Microembolic Air Load During Contrast-Transcranial Doppler: A Trigger for Migraine With Aura?

Authors

  • Luigi Caputi MD,

    1. From the Department of Cerebrovascular Diseases (L. Caputi, M.R. Carriero, and E. Parati), Headache Center (S. Usai, L. Grazzi, D. D'Amico, and G. Bussone), Department of Neuroepidemiology (C. Falcone), Neurological Institute “C. Besta,” Milan, Italy; Service of Neurology, S. Orsola Hospital FBF, Brescia, Italy (G.P. Anzola); Neurology Unit, S. Andrea Hospital, La Spezia, Italy (M. Del Sette).
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  • Susanna Usai MD,

    1. From the Department of Cerebrovascular Diseases (L. Caputi, M.R. Carriero, and E. Parati), Headache Center (S. Usai, L. Grazzi, D. D'Amico, and G. Bussone), Department of Neuroepidemiology (C. Falcone), Neurological Institute “C. Besta,” Milan, Italy; Service of Neurology, S. Orsola Hospital FBF, Brescia, Italy (G.P. Anzola); Neurology Unit, S. Andrea Hospital, La Spezia, Italy (M. Del Sette).
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  • Maria R. Carriero MD,

    1. From the Department of Cerebrovascular Diseases (L. Caputi, M.R. Carriero, and E. Parati), Headache Center (S. Usai, L. Grazzi, D. D'Amico, and G. Bussone), Department of Neuroepidemiology (C. Falcone), Neurological Institute “C. Besta,” Milan, Italy; Service of Neurology, S. Orsola Hospital FBF, Brescia, Italy (G.P. Anzola); Neurology Unit, S. Andrea Hospital, La Spezia, Italy (M. Del Sette).
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  • Licia Grazzi MD,

    1. From the Department of Cerebrovascular Diseases (L. Caputi, M.R. Carriero, and E. Parati), Headache Center (S. Usai, L. Grazzi, D. D'Amico, and G. Bussone), Department of Neuroepidemiology (C. Falcone), Neurological Institute “C. Besta,” Milan, Italy; Service of Neurology, S. Orsola Hospital FBF, Brescia, Italy (G.P. Anzola); Neurology Unit, S. Andrea Hospital, La Spezia, Italy (M. Del Sette).
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  • Domenico D'Amico MD,

    1. From the Department of Cerebrovascular Diseases (L. Caputi, M.R. Carriero, and E. Parati), Headache Center (S. Usai, L. Grazzi, D. D'Amico, and G. Bussone), Department of Neuroepidemiology (C. Falcone), Neurological Institute “C. Besta,” Milan, Italy; Service of Neurology, S. Orsola Hospital FBF, Brescia, Italy (G.P. Anzola); Neurology Unit, S. Andrea Hospital, La Spezia, Italy (M. Del Sette).
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  • Chiara Falcone MSc,

    1. From the Department of Cerebrovascular Diseases (L. Caputi, M.R. Carriero, and E. Parati), Headache Center (S. Usai, L. Grazzi, D. D'Amico, and G. Bussone), Department of Neuroepidemiology (C. Falcone), Neurological Institute “C. Besta,” Milan, Italy; Service of Neurology, S. Orsola Hospital FBF, Brescia, Italy (G.P. Anzola); Neurology Unit, S. Andrea Hospital, La Spezia, Italy (M. Del Sette).
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  • Gian P. Anzola MD,

    1. From the Department of Cerebrovascular Diseases (L. Caputi, M.R. Carriero, and E. Parati), Headache Center (S. Usai, L. Grazzi, D. D'Amico, and G. Bussone), Department of Neuroepidemiology (C. Falcone), Neurological Institute “C. Besta,” Milan, Italy; Service of Neurology, S. Orsola Hospital FBF, Brescia, Italy (G.P. Anzola); Neurology Unit, S. Andrea Hospital, La Spezia, Italy (M. Del Sette).
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  • Massimo Del Sette MD,

    1. From the Department of Cerebrovascular Diseases (L. Caputi, M.R. Carriero, and E. Parati), Headache Center (S. Usai, L. Grazzi, D. D'Amico, and G. Bussone), Department of Neuroepidemiology (C. Falcone), Neurological Institute “C. Besta,” Milan, Italy; Service of Neurology, S. Orsola Hospital FBF, Brescia, Italy (G.P. Anzola); Neurology Unit, S. Andrea Hospital, La Spezia, Italy (M. Del Sette).
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  • Eugenio Parati MD,

    1. From the Department of Cerebrovascular Diseases (L. Caputi, M.R. Carriero, and E. Parati), Headache Center (S. Usai, L. Grazzi, D. D'Amico, and G. Bussone), Department of Neuroepidemiology (C. Falcone), Neurological Institute “C. Besta,” Milan, Italy; Service of Neurology, S. Orsola Hospital FBF, Brescia, Italy (G.P. Anzola); Neurology Unit, S. Andrea Hospital, La Spezia, Italy (M. Del Sette).
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  • Gennaro Bussone MD

    1. From the Department of Cerebrovascular Diseases (L. Caputi, M.R. Carriero, and E. Parati), Headache Center (S. Usai, L. Grazzi, D. D'Amico, and G. Bussone), Department of Neuroepidemiology (C. Falcone), Neurological Institute “C. Besta,” Milan, Italy; Service of Neurology, S. Orsola Hospital FBF, Brescia, Italy (G.P. Anzola); Neurology Unit, S. Andrea Hospital, La Spezia, Italy (M. Del Sette).
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  • Conflict of Interest: None

Luigi Caputi, Department of Cerebrovascular Diseases, Neurological Institute C. Besta, Via Celoria, 11-20133 Milan, Italy.

Abstract

(Headache 2010;50:1320-1327)

Background.— There is a well-known association between migraine with aura (MA) and right-to-left shunt (RILES) because of patent foramen ovale (PFO). The occurrence of MA attacks after microbubble (MB) injection during contrast-enhanced transcranial Doppler (ce-TCD) has been recently described.

Objectives.— The aim of this study was to analyze the prevalence of RILES in a consecutive cohort of MA patients and to characterize the occurrence of MA attacks after diagnostic ce-TCD.

Methods.— A total of 159 consecutive MA patients underwent ce-TCD with air-mixed saline to disclose RILES. RILES was characterized in terms of MB amount (small-moderate or large) and occurrence at rest and/or during Valsalva maneuver (permanent or latent).

Results.— RILES was revealed in 79/159 patients (∼50%). Permanent RILES were detected in 56/79 (71%) and latent RILES in 23/79 (29%) MA patients. The occurrence of a typical MA attack was overall observed in 12/159 patients (7.5%; 95% CI: 4-12.8%), but arose only in RILES-positive ones, immediately after ce-TCD (12/79; 15.2%; P < .001). All 12 patients had permanent RILES (12/56; 21.4%; P = .015) and MA attack was mostly observed in large RILES-positive patients, even without statistical significance (P = .118).

Conclusions.— Microembolic air load could act as a trigger of MA attack. According to recent studies and to the clinical characteristics observed in our patients, microembolization because of MB injection might provoke a decrease in cerebral oxygen saturation, thus triggering cortical spreading depression and, thereafter, MA attack. Larger and prospective studies will be necessary to confirm our data and observe a wider correlation.

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