More information about text formats
I was interested to read the article by Andrew Larner in Practical Neurology suggesting that listening for orbital bruits is “useful for impressing students but is not very rewarding”.
I had not heard of Charles Warlow’s challenge before.
My mentor as a trainee, Bernard Gilligan, would routinely listen to carotids and orbits and often femoral arteries as well - we saw a lot of large vessel arterial disease in those days – and I got into the habit of auscultating at least carotids and orbits.
It paid off at least once: I enclose extracts from a letter I wrote in 2001.
Thank you for referring this most interesting 30 year old lady. She has had migraines from her early twenties. Initially they were quite occasional but severe when they occurred. They tended to be triggered by exams or stress.
She moved to Australia about 3 years ago and since then has had unusual episodes of bouts of migraine. In the first of these she had migraine every day for a week or so. Since then the attacks seem to be becoming more frequent and more prolonged so that the most recent one which finished about 2 weeks ago had lasted for 3 weeks or more.
Typically at the start of a bout she will have aura symptoms consisting of numbness of the left finger, arm and face and blurred vision in the left visual field. In the early days of a bout there may be no headache following this. However then a pattern establishes with headache occurring on a virtually...
Typically at the start of a bout she will have aura symptoms consisting of numbness of the left finger, arm and face and blurred vision in the left visual field. In the early days of a bout there may be no headache following this. However then a pattern establishes with headache occurring on a virtually daily basis. For example in the middle of a bout typically an attack will start with visual blurring in the left field. This has a shimmering quality and would stay there for 30 to 60 minutes. The headache then comes on while the vision is still abnormal. It would be right sided always involving forehead, temple and neck. She uses Panadol and Naramig and the headache usually settles within 4 hours. Sleeping helps. After that she can function but the headache will come back again in 12 to 24 hours. Towards the end of the bout the headaches become milder but the visual episodes may still occur for a few days until they also settle.
She has been taking Inderal during the bouts but it is not clear whether this is helping at all.
She has had no other illness. In the family her mother gets migraine every week or two but there is no aura.
Blood pressure was 120/70. There was a long loud right carotid bruit which extended into diastole. There was probably in addition a soft right orbital bruit. Fundi, cranial nerves and neurological examination were normal.
The history is certainly unusual. Migraine usually doesn’t occur in bouts like this. The finding of the prominent right carotid bruit made me concerned that she may have a right cerebral arterio-venous malformation and I thought because of the crescendo nature of her episodes we ought to get this clarified quickly. I have therefore arranged for her to have an MRI brain and MRA later this afternoon.
MRI and MRA did indeed demonstrate an AVM in the right occipital lobe and this was successfully excised. The patient still gets migraines and still comes to see me.
A couple of other patients with AVMs have had orbital bruits but this was recognised after they had been diagnosed already. They also had long carotid bruits and I think that hearing a carotid bruit extending into diastole might be a reasonable basis for spending 10 seconds on listening for an orbital bruit. However, I recognise that carotid auscultation is now also going out of favour.