Prognosis/Prophylaxis Post-Stoke in Young Women

[hot*java]

My wife (age 31) has suffered from migraines since adolescence. She began taking birth control pills four years ago to control the migraines, as the management of her cycle confined migrainous events to the time around her period. Any events occuring during her period were treated abortively using triptans (Zomig).



In September she experienced some numbness in the right side of her body. At first she thought it was an aura migraine, but an MRI led to a diagnosis of stroke. She did not take Zomig at any point in time close to the event. Subsequent investigation, including bloodwork, echocardiogram, carotid echogram, and TEE have left the event classified as cryptogenic, although the presence of a PFO was identified as a potential risk factor.



We are left trying to determine what actions we should take to prevent an occurance from happening again, without knowing what the original causes were. Obviously, she is off birth control. She is using Toprol XL and Topamax for migraine prophylaxis, and has had no migraines since beginning this treatment. She is also taking aspirin daily (325mg).



In retrospect, the combination of migraine, birth control, and PFO seems quite dangerous, based on what we can glean from the literature, although each factor singly is quite common.



The PFO is apparently quite small, and its importance as a risk factor is controversial, so we're not inclined now to have it occluded. Is it your opinion that removal of the birth control pill risk, combined with migraine avoidance and aspirin therapy, is a sufficient course of prophylaxis?

[CCF-Neuro-M.D.-JT]

Sorry to hear about your wife's recent stroke. Each of those factors that you mentioned: oral contraceptives, migraine, and PFO have been found to be associated with strokes independently in different studies. You've done the right things in terms of stopping the birth control and aggressive migraine prevention and treatment.  As for the PFO, the jury is still out as to what the best approach is: Invasively, there is surgery vs percutaneous closure. But you're absolutely right in that it;s unclear at this point as to whether or not the stroke is really due to the PFO (29% population have been found to have PFO at autopsy).



In terms of medical therapy there is coumadin (which is a more aggressive approach in that you're using an anticlotting medication that needs to be followed closely) vs aspirin or other antiplatelet agent like Plavix.  At this time, there have only been a handful of studies looking at what the best medical therapy would be. One recent study from NY in June of this year looking at PFO and cryptogenic stroke  found no significant difference between aspirin or coumadin for recurrence of stroke. So long answer to your question (without knowing your wife's full clinical history), yes I think she is on an appropriate course of treatment at this time. Also, if she smokes, she should definitely stop. Followup will be important with a good neurologist, preferably a stroke specialist.  If you are in the area, Cathy Sila ,MD is one of our stroke docs and has a special interest in young persons with stroke. Good luck.

[LynnSB]

well, I don't know if you can "prove" a PFO caused or didn't cause a stroke but I sure thought it was a risk factor. I remember talking to a woman, a 32 year old nurse, who was opening Christmas presents one year and suddenly had a stroke. She did not know she had a small PFO until later.. after a few more strokes. She had a fairly new procedure that closes the PFO with no surgery. It's a minimally invasive procedure. You might want to look into that.. just my opinion. here's one news story about the procedure: http://www.sciencedaily.com/releases/2001/05/010504083553.htm

[nurse12hr]

Did she have clotting factors investigated?  Particularly (I think) factor V?  

I worked with a 20 year old healthy gal, who was on BCP and smoked maybe 2 cigs per day.  she had a history of severe migraines, and last year she had a bad one, went to the hosp and was given pain meds.  

She was discharged from the ER, laid down to rest and began seizing uncontrollably.  She had a massive clot and it was ultimately found to be something related to factor V.

[hot*java]

We are familiar w/ the potential risks of a PFO. Our cardiologist would use the Amplatzer occluder (this is a transcatheter procedure like the one mentioned in the article you reference). However, the PFO is not widely patent and it was left for us to decide which course to take - we were not strongly urged one way or the other.



Bloodwork has turned up nothing indicating a hypercoagulable state, although I'm not sure if the test you referenced was performed.

[LynnSB]

When you talk about bloodwork, I'm assuming they checked for anti-cardiolipid or anti-phospholipid antibodies?



You know, migraines do up the risk of stroke a bit, especially in young women taking birth control pills --- it may be,unfortunately, just several circumstances (including the PFO, perhaps) that all came together to produce the stroke. Hopefully, it will never happen again!



Good luck.

[dizz]

sorry to hear about your wife.  Keep in mind a PFO does not cause a stroke, but its presence may be a "pathway" for a stroke to occur by allowing blood to flow from the venous system to the arterial system without going through the lungs first. One of the important functions of the lungs, in addition to oxygen exchange, is to filter debris from the venous blood returning to the heart. If this debris gets into the arterial circulation, it can lodge in an artery serving the brain, heart, or other major organ causing an arterial embolization. When it lodges in the brain a stroke occurs.



Here's more info on the cardio-seal procedure:

http://www.nmtmedical.com/products/ci/index.htm