Silvia Angeli

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.

Prevalence of patent foramen ovale in subjects with obstructive sleep apnea: a transcranial Doppler ultrasound study

BACKGROUND Under particular conditions a patent foramen ovale (PFO) can potentially give rise to ischemic stroke by means of paradoxic embolization. In obstructive sleep apnea syndrome (OSAS) right to left shunting (RLSh) can occur through PFO during periods of nocturnal apnea. Our study aimed to evaluate the prevalence of PFO diagnosed by means of transcranial Doppler (TcD) in subjects with OSAS. METHODS Seventy-eight consecutive subjects with OSAS (mean age 53+/-12 years) and 89 normal controls (mean age 48+/-9 years) underwent TcD with intravenous application of agitated physiological saline solution. The test was performed on patients at rest and during Valsalva maneuver. RESULTS PFO was present in 21 out of 78 patients with OSA (27%) and in 13 out of 89 control patients (15%). Seventeen out of 21 patients with OSA showed PFO only during Valsalva maneuver (85%) with respect to 12 out of 13 subjects of the control group (92%). Prevalence of PFO in OSAS was statistically different with respect to the control group (P<0.05). However, no statistically significant differences could be found for the prevalence of provocative-only shunting PFO with respect to already at rest shunting PFO in patients with OSAS with respect to the control group. CONCLUSIONS Prevalence of PFO in subjects with OSA is significantly higher than in normal controls. The shunt is frequently present only during Valsalva maneuver.

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.

Transcranial Doppler in the diagnosis of cardiac patent foramen ovale

Abstract Right-to-left shunt due to patent foramen ovale is a well-established risk factor for ischemic stroke, especially in young subjects and in patients with cryptogenic stroke. We report a detailed method for the diagnosis of a right-to-left shunt by means of transcranial Doppler as established at a recent consensus conference, and review the literature on the indications for the test.

Very High Prevalence of Right-to-Left Shunt on Transcranial Doppler in an Italian Family with Cerebral Autosomal Dominant Angiopathy with Subcortical Infarcts and Leukoencephalopathy

Background and Purpose: Cerebral autosomal dominant angiopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an autosomal dominant hereditary disease whose clinical expression is a stepwise subcortical vascular dementia. Initial presentation of the disease involves transient or stabilized focal neurological deficits, migraine and mood changes. Recently, a high prevalence of right-to-left shunt (RLS) due to patent foramen ovale has been reported in subjects with migraine. The aim of our study was to determine the prevalence of RLS in CADASIL with and without migraine. Methods: We performed transcranial Doppler with gaseous contrast in 5 members of an Italian family with CADASIL, diagnosed by means of genetic and skin biopsy criteria. We then compared the prevalence of RLS in 40 consecutive subjects with juvenile stroke, 80 asymptomatic subjects affected by migraine with aura and 50 normal controls. Results: A very high prevalence of RLS was found in CADASIL patients (4/5, 80%), as opposed to young subjects with ischemic stroke (15/40, 37%), asymptomatic subjects with migraine (32/80, 40%) and normal controls (8/50, 16%). All the subjects with CADASIL and migraine (4/4) showed RLS. The difference between CADASIL patients and controls was highly significant (p = 0.006). Conclusions: We suggest an association between CADASIL and RLS, possibly due to the abnormal development of the endocardial cushion influenced by Notch 3 mutation. Our hypothesis needs to be tested in larger samples.

Cluster headache and right-to-left shunt on contrast transcranial Doppler: a case-control study.

The authors evaluated the prevalence of right-to-left shunt in 40 subjects with cluster headache (CH) vs 40 subjects without primary headaches or cerebrovascular disease. The diagnosis of shunt was made by means of transcranial Doppler with contrast medium. A shunt was found in 17 CH patients (42.5%) and in 7 controls (17.5%) (p = 0.029; OR = 3.48; 95% CI = 1.13 to 10.69).

Tilt-table test during transcranial Doppler monitoring in Parkinson's disease

Cardiovascular autonomic dysfunction can occur in Parkinsons disease (PD) and intracranial vascular modifications following orthostatism may be relevant to diagnostic and therapeutic decision-making. We performed transcranial Doppler monitoring of right middle cerebral artery (MCA) at rest and during passive 70 degrees tilt in 19 patients with idiopathic PD and in 19 age-matched normal controls. Brachial arterial blood pressure (systolic, diastolic and mean), cardiac frequency (CF), respiratory frequency and mean velocity (MV) of the MCA were recorded after 10 min of rest in supine position, and each minute during 9 min of tilting and 5 min of restored clinostatic position. The pulsatility and cerebrovascular resistances (CVR) indexes were calculated. At rest there was no significant difference in blood pressure, CF, respiratory frequency and MCA mean velocity between patients and controls. During tilt test, PD patients showed a trend to higher pulsatility index values (p=0.09) and significant lower diastolic blood pressure (p=0.001), while there was no significant difference in CVR index. In conclusion, PD patients showed mild hypotensive response to orthostatic stress, with intracranial compensatory vasodilation. Our findings suggest a preserved intracerebral autoregulation in PD without symptoms of orthostatic intolerance.

The Migraine-PFO Connection Is Independent of Sex

Independent investigations carried out in Brescia and Genoa [1, 2] have shown that a right-to-left shunt (RLS) through a patent foramen ovale (PFO), as assessed with transcranial Doppler with intravenous saline, may be found approximately twice as frequently in migraine patients as compared to age-matched controls. This finding prompted speculations about the possible role of RLS, leading to paradoxical cerebral embolism, in enhancing the risk of stroke in migraine sufferers. However, a pitfall of both investigations was the unbalanced sex ratio between migraine patients and controls. If PFO is more frequent in women, the association found with migraine might be spurious and simply result from the overrepresentation of the female gender in migraine sufferers. To study the interaction of sex and migraine on the prevalence of RLS, raw data from both centers were collated for controls and patients suffering from migraine with aura. Three cases were ruled out because of missing data. The resulting database included 155 patients suffering from migraine with aura (123 females, 32 males; mean age 33 B 12), diagnosed according to the criteria of the International Headache Society, and 75 controls (43 females and 32 males; mean age 34 B 10). All the subjects underwent transcranial Doppler monitoring of the middle cerebral arteries. RLS was diagnosed if embolic spikes were recorded in the cerebral vessels following the intravenous injection of an agitated solution of 10 ml glucose 10% or saline mixed with 1 ml of air. The test was performed both during normal ventilation and during the Valsalva maneuver. Due to minor methodological differences between the two studies, RLS quantification was reasssessed in patients from Genoa, assuming a threshold of ^10 bubbles for grade 1 (‘small’) and 110 bubbles for grade 2 (‘large’) RLS. The sociodemographic variables were not statistically different in the two groups. Table 1 shows the frequency of RLS in relation to sex and diagnosis. In both migraine patients and controls RLS was more frequent in women. Although the trend was not statistically significant on the ̄ 2 test, the figures suggest that the increased frequency of RLS might derive from females representing the majority of migraine sufferers. Therefore, a logistic regression model was created including sex, RLS and migraine. The results, shown in table 2, indicate that female gender and RLS were, as expected, independent predictors of migraine with aura, but the co-occurrence of these risks conferred an additional strength to the association. Table 1. Results of the logistic regression model

Transcranial Doppler Detection of Microemboli in a Stroke Patient with Polycythemia rubra vera

We report a case of a 63-year-old man without known risk factors for cerebrovascular disease who developed a right hemiparesis with slow onset and subsequent clinical improvement. Cerebral computed to

Warfarin, Aspirin and Microembolic Signals in the Acute Phase of Stroke in a Patient with Mechanical Heart Valves

We report the case of a 54-year-old woman, with atrial fibrillation and mechanical heart valves, who suffered a left-hemispheric stroke while she was under warfarin. Daily bilateral simultaneous transcranial Doppler monitoring of the middle cerebral arteries showed the presence of microembolic signals (MES), whose number remained unchanged after adding aspirin 100 mg daily. We conclude that anticoagulant plus antiplatelet therapy does not influence the number of MES in the acute phase of stroke in patients with prosthetic heart valves, suggesting the gaseous origin of MES in these patients.