Presentation
Patient without cardiovascular risk and with 20 years history of migraine without aura presented with a severe headache lasting more than three days that was complicated by aphasia and behavioral changes.
Patient Data
MR images show isointensity of the left temporal lobe surrounded by hyperintense edema and medium structures dislocation on T1, T2, and FLAIR, as well as a hypointense lesion in the left temporal lobe on SWI and DWI. Additionally, there are two subdural hematomas in the frontal and temporal regions on the left.
CT angiography did not reveal any aneurysmatic dilatations or vascular malformations.
Case Discussion
We suspected the patient of having a primary or secondary neoplastic lesion of the left temporal lobe with consequent hemorrhage in it.
Acute MRI including MR-spectroscopy did not demonstrate features of an underlying neoplasm.
The patient had no family history of cerebrovascular diseases or any other comorbid diseases except migraine without aura. Unlike this presentation, NSAIDs or triptans successfully aborted previous attacks of migraine.
Follow-up contrast brain MRI scans performed at 2 weeks and 3 months did not demonstrate a convincing vascular malformation and again did not show an underlying tumor. The size of the intraparenchymal hemorrhage reduced substantially and complete involution of the subdural hematoma occurred.
Given the strong history of migraine, the absence of visible underlying tumor or vascular malformation and the absence of other possible causative factors (e.g. dural venous sinus thrombosis) we feel that this probably represents a migrainous hemorrhagic infarct secondary to pharmacoresistant status migranosus., although these are rare.
It is worth considering the possibility of alternative diagnoses, however. Small vascular malformations can be obliterated (permanently or transiently) by the hemorrhage and cortical venous thrombosis can be difficult to identify acutely and resolve by the time follow up imaging is obtained.
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