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The danger of ignoring a migraine
  1. N P S Bajaj,
  2. P K Morrish
  1. Department of Neurology, Hurstwood Park Neurological Centre, Haywards Heath, Sussex, UK
  1. Correspondence:
 Dr Nin Bajaj;
 narinderbajaj{at}compuserve.com

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Answers on p 57.

A 31 year old man was referred with prolonged loss of vision after a typical migraine attack. His usual migraine attacks consisted of a left sided headache preceded by nausea and vomiting and a visual aura of coloured and flashing lights in both visual fields. Visual loss after his migraines could last up to one hour.

The frequency of his headaches had markedly increased eight months before presentation and these were relieved with a combination of pizotifen and naratriptan. Three weeks before presentation, he suffered a typical migraine but noticed that the visual loss after the migraine persisted as a “hole” in the vision of the left eye. Two weeks later he developed a similar scotoma in the field of the right eye with distortion of vision in that eye such that straight lines appeared wavy. He had no other relevant past medical history.

On examination, his visual acuity was restricted to perception of movement only in the left eye and 6/60 in the right eye. Fundoscopy revealed the presence of arteriolar-venous nipping, “flame shaped” and “dot and blot” retinal haemorrhages, “cotton wool” spots, and papilloedema (see fig 1C and 1D). Visual field assessment revealed the presence of bilateral scotomata. The remainder of his clinical examination was unremarkable, although his blood pressure was found to be markedly raised at 220/180 mm Hg.

Blood tests including electrolytes and full blood count were normal. Computed tomography of the brain showed symmetrical hypodense areas in the posterior temporal lobes. These hypodense areas seen on computed tomography appeared as increased signal on T2 weighted magnetic resonance imaging (MRI); further areas of increased T2 signal, not seen on the computed tomogram, were revealed in both hemispheres (fig 1A and 1B). Repeat MRI of the brain one month later was normal.

QUESTIONS

(1) What is the term used to describe the MRI brain appearance in fig 1?

(2) Give the underlying cause of the brain appearance in this case.

(3) Give three other causes of this condition.

(4) What is the likely cause of the fundal appearance in fig 1?

(5) What other investigations would you order?

Figure 1

(A) Computed tomography of the brain and (B) FLAIR (fluid attenuated inversion recovery) sequence MRI brain shows symmetrical change in the posterior parietal and occipital lobes (seen as decreased signal on computed tomography of the brain and increased signal on FLAIR MRI). (C) and (D) illustrating fundoscopic changes including “cotton wool spots”, hard exudates, arteriolar-venous nipping, “flame shaped” and “dot and blot” haemorrhages and papilloedema.

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