Stroke, Migraine and Patent Foramen Ovale Not Necessarily Temporary Associated

Cryptogenic stroke patients with migraine have high prevalence (79%) of patent foramen ovale (PFO) with right to left shunt. However, the timing of stroke in migraineurs is not usually associated to a migraine attack. These observations are consistent with the hypothesis that the most likely mechanism of stroke in these patients with migraine is a paradoxical embolus.

We know that individuals with migraine have a higher risk of stroke than the general population, but the problem is we do not have a clear physiopathology of this increased risk yet.

Given the frequent association between intra-cardiac shunt and migraine, paradoxical embolus has been proposed as a hypothesis to explain stroke in patients with PFO or intra-pulmonary arteriovenous malformations. The aim of this study was to determine the prevalence of PFO with right to left shunt in patients with cryptogenic stroke and a history of migraine.

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All patients presenting with ischemic stroke were characterized based on the ASCOD (atherosclerosis, small vessels disease, heart disease, others, dissection). Migraine diagnosis was done retrospectively, and aura was frequent (50% of the attacks). PFO diagnosis with right to left shunt was determined by a positive a bubble contrast study, either with transcranial doppler, transthoracic or transesophageal echocardiography.

Of 712 patients with ischemic stroke included in this study, 18% (127) were diagnosed as cryptogenic stroke and, of these patients, more than half (68 patients) had PFO and a history of migraine.

There was a high rate of PFO (79%) in patients with migraine and cryptogenic stroke and an even higher rate (93%) when migraine had an aura.

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Only 5 patients (4%) had a history compatible with migraine infarction.

Conclusion

In patients with cryptogenic shock with migraine, there is high prevalence of patent foramen ovale with right to left shunt. The timing of stroke is normally not associated with a migraine attack, which is why these patients’ most likely physiopathological mechanism is a paradoxical embolus, as in those not presenting migraine. Future classification of cryptogenic stroke should consider patent foramen ovale as a separate etiological category.

Original title: Frequency of Patent Foramen Ovale and Migraine in Patients with Cryptogenic Stroke.

Reference: Brian H. West et al. Stroke. 2018;49:00-00.

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