Sulcal hyperintensity mimicking subarachnoid hemorrhage in the context of hemiplegic migraine

A 31-year-old woman with migraine had reversible rightsided hemiplegia followed by a throbbing headache on the left side, and underwent a series of MRI scans over an 18-day period.

Hemiplegic migraine is a rare subtype of migraine with aura, presenting with a completely reversible unilateral weakness associated with migraine. This disorder usually has a familial autosomal dominant inheritance trait but, like our patient, can be sporadic. An MRI can show cortical edema, with sulcal hyperintensity on FLAIR ([Figure]), this being rare and of uncertain etiology, possibly due to increased vascular permeability during the aura phase mimicking subarachnoid hemorrhage[1],[2],[3].

Figure A) First MRI showed no abnormalities; B) Another MRI, one day later, revealed bilateral sulcal hyperintensity in FLAIR in the brain convexities, reversible in the following control MRI; C) two weeks later; D) MR angiography was also normal.

• References

• 1 Russell MB, Ducros A. Sporadic and familial hemiplegic migraine: pathophysiological mechanisms, clinical characteristics, diagnosis, and management. Lancet Neurol. 2011;10(5):457-70. https://doi.org/10.1016/S1474-4422(11)70048-5
• 2 Gómez-Choco M, Capurro S, Obach V. Migraine with aura associated with reversible sulcal hyperintensity in FLAIR. Neurology. 2008;70(24 pt 2):2416-8. https://doi.org/10.1212/01.wnl.0000314693.57386.f0
• 3 Bosemani T, Burton VJ, Felling RJ, Leigh R, Oakley C, Poretti A et al. Pediatric hemiplegic migraine: role of multiple MRI techniques in evaluation of reversible hypoperfusion. Cephalalgia. 2014;34(4):311-5. https://doi.org/10.1177/0333102413509432