Abstract
Objective: To report a patient with very prolonged migrainous visual aura and to discuss the significance of multimodality imaging in this clinical setting. Background The International Headache Society9s (IHS) definition of migraine with prolonged aura indicates that at least one aura symptom should persist between 60 minutes and 7 days. Migrainous infarction is an attack of migraine during which at least one aura symptom is not fully reversible within 7 days or absence of neuroimaging evidence of corresponding ischemia. A rigid time frame separating these two entities may be artificial. There is limited experience and knowledge in utilizing magnetic resonance perfusion imaging (MRI-PI) and magnetoencephalography (MEG) in this clinical setting. Design/Methods: We describe a patient with unusually prolonged migrainous aura evaluated by the authors, on whom multimodality neuroimaging was completed. Results: A 54 year-old man presented with complaints of scintillations, photopsias, and visual loss in the left hemifield, along with right temporo-occipital headache, photophobia, nausea, and emesis. Neurologic examination confirmed a complete left homonymous hemianopsia. Brain MRI revealed no acute ischemic lesion and no large cerebral vessel occlusion on MRA. MRI-PI revealed slightly increased cerebral blood flow and blood volume in the medial right occipital lobe. EEG was unremarkable. During the resting state, MEG detected expected coherent activity in bilateral occipital cortices. Unexpectedly, maximal coherence was observed in the right medial temporal region. On left hemifield stimulation, there was no MEG activity in the right occipital cortex. Valproate resolved the headache within 4 days while Humphrey Visual Field Testing confirmed resolution of left homonymous hemianopsia after 7 weeks. Conclusions: Migrainous aura can last longer than 7 days. The distinction between prolonged migrainous aura and migrainous infarction should not rely only on a rigid time frame. Multimodality neuroimaging allows this distinction to be made with clarity. The IHS criteria may need to be revised. Disclosure: Dr. Ashraf has nothing to disclose. Dr. Bowyer has nothing to disclose. Dr. Mitsias has nothing to disclose.
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