Teaching NeuroImages: Neuroimaging in hemiplegic migraine

A 31-year-old man with hemiplegic migraine presented with a 2-day history of severe right-sided throbbing headache, photophobia, and vomiting. They were associated with numbness and weakness of the left hand, which spread to his left face and left leg. Brain MRI (figure) revealed cortical swelling involving the right temporoparietal occipital region (A) with subtle high signal intensity, which exhibited gyriform enhancement (B). He recovered 12 days later. Follow-up MRI was normal (C, D). Hemiplegic migraine attacks can manifest from temporary hemiparesis to recurrent coma and prolonged hemiparesis, epilepsy, or mental retardation.1 MRI abnormalities could only be detected in a few cases depending on the scan timing. Long-lasting migraine aura is not associated with cerebral ischemia as follow-up imaging proves the resolution of cortical changes during the acute attack.2