BACKGROUND: We investigated the prevalence of post-procedural headache in patients who have undergone thrombectomy for ischemic stroke, and correlated history of migraine with risk of peri-procedural complications. A total of 314 patients underwent thrombectomy at the Danish National Hospital from January 2012 to December 2014. Eligible subjects were phone-interviewed using a purpose-developed semi-structured questionnaire according to the International Classification of Headache Disorders 3, beta version criteria. FINDINGS: Among 96 eligible subjects, there was a significant decrease in migraine (p = 0.022) within the first 3 months after EVT compared to 1 year before treatment, which was further evident at interview time (on average 1.6 years after EVT, p = 0.013). A minority of patients experienced headaches for the first time within 3 months of their EVT (migraine 2, TTH 9), which persisted at interview time for subjects with migraine. Out of 12 subjects with peri-procedural complications, 2 had a history of migraine with aura. CONCLUSION: Thrombectomy leads to a significant decrease in previously known migraine, and new onset of headache in a small subset of patients. A history of migraine does not appear to predispose to peri-procedural complications. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s10194-017-0719-0) contains supplementary material, which is available to authorized users

Amin, Faisal Mohammad

Ashina, Messoud

Ayata, Cenk

Fakhril-Din, Zainab

Florescu, Anna Maria

Gaist, David

Ghanizada, Hashmat

Hansen, Klaus

Holtmannspötter, Markus

Khan, Sabrina

Petersen, Julie Falkenberg

English

PubMed

Copenhagen University Research Information System

u n i ve r s i t y  o f  co pe n h ag e n  Københavns UniversitetEndovascular thrombectomy and post-procedural headacheKhan, Sabrina; Amin, Faisal Mohammad; Holtmannspötter, Markus; Hansen, Klaus; Florescu,Anna Maria; Fakhril-Din, Zainab; Petersen, Julie Falkenberg; Ghanizada, Hashmat; Ayata,Cenk; Gaist, David; Ashina, MessoudPublished in:Journal of Headache and PainDOI:10.1186/s10194-017-0719-0Publication date:2017Document versionPublisher's PDF, also known as Version of recordDocument license:CC BYCitation for published version (APA):Khan, S., Amin, F. M., Holtmannspötter, M., Hansen, K., Florescu, A. M., Fakhril-Din, Z., ... Ashina, M. (2017).Endovascular thrombectomy and post-procedural headache. Journal of Headache and Pain, 18, [10].https://doi.org/10.1186/s10194-017-0719-0Download date: 03. Feb. 2020SHORT REPORT Open AccessEndovascular thrombectomy and post-procedural headacheSabrina Khan1 , Faisal Mohammad Amin1, Markus Holtmannspötter2, Klaus Hansen3, Anna Maria Florescu1,Zainab Fakhril-Din1, Julie Falkenberg Petersen1, Hashmat Ghanizada1, Cenk Ayata4, David Gaist5,6and Messoud Ashina1*AbstractBackground: We investigated the prevalence of post-procedural headache in patients who have undergonethrombectomy for ischemic stroke, and correlated history of migraine with risk of peri-procedural complications.A total of 314 patients underwent thrombectomy at the Danish National Hospital from January 2012 to December2014. Eligible subjects were phone-interviewed using a purpose-developed semi-structured questionnaire accordingto the International Classification of Headache Disorders 3, beta version criteria.Findings: Among 96 eligible subjects, there was a significant decrease in migraine (p = 0.022) within the first 3months after EVT compared to 1 year before treatment, which was further evident at interview time (on average 1.6years after EVT, p = 0.013). A minority of patients experienced headaches for the first time within 3 months of theirEVT (migraine 2, TTH 9), which persisted at interview time for subjects with migraine. Out of 12 subjects withperi-procedural complications, 2 had a history of migraine with aura.Conclusion: Thrombectomy leads to a significant decrease in previously known migraine, and new onset ofheadache in a small subset of patients. A history of migraine does not appear to predispose to peri-proceduralcomplications.Keywords: EVT, Stroke, Risk, Complications, MigraineIntroductionEndovascular thrombectomy is an established procedureused to treat ischemic stroke. The risk of post-proceduralheadache has received little attention. Studies on the inter-play between headache and endovascular treatment (EVT)are contradictory [1–3]. It is also unknown whether peri-procedural vascular complications are more prevalent insubjects with migraine history, or how such complicationsmay affect headache patterns after EVT. To elucidate po-tential bidirectional links between endovascular thromb-ectomy, procedure-related complications, and headachewe retrospectively assessed headache characteristics in acohort of patients with ischemic stroke who had under-gone thrombectomy.MethodsWe identified all patients who had undergone EVT forischemic stroke at a tertiary referral center, Copenhagen,Denmark between January 2012 and December 2014. Weassessed medical records of all identified cases (n = 314)and excluded those with: 1) procedures other thanthrombectomy, and 2) aphasia, or no command of Danishor English.Eligible patients were phone interviewed once, on average1.6 years (range: 0.2–3.0) after EVT, using a purpose-developed semi-structured questionnaire. We collected infor-mation on headache status 1 year and 1 month before EVTand after EVT (3 months after and at time of interview).All headaches were classified according to the Inter-national Classification of Headache Disorders 3, betaversion [4].Frequencies and percentages were calculated for categor-ical variables and medians and range for continuous vari-ables. For comparisons of categorical data, we used the* Correspondence: ashina@dadlnet.dk1Danish Headache Center, Department of Neurology, Rigshospitalet,University of Copenhagen, Copenhagen, DenmarkFull list of author information is available at the end of the articleThe Journal of Headache                           and Pain© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made.Khan et al. The Journal of Headache and Pain  (2017) 18:10 DOI 10.1186/s10194-017-0719-0McNemar test. All p-values were two-sided and p-valuesbelow 0.05 were considered statistically significant. All ana-lyses were performed using IBM® SPSS® Statistics version 23.FindingsIn total, ninety-six patients were eligible and included inthe study (Table 1). Twenty-five subjects (26%) reportedlifetime history of migraine, 14 of these (15%) had mi-graine with aura, and 25 subjects (26%) reported lifetimehistory of tension-type headache (TTH). One year priorto thrombectomy, sixteen subjects (17%) reported mi-graine, 11 of these (12%) had migraine with aura, and 15subjects (16%) reported TTH.Headache status before and after EVTWe found a significant decrease (56%) in migraine 3 monthsafter thrombectomy compared to 1 year before the proced-ure (7 versus 16 subjects, p = 0.022) (Fig. 1, Additional file1: Table S1). At “time of interview” (on average 1.6 yearsafter EVT) we observed a larger (63%) reduction yet (6 ver-sus 16 subjects, p = 0.013). For this time window, we sawno change in TTH.We also compared patients’ headache status 1 month be-fore thrombectomy with 3 months after treatment. Here wefound an increase in TTH (6 versus 16 subjects, p= 0.013),which persisted at interview time (6 versus 19 subjects, p=0.002). For this time window, we saw no change in migraine.De novo headaches after EVTNine subjects reported new onset of tension-type likeheadache during the first 3 months after EVT (6 episodic,3 chronic) (Fig. 2). By time of interview, only 6 patientsstill experienced these new headaches (1 chronic, 4 epi-sodic, 1 data not available).Two female subjects experienced de novo migraine-like headache (one with and one without aura, ages 45and 90 years) within the first 3 months after EVT, bothreporting persistent headache at interview time, 2.1 and1.3 years after EVT, respectively.Peri-procedural complications during EVTIn 12 of 96 subjects (12.5%), the thrombectomy procedurewas complicated (Additional file 1: Figure S1 and TableS2). Peri-procedural complications arose in 8% of patientswith a pre-EVT history of migraine (2 patients withmigraine with aura) and 14% of patients with no history ofmigraine (n = 10).DiscussionConsidering the focal intravascular manipulation inflictedon the vessels, headache after thrombectomy seems likelydue to endothelial injury-induced inflammation of theintracranial vessel walls, activating sensory afferents. Insupport, a recent 3 T vessel wall MRI study reported con-trast enhancement in arterial walls in patients treated withstent-retriever thrombectomy [5]. The bidirectional linkbetween headache and EVT has thus far never been inves-tigated, hence it is unknown whether history of headachemay influence the endovascular procedure due to vascularcomplications such as distal embolization or dissection(Additional file 1: Table S2), and vice versa whether acomplicated procedure may affect headache patterns afterEVT. Studies on familial hemiplegic migraine type-1mutant mice show larger infarcts and worse neurologicaloutcomes after stroke compared to wild-type mice [6],specifically suggesting that a diagnosis of migraine withaura may predispose to vascular complications during thethrombectomy procedure.As a major finding, we report a significant drop in mi-graine prevalence after thrombectomy for subjects withpre-EVT history of migraine, resulting in prevalence esti-mates close to those for the general population. We lackeda control group to assess for decline in migraine prevalenceover time irrespective of EVT. However, we believe that thereduction of migraine observed in our study is beyond whatone would expect from the natural history of this disorderTable 1 Clinical and demographic data in 96 stroke patientsCharacteristicsMedian age at EVT (years) 67 years (range: 28–90)Males (n) 55Right-handed (n) 87Median height (cm) 174 cm (range: 152–194)Median weight (kg) 75 kg (range: 45–130)Smokers (n) 60Median pack yearsa 20 years (range: 1–92)History of hypertension (n) 38Medication history prior to EVT (n)- Antithrombotic therapyb- Antihypertensive therapyc28d38eMedication status at interview time (n)- Antithrombotic therapyb- Antihypertensive therapyc8052Thrombolysis treatment for stroke (n) 69fProcedures performed (n)- Thrombectomy- Thrombectomy + stent- Thrombectomy + coil + Onyx8961Median time from procedure tointerview (years)1.6 years (range: 0.2–3.0)aPack year = defined as 20 cigarettes smoked every day for one yearbAntithrombotic medication included clopidogrel (n = 5), acetylsalicylic acid(n = 17), warfarin (n = 5), rivaroxaban (n = 1) and dabigatran (n = 1)cAntihypertensive medication included angiotensin-II-inhibitors (n = 8),beta-blockers (n = 20), ACE inhibitors (n = 10), and calcium-antagonists (n = 7)d8 missing recordse7 missing recordsf3 missing recordsKhan et al. The Journal of Headache and Pain  (2017) 18:10 Page 2 of 4[7]. This decrease could also be explained by the initi-ation of antithrombotic medication after thrombectomy[8]. No new prophylactic migraine treatment was initi-ated after EVT.Contrary to migraine, we found that thrombectomy ledto an increase in TTH after EVT, with a significantly largerprevalence compared to 1 month prior to treatment. How-ever, when comparing the post-procedural prevalence with1-year prior to thrombectomy, we observed no change,suggesting that thrombectomy does not result in addedheadache burden in the larger scope of life-time headacheevolution. Differences in post-procedural medication (suchas antithrombotic treatment) cannot explain this disparitybetween migraine and TTH, as all subjects were started onantithrombotic treatment after thrombectomy.We also report new onset of headache in a subset ofsubjects (11%) who undergo thrombectomy. Thisheadache resolves over time for some TTH cases, butpersists for those reporting de novo migraine, suggestingthat a fraction (8%) of subjects treated with thrombec-tomy may develop persistent new headache. Any de novoheadache that occurs with close temporal relation toEVT is per definition a secondary headache, however,the current ICHD-3 beta criteria only allow any suchheadache to last up to 24 h [4]. This taxonomy is inad-equate, as post-thrombectomy headache for the majoritylasts at least 3 months, if not longer. Also, our resultsconfirm the accepted notion that migraine with aura isoverrepresented in a stroke cohort compared to thegeneral population [9], and may even be larger in ourcohort compared to other stroke case-based studies [10].Finally, our results show that 12.5% of subjects under-going thrombectomy experience peri-procedural compli-cations. Albeit underpowered, these data suggest thatFig. 1 Headache status before and after thrombectomy. Numbers represent patients. Dotted line represents endovascular procedure.MA =migraine with aura, MO =migraine without auraFig. 2 Distribution of de novo and known headache after thrombectomy. Numbers represent patients. TTH = tension-type headacheKhan et al. The Journal of Headache and Pain  (2017) 18:10 Page 3 of 4migraine with aura does not increase the risk of compli-cations during thrombectomy.In conclusion, we have presented the first report ofheadache onset and prevalence after thrombectomy.Strengths of the study include a homogenous patientgroup, direct phone interviews, and ICHD-3 beta classifi-cation [5]. Limitations include recall bias and a relativelysmall sample size. Nevertheless, we believe the data helpimprove our understanding of post-procedural headacheto optimize counseling of subjects who undergo thromb-ectomy with resultant headache. Larger, statistically robustprospective studies are warranted to establish the direc-tion and magnitude of changes in migraine and otherheadaches after thrombectomy and to further explore mi-graine as a risk factor for peri-procedural complications.Additional fileAdditional file 1: Table S1. Headache status before and afterthrombectomy. Median time from endovascular treatment to interview:1.6 years (range 0.2–3.0). Table S2. Classification system of peri-proceduralcomplications. Figure S1. Peri-procedural complications in subjects with alife-time history of migraine. (DOCX 132 kb)AcknowledgementsThe authors would like to thank Henrik Steglich-Arnholm for his assistancewith extracting medical records on peri-procedural complications for thisstudy.FundingWe thank the Lundbeck Foundation (R155-2014-171), the Novo NordiskFoundation (NNF11OC1014333), and the European Union’s SeventhFramework programme (FP/-EUROHEADPAIN-no.602633).Authors’ contributionsSK designed and performed the study, with the help of FMA, DG, CA, andMA. SK, AMF, ZF, and JFP performed interviews. SK drafted the manuscriptand performed the statistical analyses. KH and MH assisted with access tothe patient data registry, medical record review, and valuable input to themanuscript. All authors read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Ethics approval and consent to participateThe Committee on Health Research Ethics, Capital Region approved thestudy. All patients provided informed consent.Author details1Danish Headache Center, Department of Neurology, Rigshospitalet,University of Copenhagen, Copenhagen, Denmark. 2Department ofRadiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.3Department of Neurology, Rigshospitalet, University of Copenhagen,Copenhagen, Denmark. 4Stroke Service and Neuroscience Intensive CareUnit, Department of Neurology, Massachusetts General Hospital, HarvardMedical School, Charlestown, MA, USA. 5Department of Neurology, OdenseUniversity Hospital, Odense, Denmark. 6Department of Clinical Research,University of Southern Denmark, Odense, Denmark.Received: 18 November 2016 Accepted: 5 January 2017References1. Hwang G, Jeong E-A, Sohn JH, Park H, Bang JS, Jin S-C et al (2012) Thecharacteristics and risk factors of headache development after the coilembolization of an unruptured aneurysm. AJNR Am J Neuroradiol 33(9):1676–16782. Schwedt TJ, Gereau RW, Frey K, Kharasch ED (2011) Headache outcomesfollowing treatment of unruptured intracranial aneurysms: a prospectiveanalysis. Cephalalgia 31(10):1082–10893. Khan S, Amin FM, Hauerberg J, Holtmannspötter M, Petersen JF, Fakhril-DinZ et al (2016) Post procedure headache in patients treated forneurovascular arteriovenous malformations and aneurysms usingendovascular therapy. J Headache Pain 17(1):734. Headache Classification Committee of the International Headache Society(IHS) (2013) The International Classification of Headache Disorders, 3rdedition (beta version). Cephalalgia 33(9):629–8085. Abraham P, Cheung VJ, Lee R, Pannell JS, Gupta M, Rennert R et al (2016)302 Vessel Wall Enhancement on Magnetic Resonance Imaging AfterStent-Retriever Thrombectomy. Neurosurgery 63(Suppl 1):1866. Eikermann-Haerter K, Lee JH, Yuzawa I, Liu CH, Zhou Z, Shin HK et al (2012)Migraine mutations increase stroke vulnerability by facilitating ischemicdepolarizations. Circulation 125(2):335–3457. Bigal ME, Lipton RB (2008) The prognosis of migraine. Curr Opin Neurol21(3):301–3088. Buring JE, Peto R, Hennekens CH (1990) Low-dose aspirin for migraineprophylaxis. JAMA 264(13):1711–17139. Kurth T, Slomke MA, Kase CS, Cook NR, Lee I-M, Gaziano JM et al (2005)Migraine, headache, and the risk of stroke in women: a prospective study.Neurology 64(6):1020–102610. Putaala J, Metso AJ, Metso TM, Konkola N, Kraemer Y, Haapaniemi E et al(2009) Analysis of 1008 consecutive patients aged 15 to 49 with first-everischemic stroke the Helsinki young stroke registry. Stroke 40(4):1195–1203Submit your manuscript to a journal and beneﬁ t from:7 Convenient online submission7 Rigorous peer review7 Immediate publication on acceptance7 Open access: articles freely available online7 High visibility within the ﬁ eld7 Retaining the copyright to your article    Submit your next manuscript at 7 springeropen.comKhan et al. The Journal of Headache and Pain  (2017) 18:10 Page 4 of 4

Endovascular thrombectomy and post-procedural headache

Sabrina Khan

Faisal Mohammad Amin

Markus Holtmannspötter

Klaus Hansen

Anna Maria Florescu

Zainab Fakhril-Din

Julie Falkenberg Petersen

Hashmat Ghanizada

Cenk Ayata

David Gaist

Messoud Ashina

Springer - Publisher Connector

https://curis.ku.dk/portal/files/194648123/10194_2017_Article_719.pdf

Endovascular thrombectomy and post-procedural headache

Abstract

Similar works

Full text

Available Versions

Copenhagen University Research Information System

Springer - Publisher Connector