Gian Paolo Anzola

Shunt-associated migraine responds favorably to atrial septal repair : A case-control study

BACKGROUND AND PURPOSEnTranscatheter closure of patent foramen ovale (PFO) has been reported to improve migraine in patients with cerebrovascular disorders in noncontrolled studies. The aim of the study was to compare the course of migraine assessed prospectively over a 12-month period in symptomatic (for cerebrovascular disease) and asymptomatic patients undergoing PFO closure and in patients with PFO treated medically.nnnMETHODSnTwenty-three stroke symptomatic (SS; 39+/-10 years of age; males/females [M/F] 5/18) and 27 stroke asymptomatic (SA; 40+/-12 years of age; M/F 5/22) patients with migraine underwent PFO closure. Twenty-seven patients with migraine and PFO (controls [CTRLS]; 36+/-11 years of age; M/F 4/23) were followed up medically. Migraine severity was assessed at baseline with a scale that takes into account the frequency, duration, and intensity of the attacks and the occurrence of aura (score range 0 to 10). Six months later, the patients were given a structured diary to annotate monthly with the same scale the characteristics of the attacks for the next 6 months. By the end of 1 year, the migraine score was averaged for the last 6 months.nnnRESULTSnBaseline severity of migraine did not differ between groups (6.3 to 6.1 and 6.7 in SS, SA, and CTRLS groups, respectively). At the 1-year assessment, the overall migraine score had significantly improved by 3.7 and 2.8 points in SS and SA, respectively (P<0.001 on repeated-measure ANOVA), whereas it had nonsignificantly worsened by 0.1 points in CTRLS. Multiple linear regression analysis showed that the improvement in SS and SA was independent of migraine type, age, and cerebrovascular risk factors. Twenty-one of 21 patients with migraine with aura in the CTRLS group still had aura at the end of follow-up, whereas only 3 of 14 among SA and 4 of 19 among SS continued to have migraine preceded by aura (P<0.0001 on Fisher exact test).nnnCONCLUSIONSnCompared with medical treatment, closure of PFO brings about a significant overall improvement in migraine. This seems to occur irrespective of migraine type and of previous cerebrovascular disease. In addition to the overall improvement, in migraine with aura, the occurrence of aura is dramatically reduced.

Different degrees of right-to-left shunting predict migraine and stroke: Data from 420 patients

The authors analyzed the extent of right-to-left shunting in patients with migraine, patients with cryptogenic stroke, and controls. Patients with both migraine and stroke had larger shunts than did patients with migraine without stroke (p = 0.038), patients with no migraine with stroke (p = 0.007), and control patients (p < 0.0001). Patients with migraine have overall larger shunts than nonmigraineurs, particularly if they have had a stroke. Right-to-left shunting may be causally related to migraine and to the increased stroke risk of migraine.

Does Transcatheter Closure of Patent Foramen Ovale Really “Shut the Door?”: A Prospective Study With Transcranial Doppler

Background and Purpose— Transcatheter closure of patent foramen ovale (PFO) is increasingly being performed and monitored with transthoracic or transesophageal echocardiography, whereas contrast-enhanced transcranial Doppler (ce-TCD), which probably represents the most suitable tool to quantify right-to-left shunt (RLS) in the brain vessels, has been systematically overlooked. Our goal is to prospectively assess efficacy and safety of PFO transcatheter closure using ce-TCD. Methods— A total of 140 consecutive patients (mean age, 46±13 years; male/female ratio, 63/77) with PFO-related large RLS and no other recognized cause of focal cerebral ischemia underwent transcatheter closure. TCD was done preoperatively and 1 month after the procedure in all patients, after 3 months in 120, after 6 months in 112, and after 1 year in 104 patients. Results— Implantation was successful in all patients. During Valsalva strain, a large shunt was still detectable in 31 of 140 (22%), 15 of 120 (13%), 9 of 112 (8%), and 9 of 104 (9%) patients at the 1-, 3-, 6-, and 12-month visits, respectively. Periprocedural and postprocedural complications included atrial fibrillation in 8% and scintillating scotomata in 6% of patients. During the 1-year follow-up period, only 1 transient ischemic attack was recorded in a patient with paroxysmal atrial fibrillation and complete PFO closure. Conclusions— Transcatheter PFO closure in patients with cryptogenic stroke and large RLS may be less successful than reported previously. TCD appears the ideal tool to follow up the closure process and to identify early, during follow-up, those patients who will be left with a significant shunt. Atrial fibrillation is more common than believed previously and may underlie the occurrence of further cerebrovascular events despite complete PFO closure. Irritative visual phenomena may occur as a consequence of nickel toxicity.

Postural dependency of right to left shunt: role of contrast-enhanced transcranial Doppler and its potential clinical implications.

Background and Purpose— Right to left shunt is involved in conditions in which postural changes may be pathogenically relevant. The aim of this work was to assess the frequency of posturally dependent right to left shunt. Methods— In 109 consecutive right to left shunt-positive subjects (male/female=40/69, age 43±12 years), we assessed with contrast-enhanced transcranial Doppler the bubble load during normal breathing and after the Valsalva maneuver in both standing and recumbent position randomizing the order of testing. Results— During normal breathing, the average bubble count was 11±20 in the recumbent and 26±60 in the standing position. After the Valsalva maneuver, it was 40±38 and 42±37, respectively. The increase of bubble load in standing position occurred in 42% of patients and was independent of the order of testing. Conclusions— The amount of permanent right to left shunt is posture-dependent in 40% of patients. Testing in the sitting position may thus be warranted in doubtful or inconclusive results obtained with the subject in the horizontal position.

Silent brain embolism during transcatheter closure of patent foramen ovale : a transcranial doppler study

The aim of this report is to quantify the amount of spontaneous microembolism detected in brain vessels by transcranial Doppler (TCD) during transcatheter closure of right-to-left shunt (RLS). We examined 29 patients who had had a stroke or a transient ischaemic attack (17 females and 12 males; mean age 45±15 years). They all underwent TCD monitoring during the procedure and microembolic signals (MES) were recorded. Detection of MES was distributed as follows: during femoral catheterisation in 8 patients (25%), during atrial catheterisation in 5 patients (17%), during transeptal crossing in 14 patients (48%), during left disc opening in 28 patients (96%) and during right disc opening in 7 patients (24%). The highest rates of MES were observed during left disc opening and less during transeptal crossing with an average count of 31 (range 3–135) and 3 (range 1–18) respectively. Brain embolism occurs throughout the procedure after femoral catheterisation for PFO closure. Our results indicate that the majority of MES reached the brain during the opening of the left disc in the left atrium: 28/29 patients exhibited MES with an average of 31 (3–135), thus supporting the notion that gas embolism accounted for the findings.

Patent foramen ovale closure. Pro and cons

Because patent foramen ovale (PFO) represents a lesion which may be repaired a number of expert clinicians believe that mechanical closure should be the primary treatment modality for patients with PFO after cryptogenic stroke; interest has grown on percutaneous devices and in the last years there has been great technological advancement of percutaneous techniques for PFO closure. However, we should not close a PFO before establishing the evidence-based indications. At the same time, efforts to develop safer and more effective closure devices are under way. These devices include those with little or no metal component and those with biodegradable discs. Ideally, we should be able to identify at-risk patients before they sustain a stroke and to prevent stroke by closing the PFO with a device that should result in complete closure, be made of material that conforms to both sides of the septum, and have no risk of erosion, infection, arrhythmia, or thrombogenicity. Randomised trials comparing medical and percutaneous closure approaches are underway, but large patient enrollment is necessary because of the low event rate in the younger patients. Meanwhile, as the complication rate from device implantation decreases and simpler devices are developed with reliability further demonstrated, the threshold for percutaneous closure is likely to decline.

Response to Letter by Gupta

Response:nnDr Gupta’s letter highlights the need to avoid prejudicially mislead conclusions inasmuch as his quotation of postclosure aggravation of migraine is misplaced as long as patent foramen ovale (PFO) is mistaken for an atrial septum defect. However, his observations offer the opportunity to try to disentangle the apparent paradox of migraine associated with PFO on one side and the reported aggravation or the novo appearance of headache after the fixing of atrial septal defects (ASD) on the other. This superficially apparent contradiction is likely to result from the attitude, among many noncardiologists, to assimilate PFO to ASD, whereas the 2 conditions are totally different in terms of …

Response to Letter by Di Legge et al

Response:nnDi Legge and colleagues suggest that modifying conventional vascular risk factors (RF) as well as lifestyle habits may influence migraine outcome, and the lack of control on this variable may have interfered with the effect of patent foramen ovale closure in our study. In support of this contention they quote the higher load of …