Case Study: Persistent Visual Aura in a 28-Year-Old Female with Infrequent Headaches

Case at a Glance

A 28-year-old female presents with constant, localized visual phenomena and very infrequent headaches. A neurologist suggests a migraine variant, but orders an MRI to rule out other pathologies. The patient expresses significant anxiety regarding the use of gadolinium contrast, prompting a discussion on the necessity and safety of contrast-enhanced imaging in this clinical context.

Patient's Story

The patient is a 28-year-old female who reports a history of persistent visual disturbances. She describes them as 'eye flashes' that are consistently located in the same spot in her visual field. These flashes are ever-present and have not resolved. She notes that their appearance can change, shifting between black and a combination of black and white. In addition to these constant visual symptoms, she experiences approximately two severe headaches per year. The headaches are debilitating but transient, whereas the visual phenomena are perpetual and independent of the headache episodes.

Initial Assessment

The patient was evaluated by a neurologist. Given the nature of the visual disturbances, a working diagnosis of Migraine with Persistent Aura was proposed. However, due to the atypical presentation—specifically, the constancy of the visual symptoms and the very low frequency of associated headaches—the neurologist recommended a brain MRI to rule out any underlying structural or vascular abnormalities that could mimic this presentation.

The Diagnostic Journey

Following the recommendation for an MRI, the patient developed significant anxiety, primarily focused on the potential use of a gadolinium-based contrast agent. She reported having read anecdotal 'horror stories' online and expressed concern about gadolinium being a 'heavy metal' with potential for retention in the body. Her anxiety was substantial enough that she sought out a specific imaging center equipped with a high-field strength 3T MRI machine, under the impression that this advanced technology might obviate the need for contrast. The central diagnostic question became whether a non-contrast MRI would be sufficient to rule out significant pathology in her case. The clinical consideration was to weigh the low pre-test probability of a contrast-enhancing lesion against the patient's profound anxiety, which could impact her willingness to complete the recommended workup.

Final Diagnosis

Pending neuroimaging. The working diagnosis remains Migraine with Persistent Aura.

Treatment Plan

The immediate plan is diagnostic. An initial brain MRI without contrast was deemed appropriate. The use of a 3T scanner was supported, as it can provide higher resolution images, which is beneficial for evaluating subtle structural details. The plan stipulated that if the non-contrast study revealed any ambiguous or concerning findings, a follow-up study with contrast would be strongly recommended after a thorough discussion of the risks and benefits with the patient. This phased approach aimed to address the clinical question while respecting the patient's concerns.

Outcome and Follow-up

The outcome is pending the results of the MRI scan. A follow-up appointment with the neurologist is scheduled to review the imaging findings. This consultation will be crucial for either confirming the diagnosis of a migraine variant or directing further investigation. Management will also focus on patient education regarding her condition and addressing her health anxiety, which is a significant component of her clinical presentation.