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Migraine with Vasospasm and Delayed Intracerebral Hemorrhage

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Migraine with Vasospasm and Delayed Intracerebral Hemorrhage Migraine With Vasospasm and Delayed Intracerebral Hemorrhage Andrew J. Cole, MD, Michel Aub\l=e'\,MD \s=b\Three women with well-documented brain-stem lesions have each been de¬ difficult to arouse, and was again brought to migraine associated with intracerebral scribed. In the majority, neurological the emergency department. She was hyper- hemorrhage are described. In each case, dysfunction is attributed to ischemie tesive, bradycardic, and stuporous, but, af¬ ter was able to follow migraine headaches began during adult- stroke, presumably secondary to vas¬ stimulation, simple commands. She had a dense left hemiplegia hood. Unusually severe and protracted cular spasm. Intracerebral hemor¬ associated with a left-sided homonymous headache heralded the onset of fixed neu- in has rhage migrainous patients only hemianopia and right gaze preference. rological deficits associated with lobar in- rarely been reported,7 and has some¬ Brain computed tomographic scanning tracerebral carotid hemorrhage. Striking times been associated with preexisting demonstrated a right frontoparietal intra¬ artery tenderness was characteristic. Ex- arteriovenous malformations.8·9 This cerebral hemorrhage (Fig 1, center). A ca¬ cept for a history of migraine, no cause for article describes a group of patients, rotid arteriogram showed narrowing of the intracerebral hemorrhage could be estab- all of whom are female, affected with Ml segment of the right middle cerebral lished. In each case arteriography showed migraine who presented with lobar in¬ artery (Fig 1, right). There was mass effect related to the but no evidence of extensive spasm of the appropriate ex- tracerebral hemorrhage either during hematoma, arteriovenous or tracranial or intracranial artery. Surgical or mi¬ malformation, aneurysm, immediately following typical tumor. A pathology following evacuation of two attacks. All were in¬ right frontoparietal craniotomy graine patients was performed with evacuation of the hem¬ hematomata demonstrated signs of ves- in no evidence of un¬ vestigated detail; atoma. Pathologic examination of the sur¬ sel wall necrosis associated with subacute derlying vascular malformation or tu¬ gical material showed areas of cerebral inflammatory changes. Vasospasm asso- mor was discovered. Radiologie studies necrosis surrounding partially necrotic ciated with severe migraine attacks may suggested that early and severe vaso¬ ruptured small arteries without evidence of result in ischemia of intracranial vessel spasm of either the intracranial or ex¬ vascular malformation, tumor, or amyloid walls, leading to necrosis and subsequent tracranial vessels was important in angiopathy. She made a slow recovery and vessel rupture when perfusion pressure is the of was discharged with a persistent neurolog¬ development hemorrhage. ical deficit. restored. REPORT OF CASES woman suffered (Arch Neurol. 1990;47:53-56) Case 2.—A 45-year-old Case 1.—A 61-year-old woman had a from common migraine headaches associ¬ 4-year history of migraine headaches pre¬ ated with photophobia and nausea for sev¬ eral She took no medications and in that ceded by an aura of left-sided paresthesias. years. 1881, suggested any to the used no illicit drugs. One day prior to Charcot,the transient neural She presented emergency depart¬ of dysfunc¬ ment complaining of severe bitemporal admission she had an attack similar to her tions of migraine could become headache, similar to previous attacks. A usual headaches, but somewhat more se¬ permanent.1 Since then, migraine has neurological consultant found the patient vere. Twenty-four hours later, she suddenly been associated with residual neuro¬ to be normotensive, and the examination developed a left hemiparesis, associated logical deficits in a large number of results to be entirely normal. A lumbar with left hemihypesthesia. On admission, her blood and heart rate were cases, and the concept of compli¬ puncture was performed and the results re¬ pressure cated has become vealed normal cerebrospinal fluid. She was normal. She was alert and cooperative. migraine widely was tenderness over the Retinal, cortical, and discharged on analgesics and propranolol. There striking accepted.26 Two days later she returned complaining right carotid artery, but the pulse was nor¬ of severe headache, and, on this occasion, mal and there were no bruits. She had a Accepted for publication April 24,1989. had a mild left hemiparesis with a left dense left hemiplegia. From the Montreal (Canada) Neurological Hos- Babinski's sign. Blood pressure was again Brain computed tomographic scanning now the pital and Institute. Dr Cole is with normal. Computed tomographic scans of showed a homogeneous, well-defined, round Departments of Neurology and Neuroscience, The the brain, with and without contrast infu¬ hyperdensity in the right frontoparietal Johns University School of Medicine, Hopkins were normal 1, and she was consistent with an intracerebral he¬ Baltimore, Md. sion, (Fig left), region on in an ef¬ matoma 2, A internal Reprint requests to Department of Neuro- discharged prednisone therapy (Fig left). right-sided science, The Johns Hopkins University School of fort to abort a severe migraine attack. carotid arteriogram demonstrated an avas- Medicine, 725 N Wolfe St, Baltimore, MD 21205 Twenty-four hours later her headache cular mass in the right frontal lobe. There (Dr Cole). worsened. The following morning she was was beadlike narrowing of the extracranial Downloaded From: http://jamanetwork.com/ by a Harvard University User on 12/29/2016 Fig 1.—Case 1. Left, Normal brain computed tomographic scan with intravenous contrast infusion 2 days prior to intrace¬ rebral hemorrhage. Center, Brain computed tomographic scan without contrast at time of admission showing large right-sided frontoparietal hematoma. Right, Right-sided internal carotid arteriogram showing focal spasm of initial segment of right middle cerebral artery. portion of the right internal carotid artery (Fig 2, right), which was unchanged on two separate injections. Two days later, because of the suspicion of underlying tumor, a right-sided frontal craniotomy with evacuation of the hem¬ atoma was performed. There was no patho¬ logic evidence of tumor or of underlying vascular abnormality. A subacute inflam¬ matory infiltrate composed mainly of mac¬ rophages was seen in the neuropil (Fig 3). There was some thickening of vessel walls with increased cellularity and a mild lym- phocytic perivascular infiltrate. Case 3.—A 46-year-old woman with a 20- year history of common migraine developed a right frontal throbbing headache associ¬ ated with nausea and photophobia, which was similar to her usual attacks, but in¬ creased progressively over several days. She was treated with analgesics that pro¬ vided partial relief. Four days later, after continued headache, she noted left face and arm weakness and numbness, and came to the emergency department. Blood pressure Fig 2.—Case 2. Left, Brain computed tomographic scan without contrast, showing large left-sided and heart rate were normal. Carotid pulses frontoparietal intracerebral hemorrhage. Right, Left internal carotid arteriogram showing spasm of were full, but there was tenderness over the extracranial portion of internal carotid artery. Intracranial vessels are displaced by large avascu- right carotid artery. She had right-gaze lar mass. preference associated with a left hemipare¬ sis involving the face and arm more than the leg and a left Babinski's sign. Computed that had been present on the first study (Fig rhage in each of these patients can tomographic scan showed a right-sided 4, right). be inferred. Intracerebral hemor¬ frontoparietal hematoma (Fig 4, left). A only is selective digital right-sided carotid arterio¬ COMMENT rhage most commonly associated gram demonstrated severe narrowing of with hypertension, aneurysmal bleed¬ the extracranial portion of the internal ca¬ These patients all manifested a rel¬ ing, rupture of macroscopic or cryptic rotid artery (Fig 4, center). There was no atively stereotyped pattern of head¬ vascular malformations, tumor necro¬ evidence of arteriovenous malformation. ache associated with intracerebral sis, primary vasculopathy, or, in popu¬ Over the next 24 severe hours, right-sided hemorrhage (Table). Two had common lations at risk, amphetamine or co¬ headache and was associated with persisted migraine and one suffered from classic caine abuse. None of these conditions tenderness over the on the side. scalp right was demonstrated either the clin¬ She was discharged with residual left-sided migraine. Suddenly, following typical by each suffered lobar in¬ or weakness, and continued to make a slow re¬ attacks, major ical, artériographie, pathologic covery. Three months later she underwent tracerebral bleeding. studies. a repeated right-sided carotid arteriogram A relationship between preexisting The finding of tenderness over the that showed resolution of the narrowing migraine and intracerebral hemor- appropriate carotid artery was strik- Downloaded From: http://jamanetwork.com/ by a Harvard University User on 12/29/2016 ing in two of the patients, and sug¬ gested by the artériographie findings performed 2 days before the hemor¬ gested that carotid vessel pathologic in case 3, remains a possibility in that rhage occurred, was entirely normal. findings were important in the devel¬ case, but has typically been associated There was no evidence of ischemia or opment of intracerebral hemorrhage. with ischemie stroke.12 of vascular malformation.
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