title: Migraine-like Visual Aura Rriggered by a Large Aneurysm in the Left Extracranial Internal Carotid Artery with Successful Prevention of Recurrence by the new Anticoagulant Dabigatran: First Case Report.
abstract: OBJECTIVE
  We present a rare case of late-onset migraine-like visual aura triggered by a large aneurysm in the left extracranial internal carotid artery. To the best of our knowledge, this is the first case of migraine-like visual aura triggered by an extracranial internal carotid artery (ICA) aneurysm. This is also the first case of migraine-like visual aura with probable thromboembolic trigger being successfully treated with a new anticoagulant, dabigatran.
  
  
  METHODS
  A 61-year-old woman complained about stereotypical episodes of a short-lasting flickering light in the right visual field for about half a year. Magnetic resonance imaging (MRI) of the head revealed a large aneurysm arising from the mid-cervical portion of the left internal carotid artery (ICA). After anticoagulant therapy with 110 mg of dabigatran twice a day, she became free from the visual symptom.
  
  
  CONCLUSIONS
  Late-onset migraine with aura, especially typical aura without headache should be diagnosed carefully since it can be a challenge to distinguish it from signaling something serious. Micro-thromboembolism, commonly cardiogenic, but rarely arising from a carotid aneurysm, can trigger cerebral ischemic injury, causing transient neuronal hyperexcitability and cortical spreading depression (CSD)-like ''spontaneous'' waves propagating through the penumbra of the injured region into normally perfused tissue. The resultant symptoms may semiologically mimic visual aura. Migraine-like visual aura in this patient was successfully treated with dabigatran. It may not only imply that the patient's migraine-like visual aura was a thromboembolic event, but may also suggest the potential efficacy of the new anticoagulant, dabigatran, as the optimal alternative of warfarin in treating a thromboembolic event arising from a carotid aneurysm.
authors.affiliation: Department of Neurology, Chung Shan Medical University Hospital, Taichung, Taiwan.
authors.forename: Sheng-Ling
authors.initials: SL
authors.lastname: Kung
authors.affiliation: School of Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan.
authors.forename: Chao-Yu
authors.initials: CY
authors.lastname: Shen
authors.affiliation: School of Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan.
authors.forename: Ting-Ting
authors.initials: TT
authors.lastname: Ling
mesh_terms: D017668:Age of Onset; D000783:Aneurysm / Q000150:complications / Q000188:drug therapy*; D000991:Antithrombins / Q000008:administration & dosage / Q000494:pharmacology*; D002343:Carotid Artery, Internal / Q000473:pathology*; D000069604:Dabigatran / Q000008:administration & dosage / Q000494:pharmacology*; D005260:Female; D006801:Humans; D008875:Middle Aged; D020325:Migraine with Aura / Q000188:drug therapy* / Q000209:etiology
chemical_list: D000991:Antithrombins; D000069604:Dabigatran