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INTRODUCTION: Telestroke enables timely and remote evaluation of patients with acute stroke syndromes. However, stroke mimics represent more than 30% of this population. Given the resources required for the management of suspected acute ischemic stroke, several scales have been developed to help identify stroke mimics. Our objective was to externally validate four mimic scales (Khan Score (KS), TeleStroke Mimic Score (TS), simplified FABS (sFABS), and FABS) in a large, academic telestroke network. METHODS: This is a retrospective, Institutional Review Board-exempt study of all patients who presented with suspected acute stroke syndromes and underwent video evaluation between 2019 and 2020 at a large academic telestroke network. Detailed chart review was conducted to extract both the variables needed to apply the mimic scales, the final diagnosis confirmed by final imaging, and discharge diagnosis (cerebral ischemic vs stroke mimic). Overall score performance was assessed by calculating the area under curve (AUC). Youden cutpoint was established for each scale and used to calculate sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy. RESULTS: A total of 1043 patients were included in the final analysis. Final diagnosis of cerebral ischemia was made in 63.5% of all patients, and stroke mimic was diagnosed in 381 patients (36.5%). To predict stroke mimic, TS had the highest AUC (68.3), sensitivity (99.2%), and NPV (77.3%); KS had the highest accuracy (67.5%); FABS had the highest specificity (55.1%), and PPV (72.5%). CONCLUSIONS: While each scale offers unique strengths, none was able to identify stroke mimics effectively enough to confidently apply in clinical practice. There remains a need for significant clinical judgment to determine the likelihood of stroke mimic at presentation.
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BACKGROUND: Antiphospholipid syndrome (APLS) is an established cause of thrombosis and hypercoagulability. However, the clinical characteristics of those with APLS or patients with positive antiphospholipid antibodies (APLA) in the embolic stroke of undetermined source (ESUS) have not been well studied. METHODS: A retrospective analysis was conducted between January 1, 2010, and December 31, 2020, across all three Mayo Clinic sites. Patients who were included in the study were tested for APLA and had a diagnosis of ESUS. Baseline characteristics, radiographic parameters, and outcome data were collected and compared between those who tested positive for APLS or had positive APLA and those who were negative. RESULTS: A total of 206 patients were included in the study. Eight (4%) patients were diagnosed with APLS, and 21 (10%) patients had positive APLA. On comparing those with a diagnosis of APLS and those without, patients with APLS were found to be significantly older (75 years old ± 9 vs. 58 years old ± 14, p = 0.001) and were more likely to have a history of cancer (50% vs. 13%, p = 0.012). Those with positive APLA had similar findings of being older (67 years old ±13 vs. 58 years old ± 14 p = 0.003) and more likely to have a history of cancer (29% vs. 8.4% p = 0.027). Radiographically, those with APLS had a higher white matter disease burden (Fazekas score median 2 (IQR 1.5-3) vs. median 1 (IQR 1-2), p = 0.028). CONCLUSION: Both APLS and positive APLA are associated with older age and a history of malignancy. These findings highlight the importance of considering a hypercoagulable evaluation even in the elderly ESUS population.
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BACKGROUND: Erenumab is a monoclonal antibody that targets the calcitonin gene-related peptide (CGRP) receptor and is approved for the preventative treatment of migraine in adults. CGRP is involved in the regulation of vasomotor tone under physiologic and pathologic conditions, including hypertension. While there has not been evidence of hypertension in preclinical models or clinical trials, post-marketing data suggest erenumab may be associated with hypertension. This led to a warning in the United States Food and Drug Administration prescribing information for erenumab. OBJECTIVE: To determine the frequency of worsening blood pressure (BP) after initiation of erenumab in patients with migraine and how this is associated with hypertension. METHODS: This is an observational retrospective cohort study evaluating patients at a tertiary headache or neurology department. Systolic and diastolic BPs were compared between the initial visit prior to initiation of erenumab, and follow-up visit while on erenumab. Worsening BP was defined as moving from a lower stage to a higher stage of BP, as defined by the American Heart Association. Serious adverse vascular events were also recorded. RESULTS: A total of 335 patients were included in the final analysis (mean [SD] age of 45.7 [14.40] years, 83.9% [281/335] female). At baseline, 20.9% (70/335) of patients had a prior diagnosis of hypertension. The median (interquartile range) time to follow-up appointment from initial appointment was 20.5 (13.3-35.3) weeks. The mean (SD) BP at baseline was systolic 124.7 (15) mmHg and diastolic 77 (11) mmHg, and at follow-up was systolic 124.0 (15) mmHg and diastolic 77.8 (9) mmHg. Overall, 23.3% (78/335) of all patients had worsening BP, whereas 13/225 (3.9%) patients had improvement in their BP. Patients with atrial fibrillation were more likely to develop worsening BP (odds ratio, 4.9, 95% confidence interval 1.12-21.4; p = 0.035). There was no association between worsening BP and pre-existing hypertension, sex, body mass index, or age. One patient had non-ST elevation myocardial infarction attributed to a hypertensive emergency while on erenumab. CONCLUSION: We found that 23.3% of patients initiated on erenumab may have developed worsening BP, suggesting the need for BP monitoring in patients initiated on erenumab.
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Anticuerpos Monoclonales Humanizados , Hipertensión , Trastornos Migrañosos , Adulto , Femenino , Humanos , Presión Sanguínea , Péptido Relacionado con Gen de Calcitonina , Antagonistas del Receptor Peptídico Relacionado con el Gen de la Calcitonina/uso terapéutico , Hipertensión/tratamiento farmacológico , Trastornos Migrañosos/tratamiento farmacológico , Receptores de Péptido Relacionado con el Gen de Calcitonina , Estudios Retrospectivos , Masculino , Persona de Mediana EdadRESUMEN
Phyllanthus fraternus (PF), a plant from the Euphorbiaceae family, is used extensively in ayurvedic formulations for its significant medicinal properties. When PF is administered alongside conventional drugs, there could be potential herb-drug interactions between the active compounds and the genes involved in drug transport and metabolism. Hence, this study was designed to investigate potential herb-drug interactions, focusing on elucidating their functional and pharmacological mechanisms, using an integrated approach of metabolite profiling and network pharmacology. We utilized LC-MS to generate metabolite profiling of PF and network pharmacology for predicting key targets and pathways. This comprehensive analysis involved the construction of networks illustrating the relationships among compounds, targets, and pathways and the exploration of protein-protein interactions and protein-ligand interactions. In this study, a total of 79 compounds were identified in LC-MS, such as alkaloids, steroids, saponins, flavonoids, lignans, phenolic acids, tannins, terpenoids, and fatty acids. The identified compound's physicochemical properties were predicted using SwissADME. Network analysis predicted 1076 PF-related genes and 1497 genes associated with drug transport and metabolism, identifying 417 overlapping genes, including 51 related to drug transport and metabolism. Based on the degree of interaction the hub targets like ABCB1, CYP1A1, CYP1A2, CYP2C9, and CYP3A4 were identified. In the compound-target-pathway network, 2,4-bis(1,1-dimethyl ethyl)-phenol; 5-Methoxy-N-[(5-Methylpyridin-2-yl) sulfonyl]-1h-Indole-2-Carboxamide; and E,E,Z-1,3,12-Nonadecatriene-5,14-diol possessed more interactions with the targets. This study helps identify bioactive compounds, essential targets, and pathways potentially implicated in these interactions, laying the foundation for future studies (in vitro and in vivo) to verify their potential to explore their clinical implications.Communicated by Ramaswamy H. Sarma.
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OBJECTIVE: The objective of this study was to critically assess current evidence regarding the role of prophylactic antiseizure medication in patients presenting with acute intracerebral hemorrhage (ICH). METHODS: The objective was addressed through the development of a structured critically appraised topic. This included a clinical scenario with a clinical question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom-line conclusions. Participants included resident neurologists, a medical librarian, and content experts in the fields of epilepsy, stroke neurology, neurohospitalist medicine, and neurocritical care. RESULTS: A randomized clinical trial was selected for critical appraisal. The trial assessed whether prophylactic levetiracetam (LEV) use reduced the risk of acute seizures in patients with ICH, as defined by clinical or electrographic seizure, captured by continuous electroencephalogram 72 hours after enrollment. A total of 42 patients were included in the final analysis (19 in the LEV group and 23 in the placebo group). There was a significantly higher occurrence of seizures in the placebo versus LEV group (LEV 16% vs placebo 43%, P = 0.043). There were no differences in functional outcomes between the groups at 3, 6, or 12 months (P > 0.1). CONCLUSIONS: The role of prophylactic treatment with antiseizure medication in ICH remains unclear.
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Epilepsia , Neurología , Accidente Cerebrovascular , Humanos , Hemorragia Cerebral/complicaciones , Hemorragia Cerebral/tratamiento farmacológico , Convulsiones/tratamiento farmacológico , Convulsiones/etiología , Convulsiones/prevención & control , Epilepsia/tratamiento farmacológicoRESUMEN
INTRODUCTION: Prehospital telestroke evaluations may improve stroke triage compared to paramedic-applied large vessel occlusion scales, but ambulance-based video National Institutes of Health Stroke Scale assessments are challenging. The accuracy of telestroke-administered large vessel occlusion scales has not been investigated, so we sought to evaluate this further. METHODS: This retrospective study included all in-hospital telestroke encounters in a large academic telestroke network from 2019 to 2020. We retrospectively calculated seven large vessel occlusion scales using the in-hospital telestroke National Institutes of Health Stroke Scale (Rapid Arterial oCclusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Field Assessment Stroke Triage for Emergency Destination, 3-Item Stroke Scale, Prehospital Acute Stroke Severity, Vision-Aphasia-Neglect, and Gaze-Face-Arm-Speech-Time). Diagnostic performance was assessed via sensitivity, specificity, negative predictive value, positive predictive value, positive likelihood ratio, negative likelihood ratio, and accuracy using established scale thresholds. These results were compared to the National Institutes of Health Stroke Scale at thresholds of 6, 8, and 10. The area under curve was calculated using c-statistics by treating scales as continuous variables. RESULTS: A total of 625 patients were included; 111 (17.8%) patients had an anterior large vessel occlusion, 118 (18.9%) patients had any large vessel occlusion, and 182 (29.1%) patients had stroke mimic diagnosis. The mean age (SD) was 67.9 (15.9), 48.3% were female, and 93.4% were white. The Mean National Institutes of Health Stroke Scale (SD) was 14.9 (8.4) for patients with anterior large vessel occlusion, 4.7 (5.0) for patients with non-large vessel occlusion ischemic stroke, and 4.4 (5.8) for stroke mimic (p < 0.001). Compared to the National Institutes of Health Stroke Scale, Field Assessment Stroke Triage for Emergency Destination, and Rapid Arterial oCclusion Evaluation scales demonstrated higher accuracy and area under curve for large vessel occlusion detection. DISCUSSION: Both the Field Assessment Stroke Triage for Emergency Destination and Rapid Arterial oCclusion Evaluation scales outperformed the National Institutes of Health Stroke Scale for large vessel occlusion detection in patients evaluated by in-hospital telestroke. These scales may be valid alternatives to the National Institutes of Health Stroke Scale examination in this setting.
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Migraine is a highly prevalent and disabling neurological disorder. However, information about migraine management in real-world settings is limited to traditional health information sources. In this paper, we (i) verify that there is substantial migraine-related chatter available on social media (Twitter and Reddit), self-reported by those with migraine; (ii) develop a platform-independent text classification system for automatically detecting self-reported migraine-related posts, and (iii) conduct analyses of the self-reported posts to assess the utility of social media for studying this problem. We manually annotated 5750 Twitter posts and 302 Reddit posts, and used them for training and evaluating supervised machine learning methods. Our best system achieved an F1 score of 0.90 on Twitter and 0.93 on Reddit. Analysis of information posted by our 'migraine cohort' revealed the presence of a plethora of relevant information about migraine therapies and sentiments associated with them. Our study forms the foundation for conducting an in-depth analysis of migraine-related information using social media data.
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BACKGROUND: Levetiracetam is a commonly used anti-seizure medication, with the development of neuropsychiatric symptoms being the most common side effect. Preliminary literature describes the improvement of these symptoms with pyridoxine, mostly within the pediatric population. However, randomized control trial data investigating this relationship is sparse. OBJECTIVE: The objective of this study was to critically assess evidence regarding the role of pyridoxine in the treatment of neuropsychiatric symptoms from levetiracetam. METHODS: The objective was addressed through the development of a structured, critically appraised topic. This included a clinical scenario with a clinical question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, medical librarians, clinical epidemiologists, and content experts in the field of epilepsy. RESULTS: A randomized, placebo-controlled clinical trial was selected for critical appraisal. This trial compared pyridoxine versus placebo for the treatment of neuropsychiatric symptoms from levetiracetam in a pediatric population and included 105 patients (46/105 received pyridoxine, 59/105 received placebo). It found that both groups had a significant reduction in behavioral symptoms at the 2-,4-and 6-week time points ( P <0.05). However, the authors noted that the pyridoxine group had almost double the relative reduction when compared with the placebo group at all time points: 1.9 at 2 weeks, 2.0 at 4 weeks, and 1.8 at 6 weeks ( P =0.001). CONCLUSIONS: This study suggests that pyridoxine for the treatment of levetiracetam-induced behavioral side effects may result in modest improvement, although many limitations prevent conclusive results. There remains a need for a double-blinded, randomized control trial in both the adult and pediatric populations.
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Epilepsia , Piridoxina , Adulto , Humanos , Niño , Levetiracetam/efectos adversos , Piridoxina/uso terapéutico , Epilepsia/tratamiento farmacológicoRESUMEN
PURPOSE OF REVIEW: Post-COVID headache may be unique in presentation and mechanism, often presenting as a new phenotype in patients with a history of a primary headache disorder or resulting in a new headache syndrome in those without history of headache. This review presents a description of the literature published focused on post-COVID headache. Additionally, we discuss potential mechanisms and considerations for treatment of post-COVID headache. RECENT FINDINGS: Headache is one of the most common symptoms of COVID. Common characteristics are revealed when reviewing the phenotypes of headaches that have been described in patients with COVID-19, with most headache phenotypes resembling migraine and new persistent daily headache. Post-COVID headaches are often described as moderate to severe, persistent, and treatment refractory. This review highlights the diversity of presentation of headaches that present as a complication of COVID-19. Treatment of post-COVID headache is challenging, especially in the setting of a pandemic where resources are limited. CLINICAL CASE: A 42-year-old woman with a history of episodic migraine without aura presents over video visit with a new headache type. Her typical headaches are predominantly left sided, throbbing in nature, and associated with photophobia and phonophobia. They are fully relieved by oral sumatriptan 2 h after treatment. She describes this new headache as a constant, pulsating, holocephalic pain with no other migrainous features that have been ongoing for 6 weeks. She notes that the headache has been persistent since that time. She has tried over-the-counter acetaminophen and ibuprofen and her typical migraine abortive therapy without relief. She is debilitated and wonders if there is anything that will take the pain away. She shares that she tested positive for COVID-19 about 2 days prior to headache onset and has associated rhinorrhea, anosmia, and ageusia.
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COVID-19 , Epilepsia , Trastornos Migrañosos , Femenino , Humanos , COVID-19/complicaciones , Cefalea/etiología , Cefalea/tratamiento farmacológico , Sumatriptán/uso terapéutico , Trastornos Migrañosos/diagnóstico , Trastornos Migrañosos/etiología , Trastornos Migrañosos/tratamiento farmacológicoRESUMEN
RATIONALE: Immunoglobulin (Ig) G4-related disease (IgG4-RD) reportedly has a strong relationship with adult-onset asthma and periocular xanthogranuloma (AAPOX) and may be linked to sclerosing mucoepidermoid carcinoma (MEC). We present a rare case of IgG4-RD and AAPOX occurring in a patient with resected eosinophilic or oncocytic MEC. PATIENT CONCERNS: A 52-year-old woman was referred to our rheumatology clinic in 2020 to be evaluated for suspected IgG4-RD. DIAGNOSES: The patient had diagnoses of periorbital xanthelasmas, worsening glucocorticoid-dependent chronic rhinosinusitis and adult-onset asthma, and cervical lymphadenopathy persisting 2 years after resection of a low-grade MEC of a minor salivary gland. INTERVENTIONS: Because the patient's symptomatic relief was glucocorticoid dependent, IgG4-RD was suspected, and she was referred to our medical center. Her amylase and lipase levels were elevated. Serum IgG4 levels were initially within normal limits, but IgG4-RD was diagnosed because of the presence of lymphadenopathy and evidence of pancreatitis, which was shown on positron emission tomography/computed tomography. Furthermore, the IgG4 levels later increased without explanation. After the patient began combination therapy with a glucocorticoid (prednisone) and methotrexate, her symptoms improved but recurred when the daily oral glucocorticoid dosage decreased below 10 mg. An excisional biopsy of her right submandibular gland in 2021 yielded results consistent with IgG4-RD. In addition, AAPOX was diagnosed, given the presence of periocular edema and plaques, adult-onset asthma, and rhinosinusitis. OUTCOME: The patient was carcinoma free at last follow-up and was receiving medication to treat the other conditions. LESSONS: The diagnosis of these 3 concomitant, uncommon entities required approximately 7 years of medical investigations. Clinicians should know that IgG4-RD, AAPOX, and MEC may occur together.
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Asma , Carcinoma Mucoepidermoide , Enfermedad Relacionada con Inmunoglobulina G4 , Linfadenopatía , Xantomatosis , Adulto , Asma/complicaciones , Asma/diagnóstico , Asma/tratamiento farmacológico , Carcinoma Mucoepidermoide/complicaciones , Carcinoma Mucoepidermoide/diagnóstico , Carcinoma Mucoepidermoide/cirugía , Femenino , Glucocorticoides/uso terapéutico , Granuloma/tratamiento farmacológico , Humanos , Inmunoglobulina G , Enfermedad Relacionada con Inmunoglobulina G4/complicaciones , Linfadenopatía/complicaciones , Persona de Mediana Edad , Xantomatosis/complicacionesRESUMEN
OBJECTIVE: To compare the artificial intelligence-enabled electrocardiogram (AI-ECG) atrial fibrillation (AF) prediction model output in patients with migraine with aura (MwA) and migraine without aura (MwoA). BACKGROUND: MwA is associated with an approximately twofold risk of ischemic stroke. Longitudinal cohort studies showed that patients with MwA have a higher incidence of developing AF compared to those with MwoA. The Mayo Clinic Cardiology team developed an AI-ECG algorithm that calculates the probability of concurrent paroxysmal or impending AF in ECGs with normal sinus rhythm (NSR). METHODS: Adult patients with an MwA or MwoA diagnosis and at least one NSR ECG within the past 20 years at Mayo Clinic were identified. Patients with an ECG-confirmed diagnosis of AF were excluded. For each patient, the ECG with the highest AF prediction model output was used as the index ECG. Comparisons between MwA and MwoA were conducted in the overall group (including men and women of all ages), women only, and men only in each age range (18 to <35, 35 to <55, 55 to <75, ≥75 years), and adjusted for age, sex, and six common vascular comorbidities that increase risk for AF. RESULTS: The final analysis of our cross-sectional study included 40,002 patients (17,840 with MwA, 22,162 with MwoA). The mean (SD) age at the index ECG was 48.2 (16.0) years for MwA and 45.9 (15.0) years for MwoA (p < 0.001). The AF prediction model output was significantly higher in the MwA group compared to MwoA (mean [SD] 7.3% [15.0%] vs. 5.6% [12.4%], mean difference [95% CI] 1.7% [1.5%, 2.0%], p < 0.001). After adjusting for vascular comorbidities, the difference between MwA and MwoA remained significant in the overall group (least square means of difference [95% CI] 0.7% [0.4%, 0.9%], p < 0.001), 18 to <35 (0.4% [0.1%, 0.7%], p = 0.022), and 35 to <55 (0.5% [0.2%, 0.8%], p < 0.001), women of all ages (0.6% [0.3%, 0.8%], p < 0.001), men of all ages (1.0% [0.4%, 1.6%], p = 0.002), women 35 to <55 (0.6% [0.3%, 0.9%], p < 0.001), and men 18 to <35 (1.2% [0.3%, 2.1%], p = 0.008). CONCLUSIONS: Utilizing a novel AI-ECG algorithm on a large group of patients, we demonstrated that patients with MwA have a significantly higher AF prediction model output, implying a higher probability of concurrent paroxysmal or impending AF, compared to MwoA in both women and men. Our results suggest that MwA is an independent risk factor for AF, especially in patients <55 years old, and that AF-mediated cardioembolism may play a role in the migraine-stroke association for some patients.
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Fibrilación Atrial , Epilepsia , Migraña con Aura , Migraña sin Aura , Adolescente , Adulto , Inteligencia Artificial , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Estudios Transversales , Electrocardiografía , Epilepsia/complicaciones , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Migraña con Aura/complicaciones , Migraña con Aura/diagnóstico , Migraña con Aura/epidemiología , Migraña sin Aura/complicacionesRESUMEN
External iliac vein stenosis related to cycling has rarely been reported as a cause of deep vein thrombosis. Ischemic stroke occurring in this condition due to paradoxical embolism across a preexisting patent foramen ovale (PFO) has yet to be reported. Here we report a case of embolic ischemic strokes in a young, avid cyclist with no prior known vascular risk factors. A thorough cerebrovascular workup revealed a right-to-left shunt on transesophageal echocardiogram that prompted venous thrombosis evaluation. Pelvic MR venogram demonstrated a 3.5 cm high-grade stenosis of the right external iliac vein, concerning for possible prior thrombotic disease. His strokes were deemed most likely a result of paradoxical emboli originating in the pelvis at the site of right external iliac vein stenosis. The patient ultimately opted for PFO closure for secondary stroke prevention, as he wished to continue daily cycling. This case highlights the importance of neurohospitalists considering iliac vein stenosis as a potential cause of embolic stroke of undetermined source, especially in young patients who are avid cyclists, as part of a thorough vascular workup.
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BACKGROUND: Retinal migraine is defined by fully reversible monocular visual phenomena. We present two cases that were complicated by permanent monocular vision deficits. CASES: A 57-year-old man with history of retinal migraine experienced persistent monocular vision loss after one stereotypical retinal migraine, progressing to finger-count vision over 4 days. He developed paracentral acute middle maculopathy that progressed to central retinal artery occlusion. A 27-year-old man with history of retinal migraine presented with persistent right eye superotemporal scotoma after a retinal migraine. Relative afferent pupillary defect and superotemporal visual field defect were noted, consistent with ischemic optic neuropathy. CONCLUSION: Retinal migraine can complicate with permanent monocular visual loss, suggesting potential migrainous infarction of the retina or optic nerve. A thorough cerebrovascular evaluation must be completed, which was unrevealing in our cases. Acute and preventive migraine therapy may be considered in retinal migraine patients, to mitigate rare but potentially permanent visual loss.
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Trastornos Migrañosos , Oclusión de la Arteria Retiniana , Enfermedades de la Retina , Adulto , Ceguera , Humanos , Infarto/complicaciones , Masculino , Persona de Mediana Edad , Trastornos Migrañosos/complicaciones , Oclusión de la Arteria Retiniana/complicaciones , Enfermedades de la Retina/complicaciones , Trastornos de la VisiónRESUMEN
OBJECTIVES: Patients with migraine with visual aura (MwvA) often present to eye care providers for evaluation. A thorough ophthalmological history and examination is needed to exclude ophthalmologic disorders. Additionally, it has been increasingly recognized that MwvA is associated with ischemic stroke (IS). The aim of this narrative review is to provide a comprehensive overview of the differential diagnosis of MwvA and its association with IS. MATERIALS AND METHODS: We conducted a PubMed search using key words including "migraine aura", "visual aura without headache", "late onset migraine accompaniment", "migraine and stroke", "migraine and atrial fibrillation", and "migraine and patent foramen ovale (PFO)". We narratively summarized the main findings of the identified studies in sections including age of onset and frequency of migraine with aura, stroke subtypes, and the role of cardioembolism in the migraine-stroke association. RESULTS AND CONCLUSION: For women younger than 50 years, MwvA is associated with an increased risk of IS, and the risk further increases in patients who also smoke and use oral contraceptives. Age of onset of MwvA 50 years or greater is associated with IS that occurs in late life. Studies reported that increased frequency of aura is associated with an increased risk of IS in women. MwvA is associated with an increased risk of cardioembolic stroke and a higher incidence of atrial fibrillation compared to migraine without aura. Most studies that assessed the migraine-stroke association were based on patients with MwvA. The risks of stroke associated with other types of migraine aura or aura without headache, as well as such association in men require further investigation. More data is needed to determine the absolute risk of stroke when evaluating MwvA in situations including smoking and low dose estrogen use, new or late onset (>50 years) MwvA, to facilitate the development of practice guidelines for stroke prevention in specific clinical scenarios.
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Migraña con Aura , Accidente Cerebrovascular , Diagnóstico Diferencial , Humanos , Migraña con Aura/diagnóstico , Migraña con Aura/epidemiología , Medición de Riesgo , Accidente Cerebrovascular/epidemiologíaRESUMEN
BACKGROUND AND PURPOSE: Investigation for patent foramen ovale (PFO) is warranted in patients with cryptogenic stroke (CS), as PFO closure is recommended in select CS patients for secondary stroke prevention. Transcranial Doppler (TCD) is noninvasive and has high sensitivity for PFO screening. However, 10% of the population has insufficient temporal bone windows to perform standard TCD monitoring of the middle cerebral arteries (MCAs). Prior reports showed similar diagnostic accuracy between the basilar artery and MCAs insonation. Our objective was to assess the accuracy of transforaminal insonation of the basilar artery (TIBA) in diagnosis of right-to-left shunt (RLS) in patients with inadequate temporal windows. METHODS: We performed a retrospective, single-center, observational study of TIBA in patients with CS and inadequate temporal windows. We compared the PFO screening accuracy using TIBA versus echocardiogram, either transthoracic (TTE) or transesophageal echocardiogram (TEE). RESULTS: Sixteen females and four males were included (mean age 63.2). All patients underwent TTE, 10 (50%) underwent gold-standard TEE. Nine patients had positive PFO with both TCD and echocardiogram. Two patients with negative echocardiogram had TCD-positive shunt. Three patients had PFO present on echocardiogram, whereas TCD was negative. Six patients had absent shunt with both TCD and echocardiogram. The sensitivity and specificity of TIBA for RLS detection were 75%, positive predictive value 82%, and negative predictive value 67%. CONCLUSION: PFO screening accuracy using TIBA was 75%. Prospective evaluation of CS patients with TIBA and comparison to the gold-standard TEE should be performed to further guide clinical practice.