Cerebellar infarction, visual aura, and patent foramen ovale: A case report with pathophysiological considerations
Marina Romozzi, Silvia Falso, Giuseppe Garignano, Martina Petracca, Catello Vollono, Masahito Katsuki, Yasuhiko Matsumori, Federico TostoBackground
Brain magnetic resonance imaging (MRI) abnormalities, including small infarcts in the posterior circulation, were historically described in patients with migraine with aura. However, recent population-based studies and meta-analyses have questioned the consistency of this association. The pathophysiological significance of these MRI findings remains uncertain, particularly when detected outside the acute or subacute phase.
Case
We report a 29-year-old woman with a 15-year history of migraine without aura who experienced two consecutive episodes of first-ever visual aura within 24 h. Brain MRI performed three days after symptom onset disclosed a small diffusion-weighted imaging/fluid-attenuated inversion recovery (FLAIR)-hyperintense focus in the left cerebellar hemisphere, without clear apparent diffusion coefficient restriction. Follow-up MRI performed two months later demonstrated marked regression of the previously described cerebellar abnormality, with persistence of a small residual T2/FLAIR hyperintense focus consistent with a gliotic sequela. Cardioembolic workup revealed a patent foramen ovale with a mild right-to-left shunt. The patient was started on amitriptyline and later on onabotulinumtoxinA, with no further aura episodes during 12 months of follow-up.
Conclusion
This case supports a vascular-neurogenic continuum linking paradoxical microembolism, cortical spreading depression, and small ischemic lesions in selected patients with migraine with aura and raises the question of how often similar lesions are misclassified as non-specific gliosis when imaging is performed remote from the inciting event.