PO-33 | Visual hallucinations: a non-unique symptom

Francesca Traccitto, Giada Giuliani, Davide Chiffi, Chiara Zilli, Mariangela Fratino, Marta Altieri | Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy

Background: Different mechanisms involved in migraine pathophysiology, especially in migraine with aura (MA), might contribute to the development of ischemic brain injury, such as impaired cerebral autoregulation, cortical spreading depolarization, embolism and endothelial dysfunction.

Methods: We present the case of a patient with MA and cardiovascular risk factors who developed a cerebral ischemic lesion during hospitalization for myocardial infarction.

Results: A 75-year-old man was affected by MA since the age of 30, with monthly episodes of scintillating scotomas, rarely followed by headache. In March 2025, because of myocardial infarction, he underwent coronary angioplasty. During hospitalization, he noticed the sudden onset of persistent visual hallucinations, such as moving figures and black grotesque masks on a red background, accompanied by typical migraine. Due to the persistence of the disorder and its singularity, the patient underwent basal electroencephalogram, which was normal, and brain MRI, that showed the presence of a small acute ischemic lesion in the right occipital cortical area with normal representation of the main intracranial arterial afferents. Considering the history of MA, lamotrigine, gradually increased up to 50 mg/day, was started with rapid disappearance of the symptoms and sustained benefit after two months.

Conclusion: Patients with a history of MA can underestimate stroke symptoms due to their similarity to those of the aura, making the diagnosis a challenge. The peculiar picture of our patient did not meet the criteria for either a “migrainous infarction”, characterized by a typical aura except for the duration, or a “status migrainosus”. In stroke pathogenesis, beyond vascular risk factors such as arterial hypertension and dyslipidaemia, we cannot overlook the potential role of MA and recent coronary angioplasty. Vasodilator drugs and embolic phenomena resulting from the revascularization procedure might have acted synergically with impaired cerebral regulation, causing the ischemic lesion. This suggests the importance of including also non-traditional risk factors (e.g., migraine) in the management of the vascular patient, as exemplified by the QRISK3.