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Migraine with prolonged aura can mimic an acute ischemic stroke (AIS), as each may present with accompanying headache and focal neurologic deficits. During the acute episode, perfusion imaging like perfusion-weighted MRI (PWI) can show focal abnormalities corresponding to the neurologic deficits in both entities, making clinical distinction challenging, especially considering the time urgency of AIS treatment. In this case report, we discuss how we utilized hyperacute PWI in conjunction with clinical reasoning to propose the diagnosis of migraine-like headache with prolonged aura.
Case report.
A 46-year-old woman presented to the emergency department within 1 hour of sudden onset of bilateral tunnel vision. Over several minutes, this evolved into a right upper quadrant arc-shaped scotoma and then to right homonymous hemianopsia. She also developed a severe nonthrobbing right retro-orbital headache, which progressed to the bilateral occipital area with right face and arm paresthesias. Past history included allergy to iodinated contrast, Ehlers-Danlos type IV, and several years of frequent severe unilateral throbbing headaches with photophobia/phonophobia and nausea as a teenager. She had to miss school, had no aura, and had not been diagnosed with migraine, but her mother carried this diagnosis.
Examination revealed right homonymous hemianopsia, decreased pinprick over the right face and arm, with no motor deficits, nuchal rigidity, or bruits (NIH Stroke Scale = 3). Vital signs and noncontrast head CT were normal. To exclude AIS, we obtained an emergent gadolinium-enhanced MRI with diffusion-weighted imaging, PWI, and magnetic resonance angiogram (MRA) of the head and neck, 150 minutes after symptom onset (figure). The MRI did not demonstrate any area of reduced diffusion, vascular occlusion, abnormal arterial caliber, or dissection. Thrombolytic was not administered and the remaining magnetic resonance sequences revealed normal fluid-attenuated inversion recovery (FLAIR). After the MRI, …
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