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Show f. Clin. Neuro-ophthalmol. 4: 219-220, 1984. Editorial Practical Questions in the Neuroradiologic Workup of Ophthalmoplegic Migraine This issue of the Journal features two articles on ophthalmoplegic migraine back to back that, if viewed individually, could lead the reader to entirely different conclusions. If one starts with the thorough and basic approach to this problem described by Bailey et al., one might conclude that angiography should not be performed in a patient with ophthalmoplegic migraine. However, after seeing the beautiful computed tomographic and arteriographic pictures documenting the patient of Imes et al., one might wonder if arteriography shouldn't be obtained after all in such a rare disorder. In this regard, perhaps shedding a little light as to what went on behind the scenes at the editorial office might be illuminating. When the paper by Imes et al. was first submitted, the authors suggested that their 31-yearold man with a typical history of ophthalmoplegic migraine in that he had recurrent bouts of right third nerve palsy associated with migrainous attacks since age 5, was actually being caused by an arteriovenous malformation anatomically involving the right third nerve. Your editor actually accepted this paper too promptly and before adequate review, primarily because of the name of such a renowned neuro-ophthalmologist and close friend on the title page! A valuable lesson was learned in that regard, however, for when our neuroradiologist editor reviewed the paper, he concluded that this was not an arteriovenous malformation at all because he did not see any early draining veins in the arteriographic pictures prOVided. A flurry of correspondence then ensued, and the paper by Imes et al. is now entitled "Ophthalmoplegic Migraine with Proximal Posterior Cerebral Artery Vascular Anomaly." The comments of one of us (RMQ) in this regard are as follows: "This case which we feel demonstrates a right posterior cerebral artery aneurysm emphasizes the need to carefully study all patients with atypical ophthalmoplegic migraine. Thin section pre- and postcontrast highresolution computed tomography of the brain along the plane of the visual pathways, including December 1984 the optic nerves, chiasm, optic radiations, and occipital lobes, is recommended. Arteriography, either utilizing routine cut film angiography or digital subtraction angiography, should then be performed if the CT indicates the presence of a mass lesion or a vascular lesion. The CT presented here shows an enhancing lesion in the right ambient cistern, in close relationship to the course of the right third nerve. Arteriography shows a PI segment aneurysm of the posterior cerebral artery, and there are no early veins to suggest the presence of an arteriovenous malformation." The fact remains, however, that Imes et al. have documented a patient with a tight clinical diagnosis of ophthalmoplegic migraine who does indeed have a neuroradiologically demonstrable vascular abnormality (of some type, whether arteriovenous malformation, aneurysm, or other specific form of anomaly), right smack at the position of the right third nerve! Another patient needs to be mentioned. I (JLS) have also seen another 31-year-old man with recurrent bouts of ophthalmoplegic migraine, always on the right side, since age 5. He had a direct carotid arteriogram in New York at about age 12-15 years, which was reported as normal, but the films have subsequently been discarded, and are no longer available for review. After many, many recurrent attacks of unilateral III nerve paresis, he was left with a permanent residual of modest degree which increases with subsequent attacks. A good quality computed tomographic scan without and with enhancement was quite normal. The next year (after more attacks), a digital subtraction intravenous angiogram was obtained. This showed a small intracavernous carotid aneurysmal dilatation on the otlzer sideperhaps an ;bnormal takeoff of the trigeminal artery. Thus, even though the lesion was on the wrong side in that case, it also did sho"v a modest congenital vascular anomaly in a man with ophthalmoplegic migraine and third nerve involvement. I (JLS) believe that the best way to summarize the data now available is as follows-ophthal- 219 Editorial: Ophthalmoplegic Migraine moplegic migraine is a disorder that characteristically has its first onset before 10 years of age. The first attack after age 20 is so exceedingly rare that it should be viewed with great suspicion. If one has a classic story, with a positive family history of sick headaches, and a child develops a unilateral oculomotor nerve palsy following a migraine attack, I believe it is proper to get a good quality high-resolution computed tomographic brain scan without and with enhancement as just described by Dr. Quencer. This would appear preferable to nuclear magnetic resonance imaging at this stage of the technologic development because of the need for contrast enhancement and the small size of such associated vascular lesions in some cases. If this computed tomographic scan is normal, after proper neuroradiologic review, the patient can be followed, and perhaps treated with Inderal, if necessary for prophylaxis for subsequent attacks. However, if the ophthalmoparesis occurs one or two more times, then a digital intravenous subtraction angiogram as a minimum, or probably even better, a proper arterio- 220 graphiC study with subtraction views, should be performed. The "bottom line" at this time is that ophthalmoplegic migraine usually occurs without any associated neuroradiographically demonstrable vascular problem. There have been a few cases showing such a lesion, however, and one is documented in this issue. Therefore, angiography still has a place in the evaluation of such cases, and one should use clinical prudence in ordering this. The questions of pupil involvement, relative pupillary sparing, frequency of development of aberrant regeneration, and the true incidence of associated vascular anomalies will await further studies of ophthalmoplegic migraine. I also certainly learned to always have every paper carefully reviewed. Two very valuable lessons can be summarized here-"Where no counsel is, the people fall; but in the multitude of counsellors there is safety"; and also "The fear of the Lord is the instruction of wisdom; and before honour is humility." J. Lawton Smith, M.D. Robert M. Quencer, M.D. Journal of Clinical Neuro-ophthalmology |