Objective:

To present a unique case of a patient with a long history of visual migraine aura who developed an acute ischemic stroke, with workup revealing underlying antiphospholipid syndrome. 

Background:

Migraine with visual aura has been linked to an increased risk of ischemic stroke, namely cardioembolic strokes. However, the role of hematologic conditions in patients with prolonged visual aura without headache remains underexplored. 

Design/Methods:

N/A

Results:

A 73-year-old male with a history of chronic migraine with visual aura presented with an acute worsening of visual disturbances. He reported a decades-long history of migraine headaches with transient right hemifield visual auras, characterized by wavy, translucent lights. These migraines and visual auras were previously mild, but then suddenly became severe and constant for two days without his typical headache. MRI Brain showed a large acute ischemic stroke involving the left occipital lobe and extending into the medial temporo-parietal region. There was no evidence of hypertension or carotid atherosclerosis, and telemetry monitoring was negative for atrial fibrillation. Hematologic testing showed elevated beta-2 glycoprotein IgM and cardiolipin IgM - confirming antiphospholipid syndrome. The patient was started on warfarin, with no subsequent ischemic events. Visual symptoms gradually improved with daily oral magnesium glycinate.

Conclusions:

This case highlights an atypical presentation of ischemic stroke, where chronic visual migraine aura, typically transient, became constant and severe following an occipital lobe stroke. Notably, the patient lacked common stroke risk factors, and his stroke was attributed to newly discovered Antiphospholipid Syndrome, a hematologic cause not previously associated with this pattern of migraine aura. This case underscores the importance of considering hematologic etiologies in patients with longstanding history of migraine with visual auras. In patients with chronic visual aura, hematologic screening could help identify underlying hypercoagulable conditions, potentially preventing further ischemic events.