MRA captures vasospasm in fatal migrainous infarction

Imaging of Reversible Cerebral Vasoconstriction Syndrome and Posterior Reversible Encephalopathy Syndrome

PRES and RCVS are increasingly recognized due to the wider use of brain MRI and increasing clinical awareness. Imaging plays a crucial role in confirming the diagnosis and guiding clinical management for PRES and RCVS. Imaging also has a pivotal role in determining the temporal progression of these entities, detecting complications, and predicting prognosis. In this review, we aim to describe PRES and RCVS, discuss their possible pathophysiological mechanisms, and discuss imaging methods that are useful in the diagnosis, management, and follow-up of patients.

Diagnosis of Migrainous Infarction: A Case Report and Analysis of Previously Published Cases

Migrainous infarction (MI) is a rare disorder. The precise diagnostic criteria for this diagnosis have been available in the International Classification of Headache Disorders (ICHD) since 1988, but many cases do not fulfil these criteria. This paper describes a good example of MI and analyzes previously published case reports. We report a very special case of MI in an 18-year-old woman who had a recurrent episode of migraine with a similar aura with numbness of the right arm and speech disturbances which had an unusually long duration (>120 min). On admission to the headache centre "Europe-Asia", she complained of slowness of speech and problems with choice of words. An MRI showed acute lacunar infarcts in the left parietal subcortical area. Ischemic infarcts were localized in a relevant area on the left side and the aura symptoms were right-sided. The patient, therefore, fulfilled the ICHD-3 diagnostic criteria for "Migrainous infarction". An analysis of 35 previously published articles with case reports about MI showed that 22 did not meet the diagnostic criteria of the ICHD for migrainous infarction. Using all this, we developed diagnostic recommendations for migrainous infarction which can help to improve the quality of diagnosis when used together with the diagnostic criteria of the ICHD for migrainous infarction.

Migraine and Stroke: In Search of Shared Pathways, Mechanisms, and Risk Factors

Migraines are one of the emerging causes of disabilities experienced worldwide, and strokes are the second leading cause of death globally. Migraines with aura have been reported to be associated with a higher risk of ischemic strokes, whereas hemorrhagic strokes are more closely associated with migraines without aura, possible mechanisms that link migraines to strokes. These can be categorized into vascular mechanisms such as vasospasm, endothelial and platelet dysfunction, and alteration in the vessel wall seen in migraineurs, further perpetrated by vascular risk factors such as hypertension and hyperlipidemias. Cerebral hypoperfusion that occurs in migraines can cause an electrical aberrance, leading to a phenomenon known as "spreading depression" which can contribute to strokes. In this review, we discuss bloodstream elevation in procoagulants such as antiphospholipid antibodies, homocysteine, von Willebrand factor, and prothrombin. Maintaining pregnant women who actively experience migraines with aura under close observation may be of some value in achieving better outcomes. Women who experience migraines after starting hormonal contraception are at a higher risk of experiencing strokes and stand to benefit from being switched to non-hormonal methods. In this article, we discuss the mechanisms linking migraines and strokes, briefly discuss the pathogenesis, and explore the risk factors contributing to the association therein. In addition, we examine the relationship between migraines and ischemic strokes, as well as hemorrhagic strokes, and review management considerations.

Case Report and Review of the Literature: Fatal Reversible Cerebral Vasoconstriction Syndrome

Background: A fatal outcome occurs in 2% of patients with Reversible Cerebral Vasoconstriction Syndrome (RCVS). Due to its rarity, guidelines for the management of the most severe forms of RCVS are lacking.

Case presentation: Here, we describe the case of a 55 year-old woman who died from complications of RCVS and reviewed patients with fatal outcome reported in the literature. In our patient, the first episode of neurological deterioration was preceded by an increase of cerebral blood flow velocities assessed with transcranial Doppler. A fatal evolution could not be prevented despite therapeutic escalation consisting of multiple non-invasive and invasive treatments including cervical sympathetic bloc and continuous arterial infusion of nimodipine at the site of severe vasoconstriction.

Conclusion: This case and the review of literature illustrate the challenges in the management of patients with severe RCVS. We describe here how monitoring of cerebral blood flow might help anticipate clinical worsening at the beginning of the disease and propose novel invasive and non-invasive therapeutic strategies based on monitoring of neurophysiological parameters.

Spontaneous intracranial hypotension: key features for a frequently misdiagnosed disorder

Spontaneous intracranial hypotension (SIH) is a rare neurological condition caused by low cerebrospinal fluid (CSF) volume, most commonly due to a CSF leak. The most common presenting symptom is an orthostatic headache, but some patients may present with atypical neurological manifestations such as cranial nerve palsies, an altered mental status, and movement disorders, which complicate the clinical diagnosis. Therefore, the diagnosis is based on the combination of clinical signs and symptoms, neuroimaging, and/or a low cerebrospinal fluid pressure. In this review, we describe the wide variety of neurological manifestations and complications seen in patients with SIH as well as the most common features described on imaging studies, including both subjective and objective measurements, in order to lead the clinician to a correct diagnosis. The prompt and correct management of patients with SIH will help prevent the development of life-threatening complications, such as subdural hematomas, cerebral venous thrombosis, and coma, and avoid unnecessary invasive procedures.

Cerebral vasomotor reactivity in migraine: effect of patent foramen ovale and aerogenic microembolism

OBJECTIVE

The first data on the effect of presence of patent foramen ovale (PFO) with high-volume right-to-left shunt (RLS) on cerebral vasomotor reactivity (CVMR) in migraineurs are herein presented. In addition, the immediate effect of air microbubbles on CVMR has been determined.

METHODS

Breath-holding index (BHI) and percent velocity decrease during hyperventilation (HPV) tests were performed before and after agitated saline injections in bilateral middle and posterior cerebral arteries (MCA and PCA) in 38 migraineurs (19 with aura) and 18 control subjects.

RESULTS

Presence of PFO correlated with a significant decrease of MCA BHI (1.43 ± 0.39 vs 1.04 ± 0.67, p = 0.032) and marginal reduction of PCA BHI (1.25 ± 0.46 vs. 1.01 ± 0.39, p = 0.090) in migraineurs. After agitated saline injection, PCA BHI significantly decreased from 1.03 to 0.78 (p = 0.007) in patients with PFO, from 1.15 to 0.91 (p = 0.014) in those without PFO, and from 1.01 to 0.76 (p = 0.023) in subjects with migraine and PFO. No significant MCA BHI difference was noted soon after bubble injection.

CONCLUSIONS

The presence of high grade RLS is associated with reduced vasodilatory CVMR in migraineurs. Further decrease of CVMR of PCA upon aerogenic microemboli passage may support the mechanism of 'facilitation with subclinical cerebral ischemia caused by microembolism', hypothesis explaining the onset of migraine.

ABBREVIATIONS

BHI: Breath-holding index; BHT: Breath Holding Test; CVMR: Cerebral vasomotor reactivity; EDV: End-diastolic velocity; HIT-6: Headache Impact Test; HPV: Hyperventilation; MCA: Middle cerebral artery; MIDAS: migraine disability Assessment score; PCA: Posterior cerebral artery; PFO: Patent foramen ovale; PI: Pulsatility index; PSV: Peak systolic velocity; RLS: Right-to-left shunt; TCD: Transcranial Doppler; Vmean: Mean velocity.

Migrainous Infarction And Cerebral Vasospasm: Case Report And Literature Review

Migrainous infarction (MI) is a rare complication of migraines that accounts for 0.5-1.5% of all ischemic strokes. Although the pathogenesis of MI is still debated, cortical spreading depression and the consequent biochemical cascade and hemodynamic changes are presumed to play an important role. Here we describe a case of MI and systematically review the literature on the complex and possibly bidirectional relationship between migraine and stroke. A 44-year-old female with history of migraine with visual aura presented at the Emergency Department due to a sudden onset of left limb paresis and hypoesthesia. Brain magnetic resonance imaging revealed right fronto-parietal ischemic stroke. Two days after hospitalization, the patient experienced a prolonged visual aura and showed ultrasound evidence of intracranial artery vasospasm. To date, there have been 33 published articles on a total 119 patients with MI, although intracranial vasospasm has rarely been reported. Sustained hyperexcitability of cortical neurons, impairment of γ-aminobutyric acid inhibitory circuitry, altered serotonergic transmission, release of vasoconstrictive molecules, and cerebral blood flow changes have been proposed as pathogenic mechanisms of MI. The present case provides insight into the pathophysiological link between stroke and migraine, thus aiding clinicians in therapeutic decision-making although additional studies are needed to clarify the clinical, neuroradiological, and ultrasound findings that link MI and stroke-related migraine.

Fatal reversible cerebral vasoconstriction syndrome: A systematic review of case series and case reports

OBJECTIVE

To describe patient characteristics, radiological findings and the clinical course of adults with fatal reversible cerebral vasoconstriction syndrome (RCVS).

METHODS

A systematic literature search from January 1, 2000, until December 31, 2018, was performed using PubMed, EMBASE, Scopus, Cochrane reviews, LILACS and Scielo. Studies reporting RCVS in adult patients with fatal outcomes were included.

RESULTS

430 studies were initially identified, 179 full-text articles were reviewed, and 9 publications describing 12 subjects were included. The vast majority of the reports were from the U.S. Most of the female cases occurred during postpartum. All patients had a headache on initial presentation, although only 42% had thunderclap headache. A CT scan was performed on 67% of the patients. Imaging results were diverse, with a tendency toward cerebral hemorrhage followed by mixed cases. The main course of treatment included steroids (58% of the patients), with only 42% receiving nimodipine. The time to death ranged from 4 to 14 days, with a median of 9.2 days (SD ± 3.2).

CONCLUSION

We found that the majority of fatal cases reported in the literature are most likely related to postpartum angiopathy. We established a tendency in the onset of brain hemorrhage and the combination of infarction and brain hemorrhage. We described various markers for poor prognosis, including focal signs, the presence of hemorrhage and infarct in the first diagnostic image obtained and the need for invasive interventions. The majority of fatal cases in our report occurred in women, with over half of those cases during the puerperium period.

Migrainous Infarction And Cerebral Vasospasm: Case Report And Literature Review

Migrainous infarction (MI) is a rare complication of migraines that accounts for 0.5-1.5% of all ischemic strokes. Although the pathogenesis of MI is still debated, cortical spreading depression and the consequent biochemical cascade and hemodynamic changes are presumed to play an important role. Here we describe a case of MI and systematically review the literature on the complex and possibly bidirectional relationship between migraine and stroke. A 44-year-old female with history of migraine with visual aura presented at the Emergency Department due to a sudden onset of left limb paresis and hypoesthesia. Brain magnetic resonance imaging revealed right fronto-parietal ischemic stroke. Two days after hospitalization, the patient experienced a prolonged visual aura and showed ultrasound evidence of intracranial artery vasospasm. To date, there have been 33 published articles on a total 119 patients with MI, although intracranial vasospasm has rarely been reported. Sustained hyperexcitability of cortical neurons, impairment of γ-aminobutyric acid inhibitory circuitry, altered serotonergic transmission, release of vasoconstrictive molecules, and cerebral blood flow changes have been proposed as pathogenic mechanisms of MI. The present case provides insight into the pathophysiological link between stroke and migraine, thus aiding clinicians in therapeutic decision-making although additional studies are needed to clarify the clinical, neuroradiological, and ultrasound findings that link MI and stroke-related migraine.

A headache-free reversible cerebral vasoconstriction syndrome (RCVS) with symptomatic brain stem ischemia at late pregnancy as a rare manifestation of RCVS resolved with termination of pregnancy by semi-urgent cesarean section

A 32-year-old pregnant woman in her 39th week of pregnancy presented at the emergency room complaining of sudden-onset dizziness with gaze disturbance and was admitted to our hospital. Her past medical history included hypertension, diabetes mellitus and infarction in the right medulla oblongata 18 months prior to this event. Magnetic resonance (MR) angiography showed multiple irregular stenosis of the intracranial arterial system. Although MR images revealed no fresh ischemic or hemorrhagic lesions, she was diagnosed with reversible cerebral vasoconstriction syndrome (RVCS) associated with pregnancy. Cesarean section immediately resolved the headache-free ischemic RCVS. The postpartum course of the patient was uneventful as well as that of her baby. Follow-up MR angiography showed improvement of intracranial vasoconstriction and follow-up MR imaging showed improvement of a left medial pontine ischemic lesion on diffusion-weighted image. This report describes a rare manifestation of pregnancy-related RCVS.

Interictal cerebral and systemic endothelial dysfunction in patients with migraine: a case-control study

BACKGROUND

Although systemic endothelial function is unimpaired in migraine, it is unknown whether cerebral endothelial function impairment exists in migraineurs.

MATERIALS AND METHODS

We conducted a prospective study to assess endothelial function in migraineurs (n=45) and healthy volunteers (n=44). Cerebral endothelial function was assessed by Breath Holding Index (BHI) on transcranial Doppler in bilateral middle cerebral artery (MCA at 30-60 mm), posterior cerebral artery (PCA at 60-80 mm) and basilar artery (BA at 80-120 mm) using bilateral monitoring probes fixed on headband. Brachial artery flow-mediated dilation (FMD) was used as measure of systemic endothelial function.

RESULTS

There was no difference in baseline mean velocities of MCA, PCA, BA among migraineurs and controls. Mean BHI was significantly lower in PCA (p<0.001) and BA (p<0.001) in patients with migraine with no difference in MCA (p=0.909, 0.450). Cerebral endothelial dysfunction (BHI<1.15) was present in 62.2% of migraineurs in the right PCA (p<0.001), 57.8% in left PCA (p<0.001) and 77.8% in BA (BHI <0.83, p<0.001). There was no difference in BHI among migraineurs without and with aura (n=15). Cerebral and systemic endothelial function had no correlation in migraineurs. Increasing BMI was identified as a predictor of impaired BHI in the BA in migraineurs (p=0.020). Age, sex, presence of aura, lateralisation of headache, headache frequency, time to last attack and impaired FMD were not associated with impaired PCA and BA BHI in migraineurs.

CONCLUSIONS

Migraineurs may have isolated cerebral endothelial dysfunction restricted to the posterior circulation in the absence of systemic endothelial dysfunction.

Dissecting the association between migraine and stroke

Migraine is a common disabling neurological disorder resulting from excessive cortical excitation and trigeminovascular afferent sensitization. In addition to aberrant neuronal processing, migraineurs are also at significant risk of vascular disease. Consequently, the impact of migraine extends well beyond the ictal headache and includes a well-documented association with acute ischemic stroke, particularly in young women with a history of migraine with aura. The association between migraine and stroke has been acknowledged for 40 years or more. However, examining the pathobiology of this association has become a more recent and critically important undertaking. The diversity of mechanisms underlying the association between migraine and stroke likely reflects the heterogenous nature of this disorder. Vasospasm, endothelial injury, platelet aggregation and prothrombotic states, cortical spreading depression, carotid dissection, genetic variants, and traditional vascular risk factors have been offered as putative mechanisms involved in migraine-related stroke risk. Assimilating these seemingly divergent pathomechanisms into a cogent understanding of migraine-related stroke will inform future studies and the development of new strategies for the prevention and treatment of migraine and stroke.

Postpartum reversible cerebral vasoconstriction syndrome: Review and analysis of the current data

Postpartum reversible cerebral vasoconstriction syndrome (PPRCVS) is a rare but serious cause of headache that occurs in the early postpartum period. The rarity of this disorder has limited the current literature to single case reports and small, observational case series. The lack of familiarity with PPRCVS may contribute to mismanagement of these unique patients and lead to poor outcomes. To address current gaps in the understanding of PPRCVS, this review and data analysis characterizes the demographics, presentation, clinical course, management and prognosis of PPRCVS and provides a general review of the epidemiology, pathophysiology and diagnosis to assist clinicians who may care for patients with this rare disorder.

Reversible cerebral vasoconstriction syndrome

Reversible cerebral vasoconstriction syndrome is characterized by severe headaches with or without focal neurologic deficits and/or seizures, and segmental constriction of cerebral arteries that resolves within 3 months. This increasingly recognized syndrome is supposedly due to a transient disturbance in the control of cerebral vascular tone with sympathetic overactivity. It can cause stroke in the young. It affects mainly middle-aged women. More than half the cases occur after exposure to vasoactive substances or during postpartum. The manifestations have a monophasic course, without new clinical symptom after 4 weeks, and range from pure cephalalgic forms with recurrent thunderclap headaches over 1-2 weeks to rare catastrophic forms with multiple hemorrhagic and ischemic strokes, brain edema and death. Diagnosis may be hampered by the dynamic nature of clinicoradiological features. Convexity subarachnoid hemorrhage or stroke may occur a few days after initial normal imaging, and cerebral vasoconstriction is maximal on angiography 2-3 weeks after clinical onset. Symptomatic treatment includes rest and removal of vasoactive substances. Nimodipine has been proposed to reduce thunderclap headaches within 48 hours, but has no proven effect on the hemorrhagic and ischemic complications.

Prothrombotic States in Migraine

The increased risk of cardiovascular and cerebrovascular events in patients with migraine remains unexplained. Prothrombotic states are thought to contribute to this increased risk. The present study aimed to compare the prevalence of prothrombotic states in patients with migraine and headache-free controls. We conducted a case–control study to screen for prothrombotic states protein C, protein S (PS), antithrombin III, factor V Leiden, lupus anticoagulant, anticardiolipin, and anti-β2-glycoprotein 1 antibodies in 101 consecutive patients with migraine and 148 controls. An underlying prothrombotic state was encountered in 11.8% of the patients with migraine, PS deficiency being the most common (4.0%). There was no significant difference in the prevalence of prothrombotic states in patients with migraine compared to controls. Traditional prothrombotic states do not seem to have a higher prevalence in patients with migraine compared to controls.

Reversible cerebral vasoconstriction syndrome

Recurrent thunderclap headaches, seizures, strokes, and non-aneurysmal subarachnoid haemorrhage can all reveal reversible cerebral vasoconstriction syndrome. This increasingly recognised syndrome is characterised by severe headaches, with or without other symptoms, and segmental constriction of cerebral arteries that resolves within 3 months. Reversible cerebral vasoconstriction syndrome is supposedly due to a transient disturbance in the control of cerebrovascular tone. More than half the cases occur post partum or after exposure to adrenergic or serotonergic drugs. Manifestations have a uniphasic course, and vary from pure cephalalgic forms to rare catastrophic forms associated with several haemorrhagic and ischaemic strokes, brain oedema, and death. Diagnosis can be hampered by the dynamic nature of clinicoradiological features. Stroke can occur a few days after initial normal imaging, and cerebral vasoconstriction is at a maximum on angiograms 2-3 weeks after clinical onset. The calcium channel blocker nimodipine seems to reduce thunderclap headaches within 48 h of administration, but has no proven effect on haemorrhagic and ischaemic complications.

Migrainous infarction: aspects on risk factors and therapy

Migraine and stroke are related in more than one way. Migraine with aura is a risk factor for ischemic stroke in women under age 45 years, particularly when combined with other risk factors such as smoking and oral contraceptives. Further, individuals with migraine with aura seem to have more white matter lesions and ischemic infarctions than control patients. Migraine has been correlated to cervical artery dissection, the symptoms of which can mimic migraine. Correspondingly, migraine with aura sometimes is mistaken for stroke. Migrainous infarction is a rare but specific type of ischemic stroke developing during an attack of migraine with aura. It is important to recognize this unusual complication of migraine because the management probably is important. In this review, we will discuss the present knowledge of migrainous infarction, the clinical picture, possible mechanisms, and potential prevention and treatment.

[Reversible cerebral vasoconstriction syndrome]

The reversible cerebral vasoconstriction syndrome (RCVS) is an under-estimated transient acute cerebrovascular disorder. It has long been mistaken as central nervous system vasculitis whereas it is now believed to result from an acute but prolonged vasospasm of cerebral arteries. This disorder can be precipitated by postpartum or vasoactive drug. However, it occurs spontaneously in a significant number of cases. The characteristic clinico-radiological presentation and disease course of the RCVS has been delineated only recently. Mean age at onset is 40-45 years, with a female predominance. A provocative factor can be identified in 12-60% out of the patients. Clinical presentation is predominantly marked by recurrent thunderclap headaches, but can be complicated with focal neurological deficit or seizures. Brain imaging is normal in most cases, but can reveal hemorrhagic or ischemic complications. Cortical subarachnoid hemorrhage is a suggestive finding. A posterior reversible encephalopathy syndrome (PRES) can be seen occasionally. Cerebral angiography reveals multifocal arterial narrowing with string and bead appearance. Cerebrospinal fluid reveals no or mild abnormalities. The disease resumes spontaneously within several days to weeks, whereas vasoconstriction reverses within 1 to 3 months. This clinico-radiological presentation should be promptly recognized in order to avoid unnecessary investigations and aggressive treatment, and lead to search for a triggering factor. Further studies are required in order to clarify the precipitating role of several drugs, and clinical trials are needed to reduce the occurrence of strokes.

Migrainous infarction: a Nordic multicenter study

BACKGROUND AND PURPOSE

Migrainous infarction (MI), i.e., an ischemic stroke developing during an attack of migraine with aura is rare and the knowledge of its clinical characteristics is limited. Previous case series using the International Classification of Headache Disorders (ICHD) included <10 cases which make conclusions less valid. This study aimed to describe characteristics and outcome of MI in a larger sample.

METHODS

We analyzed demographic data, risk factors, migraine medication, stroke localization, symptoms, and outcome in a sample of 33 patients with MI according to second edition of the ICHD criteria collected from seven Nordic headache clinics.

RESULTS

Amongst 33 patients with MI, there were 20 (61%) women and 13 (39%) men with the median age for stroke of 39 (range 19-76) years. Traditional risk factors for stroke were rare compared with Scandinavian young ischemic stroke populations. During the acute phase, 12 (36%) patients used ergotamines or triptans. Stroke was located in the posterior circulation in 27 (82%) patients and cerebellum was involved in 7 (21%). Except in two patients with brainstem infarctions, the outcome was favorable with total recovery or limited residual symptoms.

CONCLUSIONS

The prevalence of traditional risk factors was low and the infarctions were predominantly located in posterior circulation territory, supporting theories of migraine specific mechanisms. The outcome was in general favorable.

Migraine and stroke

An association between migraine and ischemic stroke has been observed for many years but exact mechanisms by which migraine can lead to stroke are currently still under investigation. Migraine is related to stroke in several ways. First, ischemic stroke can develop as a complication of an attack of migraine with aura (so called migraineous infarction). Second, epidemiological studies suggest that migraine with aura is a risk factor for ischemic stroke. Third, a patent foramen ovale (PFO) is a well known risk factor for stroke and on the other hand, seems to be associated with migraine with aura. The purpose of this review is to summarize the current literature linking the two neurological diseases: migraine and stroke. For many years, migraine and cerebral ischemic stroke have been linked together. The association between these two diseases is multidimensional and rather complex.

Noninvasive imaging techniques in the diagnosis and management of aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating condition, requiring prompt diagnosis and therapeutic intervention as well as close monitoring for the development of complications including vasospasm (VS). Although digital subtraction angiography is still considered the gold standard for the diagnosis of aSAH (and vasospasm), new and less invasive modalities are emerging including ultrasound, CT, CT angiography and CT perfusion, and MR imaging. The current evidence for the use of these newer modalities is described for the diagnosis of aSAH and the management of its sequelae including VS.

Thrombolytic treatment of ischaemic stroke occurring during a migrainous attack: a case report

Authors report a case of young female suffering from the acute ischaemic stroke with right-sided hemiplegia, hemianopsia and hemihypoaesthesia during a migrainous attack without aura. Magnetic resonance imaging detected infarction in the left occipital lobe and occlusion of branches of the posterior cerebral artery (PCA). Combined treatment with systemic thrombolysis and sonothrombolysis was used, leading to the early PCA recanalization, and to a favourable clinical outcome after 1 month. Intravenous thrombolytic treatment administered within the therapeutic window may be useful in cerebral ischaemia associated with migraine when an arterial occlusion is documented.

Reversible cerebral vasoconstriction syndrome

Reversible cerebral vasoconstriction syndrome (RCVS) is an under-recognised condition. It is characterised by sudden and severe headaches (of "thunderclap" type) associated with multifocal reversible narrowing of the intracranial arteries on neuroradiology. The diagnosis is often established with the resolution of headaches and vasoconstriction. We report two patients with RCVS and review the available literature, to clarify the diagnostic criteria and discuss the treatment options.

Migraine and stroke: current perspectives

OBJECTIVE

The purpose of this article is to review the latest concepts regarding migraine and ischemic stroke. In addition, focal neurological deficits and MRI changes in migraine patients will be reviewed.

METHODS

A PubMed search of neurological literature pertaining to this study was conducted using specific keyword search terms pertaining to migraine and ischemic stroke.

RESULTS

Migraine, especially with aura, is a relative risk factor for stroke. Neuroimaging demonstrates the posterior circulation as being most vulnerable, although the reason for this distribution is unclear. Factors that may contribute to stroke in migraine include changes during cortical spreading depression with hyper- or hypoperfusion of neural tissue, vasospasm and endothelial dysfunction. Estrogen affects migraine expression as well as cerebral circulation, yet most women with migraine without aura are not at increased risk. Co-morbidity with patent foramen ovale can be mechanism of both disorders via presumed lack of filtration of microemboli or toxic substances; however, closure with reversal of right to left shunt seems to be more beneficial for cryptogenic stroke than migraine. Migraine and stroke are found in specific genetic disorders such as CADASIL, HERNS and MELAS giving clues to genetic factors. Stroke associated with migraine treatments such as ergots or triptans is rare, and usually associated with special circumstances such as overuse or concomitant thrombogenic conditions.

CONCLUSION

Although true migrainous infarction is rare, our understanding of the subtle associations between migraine and cerebrovascular behavior is expanding.

From migraine to stroke

An association between migraine and ischemic stroke has been observed for many years but the exact mechanisms by which migraine can lead to stroke are currently still under investigation. Migraine seems to affect neurovascular factors and substances that increase the risk of stroke during and in between migraine attacks. Ischemic stroke can occur as a complication of an attack of migraine with aura. Epidemiological studies suggest that vascular risk factors are increased in migraineurs, thus increasing the incidence of stroke. Another important issue is a patent foramen ovale (PFO), which is a well-known risk factor for stroke and which, on the other hand, seems to be more frequent in migraineurs than in people without. The purpose of this review is to summarize the current literature linking the two neurological diseases: migraine and stroke.

Migraine and ischaemic heart disease and stroke: potential mechanisms and treatment implications

The migraine-ischemia relationship is best understood in the context of the pathophysiology of migraine. Potential mechanisms of migrainous infarction (stroke occurring during migraine) include vasospasm, hypercoagulability, and vascular changes related to cortical spreading depression. Stroke occurring remote for the migraine attack may be related to arterial dissection, cardioembolism, and endothelial dysfunction. Endothelial dysfunction, a process mediated by oxidative stress, may be a cause or a consequence of migraine, and explain the relationship of migraine to vascular factors and ischemic heart disease. It remains uncertain whether stroke or myocardial infarction can be prevented by migraine prophylaxis, endothelial repair, platelet inhibition, or a combination of these strategies. Although triptans are generally considered safe for use in migraine, caution is warranted in those with multiple vascular risk factors. Known vascular disease is a contraindication to triptan use.