Meningeal Hyperperfusion Visualized by MRI in a Patient With Visual Hallucinations and Migraine

Abstract

A 41-year-old patient with a history of migraine but with no history of seizures had intermittent prolonged and variable complex visual hallucinations and illusions lasting 9 days, accompanied by unilateral headache. Electroencephalography during these visual symptoms revealed occipital epileptic discharges. Distinction between focal migrainous attacks and ictal phenomena was difficult. Magnetic resonance imaging showed a lesion in the right visual cortex probably related to low perfusion and hyperemia of meningeal vessels, representing the rarely described transient MRI changes associated with migraine. Continued treatment with antiepileptic drugs and calcium-channel blocking agents completely resolved the headache and visual symptoms, while minor EEG changes persisted. After discontinuation of treatment, a second attack occurred with a similar and reversible pattern on EEG.Key words: migraine, occipital lobe seizures, hallucinations, meningeal MRI alterations Abbreviation: VHIs visual hallucinations and illusions (Headache 1996;36:53-57) Focal migraine is often accompanied by visual symptoms such as scotomas or bizarre images, 1 or even with seizures and epileptic paroxysmal activity on EEG. 2 On the other hand, partial epilepsies inducing occipital lobe seizure disorders are frequently associated with headaches. 2 In the late 19th century, visual hallucinations and illusions (VHIs) as ictal phenomena were recognized for the first time. Later Hughlings Jackson (1931) observed that psychic phenomena may be manifestations of an epileptic discharge (cited by Sowa and Pituck 3 ). Cummings 1 emphasized the stereotypical pattern of VHIs in the individual patient. In contrast, Sowa and Pituck 3 reported on a patient with different VHIs as an ictal manifestation.Distinction between focal migrainous attacks and ictal phenomena may be difficult. This is illustrated by the patient reported here with concurrent migrainous headache, intermittent VHIs, occipital spikes during attacks, and a region of low perfusion and hyperemia of the corresponding right visual cortex. CASE HISTORYA 41-year-old right-handed man with a history of migraine with aura, (IHS 1988 4 ) with no history of seizures was admitted to hospital. One day before admission, he had noted scintillating scotomas in the left visual field after physical exertion, followed 2 hours later by a left-sided homonymous hemianopia and right hemicranial pain. Subsequently, he had repetitive visual hallucinations and persisting headache. He did not drink alcohol and denied use of drugs.On admission, he still complained of right temporal headache, left homonymous hemianopia, and scintillating scotoma in the left visual field. Left-sided hypesthesia and dysesthesia in the perioral region, the fingertips of the left hand, and the left forearm were also noted. The patient was nauseated and photophobic. He denied vomiting and phonophobia. Funduscopic examination was normal.Routine screening of blood, serum, and CSF as well as a cranial CT scan were normal. At admission, tra...

Familial Hemiplegic Migraine with Irreversible Brain Damage.

“…In somepatients with migraine with aura delayed hyperemia has been observed and it often persists longer than the headache (5). Lindner et al reported a patient who had visual hallucinations and headache and the MRIscan revealed hyperintense meningeal signal over the right visual cortex (6). They suggested that this finding was due to primary parenchymal hyperperfusion in the course of a classic migraine attack and that the MRImay be helpful in differentiating between migraine and epilepsy.…”

Neurogenic inflammation in the context of migraine

“…In contrast, in migraine without aura no changes in cerebral blood flow were observed during spontaneous migraine or that evoked by angiography (Olesen et al, 1981). In contrast to cerebral blood flow measurements, few studies have investigated flow within the meninges, although one notable exception is one case study showing a hyperemia in the meninges measured using magnetic resonance imaging in a patient suffering migraine with aura (Lindner et al, 1996).…”

Migrainous infarction in an adult: evaluation with serial diffusion-weighted images and cerebral blood flow studies

“…[10][11][12] We believe that alteration of the BBB, which may cause hyperperfusion, may be the main mechanism for our patient's particular cerebral edema. From the acute to subacute phase, it presumably represents vasogenic edema resulting from alteration of the BBB.…”