RESULT
The study involved 720 participants aged between 18 and 60, with a median age of 41 (with an interquartile range of 26-49), and 73.2% of them were females. Of these participants, 43.5% (135 individuals) were diagnosed with migraine, while 56.5% were diagnosed with ESUS. The most prevalent coexisting condition was diabetes, affecting 26.1% of the patients. All patients underwent assessment using 2D transthoracic echocardiography, contrast echocardiography, and transesophageal echocardiography. The average ejection fraction (EF%) was 59.3 (with a standard deviation of ±2.36), and the PASP was 26.21 (±7.06). Diastolic dysfunction was observed in 11.3% of the patients. While moderate or severe mitral and tricuspid regurgitation was infrequent (4.8% and 4.2%, respectively), 16.1% of the patients had moderate or severe tricuspid regurgitation.
In all patients, the median PFO length was measured at 13 mm (with a range of 7-21 mm), and the median PFO height was 7 mm (with a range of 5-9 mm). High-velocity shunting from right to left through the interatrial septum (IAS) was observed in 35.5% of the patients, while 27.4% had Eustachian valve or Chiari network, 26.5% had atrial septal aneurysm, 40% had hypermobile IAS, and 14.5% had narrow-angle between the inferior vena cava and PFO flap (≤10°). The mean RoPe score for the study patients was 6.60 (with a standard deviation of ±1.31), and 104 patients (33.5%) were identified as having anatomic and functional high-risk PFO (Table 3).
Migraine and ESUS patients were compared based on their demographic, clinical, and echocardiographic characteristics. The median age was higher in ESUS patients (Migraine: 26 [IQR: 25-41]; ESUS: 45 [39-52], p<0.001). Gender and BMI features were similar between the groups. The prevalence of coronary artery disease was similar in both groups. However, diabetes and hypertension were more prevalent in ESUS patients (p=0.003 and p=0.002, respectively), while active smoking was more common among migraine patients (p<0.001). Echocardiographic evaluations showed that EF%, left and right heart dimensions, diastolic parameters, and moderate or severe valvular diseases were similar between the groups. Nevertheless, PASP was higher in ESUS patients (Migraine: 24.95±5.95; ESUS: 27.19±7.70, p=0.004) (Table 4).
The study groups were compared in terms of PFO characteristics and accompanying other structural and functional high-risk criteria for paradoxical emboli. The presence of 20 or more microbubble crossings from right to left through the IAS during rest or Valsalva maneuver was more prevalent in ESUS patients compared to migraine patients (Migraine: 26.7%; ESUS: 42.3%, p=0.004). Findings such as the Eustachian valve or Chiari network, atrial septal aneurysm, hypermobile IAS, and an angle between the inferior vena cava and PFO flap ≤ 10° were similar between the groups.
PFO length was greater in ESUS patients compared to migraine patients (Migraine: 10 mm [IQR: 5-20]; ESUS: 15 mm [IQR: 7-24], p=0.001), while PFO width was similar between the groups (Figure 1).
The RoPe score, designed to identify high-risk clinical features for stroke in ESUS patients, had similar values in both groups (Migraine: 6.51±1.38; ESUS: 6.66±1.25, p=0.32). The High-risk PFO score, used to determine high-risk PFO based on anatomic and functional criteria, was higher in ESUS patients, but statistically similar in both groups (Migraine: 27.4%; ESUS: 38.3%, p=0.15) (Figure 2).