Objective:

We describe the clinical course, including neuroimaging at multiple time points, of a patient who presented with acute-onset numbness and weakness due to hemiplegic migraine, illustrating perfusion alterations coinciding with symptom changes.

Background:

Hemiplegic migraine is a subtype of migraine associated with motor weakness. Changes in arterial and venous blood flow in the affected cerebral hemisphere have been noted but are not consistently captured, possibly due to timing of the imaging.

Design/Methods:

A 17-year-old, right-handed, typically developing and generally healthy female with a remote history of migraine headaches with aura presented with acute-onset numbness preceding severe headache followed by weakness of the right upper extremity, raising concern for acute stroke. Brain MRI obtained in the emergency center approximately 5 hours after onset of numbness revealed decreased left hemispheric perfusion, sparing deeper grey matter structures (thalamus, lentiform nucleus, and subinsular cortex) with left-sided venous engorgement. Repeat neuroimaging was obtained around 18 hours from symptom onset. Second brain MRI revealed resolution of prior hypoperfusion with relatively increased left hemispheric perfusion. MR angiogram of the head and neck were normal. There was gradual symptomatic improvement throughout the hospital course with near complete resolution of symptoms at the time of discharge.

Results:

This case provides a timeline of perfusion alterations noted on neuroimaging in a patient with evolving hemiplegic migraine.

Conclusions:

Hemiplegic migraine is a key differential consideration in children presenting with focal neurological symptoms. This case report describes the presentation, clinical course, and neuroimaging findings associated with pediatric hemiplegic migraine.