Abstracts

Rationale: Occipital epilepsy is rare, while migraine with visual aura is common. Distinguishing between these two conditions presents diagnostic challenges due to their overlapping symptomatology. This case emphasizes the need for comprehensive clinical evaluation and imaging to effectively differentiate these conditions.


Methods: A 19-year-old man with a history of anxiety and migraine presented for evaluation of complex visual symptoms frequently followed by headaches. An initial diagnosis of migraine with aura was provided by an outside facility. Upon a more detailed history, the patient reported complex visual disturbances, including binocular visual obscurations and vivid, colorful hallucinations of animated characters and mathematical symbols, associated with motor symptoms and occasional migraine-type headaches. These episodes occurred up to four times weekly, lasting no more than 60 minutes each. Although previous imaging was reported unremarkable, symptoms prompted a repeat brain MRI.

Results: The updated MRI of the brain revealed right greater than left occipital-temporal subependymal gray matter heterotopia (Figure 1). The examination of the patient's complex visual auras—ranging from multicolored spots to structured, dynamic scenes, coupled with motor phenomena—and the imaging findings, facilitated a revised diagnosis of symptomatic focal epilepsy.



Figure 1: A. and B. Coronal T1-weighted MRI images demonstrating abnormal nodularity along the ependymal margins of the bilateral occipital horns.








Conclusions: This case underscores the importance of recognizing the spectrum of visual phenomena in occipital epilepsy, which can extend beyond the typical brief durations noted in classical cases and may mimic migraine with aura. Key learning points include the necessity for a thorough patient history focusing on the timing, frequency, and characteristics of visual symptoms, alongside vigilant interpretation of neuroimaging. These strategies are crucial for accurate diagnosis and appropriate management of cases with potentially ambiguous neurological presentations.

Funding: None