by Elena Moro
For March 2017, we have selected: Timm FP, Houle TT, Grabitz SD, et al. Migraine and risk of perioperative ischemic stroke and hospital readmission: hospital based registry study. BMJ 2017 Jan 10;356:i6635. doi: 10.1136/bmj.i6635.
A higher risk of ischemic stroke has been found in patients with migraine, especially in those with migraine with aura. Stroke within 30 days after surgery has been estimated to happen somewhat frequently (up to 7.4%) after major cardiac and vascular surgery, and it is associated with higher risk of mortality and severe long-term morbidities. Migraine might be also a risk factor for perioperative ischemic stroke and might possibly increase hospital readmission after surgery.
To test these hypotheses, the authors of this paper analyzed data from patients who underwent surgery under general anesthesia in three Massachusetts hospitals between January 2007 and August 2014. History of migraine was determined using the ICD-9 (International Classification of Diseases, ninth edition) diagnosis code. Diagnosis of stroke was retained after reviewing brain scan reports, neurology consultation notes, and discharge summaries. Main outcome was perioperative ischemic stroke within 30 days after surgery, whereas secondary outcome was hospital readmission within 30 days of discharge, both outcomes evaluated in patients with migraine compared with those without migraine. Multivariable adjusted logistic regression analysis was used for both outcomes. Several variables were tested to evaluate other risk factors, and several a priori planned sensitivity and exploratory analyses were also performed.
A total of 124,558 surgical cases were retrieved, of whom 10,179 (8.2%) with migraine. Of this migraine patients 1,278 (12.6%) had migraine with aura. There was a total of 771 (0.6%) perioperative ischemic strokes, especially following vascular surgery (4.0%), cardiac surgery (3.5%), and neurosurgery (2.4%). Of these stroke patients, 71 (9.2%) had migraine without aura, and 18 (2.3%) migraine with aura. Overall, patients with migraine had an increased risk of perioperative ischemic stroke compared to those without migraine (adjusted odd ratio 1.75, 95% CI 1.39-2.21); this same risk was increased either in patients with migraine with (adjusted odd ratio 2.61, 95% CI 1.59-4.29) and without (adjusted odd ratio 1.62, 95% CI 1.26-2.09) aura. Migraine with aura patients had higher risk (adjusted odd ratio 2.61, CI 1.59-4.29) compared to those without aura (adjusted odd ratio 1.62, CI 1.26-2.09). Moreover, compared to patients without migraine, migraine patients had higher risk of perioperative posterior circulation stroke (adjusted odd ratio 1.96, CI 1.26-3.05), and partial anterior stroke (adjusted odd ratio 1.95, CI 1.08-3.52). Perioperative ischemic stroke occurred most frequently within the first two days after surgery (46.2%), but 25.3% occurred after hospital discharge.
There were 10,088 patients who were readmitted to the hospital within 30 days. Patients with migraine had a higher rate of readmission (adjusted odd ratio 1.31, CI 1.22-1.41), and higher risk of post-discharge stroke (adjusted odd ratio 1.94, CI 1.18-3.20). The risk of perioperative stroke was also higher in the subgroup of patients of ambulant surgery, and in patients with migraine with aura and high dose vasopressor.
“This study adds that patients with migraine, either with or without aura, have an increased risk of perioperative ischemic stroke within 30 days after surgery; migraine patients had also an increased risk of hospital readmission after surgery”, says Prof. S. Evers, Department of Neurology, Coppenbrugge, Germany. “The predicted absolute risk of perioperative ischemic stroke was 2.4 (95% CI 2.1-2.8) for every 1,000 surgical patients, which increased to 4.2 (3.2-5.3) for every 1,000 patients with any migraine diagnosis.
The highest risk for the migraine-ischemic stroke association was in patients with the otherwise lowest baseline risk of perioperative ischemic stroke.”
“Several hypotheses have been proposed to explain the higher risk of stroke in patients with migraine especially with aura, including genetic predisposition and increased perioperative vulnerability to cerebral ischemia”, says Prof. S. Sacco, Department of Neurology, University of L’Aquila, Italy. “High dose vasopressors during surgery together with possible right-to-left shunt, were independent predictors of perioperative stroke when combined and produced a joint risk that was numerically greater than the sum of both. Overall, findings coming from this study indicate that migraine should be included in the perioperative risk assessment for ischemic stroke”.
The other nominees for the March paper of the month are:
- Nielsen PB, Skjøth F, Søgaard M, Kjældgaard JN, Lip GY, Larsen TB. Effectiveness and safety of reduced dose non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ 2017 Feb 10;356: j510. doi: 10.1136/ bmj.j510. In this Danish study, apixaban 2.5 mg, dabigatan 110 mg, and rivaroxaban 15 mg were compared to warfarin in a cohort of 55.664 patients with atrial fibrillation. The rate of ischemic stroke/systemic embolism did not significantly differ between the three non-vitamin K antagonists and warfarin. Dabigatran patients had significantly lower rates of bleedings compared to warfarin.
- Qiang W, Yau W-M, Lu J-X, Collinge J, Tycho R. Structural variation in amyloid-β fibrils from Alzheimer’s disease clinical subtypes. Nature 2017; doi:10.1038/nature20814. In this letter the authors present findings that link the different Alzheimer’s disease phenotypes (rapidly progressive form, posterior cortical atrophy variant, and prolonged-duration form) to specific amyloid-beta fibril structures (Abeta40 and Abeta 42).
- Hanley DF, Lane K, McBee N, et al., for the CLEAR III investigators. Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial. Lancet January 9, 2017;
This paper is discussed in the Neurology Updates of the EAN website.