The extent of right-to-left shunt fails to correlate with severity of clinical picture in migraine with aura.

Several investigations have documented an increased incidence of right-to-left shunt (RLS) in migraine with aura (MA) and have emphasised its role in the physiopathology of aura; so far, however, no data are available concerning a possible correlation between the extent of the RLS and the clinical picture of MA patients. To investigate the possible relationship between the extent of the RLS, revealed by the number of microbubbles (MB) detected during transcranial Doppler with IV injection of ultrasound contrast (TCDc), and the clinical characteristics of MA (age at first onset of migraine, mean annual frequency of attacks and mean duration of the aura phase), 30 consecutive patients with typical aura and migraine headache positive on TCDc evaluation for RLS were enrolled. Permanent RLS was found in 12 patients and latent RLS was found in 18 patients; of these, 6 had a high-grade RLS, 5 medium-grade RLS and 7 low-grade RLS. No correlation has been documented between the number of MBs and the clinical parameters of both patients with latent shunts and those with permanent ones, nor between the clinical parameters of the two groups of patients. These data show that RLS does not seem to affect the clinical manifestation of MA and that the extent of RLS fails to correlate with the severity of the clinical picture of the disorder.

Dissection and atherosclerosis of carotid arteries in the young: role of the apolipoprotein E polymorphism.

Twenty-seven young (<50 years old) patients with spontaneous carotid artery dissection in 11 cases and carotid atherosclerosis in 16 cases were evaluated to determine the apolipoprotein E polymorphism. At the DNA analysis the epsilon3/epsilon3 genotype was observed in all patients with dissection, in 13 of 16 (81.2%) patients with atherosclerosis and in 27 of 30 (90%) controls. Three of 16 (18.8%) patients with atherosclerosis and 3 of 30 (10%) controls presented with the epsilon4/epsilon3 genotype, and this difference was not statistically significant. Moreover, observation of the epsilon4/epsilon3 genotype was not significantly higher in patients with atherosclerosis compared with those with dissection. No homozygote epsilon4/epsilon4, epsilon2/epsilon2 or heterozygote epsilon2 genotype was observed. No correlation was found between the presence of the epsilon4/epsilon3 genotype and vascular risk factors. Therefore, the epsilon4 allele seems to be involved in carotid premature atherosclerosis development whereas it may appear to be protective for artery dissection occurrence. A larger sample size is needed to support this suggestion.

Characteristics of cerebral microembolism during carotid stenting and angioplasty alone.

BACKGROUND: Cerebral microembolism has often been documented by transcranial Doppler imaging during carotid angioplasty and stenting. However, few data are available about its characteristics during the 2 different kinds of procedure. OBJECTIVES: To compare the incidence of microemboli occurring during angioplasty alone with that during stenting in the different phases of the procedures and to relate it to periprocedural cerebrovascular complications. PATIENTS AND METHODS: Thirty-eight patients underwent 41 procedures (15 angioplasty alone and 26 stenting) for symptomatic carotid stenoses of 70% or more. Transcranial Doppler monitoring was performed to detect microemboli in the middle cerebral artery during 3 phases of the procedure: (1) guidewire crossing, (2) first dilatation in case of angioplasty alone or stent release with predilatation if performed, and (3) further dilatation. RESULTS: Microemboli occurred in all cases in phase 1 of the procedure but less frequently in the arteries treated with stenting when compared with those treated with angioplasty alone in phase 2 and particularly (P<.02) in phase 3. The mean number of microemboli was highest in phase 2, predominant (P<.05) during angioplasty alone, and particularly reduced (P<.02) in phase 3 during the stenting procedures. During 2 (5%) of the 41 procedures, cerebrovascular complications occurred in phase 1, with the number of microemboli being higher than mean values. CONCLUSIONS: Cerebral microembolism is a very common event, especially during guidewire crossing and angioplasty alone compared with stenting. Further studies concerning the prognostic significance of this are advisable.

Transient autonomic nervous system dysfunction during hyperacute stroke.

Forty-four patients suffering a stroke for the first time were examined within 10 h of the onset of symptoms; the tests performed on their admission to hospital, and thereafter on the third and seventh day, were 24-h Holter EKG with spectral analysis of heart rate variability, evaluation of arterial blood pressure and the levels of catecholamine in the blood and 24-h urine. The dynamic EKG on admission revealed that 31 (70.5%) out of the 44 patients already had arrhythmia. These alterations were observed in 9 (75%) out of 12 haemorrhagic patients with a significant (P < 0.05) prevalence compared to 22 (68.8%) of the 32 ischaemic ones. Arrhythmia showed up in 16 (76.2%) out of 21 cases with right hemisphere lesions and in 12 (63.2%) out of 19 cases of left hemisphere lesions; this difference was also significant (P<0.05). Arrhythmia was still present in 19 (43.2%) patients after 3 days and only in 2 (6.5%) patients after 7 days. The spectral analysis parameters on admission and after 3 days were significantly (P < 0.05) modified in patients with stroke plus arrhythmia, compared to patients with stroke alone and to control subjects, whereas no further differences were observed on the seventh day. Moreover, the percentage of patients with arterial hypertension and high levels of catecholamine greatly decreased from the third day onwards. A transient autonomic nervous system imbalance with prevalent sympathetic activity may justify this cardiovascular impairment during the hyperacute phase of stroke.