Impact of percutaneous patent foramen ovale closure on migraine course

Migraine is a neurological disorder characterized by an increased individual susceptibility to respond to certain triggers by a propagating wave of neuronal depolarization that culminates in typical migraine headaches. Patients with a patent foramen ovale or any kind of right-to-left shunt are more likely to have migraine; and patients with migraine with aura are more likely to have a patent foramen ovale than patients without migraine. Nonrandomized reports of patent foramen ovale closure in divers, in patients with paradoxical embolism and in migraine patients with ischemic brain lesions have shown an impressive reduction in migraine headaches during follow-up. To date, the only double-blind, randomized controlled trial with a sham procedure in the control arm failed to show any benefit, probably owing to inadequate patient selection and maybe because of a high residual shunt rate. Two other randomized trials continue to enroll patients with migraine with aura and drug-refractory headaches and their results are awaited.

Patent foramen ovale closure: a new therapy for migraine

Migraine is a recurrent disabling disorder predominantly affecting middle-aged women. Migraine occurs with or without aura symptoms. Several studies have shown an increased prevalence of right-to-left shunts (RLSs) in migraine with aura. The overwhelming majority of these shunts were due to a patent foramen ovale (PFO). Furthermore, migraine with aura is more prevalent in clinical entities associated with a RLS, e.g. cryptogenic stroke, decompression illness in divers, or in patients with hereditary hemorrhagic teleangiectasia and pulmonary arteriovenous fistulas. Retrospective studies have consistently shown that shunt closure was associated with a significant reduction in migraine frequency. Its beneficial effect seemed to exceed the efficacy of conventional migraine therapy. Several randomized clinical trials to prospectively assess the benefit of shunt closure in migraine patients have been initiated. The only one completed, the MIST trial (Migraine Intervention with STARFLEX Technology), showed a significant reduction of migraine with aura after device implantation, compared with controls. However, the benefit of PFO closure was more modest than expected. This review recapitulates the current data regarding PFO closure and migraine with aura and summarizes in brief the current knowledge regarding migraine pathophysiology and the link to a RLS.

Percutaneous closure of patent foramen ovale for migraine headaches refractory to medical treatment

BACKGROUND: Patent foramen ovale (PFO) has been linked to migraine, and several retrospective studies reported an improvement in migraine prevalence or frequency after PFO closure for other reasons, mostly for secondary prevention of paradoxical embolism or following diving accidents. We investigated the outcome of patients undergoing PFO closure solely for migraine headaches refractory to medical treatment. METHODS: Seventeen patients (age 44 +/- 12 years; 76% female; one atrial septal aneurysm) underwent percutaneous PFO closure using the Amplatzer PFO Occluder (AGA Medical Corporation, Golden Valley, MN). An 18-mm device was used in two patients, a 25-mm device in 13, and a 35-mm device in two. The interventions were solely guided by fluoroscopy, without intraprocedural echocardiography. RESULTS: All implantation procedures were successful. There were no peri-procedural complications. Contrast transesophageal echocardiography after Valsalva maneuver at 6 months showed complete PFO closure in 16 patients (94%), whereas a minimal residual shunt persisted in one (6%). During 2.7 +/- 1.5 years of follow-up, no deaths and no embolic events occurred. After PFO closure, migraine headaches disappeared in four patients (24%), and improved in eight additional patients (47%). Three patients (18%) reported a decrease of their headaches by 75%, three patients (18%) a decrease of 50%, and two patients (12%) a decrease of 25%, while headaches remained unchanged in five patients (29%). No patient experienced worsening headaches. Moreover, the prevalence of migraine with aura decreased from 82 to 24% (P = 0.002). CONCLUSIONS: These results suggest that percutaneous PFO closure durably alters the spontaneous course of shunt associated migraine.

Effects of {beta}-blocker selectivity on blood pressure variability and stroke: A systematic review

β-Blockers increase variability in systolic blood pressure (SBP), which probably explains their lesser effectiveness in preventing stroke vs myocardial infarction compared with other agents. This increase in variability in blood pressure (BP) may be particularly marked on non-cardioselective agents, potentially calling into question the widespread first-line use of propranolol in migraine with aura, elderly patients with essential tremor or anxiety, and other groups at risk of stroke.

Syncope

Syncope is defined as an acute, brief and transient loss of consciousness and postural tone with spontaneous and complete recovery. Neurovascular ultrasound has contributed to elucidate the underlying mechanism of different types of syncope. In routine diagnostic work-up of patients with syncope, however, neurovascular ultrasound is not among the first line tools. In particular, an ultrasound search for occlusive cerebro-vascular disease is of limited value because cerebral artery obstruction is a very rare and questionable cause of syncope. Transcranial Doppler sonography monitoring of the cerebral arteries is useful in the diagnostic work-up of patients with suspicion of postural related, cerebrovascular, cough and psychogenic syncope, and in some cases for differentiating focal epileptic seizures from transient ischemic attacks and migraine with aura.

Ultrasound diagnosis of spontaneous carotid dissection with isolated Horner syndrome

BACKGROUND AND PURPOSE: Isolated Horner syndrome without associated cranial nerve palsies or ischemic symptoms is an important presentation of spontaneous internal carotid artery dissection (sICAD). Ultrasound is often used as a screening method in these patients because cervical MRI is not always available on an emergency basis. Current knowledge on ultrasound findings in patients with sICAD presenting with isolated Horner syndrome is limited. METHODS: Patients were recruited from prospective cervical artery dissection databases of 3 tertiary care centers. Diagnosis of sICAD was confirmed by cervical MRI and MR angiography or digital subtraction angiography in all patients. Data on Doppler sonography and color duplex sonography examinations performed within 30 days of symptom onset were analyzed. RESULTS: We identified 88 patients with Horner syndrome as the only sign of sICAD. Initial ultrasound examination was performed in 72 patients after a mean time interval from symptom onset to examination of 11 (SD 8) days. The overall frequency of false-negative ultrasound findings was 31% (22 of 72 patients). It showed stenosis >or=80% or occlusion in 34 (47%) patients, and stenosis with normal ultrasound were less frequently smokers (9% versus 28%, P=0.034), and had less frequently migraine without aura (9% versus 43%, P=0.012) or neck pain (18% versus 62%, P=0.003) than those with pathological ultrasound findings. CONCLUSIONS: Nearly one third of patients with Horner syndrome as the only sign of sICAD presented with normal ultrasound findings. These results indicate that ultrasound is not a reliable method to diagnose sICAD in patients with isolated Horner syndrome.

Electroencephalographic changes and seizures in familial hemiplegic migraine patients with the CACNA1A gene S218L mutation

The S218L CACNA1A mutation has been previously described in two families with familial hemiplegic migraine. We present three siblings with the mutation with the novel association of childhood seizures, and highlight the dynamic changes seen on electroencephalography during hemiplegic migraine attacks. Depressed activity contralateral to the hemiparesis was seen on electroencephalography during acute hemiplegic migraine attacks, which may be due to changes to calcium channels caused by the S218L mutation. Both parents were asymptomatic and did not carry the S218L mutation in their blood. This suggests the presence of mosaicism in the transmitting parent.

Validation of MIPAS IMK/IAA temperature, water vapor, and ozone profiles with MOHAVE-2009 campaign measurements

MIPAS observations of temperature, water vapor, and ozone in October 2009 as derived with the scientific level-2 processor run by Karlsruhe Institute of Technology (KIT), Institute for Meteorology and Climate Research (IMK) and CSIC, Instituto de Astrofísica de Andalucía (IAA) and retrieved from version 4.67 level-1b data have been compared to co-located field campaign observations obtained during the MOHAVE-2009 campaign at the Table Mountain Facility near Pasadena, California in October 2009. The MIPAS measurements were validated regarding any potential biases of the profiles, and with respect to their precision estimates. The MOHAVE-2009 measurement campaign provided measurements of atmospheric profiles of temperature, water vapor/relative humidity, and ozone from the ground to the mesosphere by a suite of instruments including radiosondes, ozonesondes, frost point hygrometers, lidars, microwave radiometers and Fourier transform infra-red (FTIR) spectrometers. For MIPAS temperatures (version V4O_T_204), no significant bias was detected in the middle stratosphere; between 22 km and the tropopause MIPAS temperatures were found to be biased low by up to 2 K, while below the tropopause, they were found to be too high by the same amount. These findings confirm earlier comparisons of MIPAS temperatures to ECMWF data which revealed similar differences. Above 12 km up to 45 km, MIPAS water vapor (version V4O_H2O_203) is well within 10% of the data of all correlative instruments. The well-known dry bias of MIPAS water vapor above 50 km due to neglect of non-LTE effects in the current retrievals has been confirmed. Some instruments indicate that MIPAS water vapor might be biased high by 20 to 40% around 10 km (or 5 km below the tropopause), but a consistent picture from all comparisons could not be derived. MIPAS ozone (version V4O_O3_202) has a high bias of up to +0.9 ppmv around 37 km which is due to a non-identified continuum like radiance contribution. No further significant biases have been detected. Cross-comparison to co-located observations of other satellite instruments (Aura/MLS, ACE-FTS, AIRS) is provided as well.