ABSTRACT 5
Migraine Induction by Brain Micro-Embolization During Contrast Transcranial Doppler Evaluation of Right-to-Left Shunt
American Journal of Cardiology 2005; 96 (suppl 7) : 9
Sherman G Sorensen1, Deborah L Davis2, Laurie Raleigh2, Heather Aguilar2, Peter J Casterella1, Brianna S Ronnow3, Ali K Choucair4, Donald L Lappé1, Heidi Thomas3, Joseph B Muhlestein3
1Utah Heart Clinic and LDS Hospital Cardiology, Salt Lake City, UT;2Utah Heart Clinic, Salt Lake City, UT;3LDS Hospital Cardiology, Salt Lake City, UT;4LDS Hospital Neurology and Cardiology, Salt Lake City, UT
BACKGROUND: Brain micro-embolization (mEMB) due to right-to-left shunt (RLS) has been described with contrast echocardiography, brain imaging (MRI) of divers with decompression illness, and while crossing a patent foramen ovale (PFO) during closure procedures. RLS occurs in 50% of migraine (MHA) patients (pts) with several reports describing migraine improvement or even resolution with PFO closure. We have observed severe MHA symptoms (MHA, A, visual loss, vertigo [MHA-SX]) induced by TCD suggesting that brain mEMB may be a trigger for MHA.
METHODS: Of 490 pts undergoing percutaneous PFO closure for recurrent stroke, 176 (36%) reported active MHA before closure with 49 (28%) having aura (A). Pre- and 90 day post-procedural power M-mode transcranial Doppler (TCD) with rest (R) and calibrated valsalva (V) agitated saline contrast intra-venous injections were compared (N=148). Cerebral mEMB events were quantified by automatic embolic detection program (scale of 1-5). A separate group of 225 consecutive pts referred for diagnostic TCD were evaluated by questionnaire as to the onset of MHA-SX with TCD. Indications for diagnostic TCD: cerebrovascular accident (CVA)=22%, transient ischemic attack (TIA)=30%, MHA=49%, and abnormal MRI=69%.
RESULTS: Responses to PFO closure pre- vs. 90-day post procedure included reduced incidence of active MHA: 176 vs. 23 pts (p=0.001), reduced TCD-R: 2.74+1.02 vs. 0.52+1.02 (p=0.0001), and TCD-V: 4.73+0.73 vs. 1.86+1.71 (p=0.0001). Migraine symptoms during TCD testing occurred in 23% of the 225 pts, and MHA-SX was associated with severe shunt (p=0.003). Of pts with severe shunting, 31% had MHA-SX. In the MHA pts, 49.6% had a grade 5 TCD-V, and 50% had MHA-SX during testing. Although, MHA-SX were induced in pts without prior history of MHA, MHA pts were 4 times as likely to have MHA-SX with TCD (p=0.01) than non-MHA pts.
CONCLUSIONS: We postulate that: 1) Brain micro-embolization during contrast TCD may trigger migraine symptoms in pts with RLS, 2) Brain sensitization in migraine sufferers results in heightened response to mEMB, and 3) Spontaneous mEMB during daily life in pts with large RLS may trigger MHA or other neurologic symptoms.
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