Crescendo transient Aura attacks: a transient ischemic attack mimic caused by focal subarachnoid hemorrhage.
OBJECTIVE
Diagnosis of transient ischemic attack can be difficult because many mimics exist. We report the clinical and neuroimaging features of a distinct hemorrhagic transient ischemic attack mimic.


METHODS
Case series.


RESULTS
We describe 4 elderly patients presenting with a cluster of stereotyped somatosensory migraine auras, initially referred for "crescendo transient ischemic attacks". Neuroimaging in each patient revealed an unexpected finding of spontaneous focal subarachnoid hemorrhage conforming to a cortical sulcus in the contralateral hemisphere. We postulate that the episodic aura symptoms corresponded to recurrent cortical spreading depression triggered by the presence of subarachnoid blood, and speculate that such episodes could be a presenting feature of cerebral amyloid angiopathy in the absence of typical cerebral microbleeds or history of cognitive impairment.


CONCLUSIONS
Focal subarachnoid hemorrhage can present clinically with transient repetitive migraine auras. Awareness of this entity is important because misdiagnosis as cerebral ischemic events could lead to incorrect treatment. We recommend that elderly patients presenting with a cluster of new unexplained migraine auras should be investigated ideally with MRI to detect focal subarachnoid hemorrhage.
Izenberg
Aaron
A
Dr Thomas and Harriet Black Acute TIA Unit and Regional Stroke Prevention Clinic, Division of Neurology and Brain Sciences Program, Sunnybrook Health Sciences Centre, Department of Medicine, University of Toronto, Toronto, Toronto, Ontario Canada.
Aviv
Richard I
RI
Demaerschalk
Bart M
BM
Dodick
David W
DW
Hopyan
Julia
J
Black
Sandra E
SE
Gladstone
David J
DJ
D000368:Aged; D000369:Aged, 80 and over; D001921:Brain / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology; D002533:Cerebral Angiography; D002536:Cerebral Arteries / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology; D003937:Diagnosis, Differential; D018450:Disease Progression; D004827:Epilepsy / Q000209:etiology* / Q000503:physiopathology; D005260:Female; D006485:Hemosiderin / Q000032:analysis; D006801:Humans; D002546:Ischemic Attack, Transient / Q000175:diagnosis* / Q000209:etiology* / Q000503:physiopathology; D008279:Magnetic Resonance Imaging; D008297:Male; D011237:Predictive Value of Tests; D013345:Subarachnoid Hemorrhage / Q000150:complications* / Q000175:diagnosis* / Q000503:physiopathology; D013346:Subarachnoid Space / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology; D014057:Tomography, X-Ray Computed
D006485:Hemosiderin