Fluctuating Neurological Deficits in a Patient With Sporadic Hemiplegic Migraine

TL;DR

A 57-year-old man with fluctuating neurological symptoms was diagnosed with sporadic hemiplegic migraine, raising questions about the condition's pathophysiology.

Contribution

The case highlights the diagnostic challenges and unusual fluctuation of symptoms in sporadic hemiplegic migraine.

Findings

The patient's fluctuating neurological deficits were attributed to sporadic hemiplegic migraine.

Imaging ruled out stroke and transient ischemic attack as possible causes.

The case raises questions about the pathophysiology of migrainous aura and focal neurological deficits.

Abstract

This article aims to present and discuss a case of a patient presented with stroke-like symptoms that fluctuated with rapid initial improvement followed by recurrence and slow resolution over a period of six days. A 57-year-old male with a past medical history of chronic myeloid leukemia (CML), unspecified seizure disorder, hyperlipidemia (HLD), hypertension (HTN), peptic ulcer disease (PUD), and type II diabetes mellitus (T2DM) presented with right-sided focal neurological deficits (FNDs). The patient initially called the ambulance for intractable abdominal pain with a five-day history of melena and one episode of hematemesis followed by a ground-level fall, during which he was witnessed by family shaking and unresponsive. He was alert and oriented when he developed FNDs en route to the hospital. The initial differential included stroke, transient ischemic attack (TIA), seizure followed by Todd's paralysis (TP), and hemiplegic migraine (HM). The clinical picture was complex; the patient's history of T2DM, HLD, and HTN all placed him at high risk of stroke and the witnessed seizure suggested TP. Computed tomography (CT) and magnetic resonance imaging (MRI) were crucial in eliminating stroke as a possible etiology, and TIA was ruled out as symptoms persisted. Imaging, clinical findings, investigation of the patient's past medical history, and critical reasoning helped rule out TP. This was finally diagnosed and treated as a case of sporadic HM with unexpected fluctuations in aura. The fluctuation of symptom intensity raises questions about the pathophysiology of migrainous aura, how it produces FNDs, and how it can explain the presentation of this patient.

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