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Her migraines were cured: MISTifying?Oct 5, 2012 22:16 EDT
|Pumpkins and brightly colored mums dot neighborhood porches|
In south-central Kentucky when autumn leaves blush fiery orange and a morning chill calls for the season's first sweater, fleshy pumpkins and brightly colored mums dot neighborhood porches. When lacy arachnid creations crown lampposts and doorframes and fluffy clouds fly by a full harvest moon, we know it's time for our annual cystic-fibrosis (CF) chili supper and auction. My niece was diagnosed with CF at age two, so we take great pride that just five or so families in our area have raised well over a quarter of a million dollars for CF research in the past 16 years. The auction has become both a fall celebration of how well the children are doing and a casual social opportunity for families, neighbors, and friends to visit and reconnect. One of those old acquaintances, a patient I haven't seen in years, walked over just as I was about to announce the auction and said, "Remember me?" How could Deborah think I would ever forget her? "You had a [patent foramen ovale] PFO closure, and now your migraines are cured . . . right? Still cured?" I asked hesitantly. "Yes absolutely," she responded, beaming, obviously celebrating the successful new life she found and is still enjoying postprocedure.
Nine years ago, Deborah bent over to feed her dogs and lost the use of her left arm for 30 minutes. Two years later, she attempted to answer the phone at work and awoke lying against her boss in the floor. "In the ambulance, I could hear EMTs asking me simple questions like my birthday, and I just couldn't speak. It was so frustrating," she said. Her expressive aphasia lasted for a full two hours. At the young age of 38, seemingly with no risk factors for cerebrovascular accident (CVA), the experience was both horrifying and puzzling. A hypercoagulable panel was normal. The MRI confirmed embolic stroke, and when pieced together with frequent disabling migraines, the echo findings of a PFO, right-to-left shunting without Valsalva, and an atrial septal aneurysm were hardly surprising. We quickly referred her to Dr John Gurley at the University of Kentucky, Lexington. It's amazing how far we've come in the interventional world, as his letter in 2003 states "hopefully we will gain [internal review board] IRB approval by the end of the month for the Amplatzer device." Just a few weeks following a successful procedure early in the history of percutaneous closure, she was permanently migraine free.
The debate regarding the migraine-related benefit of PFO closure rages on in the literature today, but not in Deborah's heart. She knows it can work and cardiovascular specialists all over the world know it too. heartwire reported on an Italian prospective nonrandomized study on the topic in 2009. Published in the American Journal of Cardiology, Papa et al studied 76 migraine patients with indications for PFO closure including stroke, transient ischemic attack, and lone migraine associated with cerebral ischemic lesions on MRI. In the study, 97% of patients achieved total closure using one of three devices approved in Europe. "Closure abolished or improved migraines in four out of five patients," Shelley Wood reported. "At 12 months, 46% of patients reported no migraine recurrence." Dr Papa stated, "Our results have indicated that in a selected population sharing similar clinical and brain-imaging features likely due to systemic embolization, percutaneous PFO closure is highly effective in reducing migraine severity." Deborah would concur. It's been completely effective for her.
But others aren't so sure. The MIST trial, published in 2008, found no difference in the frequency or severity of migraine in those randomized to PFO closure or a sham procedure. There were allegations of incomplete closure in one-third of patients by one investigator, who was dropped from the study. His findings were in direct opposition to the published results that only four of 78 patients had residual shunting. Allegations of lack of access to shunt calculations, banished investigators, ethical debates, and legal proceedings are all ingredients that continue to bubble in a cauldron of controversy, fitting for the Halloween season approaching.
Meanwhile, Deborah is celebrating life one day at a time. She's had a baby and leads a life far more joyful than the old life that was once woven between ER visits. "The last stroke was so severe, I am certain I would be dead by now if it weren't for that procedure," she told me today while traveling on fall break in the Great Smoky Mountains with her family.
I imagine that as fall in Kentucky approaches, Deborah probably shops for mums, rakes leaves, and sweeps down spiders' webs without a single thought of needing to spend hours parked in the local emergency room. No more horrible waits with a "suffering rag" on her forehead, waiting for pain medications to kick in. I'm grateful her therapy predated publication of the cursed MIST trial. She's living proof that complete shunt closure can cure migraine in some patients with ischemic cerebral symptoms. Thanks to Dr John Gurley and this remarkable procedure, Deborah's headaches have been banished to the netherworld. Her story is another great reason for an autumn celebration indeed.