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Muroke V, Jalanko M, Haukka J, Hartikainen J, Tahvanainen A, Ukkonen H, Ylitalo K, Pihkala J, Sinisalo J. Outcome of transcatheter atrial septal defect closure in a nationwide cohort. Ann Med 2023; 55:615-623. [PMID: 36786506 PMCID: PMC9930864 DOI: 10.1080/07853890.2023.2178669] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Transcatheter (TC) atrial septal defect (ASD) closure has been the mainstay of therapy for secundum-type ASDs for over 20 years. AIMS This nationwide cohort evaluated the long-term outcome of transcatheter-closed ASDs. METHODS The study enrolled every transcatheter ASD closure performed in Finland from 1999 to 2019. Five age, sex, and municipality-matched controls per ASD patient were gathered from the general population. The median follow-up period was 5.9 years (range 0-20.8). We used the hospital discharge register to gather all hospital visits and diagnoses. Closure complications and echocardiographic changes were collected from the electronic health records. RESULTS Transcatheter ASD closure was performed in 1000 patients (68.5% females) during the study period. The median (range) age at the time of the procedure was 37.9 (1.8-87.5) years. ASD patients had an increased risk for new-onset atrial fibrillation (RR 2.45, 95% CI: 1.84-3.25), migraine (RR 3.61, 95% CI: 2.54-5.14), ischemic heart disease (RR 1.73, 95% CI: 1.23-2.45), ventricular fibrillation/tachycardia (RR 3.54 (95% CI: 1.48-8.43) and AV conduction disorder (RR 3.60, 95% CI: 1.94-6.70) compared to the control cohort. Stroke risk was not increased (RR 1.36, 95% CI: 0.91-2.03). Adverse events occurred in 6.3% (n = 63) of the patients, including four erosions and ten device embolizations. CONCLUSION After TC closure of ASD, patients had a higher risk of new-onset atrial fibrillation and migraine than controls without ASD. As novel findings, we found an increased risk for ischemic heart disease, AV conduction disorders, and ventricular fibrillation/tachycardia.Key messagesEven though patients have an excellent overall prognosis after percutaneous ASD closure, the increased incidence of major comorbidities like atrial fibrillation and heart failure prompts more thorough lifelong follow-up.This study's novel findings revealed the increased risk for ischemic heart disease, AV conduction disorders, or ventricular tachycardia/fibrillation during the follow-up.Major complications after the closure are rare; erosion is seen in 0.4% of the patients and embolization in 1.0% of the patients.
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Affiliation(s)
- V Muroke
- Department of Cardiology, Helsinki University Hospital, Helsinki, Finland
| | - M Jalanko
- Department of Cardiology, Helsinki University Hospital, Helsinki, Finland
| | - J Haukka
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - J Hartikainen
- Department of Cardiology, Kuopio University Hospital, Kuopio, Finland
| | - A Tahvanainen
- Department of Cardiology, Tampere University Hospital, Tampere, Finland
| | - H Ukkonen
- Heart Centre, Turku University Hospital, Turku, Finland
| | - K Ylitalo
- Department of Cardiology, Oulu University Hospital, Oulu, Finland
| | - J Pihkala
- Department of Cardiology, New Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - J Sinisalo
- Department of Cardiology, Helsinki University Hospital, Helsinki, Finland
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Wintzer-Wehekind J, Horlick E, Ibrahim R, Cheema AN, Labinaz M, Nadeem N, Osten M, Côté M, Marsal JR, Rivest D, Marrero A, Houde C, Rodés-Cabau J. Effect of Clopidogrel and Aspirin vs Aspirin Alone on Migraine Headaches After Transcatheter Atrial Septal Defect Closure: One-Year Results of the CANOA Randomized Clinical Trial. JAMA Cardiol 2021; 6:209-213. [PMID: 32965476 DOI: 10.1001/jamacardio.2020.4297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Adding clopidogrel to aspirin for 3 months after transcatheter atrial septal defect (ASD) closure results in a lower incidence of new-onset migraine attacks. However, the outcomes at 6- to 12-month follow-up (after clopidogrel cessation at 3 months) remain largely unknown. Objective To assess the incidence of migraine attacks at 6- and 12-month follow-up after transcatheter ASD closure. Design, Setting, and Participants This prespecified analysis of a randomized, double-blind clinical trial included patients with no prior history of migraine undergoing ASD closure from 6 university hospitals in Canada from December 2008 to November 2014. Patients were followed up at 3, 6, and 12 months, and a migraine headache questionnaire was administered at each time. Analysis began June 2019. Interventions Patients were randomized (1:1) to receive dual antiplatelet therapy (aspirin plus clopidogrel; n = 84) vs single antiplatelet therapy (aspirin plus placebo; n = 87) for 3 months following transcatheter ASD closure. After 3 months, only single antiplatelet therapy (aspirin) was pursued. Main Outcomes and Measures Incidence and severity of migraine attacks at 6- and 12-month follow-up. Results The mean (SD) age of the study population was 38 (12) years, with 106 women (62%). A total of 27 patients (15.8%) had new-onset migraine attacks within the 3 months following ASD closure (8 of 84 [9.5%] vs 19 of 87 [21.8%] in the initial clopidogrel and placebo groups, respectively; P = .03). After cessation of clopidogrel and aspirin monotherapy, the percentage of patients with migraine attacks decreased over time, with 8 (4.7%) and 4 patients (2.3%) continuing to have migraine attacks at 6 and 12 months, respectively (vs 3 months: P < .001). The severity of migraine attacks progressively decreased over time; no moderate or severe attacks occurred at 6 and 12 months (vs 3 months: P < .001). There were no differences between groups in the rate of migraine attacks at 6 months (initial clopidogrel group: 2 of 84 [2.4%]; initial placebo group: 6 of 87 [6.9%]; P = .28) and 12 months (initial clopidogrel group: 3 of 84 [3.6%]; initial placebo group: 1 of 87 [1.1%]; P = .36) after ASD closure. Only 2 patients (1.2%; 1 patient per group) presented with new-onset migraine attacks after 3 months. Conclusions and Relevance New-onset migraine attacks after ASD closure improved or resolved spontaneously within 6 to 12 months in most patients. No significant rebound effect was observed after clopidogrel cessation at 3 months. These results demonstrate a low rate of migraine events beyond 3 months following transcatheter ASD closure and support the early discontinuation of clopidogrel therapy if administered. Trial Registration ClinicalTrials.gov Identifier: NCT00799045.
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Affiliation(s)
- Jérôme Wintzer-Wehekind
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Eric Horlick
- Department of Cardiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Reda Ibrahim
- Department of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Asim N Cheema
- Department of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marino Labinaz
- Department of Cardiology, Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Najaf Nadeem
- Department of Cardiology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Mark Osten
- Department of Cardiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Mélanie Côté
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Ramon Marsal
- Epidemiology Unit of the Cardiology Department, Vall d'Hebron Hospital, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Donald Rivest
- Department of Neurology, Hôtel Dieu de Lévis, Quebec City, Quebec, Canada
| | - Alier Marrero
- Department of Neurology, Centre Hospitalier Universitaire Georges L. Dumont, Moncton, New Brunswick, Canada
| | - Christine Houde
- Department of Pediatric Cardiology, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
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Matsuoka R, Muneuchi J, Nagatomo Y, Sugitani Y, Ezaki H, Doi H, Watanabe M. Headache and Left Ventricular Efficiency After Transcatheter Closure of Atrial Septal Defect. Headache 2020; 60:2421-2430. [PMID: 33045096 DOI: 10.1111/head.13990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/12/2020] [Accepted: 08/12/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE/BACKGROUND This study aimed to clarify the relationship between migraine-like headache and ventriculo-arterial coupling after transcatheter closure of the atrial septal defect in children. We hypothesized that migraine headache after defect closure would be related to an abnormal hemodynamic response against an increased left ventricular filling. DESIGN A retrospective cohort study. METHODS We calculated the end-ventricular systolic elastance (Ees), effective arterial elastance (Ea), and ventricular energy efficiency approximated based on echocardiography before and after defect closure, and compared these parameters between the subjects with and without headache after defect closure. RESULTS A total of 167 subjects were studied. Age at the procedure, defect diameter, and pulmonary to systemic blood flow ratio were 11 (9-17) years, 12.8 (9.2-16.0) mm, and 1.8 (1.6-2.3), respectively. We identified 47 (28%) subjects with migraine headache after defect closure. Although there was no significant difference in the Ees, Ea, and ventricular energy efficiency before defect closure between the groups, the Ees (4.0 [3.4-4.9] vs 4.8 [3.7-6.1], P = .014) and ventricular energy efficiency (0.79 [0.76-0.82] vs 0.83 [0.79-0.85], P = .001) after defect closure in subjects with headache were significantly lower than those in subjects without headache. Migraine headache after defect closure was significantly associated with age (odds ratio: 0.97, 95% confidential interval: 0.94-1.00, P = .036) and a decrease in the ventricular energy efficiency after defect closure (odds ratio: 6.42, 95% confidential interval: 2.76-14.90, P < .001). CONCLUSION A loss of ventricular energy efficiency was common in pediatric subjects with migraine-like headache after transcatheter closure of the atrial septal defect, which suggested that the left ventricular function maladaptation was related to headache development after defect closure. We advocate that an impaired ventriculo-arterial coupling may be one of the mechanisms for developing attacks in not only this population but also in other patients with migraine.
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Affiliation(s)
- Ryohei Matsuoka
- Department of Pediatrics, Japan Community Healthcare Organization Kyusyu Hospital, Kitakyusyu, Japan
| | - Jun Muneuchi
- Department of Pediatrics, Japan Community Healthcare Organization Kyusyu Hospital, Kitakyusyu, Japan
| | - Yusaku Nagatomo
- Department of Pediatrics, Japan Community Healthcare Organization Kyusyu Hospital, Kitakyusyu, Japan.,Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuichiro Sugitani
- Department of Pediatrics, Japan Community Healthcare Organization Kyusyu Hospital, Kitakyusyu, Japan
| | - Hiroki Ezaki
- Department of Pediatrics, Japan Community Healthcare Organization Kyusyu Hospital, Kitakyusyu, Japan
| | - Hirohito Doi
- Department of Pediatrics, Japan Community Healthcare Organization Kyusyu Hospital, Kitakyusyu, Japan
| | - Mamie Watanabe
- Department of Pediatrics, Japan Community Healthcare Organization Kyusyu Hospital, Kitakyusyu, Japan
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Raut S, Singh U, Sarmah D, Datta A, Baidya F, Shah B, Bohra M, Jagtap P, Sarkar A, Kalia K, Borah A, Dave KR, Yavagal DR, Bhattacharya P. Migraine and Ischemic Stroke: Deciphering the Bidirectional Pathway. ACS Chem Neurosci 2020; 11:1525-1538. [PMID: 32348103 DOI: 10.1021/acschemneuro.0c00137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Migraine and stroke are common, disabling neurological conditions with several theories being proposed to explain this bidirectional relationship. Migraine is considered as a benign neurological disorder, but research has revealed a connection between migraine and stroke, predominantly those having migraine with aura (MA). Among migraineurs, females with MA are more susceptible to ischemic stroke and may have a migrainous infarction. Migrainous infarction mostly occurs in the posterior circulation of young women. Although there are several theories about the potential relationship between MA and stroke, the precise pathological process of migrainous infarction is not clear. It is assumed that cortical spreading depression (CSD) might be one of the essential factors for migrainous infarction. Other factors that may contribute to migrainous infarction may be genetic, hormonal fluctuation, hypercoagulation, and right to left cardiac shunts. Antimigraine drugs, such as ergot alkaloids and triptans, are widely used in migraine care. Still, they have been found to cause severe vasoconstriction, which may result in the development of ischemia. It is reported that patients with stroke develop migraines during the recovery phase. Both experimental and clinical data suggest that cerebral microembolism can act as a potential trigger for MA. Further studies are warranted for the treatment of migraine, which may lead to a decline in migraine-related stroke. In this present article, we have outlined various potential pathways that link migraine and stroke.
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Affiliation(s)
- Swapnil Raut
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Upasna Singh
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Deepaneeta Sarmah
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Aishika Datta
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Falguni Baidya
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Birva Shah
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Mariya Bohra
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Priya Jagtap
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Ankan Sarkar
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Kiran Kalia
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Anupom Borah
- Cellular and Molecular Neurobiology Laboratory, Department of Life Science and Bioinformatics, Assam University, Silchar, Assam 788011, India
| | - Kunjan R. Dave
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida 33136, United States
| | - Dileep R. Yavagal
- Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida 33136, United States
| | - Pallab Bhattacharya
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
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The Burden of Migraine in Adults with Atrial Septal Defect: A Nationwide Cohort Study. Sci Rep 2019; 9:7410. [PMID: 31092873 PMCID: PMC6520354 DOI: 10.1038/s41598-019-43895-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 05/03/2019] [Indexed: 11/29/2022] Open
Abstract
We aimed to investigate migraine diagnoses in a hospital setting, use of prescription migraine medicine and levels of serotonin in patients with atrial septal defect. Using Danish national registries to identify all patients born before 1994 diagnosed with atrial septal defect between 1959 and 2013, thus including 2277 patients and a gender and age matched comparison cohort of 22756. Plasma serotonin was measured in 136 patients with a small, unclosed, atrial septal defects and 18 controls. Patients with atrial septal defect had an increased risk of receiving a migraine diagnosis (HR 3.4 (95% CI: 2.6–4.6)) and receiving migraine medicine (HR 1.8 (95% CI: 1.2–2.5)). Ten years after closure, 93% of those using migraine medicine pre-closure, were still receiving this. The risk of having very high plasma serotonin levels was increased in patients with atrial septal defect compared with the control group, but there was no difference in the median values between the two groups. Migraine and use of migraine medicine were increased in atrial septal defect patients. The use of medicine was not diminished by closure of the defect. Plasma serotonin was severely elevated in 18% of the patients with atrial septal defect.
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Liu Y, Li S, Wang R, Han X, Su M, Cao X, Wang G, Cao F, Yu S. A New Perspective of Migraine Symptoms in Patients With Congenital Heart Defect. Headache 2018; 58:1601-1611. [PMID: 30444273 DOI: 10.1111/head.13453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To investigate the association between congenital heart defects (CHDs) and migraine and evaluate the efficacy of transcatheter defect closure from a new perspective. METHODS The patients with CHDs who underwent transcatheter defect closure were screened in the medical database of Chinese PLA General Hospital from January 2006 to January 2017. The assessment included basic admission information, the 3-item ID Migraine Screener, and a detailed questionnaire administered by telephone or in an outpatient clinic. Patients were divided into ventricular septal defect (VSD) group and AP group (ie, patients with ASD or PFO) based on the type of defects. The latter group could be further divided into right-to-left shunt (RLS) group and left-to-right (LRS) shunt group. Each group contained 4 subgroups according to their migraine diagnosis before and after defect closure: persistent migraine (PM), relieved migraine (RM), without migraine (WM), and new-onset migraine (NM). RESULTS The study recruited total 441 CHDs patients. Most patients in RLS group had migraine before and/or after surgery (76.4%, 42/55) and the proportion of them in NM group was higher than that of in LRS group (23.5%, 4/17 vs 6.8%, 18/266, P = .0418). Although the size of closure device or defect did not show significant differences, the ratios (R = size of closure/size of defect) were significantly higher in NM group than those in WM group (1.40 [1.26, 1.80] vs 1.22 [1.13, 1.38] in AP group, P = .00238; 1.38 [1.23, 1.50] vs 1.22 [1.13, 1.37] in LRS group, P = .024934, respectively). Further logistic regression analysis illustrated that larger R value was a risk factor for NM in AP group (OR 1.48, 95% CI 1.07-2.05, P = .0188). Besides, migraine symptoms decreased significantly after defect closure in PM group among patients with ASD and PFO. CONCLUSION This study revealed several associations between migraine and CHDs, especially the large ratio of closure device size to defect size. High-quality randomized controlled trials and animal studies are needed to further investigate and clarify the underlying association between CHDs and migraine.
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Affiliation(s)
- Yinglu Liu
- Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Sulei Li
- Department of Cardiology & National Clinical Research Center of Geriatric Disease, Chinese PLA General Hospital, Beijing, China
| | - Rongfei Wang
- Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Xun Han
- Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Min Su
- Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Xiutang Cao
- Department of Medical Statistics, Chinese PLA General Hospital, Beijing, China
| | - Guangyi Wang
- Department of Cardiology & National Clinical Research Center of Geriatric Disease, Chinese PLA General Hospital, Beijing, China
| | - Feng Cao
- Department of Cardiology & National Clinical Research Center of Geriatric Disease, Chinese PLA General Hospital, Beijing, China
| | - Shengyuan Yu
- Department of Neurology, Chinese PLA General Hospital, Beijing, China
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Dönmez-Demir B, Yemisci M, Kılıç K, Gürsoy-Özdemir Y, Söylemezoğlu F, Moskowitz M, Dalkara T. Microembolism of single cortical arterioles can induce spreading depression and ischemic injury; a potential trigger for migraine and related MRI lesions. Brain Res 2017; 1679:84-90. [PMID: 29183666 DOI: 10.1016/j.brainres.2017.11.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 11/20/2017] [Accepted: 11/21/2017] [Indexed: 12/13/2022]
Abstract
Increasing epidemiological evidence suggests an association between migraine with aura (MA) and cardiovascular events. There is experimental as well as clinical evidence implying cerebral microembolism as a potential trigger for MA attacks. Microembolism may also account for some of the ischemic MRI lesions more commonly observed in MA than in general population. Limited size of clinically-silent MRI lesions suggests isolated occlusion of a small vessel. However, it is not known whether selective thrombosis of a small arteriole (e.g. single mouse penetrating arteriole - PA), can induce cortical spreading depression (CSD), the putative cause of migraine aura and, hence, trigger an MA attack. For this, we mimiced thrombosis of a small vessel caused by microembolism by selectively occluding a PA just before diving into the cortex (radius; 10-25 µm) in the mouse. Clotting was induced with FeCl3 applied focally over the PA by a glass micropipette for 3 min. DC potential changes were recorded and the alterations in cortical blood flow were monitored by laser speckle contrast imaging. Mice were kept alive for 1-4 weeks and brain sections were stained with H&E or luxol-fast blue to evaluate changes induced by PA occlusion. We found that single PA occlusion consistently triggered a CSD originating from the tissue around the PA soon after occlusion and induced delayed, small ischemic lesions within territory of the affected vessel a few weeks later. These findings suggest that cerebral microembolism can lead to MA attacks and may account for some of the silent brain lesions.
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Affiliation(s)
- Buket Dönmez-Demir
- Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey
| | - Muge Yemisci
- Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey; Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kıvılcım Kılıç
- Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey
| | - Yasemin Gürsoy-Özdemir
- Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey; Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey; Department of Neurology, School of Medicine, Koç University, İstanbul, Turkey
| | - Figen Söylemezoğlu
- Department of Pathology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Michael Moskowitz
- Neuroscience Center, Massachusetts General Hospital, Harvard University, Boston, USA
| | - Turgay Dalkara
- Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey; Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey; Neuroscience Center, Massachusetts General Hospital, Harvard University, Boston, USA.
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