Abstract
Introduction: There is an association between cryptogenic strokes and patent foramen ovale (PFO), as well as between migraines with aura and PFO. The purpose of the current study was to compare shunt characteristics in the stroke and migraine populations.Methods: We retrospectively evaluated the degree of the shunt in 68 consecutive patients with cryptogenic stroke (n=33) or migraines with aura (n=35) evaluated in a single transcranial Doppler laboratory. All patients underwent an intravenous injection of agitated saline, followed by the insonation of the middle cerebral artery to determine the degree of the right-to-left shunt. We graded the shunt size according to the number of emboli: Grade I, none; Grade II, 1-10; Grade III, 11-100; and Grade IV, >100. Grades I and II were considered low-grade shunts, and Grades III and IV were considered high-grade.Results: In the 14-month study period, we found 31 high-grade shunts and 37 low-grade shunts. Among migraines with aura patients, 27 (77%) had high-grade shunts, whereas only 4 patients (12%) with cryptogenic stroke had high-grade shunts. These percentages were significantly different between groups (Fisher’s exact test, p<0.0001).Conclusions: In a standardized laboratory using uniform methods, we found a significant difference in shunt size associated with PFO between cryptogenic stroke and migraine with aura patients. We hypothesize that in migraines with aura, venous admixture with arterial blood is the main mechanism by which PFO contributes to the condition. In contrast, cryptogenic strokes associated with PFO are more likely to arise from an atrial septal clot within the PFO space.
Highlights
There is an association between cryptogenic strokes and patent foramen ovale (PFO), as well as between migraines with aura and PFO
In a standardized laboratory using uniform methods, we found a significant difference in shunt size associated with PFO between cryptogenic stroke and migraine with aura patients
Cryptogenic strokes associated with PFO are more likely to arise from an atrial septal clot within the PFO space
Summary
There is an association between cryptogenic strokes and patent foramen ovale (PFO), as well as between migraines with aura and PFO. The purpose of the current study was to compare shunt characteristics in the stroke and migraine populations. An association exists between cryptogenic stroke and patent foramen ovale (PFO), as well as between migraines with aura and PFO. These relationships have been described as the presence or absence of a right-to-left shunt. The initial trials in 2012-2013 investigating the role of PFO closure in the reduction of recurrent embolic stroke failed to show any benefit over medical therapy [1,2,3]. Looking at the recent trials published in the New England Journal of Medicine (NEJM), the pendulum has swung towards a consideration of the benefits of intervention in patients who otherwise would have been managed medically [4,5,6]
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