Spontaneous Bilateral Internal Carotid Artery Dissection and Migraine: A Potential Diagnostic Delay

Abstract

A 36-year-old man with a history of migraine without aura, presented with recurrent bouts of severe headache, perception of flashing lights in both visual fields, and transient bilateral neurological deficits. In view of his history, migraine with aura was considered. Ancillary investigations showed bilateral extracranial internal carotid artery dissection. This case illustrates that when attacks of severe headache with scotomata and transient bilateral neurological deficits occur in a patient with a history of migraine, the diagnosis of carotid artery dissection should be considered, especially when the pattern of headache is different or when some clinical characteristics have not been experienced previously.Key words: carotid artery, dissection, migraine Abbreviations:ICA internal carotid artery, ICAD internal carotid artery dissection (Headache 1997;37:109-112) Repeated bouts of headache associated with transient visual, motor, and speech disturbances in young or middle-aged patients with migraine may be suggestive of migraine with aura. 1 However, when the pattern of headache or neurological symptoms are different from previous attacks, another cause may be involved, including dissection of one or more cervicocephalic arteries. 2,3 This is illustrated in the following patient. CASE HISTORYA 36-year-old, right-handed man had a history of migraine without aura. Two weeks before admission, he suddenly experienced severe left-sided occipital headache radiating to the retro-orbital region. There was no history of trauma or physical exertion. The headache resolved spontaneously within 2 days. One week later, he suddenly noted flashing lights in both eyes, followed by markedly decreased visual acuity, light-headedness, left periorbital headache, and weakness of the extremities. Weakness persisted for a few minutes on the right side, and for 2 hours on the left side. The headache progressively waned within 24 hours. Five days later, left-sided frontal headache, light-headedness, and bilaterally decreased visual acuity recurred, accompanied by bilateral weakness of the extremities, more pronounced on the left. The neurological signs disappeared within 30 hours.Two days later, bifrontal headache and perception of flashing lights in both visual fields recurred, accompanied by left hemiparesis and dysarthria. As the left-sided weakness had not disappeared within 48 hours, he was referred to the emergency department. Physical examination showed a blood pressure of 200/120 mm Hg, dysarthria, left hemiparesis, left sensory and visual neglect, generalized hyperreflexia, and bilateral extensor plantar responses. Ophthalmological examination was normal.Blood chemistry and hematology were normal. There was no evidence of coagulopathy, inflammatory, or autoimmune disease. Electro-cardiogram and chest x-ray were normal. Brain CT showed a right parietal infarction.Color duplex ultrasound showed no stenosis at the level of the carotid bifurcations, but was suggestive of a high-grade stenosis at the most distal part of the righ...

Spontaneous carotid artery dissection presenting as migraine--a diagnosis not to be missed.

“…Non-traumatic cases of carotid artery dissection are increasingly recognised.2 6 Carotid artery dissection typically presents with frontotemporal (61%) or hemicranial (23%) headache, 91% being ipsilateral to the dissection. Neck pain is found in 26% and there are fluctuating neurological symptoms and signs.…”

The Visual System in Migraine: From the Bench Side to the Office

“…Kunkel noted that in contrast to migraine visual auras, visual symptoms related to transient ischemic attacks consist of static, dark dimming of vision lasting 3‐10 minutes . Vascular dissections of either the carotid arteries or the vertebral arteries may present with symptoms mimicking MA . Retinal disease, recurrent emboli, coagulopathy, or vasculitis should be suspected whenever atypical visual symptoms are present and recurrent, with duration longer than 60 minutes …”

Migraine and Stroke

“…The presence of a headache after transient neurological symptoms does not necessarily mean that these symptoms are consistent with a diagnosis of MA, because a migraine-like attack can be triggered by ischemic vascular events. 32 Another problem may occur if a patient with known MA has a rapid onset of transient neurological symptoms, because the diagnosis of an ischemic cerebral event, or risk factors for it such as artery dissection, 36 may be missed by discounting these symptoms as MA. A more detailed clinical workup is recommended for patients with known MA in whom their aura symptoms differ, are atypical, or are accompanied with clinical signs of involvement of the basilar artery.…”