Case Report: A 15-Year-Old Female with an Acute Episode of Transient Neurological Deficits

Case at a Glance

A 15-year-old female with a family history of POTS experienced a self-resolving episode of visual disturbances, severe headache, aphasia, and transient right-sided weakness, suggestive of a complex migraine with aura.

Patient's Story

The patient is a 15-year-old female who presented for discussion of a neurological event that occurred several months prior, when she was 14. She has a personal history of chronic otitis media with effusion ('glue ear') post-grommet insertion and symptoms consistent with orthostatic intolerance (lightheadedness and pain on prolonged standing). She also reports a strong family history of Postural Orthostatic Tachycardia Syndrome (POTS), with her sister and nephew both having confirmed diagnoses.

Initial Assessment

The episode began at approximately 11:00 PM while the patient was in bed. She first noted the sudden onset of blurry vision in the right visual field, which she confirmed was present in each eye individually. She had experienced similar, isolated visual disturbances in the past. Minutes later, she developed an intense pressure-like headache localized behind both eyes, accompanied by phonophobia (hypersensitivity to sound). As the headache progressed, she noted significant difficulty with language. While she could visually recognize words, she struggled to articulate them correctly (expressive aphasia with paraphasic errors) and had difficulty reading (alexia).

Around midnight, approximately one hour after the initial symptom onset, the patient became alarmed and sought her mother. At this time, she developed new symptoms, including a sensation of heaviness followed by numbness in her right hand and arm, along with weakness in her right leg. She also reported increased difficulty forming sentences and short-term memory deficits. Over the subsequent 30 minutes, the symptoms resolved sequentially in the order they had appeared: the visual disturbance, followed by the aphasia and finally the right-sided motor and sensory deficits. The headache was the last symptom to resolve, persisting until she woke the following morning. The patient did not seek emergency medical attention at the time due to logistical challenges.

The Diagnostic Journey

The patient's presentation of a sequential march of transient neurological symptoms (visual, sensory, language, motor) followed by a headache is highly characteristic of a migraine with aura. Given the presence of unilateral motor weakness, the primary differential diagnosis is a hemiplegic migraine, a rare and complex subtype of migraine with aura. The transient aphasia is also a well-recognized aura phenomenon. While other serious conditions such as a Transient Ischemic Attack (TIA) or seizure must be considered in any patient with acute focal neurological deficits, the patient's age, the progressive nature of the symptoms, and their complete resolution followed by a headache make a migraine variant the most likely etiology. The patient's sister, diagnosed with POTS, reported experiencing similar episodes prior to her own diagnosis, suggesting a possible familial predisposition to complex neurological events, potentially linked to dysautonomia.

Final Diagnosis

Provisional Diagnosis: Complex Migraine with Aura, likely Hemiplegic Migraine.

Secondary Suspected Condition: Postural Orthostatic Tachycardia Syndrome (POTS), based on symptoms and strong family history.

Treatment Plan

The recommended course of action, based on a clinical review of the case, is to establish formal medical care. The plan includes:

1. GP Consultation: An urgent appointment with her General Practitioner to document the event and initiate a formal diagnostic workup.
2. Neurology Referral: A referral to a pediatric or adult neurologist for a comprehensive evaluation of the atypical migraine and focal neurological symptoms.
3. Neuroimaging: To rule out any underlying structural brain abnormalities, a head MRI would be a crucial part of the neurological workup, particularly given the first presentation of hemiparesis.
4. POTS Evaluation: Discussion with the GP and/or neurologist about a formal evaluation for POTS, given her symptoms and family history.

Outcome and Follow-up

The acute neurological episode was self-limiting and has not recurred since the initial event. The patient has been advised to follow the proposed treatment plan, starting with a GP visit. Follow-up will be critical to confirm the diagnosis, rule out other pathologies, and establish a management plan to prevent future episodes and manage headache symptoms. This may include lifestyle modifications as well as potential abortive or prophylactic medications for migraine.