Visual migraine symptoms linked to tiny brain lesions

Visual auras, like those that occur in migraines, may be signs of small injuries to the brain’s visual cortex, according to a clinical trial at UC San Francisco that tracked the appearance of these lesions after procedures to treat abnormal heart rhythms.

The study, which appeared July 7 in Heart Rhythm, found that patients with lesions in the occipital and parietal lobe were 12 times more likely than those who did not have them to experience migraine-related visual auras.

“These data suggest that visual auras that commonly occur with migraines may actually signal brain injury or little strokes,” said Gregory M. Marcus, MD, MAS, a cardiologist and director of clinical research at the UCSF division of Cardiology, who is the senior author of the study. “This finding could change the whole paradigm of treatment, perhaps focusing more on prevention of blood clots.”

Patients were randomly assigned to two types of catheter ablation for ventricular arrhythmias. One approach was achieved by a transseptal puncture (creating a new, temporary hole between the left and right atria) and the other by a retrograde approach through the aortic valve, which did not require a transseptal puncture.

Past research had suggested that these small holes between the atria (patent formallow for shunting of an unknown chemical that goes directly from the venous circulation to the left-sided circulation (and therefore to the brain) that usually would be metabolized by the lungs. Another possible explanation is that the hole allows passage of small blood clots that form in veins of the legs and then block blood flow to small areas of the brain. Similarly, migraines have been associated with a small hole in the same location, also known as patent foramen ovale.

The day after the procedure, the researchers obtained brain MRIs for all patients in both groups. Both procedures are known to result in small brain lesions which could be seen on the MRIs the next day. Neither procedure was more likely to produce lesions. But the patients who did have lesions immediately after the procedure were far more likely to have auras a month later. By then, however, in many cases the lesions were no longer visible on brain scans.

“We know that these brain lesions are seen after very common procedures including after coronary angiograms, after transcutaneous replacement of aortic valves (TAVRs), after ablations for atrial fibrillation and ventricular arrhythmias and are often referred to ‘ACEs’ — asymptomatic cerebral emboli,” said Adi Elias, MD, a cardiac electrophysiology fellow at UCSF and the first author of the study.

“Our data show they are not asymptomatic or clinically silent,” he said. “It may be the case that we haven’t known what to look for and that we assessed for symptoms immediately without enough time for the subsequent visual auras that would occur.”

Additional UCSF Authors: Edward P. Gerstenfeld, MD, MS, FHRS, Trisha F. Hue, PhD, MPH, Feng Lin, MS, Jing Cheng, MD, PhD, Henry Hsia, MD, FHRS, Adam Lee, MBBS, Joshua Moss, MD, FHRS, Gabrielle Montenegro, Anthony S. Kim, MD, MS, William P. Dillon, MD. For a complete author list, please see the paper.

Funding: This trial was funded by Comparative Effectiveness Research grant 2017C3-9091 from the Patient Centered Outcomes Research Institute.

Disclosures: Marcus is a consultant for and owns equity in InCarda.

About UCSF Health: UCSF Health is recognized worldwide for its innovative patient care, reflecting the latest medical knowledge, advanced technologies and pioneering research. It includes the flagship UCSF Medical Center, which is a top-ranked specialty hospital, as well as UCSF Benioff Children’s Hospitals, with campuses in San Francisco and Oakland; Langley Porter Psychiatric Hospital and Clinics; UCSF Benioff Children’s Physicians; and the UCSF Faculty Practice. These hospitals serve as the academic medical center of the University of California, San Francisco, which is world-renowned for its graduate-level health sciences education and biomedical research. UCSF Health has affiliations with hospitals and health organizations throughout the Bay Area. Visit http://www.ucsfhealth.org/. Follow UCSF Health on Facebook or on Threads.

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This article was originally published on Newswise: Cardiovascular Health.