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A young woman presenting with severe headache

BMJ 2013; 346 doi: (Published 23 May 2013) Cite this as: BMJ 2013;346:f2448
  1. Maria Stavrou, foundation year 2 trainee, general medicine 1,
  2. Solomis Solomou, medical student2,
  3. Oliver Spooner, core trainee, year 23,
  4. Richard Perry, consultant neurologist 4
  1. 1North Central Thames Foundation School, London WC1E6BT, UK
  2. 2Barts and the London School of Medicine and Dentistry, London, UK
  3. 3Department of Geriatric Medicine, Lister Hospital, Stevenage, UK
  4. 4National Hospital for Neurology and Neurosurgery, London, UK
  1. Correspondence to: M Stavrou zchabz6{at}

A 20 year old woman with a history of migraine with visual aura in the form of both positive (fortification spectrum) and negative features was admitted to hospital because of unilateral pulsatile right sided headache of one day’s duration. The headache was associated with photophobia, intense nausea and vomiting, right sided facial and upper arm numbness, and a right sided temporal visual field defect. She described the headache as similar to her habitual migraines in character but “the worst ever.” On examination she was normotensive and her Glasgow coma scale was 15. On neurological examination the visual field defect was confirmed and she reported reduction in light touch over the right side of her face and right upper limb.

With the exception of recurrent migraines at intervals of two to three months her medical history was unremarkable. She was not using any drugs on a regular basis apart from a progesterone contraceptive implant. She had no history of drug or alcohol misuse and did not smoke.

Diffusion weighted magnetic resonance imaging (MRI) of the head was performed (fig 1).


  • 1 What abnormality is seen on diffusion weighted MRI?

  • 2 What was the differential diagnosis at presentation?

  • 3 How would you investigate this patient?

  • 3 What is the appropriate strategy for secondary prevention?


1 What is the abnormality seen on diffusion weighted MRI?

Short answer

The image shows an area of restricted diffusion—that is, an acute infarct in the left thalamus (fig 2).

Fig 2 Diffusion weighted magnetic resonance image of the head showing an area of increased signal (arrow) indicative of restricted diffusion that is in keeping with an acute infarct

Long answer

The area of increased signal in the left thalamus seen on the image is indicative of restricted diffusion and is in keeping with an acute infarct. The remainder of the brain parenchyma appears normal.

T1 weighted scans …

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