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      Migrainous infarction: a rare and often overlooked diagnosis

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          Abstract

          Migraine is a neurological entity and a well-known independent risk factor for cerebral infarction, which mostly afflicts the young female population. Researching focal neurological signs in this subset of the population with the diagnosis of a neurological ischemic event should always take into account the migraine as the etiology or as an associated factor. The etiology of central nervous system (CNS) ischemia is considerable. Migraine, although rare, also may be included in this vast etiological range, which is called migrainous infarction. In this setting, the diagnostic criteria required for this diagnosis is extensive. Herein, we present the case of a female adolescent who submitted to the emergency facility complaining of diplopia, dysarthria, and imbalance, which started concomitantly with a migrainous crisis with aura—a challenging clinical case that required extensive research to address all possible differential diagnoses.

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          Most cited references32

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          Migraine and cardiovascular disease: systematic review and meta-analysis

          Objective To evaluate the association between migraine and cardiovascular disease, including stroke, myocardial infarction, and death due to cardiovascular disease. Design Systematic review and meta-analysis. Data sources Electronic databases (PubMed, Embase, Cochrane Library) and reference lists of included studies and reviews published until January 2009. Selection criteria Case-control and cohort studies investigating the association between any migraine or specific migraine subtypes and cardiovascular disease. Review methods Two investigators independently assessed eligibility of identified studies in a two step approach. Disagreements were resolved by consensus. Studies were grouped according to a priori categories on migraine and cardiovascular disease. Data extraction Two investigators extracted data. Pooled relative risks and 95% confidence intervals were calculated. Results Studies were heterogeneous for participant characteristics and definition of cardiovascular disease. Nine studies investigated the association between any migraine and ischaemic stroke (pooled relative risk 1.73, 95% confidence interval 1.31 to 2.29). Additional analyses indicated a significantly higher risk among people who had migraine with aura (2.16, 1.53 to 3.03) compared with people who had migraine without aura (1.23, 0.90 to 1.69; meta-regression for aura status P=0.02). Furthermore, results suggested a greater risk among women (2.08, 1.13 to 3.84) compared with men (1.37, 0.89 to 2.11). Age less than 45 years, smoking, and oral contraceptive use further increased the risk. Eight studies investigated the association between migraine and myocardial infarction (1.12, 0.95 to 1.32) and five between migraine and death due to cardiovascular disease (1.03, 0.79 to 1.34). Only one study investigated the association between women who had migraine with aura and myocardial infarction and death due to cardiovascular disease, showing a twofold increased risk. Conclusion Migraine is associated with a twofold increased risk of ischaemic stroke, which is only apparent among people who have migraine with aura. Our results also suggest a higher risk among women and risk was further magnified for people with migraine who were aged less than 45, smokers, and women who used oral contraceptives. We did not find an overall association between any migraine and myocardial infarction or death due to cardiovascular disease. Too few studies are available to reliably evaluate the impact of modifying factors, such as migraine aura, on these associations.
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            Migraine headache and ischemic stroke risk: an updated meta-analysis.

            Observational studies, including recent large cohort studies that were unavailable for prior meta-analysis, have suggested an association between migraine headache and ischemic stroke. We performed an updated meta-analysis to quantitatively summarize the strength of association between migraine and ischemic stroke risk. We systematically searched electronic databases, including MEDLINE and EMBASE, through February 2009 for studies of human subjects in the English language. Study selection using a priori selection criteria, data extraction, and assessment of study quality were conducted independently by reviewer pairs using standardized forms. Twenty-one (60%) of 35 studies met the selection criteria, for a total of 622,381 participants (13 case-control, 8 cohort studies) included in the meta-analysis. The pooled adjusted odds ratio of ischemic stroke comparing migraineurs with nonmigraineurs using a random effects model was 2.30 (95% confidence interval [CI], 1.91-2.76). The pooled adjusted effect estimates for studies that reported relative risks and hazard ratios, respectively, were 2.41 (95% CI, 1.81-3.20) and 1.52 (95% CI, 0.99-2.35). The overall pooled effect estimate was 2.04 (95% CI, 1.72-2.43). Results were robust to sensitivity analyses excluding lower quality studies. Migraine is associated with increased ischemic stroke risk. These findings underscore the importance of identifying high-risk migraineurs with other modifiable stroke risk factors. Future studies of the effect of migraine treatment and modifiable risk factor reduction on stroke risk in migraineurs are warranted. Copyright 2010 Elsevier Inc. All rights reserved.
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              Risk of ischaemic stroke in people with migraine: systematic review and meta-analysis of observational studies.

              To explore the association between migraine and risk of ischaemic stroke. Systematic review and meta-analysis. Observational studies published between 1966 and June 2004 (identified through Medline and Embase) that examined the association between migraine and risk of ischaemic stroke. 14 studies (11 case-control studies and 3 cohort studies) were identified. These studies suggest that the risk of stroke is increased in people with migraine (relative risk 2.16, 95% confidence interval 1.89 to 2.48). This increase in risk was consistent in people who had migraine with aura (relative risk 2.27, 1.61 to 3.19) and migraine without aura (relative risk 1.83, 1.06 to 3.15), as well as in those taking oral contraceptives (relative risk 8.72, 5.05 to 15.05). Data from observational studies suggest that migraine may be a risk factor in developing stroke. More studies are needed to explore the mechanism of this potential association. In addition, the risk of migraine among users of oral contraceptives must be further investigated.
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                Author and article information

                Journal
                Autops Case Rep
                Autops Case Rep
                Autopsy & Case Reports
                São Paulo, SP: Universidade de São Paulo, Hospital Universitário
                2236-1960
                30 June 2017
                Apr-Jun 2017
                : 7
                : 2
                : 61-68
                Affiliations
                [a ]University of São Paulo, Faculty of Medicine, Internal Medicine Department . São Paulo, SP, Brazil.
                [b ]University of São Paulo, Hospital Universitário, Radiology Department . São Paulo, SP, Brazil.
                Author notes

                Author contributions: The manuscript was produced, reviewed, and approved by all the authors collectively. GADK was the doctor who consulted the patient in the emergency department and designed and wrote the manuscript and developed the discussion a on the review of causes of stroke in patients with migraine. NRAN also wrote the manuscript, developed the discussion and interpreted the findings of the neurological examination and associated them with MRI findings. PJSN was the radiologist who interpreted the imaging exams and selected the MRI images present in the case report.

                Conflict of interest: None

                Correspondence 
Gabriel Afonso Dutra Kreling
Hospital Universitário - Universidade de São Paulo (USP)
Av. Professor Lineu Prestes, 2565 – Butantã – São Paulo/SP – Brazil
CEP: 05508-000
Phone: +55 (43) 99956-2405 / +55 (11) 95236-0715
 gabriel_dutra_@ 123456hotmail.com
                Article
                autopsy-07-02061
                10.4322/acr.2017.018
                5507571
                1530c6e8-981d-4704-bc76-de177b2e0b67
                Autopsy and Case Reports. ISSN 2236-1960. Copyright © 2017.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided the article is properly cited.

                History
                : 08 March 2017
                : 01 June 2017
                Categories
                Article / Clinical Case Report

                migraine disorders,stroke,internuclear ophthalmoplegia

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