Diagnosis Of Hemiplegic Migraine Research Articles

Hemiplegic Migraines; A Barrage on the Mind

Hemiplegic migraines (HM) are a rare type of migraine with an aura phase that includes muscle weakness. This form of migraine can either occur sporadically or can be seen in patients with familial hemiplegic migraine which is an autosomal dominant subtype that runs in families. Migraines are classically accompanied by phonophobia, photophobia, neurological symptoms, nausea or vomiting. The subcategory of hemiplegic migraine involves a transient wave of motor weakness and muscle spasms secondary to decreased threshold of excitation in the neurologic system. The etiology of Hemiplegic Migraines is either idiopathic condition or genetic mutation in the CACNA1A, ATP1A2 and SCN1A encoding proteins involved in ion transport. Our case outlines a 72 year old Caucasian female with past medical history of transient ischemic attack (TIA) and paroxysmal atrial fibrillation, presenting to the emergency department with sudden onset of headache, slurred speech and numbness and tingling in the left hand and leg. Tissue plasminogen activor t-PA) was administered within the 45 minute window, and a computed tomography angiography(CTA) of the head and neck was negative. Diagnosis of Hemiplegic Migraine was suggestive given the neurologic signs and symptoms with negative neurologic imaging. The expedited movement of neuronal depolarization down the easily excitable neurons causes a high amplitude wave of energy down the muscle fibers. Other hemiparesis syndrome differentials include MELAS, hereditary hemorrhagic telangiectasia, amyloidosis, and familial infantile convulsions. This case highlights the rarity of hemiplegic migraines and although genetic testing was not performed in our patient, it has been shown that some patients have a genetic predisposition. Strong clinical skills are needed to match the concurrent neurologic symptoms with migraines.

Case report of myelin oligodendrocyte glycoprotein antibody‐positive encephalitis mimicking hemiplegic migraine

AbstractEven though symptoms are important in the diagnosis of hemiplegic migraine, myelin oligodendrocyte glycoprotein antibody‐positive benign unilateral cortical encephalitis shows unique progress and findings on magnetic resonance imaging. We encountered a case of hemiplegic migraine showing cortical hyperintensity on magnetic resonance imaging, and positive results for myelin oligodendrocyte glycoprotein antibody. A certain proportion of patients diagnosed with hemiplegic migraine appear to show myelin oligodendrocyte glycoprotein antibody‐positive benign unilateral cortical encephalitis.

Not All Patients with Hemiplegia Need Alteplase: A Case of Hemiplegic Migraine.

Hemiplegic migraine (HM) is a rare type of migraine which presents with motor and sensory impairment like a cerebrovascular accident (CVA). We present a case of a 36-year-old female, with a prior CVA treated with alteplase, who presented to the emergency department with stroke-like symptoms with a duration of 1 hour. The NIH Stroke Scale score was 22 at presentation. The patient received alteplase under the supervision of a neurologist after head CT confirmed no bleed. Further work-up revealed no acute or remote ischaemia or infarction. This case demonstrates the importance of a thorough history, intercommunication between health systems and integrated Electronic Medical Records (EMR) for early diagnosis and management of HM.LEARNING POINTSHemiplegic migraine (HM) is difficult to diagnose and can mimic stroke, resulting in administration of dangerous medications such as thrombolytics/alteplase.A thorough history, intercommunication between health systems and integrated EMR are essential for early diagnosis and management of HM.

Impact of 99mTc-HMPAO Brain Perfusion Scan in the Diagnosis of Hemiplegic Migraine

Hemiplegic migraine (HM) is an unusual type of migraine, with few cases reported in the literature. Unlike other types of migraine, aura HM presents accompanying motor deficit manifestations that do not last more than 24 hours. We report a 27-year-old man referred to us from the emergency department to carry out a cerebral perfusion SPECT with (99m)Tc-HMPAO. He presented with intense headache and motor weakness. The brain perfusion scan was performed before and after intravenous infusion with nimodipine and showed a significant change of cerebral blood flow, allowing early and correct diagnosis.

Early-Onset Cerebellar Atrophy Associated With Mutation in the CACNA1A Gene

Mutations in the CACNA1A gene were described in familial hemiplegic migraine, episodic ataxia type 2, and spinocerebellar ataxia type 6. Familial hemiplegic migraine and episodic ataxia type 2 are caused by point mutations in the CACNA1A gene, and spinocerebellar ataxia type 6 develops as a result of a CAG triple expansion in exon 1 of the gene. Phenotypic variability and clinical overlap are well recognized. We describe a 3-year-old child with clinical and radiologic signs of early-onset cerebellar atrophy. The family history was significant for migraine, and in some members of the family, a diagnosis of hemiplegic migraine was established. The combination of cerebellar atrophy in our patient and the family history suggested involvement of the CACNA1A gene. The sequence analysis of genomic DNA from the proband identified heterozygosity for a mutation (Thr666Met) in the CACNA1A gene. Subsequently, his father, who was mildly affected, and two other relatives were demonstrated to carry the same mutation. Therefore, CACNA1A gene mutations should be considered in the differential diagnosis of congenital cerebellar atrophy.

A Note on the Digiti Quinti Sign in Hemiplegic Migraine

The digiti quinti sign (DQS) was described as an indication of mild hemiparesis. It consists of a wider space between the fourth and fifth fingers at the affected side when the patient extends both arms horizontally to the front with the palms down. The three successively examined sporadic hemiplegic migraine patients presented herein disclosed no other neurological abnormality except the interictally present DQS on the same side of the motor deficits. This sign is perhaps clinically useful for the diagnosis of hemiplegic migraine.

Hemiplegic migraine associated with interscalene block and general anaesthesia

We report a case of new onset hemiplegic migraine following general anaesthesia and an interscalene block, the first reported case in the literature. A middle-aged man underwent manipulation of the left shoulder under anaesthesia. An awake left interscalene block under sedation was performed. The plexus was located easily with a 25 Stimiplex needle and 30 ml 0.5% levobupivicaine injected at an end point of 0.4 mA (biceps twitch) uneventfully. General anaesthesia was then induced with 50 μg fentanyl and 200 mg propofol. A laryngeal mask airway was placed and the patient ventilated spontaneously with oxygen, air and sevoflurane. The patient was positioned in the right decubitus position. There were no adverse events during the 40 min procedure. In recovery he was unable to move or feel the left side of his body and had difficulty responding to questions with slurred speech. Cranial nerve examination revealed reduced sensation of the left cheek, flaccid paresis of the left cheek, and left hypoglossal nerve impairment. A dense left-sided hemiplegia and hemisensory loss was found on peripheral nervous system examination. Symptoms resolved gradually. Within 4 h he was able to move his foot but sensation was still impaired on the left side of his body. Cranial nerve assessment at this time showed tongue movement and speech back to normal. At 15 h upper limb movement had partially recovered, he was able to lift the arm, but still unable to move the fingertips. By 24 h the upper limb signs had almost completely resolved, and the leg weakness appeared to be resolving. Cranial nerve examination demonstrated ongoing numbness of the left side of the tongue. He notes having very slight generalised weakness thereafter which lasted for a further 3 days. Immediate MRI of the cervical spinal cord was normal. Carotid duplex scans and cranial MRI performed later revealed no abnormality. Since the initial episode he had six further attacks of left-sided weakness. Severe stabbing pains in the head followed by mild to moderate headache have preceded each episode. Both his left arm and leg are affected. Symptoms resolve after 3 days. A diagnosis of hemiplegic migraine was made following neurological consultation. Propranolol was commenced and he was reviewed after 3 months. At this stage he reports suffering headaches every 2 weeks which were more tolerable. He had no further attacks of associated left-sided weakness or numbness. EEG undertaken was normal. Our case highlights the diagnostic dilemma posed by a neurological deficit following anaesthesia with interscalene block. A number of central and peripheral diagnoses should be considered. A left interscalene block could lead to left-sided neurology if injected directly into the substance of the spinal cord. A total spinal is likely to have occurred simultaneously. Literature describing this complication describes predominantly upper limb neurological loss, all being in individuals where interscalene block was performed under general anaesthesia [1]. Spontaneous right-sided stroke under anaesthesia is a possible differential diagnosis, but no radiology supported this, and the recurrent nature of the symptoms confirmed this. General anaesthesia is known to precipitate migraine in sufferers. Ten per cent of migraine sufferers have neurological deficits and in 4% this persists beyond the duration of the headache. Hemiplegia associated with migraine post general anaesthesia has to date only been reported in individuals with a prior history of the condition or a known strong family history of hemiplegic migraine [2]. Hemiplegic migraine is a rare disorder characterised by attacks of transient hemiparesis followed by migraine headache. Classically there is an aura, followed by development of neurological signs lasting a mean of 60 min followed by headache lasting 30 min to 5 days. Motor signs occur unilaterally in approximately 60% of cases and are never isolated – most commonly associated with sensory signs and language disturbance, and least commonly with visual disturbances – in contrast to classic migraine. Triggers for the development of migraine in these individuals are commonly minor stressful events, which is the postulated mechanism in this gentleman [3]. This case highlights that hemiplegic migraine should be considered as a possible differential when faced with neurological deficit postoperatively.