Solving the conundrum. A migrainous infarction or an infarct-induced migrainous attack?

Solving the conundrum between a migrainous infarction (MI) and an infarct-induced migrainous attack (MA) is challenging. A 35-year-old woman with previous history of migraine with visual auras was addressed for acute aphasia followed by progressive right hemibody paresthesia and then by positive visual symptoms in her right visual field. These phenomena were followed by a migrainous headache. A perfusion CT performed during symptoms showed an extended hypoperfusion in the left temporo-occipital region corresponding to a migraine during an aura attack. An ASL sequence brain MRI undertaken 12 hours later (while the patient was only cephalalgic) showed an area of diffuse hyper-perfusion in the left hemisphere. DWI sequence showed a left middle cerebral artery territory infarction. We believe our case was most likely to have been an infarct-induced MA. To conclude, it is crucial to rule out cerebral infarction in cases where a patient experiences an atypical aura even in the context of established migraine.