is ultrasound foam sclerotherapy contraindicated in patients with migraine? by claudine...
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Is ultrasound foam
sclerotherapy
contraindicated
in patients with migraine?By Claudine HAMEL-DESNOS, Caen, France
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FoamPatent
foramen ovale
MIGRAINE
Neurological
disturbances?
Should we treat varicose veins using UGFS* in patients with migraine?
*Abbreviations: PFO, patent foramen ovale;
UGFS,
ultrasound-guided foam sclerotherapy
Meier B et al. Eur Heart J 2012;33:705-713
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« The results of NOMAS can be seen as the strongest evidence against an association between
migraine or migraine with aura and PFO »
Kurth K, Tzourio C, and Bousser MG. Editorial
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How does foam progress?• In vitro,
2 ml of 3% sodium tetradecyl sulphate are deactivated by only 1 ml of blood in a short period of time (15 s)
• The sclerosing agent does not reach the brain circulation
• Only “bubbles” remain
Watkins M.R. Deactivation of sodium tetradecyl sulphate injection by blood proteins. Eur J Vasc Endovasc Surg. 2011;41:521-525. 4
Neurological disturbances
• Visual (1.4%)
• Migraine (4.2%)
• Transient ischemic attacks
• Stroke
Jia X, Mowatt G, Burr JM, Cassar K, Cook J, Fraser C. Systematic review of foam sclerotherapy for varicose veins. Br J Surg. 2007;94(8):925-936.
Mostly case reports Good recovery
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What’s a migraine?
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The International Headache Societymigraine without aura: diagnostic
criteriaA. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
C. At least two of the following characteristics:
– Unilateral location
– Pulsating quality
– Moderate or severe pain intensity
– Aggravation by or causing avoidance of routine physical activity (eg walking or climbing stairs)
D. At least one of the following symptoms:
– Nausea and/or vomiting
– Photophobia and phonophobia
E. Not attributed to another disorder
The International Classification of Headache Disorders. Cephalalgia. 2004;24:S9-S160. 7
A. At least 2 attacks fulfilling criteria B-D
B. Aura consisting of at least 1 of the following, but no motor weakness: 1. fully reversible visual symptoms including positive features (eg, flickering
lights, spots, or lines) and/or negative features (i.e, loss of vision);
2. fully reversible sensory symptoms including positive features (i.e, pins and needles) and/or negative features (i.e, numbness);
3. fully reversible dysphasic speech disturbance
C. At least 2 of the following :
1. homonymous visual symptoms and/or unilateral sensory symptoms
2. at least 1 aura symptom develops gradually over ≥5 min and/or diferent aura symptoms occur in succession over ≥5 min
3. each symptom lasts >5 and <60 minutes
D. Headache fulfilling criteria B-D for migraine without aura begins during the aura or follows the aura within 60 minutes
E. Not attributed to another disorder
The International Headache Societymigraine with aura : diagnostic
criteria
The International Classification of Headache Disorders. Cephalalgia. 2004;24:S9-S160. 8
Pathophysiology of migraine associated with Ultrasound-Guided Foam
Sclerotherapy (UGFS)
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Pathophysiology of migraine with aura (AM)
Extensive cortical depression (propagated):
Depolarization wave from the occipital cortex to the forehead (may be limited): occipital = visual troubles parietal = paresthesias frontal = speech troubles
Endothelin-1 (powerful vasoconstrictor) = triggers AM
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Endothelin and foam
Varicose vein endothelium is damaged by foam and releases endothelin-1, which reaches the cerebral cortex via the PFO, triggering an aura.
Visual disturbances are not transient ischemic attacks
Visual
disturbances=
AM
Foam →release
of endothelin-1
Gillet et al. Phlebology. 2010;25:261-266. Frullini et al. Phlebology. 2011;26:203-208.11
According to expert recommendations:
MIGRAINE WITH OR WITHOUT AURA IS NOT A
CONTRAINDICATION FOR UGFS
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Breu FX, Guggenbichler S, Wollmann JC. 2nd European consensus meeting on foam sclerotherapy 2006. Tegernsee, Germany: Vasa 2008;S/713-729.
Berridge D, Lees T, Earnshaw JJ. The VEnous Intervention (VEIN) project. Phlebology. 2009;24 (suppl 1):1-2.
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LITERATURE REVIEW
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• 1023 articles analyzed• 41 articles retained reporting the presence of
stroke, transient ischemic attacks (TIA) or visual or speech disturbances, migraine, cephalalgia (63% foam and 37% liquid)
12 cases of stroke 9 TIAs 29 cases of migraine (0.27%)
Sarvananthan T, Sheperd AC, Willenberg T, Davis AH. Neurological complications of sclerotherapy for varicose veins. J Vasc Surg . 2012;55:243-251.
No personal history of migraine described
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There are insufficient data to determine the role of:
The technique used to generate foam, The gas used,
The volumes injected, The type of veins treated,
The different types of measures taken to avoid complications
• « The pathologic mechanisms resulting in CVA are likely to be different to those leading to migraine and visual disturbances »
• « Precautions should be exercised particularly in patients with a known PFO and perhaps those known to suffer from migraine »
Sarvananthan T, Sheperd AC, Willenberg T, Davis AH. Neurological complications of sclerotherapy for varicose veins. J Vasc Surg 2012; 55:243-251.
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PRACTICAL RECOMMENDATIONSA symptomatic PFO is a contraindication for UGFS A personal history of migraine is not a contraindication for UGFS. However, it must be reported along with the presence or absence of aura Should migraine with/without aura occur after UGFS:
• Treat the patient with his/her usual antimigraine treatment (or with NSAI)
• In case of VDs, do not let the patient drive unaccompanied until the cessation of disturbances
• The risk/benefit ratio should be reviewed before continuing sclerotherapy treatment (preventative antimigraine treatment?)
In case of stroke: assessment (Doppler examination of the supra-aortic vessels, consultation with a neurologist, consultation with a cardiologist, MRI); pharmacovigilance report.
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CONCLUSION
• Neurological disturbances after UGFS should not be overlooked; however, they are usually AM variants
• Strokes are rare side-effects and are not the result of the same underlying mechanisms; no link with a personal history of migraine has been established; stroke diagnosis must be confirmed
• Currently, a history of migraine is not a contraindication for UGFS though it may contribute to the development of AM (or AM variant)
• Further studies are needed
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