Syncope may have a migrainous basis more commonly than previously suspected, and we suggested criteria to identify these patients. Syncopal migraine appears epidemiologically more closely related to migraine than to reflex syncope.
53-year-old male-to-female transgender patient on cross-sex hormone replacement therapy (CSHT), estradiol 8 mg daily, presented to the emergency department (ED) with acute-onset headache and left visual field disturbances after a recent mechanical fall with head trauma. The medical history was notable for hyperlipidemia. There was no personal or family history of clotting disorders and no history of tobacco use.In the ED, the patient experienced a generalized tonic-clonic seizure characterized by forced left gaze deviation lasting 1 minute. Neurologic examination was notable for left inferior quadrantanopia. Noncontrast CT of the head showed a right parietal hypodensity. MRI revealed infarction involving the left parietal-occipital cortex in a nonarterial distribution suggesting venous infarction. Magnetic resonance venography (MRV) confirmed a cortical vein thrombosis with cortical microhemorrhage (figure).Hospital management included cessation of CSHT and initiating systemic anticoagulation with heparin as a bridge to warfarin with goal international normalized ratio 2-3.Laboratory evaluation for hypercoagulability was negative. The patient's headache and visual field deficits improved and she was discharged home without functional deficit.At 90-day follow-up, the patient's headache and vision continued to subjectively improve. Interval MRV showed recanalization of the cortical vein (figure). Repeat serologic evaluation for hypercoagulability was negative. With resolution of the thrombus, anticoagulation was discontinued, aspirin 81 mg daily was started for antithrombotic effect, and CHST with lower dose estradiol 4 mg daily was resumed.
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