more than twice as common in females as in males, and women experience more frequent, longer lasting and more painful attacks, have more disability and a risk of transition from episodic to chronic migraine greater than men, but the mechanisms behind these differences are still poorly understood. The role of sex hormones, genes, and the differences in brain function and structure are discussed. Finally, we evaluate the many gender-related questions about treatment of migraine in women. In future research data should be analyzed separately for men and women to ensure that differences between the sexes could be identified.

Twenty-four-hour beta-endorphin secretory pattern in stroke patients.

BACKGROUND AND PURPOSE Abnormalities of hypothalamo-pituitary-adrenocortical axis function have been observed frequently in stroke patients. The aim of this study was to investigate plasma beta-endorphin and cortisol 24-hour secretory patterns in patients early after stroke and in the convalescent period to evaluate a possible influence of brain damage on hormonal circadian pattern. METHODS Patients (n = 15; age, 46 to 75 years) were evaluated in the first 24 hours and 10 days after hospital admission for ischemic cerebral stroke and compared with 15 age- and sex-matched normal subjects. Blood samples for beta-endorphin and cortisol determination were drawn every 4 hours from 8 AM to 8 PM and every 2 hours from midnight to 6 AM. RESULTS Mean 24-hour beta-endorphin and cortisol levels, recorded in the acute phase, were significantly (P < .05) higher than those recorded in normal subjects; circadian rhythm was not demonstrable for either hormone. In the convalescent period, plasma cortisol 24-hour mean values and circadian rhythm returned to the normal range, whereas the plasma beta-endorphin 24-hour mean values and circadian rhythm did not. CONCLUSIONS Cerebral stroke induces abnormalities of beta-endorphin and cortisol circadian secretion. Whereas cortisol abnormalities are transient, those of beta-endorphin last longer. The dissociation between beta-endorphin and cortisol 24-hour secretory patterns might potentially serve as a marker of psychoneurological abnormalities occurring after stroke.

Diffusion MRI During Migraine With Aura Attack Associated With Diagnostic Microbubbles Injection in Subjects With Large PFO

The relationship between migraine with aura and patent foramen ovale (PFO) is still debatable. We report 2 cases of migraine with aura attacks after diagnostic microbubble injection for contrast transcranial Doppler (cTCD), in subjects with large PFO. In one case MR images, including diffusion weighted imaging and apparent diffusion coefficient, performed during aura did not show any signal abnormality. Patients with migraine with aura may have an attack during cTCD, probably by a “non‐ischemic” mechanism.