The Visual Aura Rating Scale as an Outcome Predictor for Persistent Visual Aura Without Infarction

Abstract

Persistent visual aura without infarction is rare. Its pathogenic mechanism is unknown, and the response to migraine prophylactic agents varies. A systematic analysis of 29 patients (23 from the literature and six in the present report; 6M/23F, mean age 37.6 years) was carried out in terms of demographics, headache and visual symptom profiles, treatment regimens and outcomes. Patterns of visual disturbances (VDs) were re-assessed with the Visual Aura Rating Scale (VARS, score 0-10). Even though the majority of patients had headache improvement, only eight (27.6%) had complete resolution of persistent VD, without definite relevance to any specific agent. Patients with complete resolution of VD tended to have scotoma (50.0% vs. 0%; P = 0.003), unilateral/homonymous involvement (62.5% vs. 9.5%; P = 0.008), higher VARS scores (1.88 +/- 1.73 vs. 0.10 +/- 0.30; P < 0.001) and shorter duration of illness (10.0 +/- 12.9 vs. 60.2 +/- 90.9 months, P = 0.008) compared with those without. These findings remained even when the six current patients were not included for analyses. In conclusion, the prognosis of persistent VD was poor, and higher VARS scores, i.e. more typical of migraine visual aura, predicted a better outcome. For those with a potential for complete resolution, improvement would occur early in the course.

The Relation Between Migraine, Typical Migraine Aura and “Visual Snow”

“…In our study population, the majority of patients with VS had comorbid migraine (58%), and 31% had typical migraine aura. This high comorbidity, when compared with the general population, has led to the assumption that VS might represent persistent migraine aura as often discussed in the initial case series,1‐3 although the clinical presentation is clearly different from typical migraine aura …”

“…The symptoms are continuous and can persist over years. Persistent visual disturbance is mentioned sporadically in the literature without larger systematic studies 1‐3. Patients are often diagnosed as having persistent migraine aura, malingering, or psychogenic disorder because objective measures for the condition are not available to date.…”

Should 'visual snow' and persistence of after-images be recognised as a new visual syndrome?

“…Other authors associate visual snow like symptoms with persistent visual aura in the context of migraine,3 with modifications in corticocortical and corticosubcortical interconnectivity postulated to account for permanent perceptual changes 4. Treatment with acetazolamide and valproic acid has been reported successful in some persistent aura cases, with a more marked effect on headache than on the visual disturbance 5. The prevalence of migraine and visual aura in cases presenting with visual snow symptoms should await a prospective study.…”

Visual Snow—Persistent Positive Visual Phenomenon Distinct from Migraine Aura

“…These studies suggest VS behaves differently in outcome [4] and electrophysiological behaviour [6] than 'persistent visual aura without infarction'.…”

“…All three subjects with VS were put in the third group since the beginning was not associated with migraine, but there was a clear migraine history suggesting some relation. In an attempt to predict the outcome of persistent visual aura without infarction, Wang et al [4] assessed six of their own patients and 23 patients from the literature using the visual aura rating scale [5] giving points to the presence of a duration of 5-60 min, gradual development over more than 5 min, presence of scotoma, zigzag lines, and unilaterality (homonymous presence in both eyes). They found that the prognosis was better in subjects with a higher score, i.e.…”