Recurrent and Residual Shunts After Patent Foramen Ovale Closure: Results From a Long-Term Transcranial Doppler Study.

OBJECTIVES: Assess the evolution of right-to-left shunt (RLS) after transcatheter patent foramen ovale (PFO) closure. BACKGROUND: Despite the high number of interventional procedures performed worldwide, limited systematic data on the long-term abolition of RLS after percutaneous closure are available. METHODS: All patients treated at our Institution between February 2001 and July 2009 were included in this single center, prospective study, and were asked to repeat late contrast transcranial Doppler (cTCD). Rate of complete closure, residual RLS (i.e., a shunt that persists after closure), and recurrent RLS (i.e., a shunt that reappears after a previous negative cTCD) was assessed. RESULTS: Long-term follow-up was completed in 120 patients (56% male). RLS was still detectable 4.9 ± 2.3 years (range 1.3-10.3) after the procedure in 55 patients; 20 (17%) had residual RLS and 35 (29%) had recurrent RLS. Multivariate analysis revealed that significant predictors of residual RLS included post-procedural shunt at transesophageal echocardiography (OR 3.07, 95%CI 0.97-9.7), use of a bigger device (35 vs 25 mm, OR 3.85, 95%CI 1.22-12.2) and length of follow-up (OR 0.75, 95%CI 0.57-0.98), while only length of follow-up (OR 0.77, 95%CI 0.62-0.95) was associated with recurrent RLS. Neurological recurrences (1 stroke, 6 transient ischemic attacks) were equally distributed between the groups. CONCLUSION: A significant number of recurrent and residual shunts may be observed by cTCD up to 5 years after PFO closure. Management of late RLSs includes periodic re-evaluation, exclusion of device-induced complications or secondary sources of RLS, and optimization of antithrombotic treatment with or without a second intervention.

Food as trigger and aggravating factor of migraine.

A relevant proportion of patients say that their migraine attacks may be precipitated by dietary items, the percentage of patients reporting foods as trigger ranging in different study from 12 to 60 %. Fasting, alcohol, chocolate and cheese are the dietary precipitating factors more frequently reported. The finding that diet-sensitive migraineurs are usually sensitive to several and different foods, lead to the hypothesis of antigenic similarities between these disparate foods or common chemical constituents, but a clear scientific explanation of the mechanisms implicated in the development of migraine attacks supposedly precipitated by food is still lacking. The possibility that the elimination diets based on the hypothesis of food hypersensivity IgE or IgG-mediated improve migraine has been explored in different studies but the results are inconclusive. Fasting as trigger for migraine is frequently reported. Some migraineurs show reactive hypoglycaemia due to diet-induced hyperinsulinism. In conclusion, identification of environmental factors (including dietary factors) that consistently trigger migraine in some subjects may be helpful to reduce attacks frequency. The biological mechanism by means of triggers in general and food in particular precipitate migraine attacks remains obscure.

COVID-19 vaccine-related Guillain-Barré syndrome in the Liguria region of Italy: A multicenter case series.

BACKGROUND AND PURPOSE: Guillain-Barré-Syndrome (GBS) can follow COVID-19 vaccination, with clinical and paraclinical features still to be precisely assessed. We describe a cohort of patients who developed GBS after vaccination with different types of COVID-19 vaccines. METHODS: Patients with post-COVID-19 vaccination GBS, admitted to the six hospitals that cover the whole Liguria Region, Northwestern Italy, from February 1st to October 30th 2021, were included. Clinical, demographic, and paraclinical data were retrospectively collected. RESULTS: Among the 13 patients with post-COVID-19 vaccination GBS (9 males; mean age, 64 year), 5 were vaccinated with Oxford-AstraZeneca, 7 with Pfizer-BioNTech, and one with Moderna. Mean time between vaccination and GBS onset was 11.5 days. Ten patients developed GBS after the first vaccination dose, 3 after the second dose. Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) was the predominant GBS variant, mainly characterized by sensory involvement. Bilateral seventh cranial nerve involvement followed AstraZeneca vaccination in two cases. Three patients presented treatment-related fluctuations, and 4 mild symptoms that delayed treatments and negatively affected prognosis. Prognosis was poor (GBS-disability score, ≥3) in 5/13 patients, with a disability rate of 3/13. CONCLUSIONS: Our findings confirm that most post-COVID-19 vaccination GBS belong to the AIDP subtype, and occur after the first vaccine dose. Treatment-related fluctuations, and diagnosis-delaying, mild symptoms at onset are clinical features that affect prognosis and deserve particular consideration.