Abstract
Background
Cortical spreading depression has been suggested to be the main substrate for migraine, but its pathobiology is not completely understood. Recently, the microembolic hypothesis as a promoting factor of cortical spreading depression has been demonstrated in an animal model. Our study is aimed to present a series of patients in whom early migraine attacks immediately after closure procedure predicted migraine with aura resolution on the long term, suggesting a role for microembolization in migraine genesis.
Methods
Our study consisted of 42 patients with migraine (36 female, mean age 35±6.7 years, mean Migraine Disability Assessment Score 29.9±9) and previous stroke who underwent transcatheter PFO closure during the last 2 years at the Rovigo General Hospital using different devices selected on the basis of specific anatomies. Procedural, technical, and clinical variables have been recorded and analyzed searching for potential relationships among postprocedural migraine, migraine improvement, and microembolization.
Results
Sixteen patients (38%) experienced a migraine attack of mean duration 3.5±2.4 h immediately (<60 min) after closure procedure. These patients more frequently had a severe migraine with aura and a permanent shunt on transcranial Doppler. There were no differences in terms of procedure time, occlusion time, and type of device used.
After a mean follow-up of 32.2±10.6 months, only patients with postprocedural migraine attacks reported resolution of aura and a significant improvement in migraine symptoms.
Conclusions
Our series seem to indirectly confirm in vivo the experimental animal data of microembolization-driven cortical spreading depression. It also confers the recent hypothesis about air microbubble-induced cerebral deoxygenation linking the micromebolic hypothesis with cortical spreading depression.
1
Introduction
Conflicting studies based on microembolic genesis of migraine have investigated the association of patent foramen ovale (PFO) with migraine . Cortical spreading depression has been suggested to be the main substrate for migraine, but its pathobiology is not completely understood. Recently, the microembolic hypothesis as a promoting factor of cortical spreading depression has been demonstrated in an animal model . Microembolization during transcatheter PFO closure is a well-described occurrence at the time of crossing the septum with the guide wire or at the opening of left disk . Our study is aimed to present a series of patients in whom early migraine attacks immediately after closure procedure predicted migraine with aura resolution on the long term suggesting a role for microembolization in migraine genesis.
2
Methods
Our study consisted of 42 patients with migraine (36 female, mean age 35±6.7 years) and previous stroke who underwent transcatheter PFO closure during the last 2 years at the Rovigo General Hospital.
International Headache Society criterion Migraine Disability Assessment Score (MIDAS) was used to assess migraine with aura incidence and severity routinely in all patients referred to our center (mean MIDAS 29.9±9). The Amplatzer Occluder (AGA Medical Corporation, Golden Valley, MN) was selected in cases of associated atrial septal aneurysm (ASA), whereas the Premere Occlusion System (St Jude Medical Corp.) was used in case of tunnelized (tunnel length >10 mm) PFO without ASA. A 9F 9MHz UltraICE catheter (EP Technologies, Boston Scientific Corporation, San Jose, CA) was used to perform a complete intracardiac study. Heparin 70 U/kg was given to all patients after catheterization in order to obtain an activated coagulation time around 250 for the duration of the procedure. All patients were managed with aspirin 100 mg/day 1 week before and for 6 months after the procedure. Follow-up was conducted by means of transesophageal echocardiography at 1 month, and if at least a small shunt was detected, at 6 months; transthoracic echocardiography at 1, 6, and 12 months; transcranial Doppler at 1 month; ECG Holter monitoring at 1 month; and combined cardiologic and neurological visit at 1, 6, and 12 months with MIDAS administration. Residual shunt was assessed by contrast transesophageal echocardiography and transcranial Doppler. Data are expressed as mean±S.D. and as percentages. Variables were compared with Student t and Fisher tests and ANOVA. A significant level was defined when P < .05. All analyses were performed using SPSS 10.0 (SPSS Inc., Chicago, IL).
2
Methods
Our study consisted of 42 patients with migraine (36 female, mean age 35±6.7 years) and previous stroke who underwent transcatheter PFO closure during the last 2 years at the Rovigo General Hospital.
International Headache Society criterion Migraine Disability Assessment Score (MIDAS) was used to assess migraine with aura incidence and severity routinely in all patients referred to our center (mean MIDAS 29.9±9). The Amplatzer Occluder (AGA Medical Corporation, Golden Valley, MN) was selected in cases of associated atrial septal aneurysm (ASA), whereas the Premere Occlusion System (St Jude Medical Corp.) was used in case of tunnelized (tunnel length >10 mm) PFO without ASA. A 9F 9MHz UltraICE catheter (EP Technologies, Boston Scientific Corporation, San Jose, CA) was used to perform a complete intracardiac study. Heparin 70 U/kg was given to all patients after catheterization in order to obtain an activated coagulation time around 250 for the duration of the procedure. All patients were managed with aspirin 100 mg/day 1 week before and for 6 months after the procedure. Follow-up was conducted by means of transesophageal echocardiography at 1 month, and if at least a small shunt was detected, at 6 months; transthoracic echocardiography at 1, 6, and 12 months; transcranial Doppler at 1 month; ECG Holter monitoring at 1 month; and combined cardiologic and neurological visit at 1, 6, and 12 months with MIDAS administration. Residual shunt was assessed by contrast transesophageal echocardiography and transcranial Doppler. Data are expressed as mean±S.D. and as percentages. Variables were compared with Student t and Fisher tests and ANOVA. A significant level was defined when P < .05. All analyses were performed using SPSS 10.0 (SPSS Inc., Chicago, IL).
3
Results
Sixteen patients (38%) experienced a migraine attack of mean duration 3.5±2.4 h immediately (<60 min) after closure procedure. These patients more frequently had a severe migraine with aura and a spontaneous shunt on transcranial Doppler. The procedures time, type of device used, and occlusion times did not differ between the two groups of patients ( Table 1 ). There were no intraprocedural or late complications including no supraventricular arrhythmias. After a mean follow-up of 32.2±10.6 months, patients with postprocedural migraine attacks reported complete resolution of aura and a more significant improvement in migraine symptoms demonstrated by decrease of mean MIDAS and mean number of anti-headache medications ( Table 2 , Fig. 1 ).
