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Images From Headache

A 64-year-old female with a history of hypertension and right thalamic lacunar stroke and no prior history of migraine reported 3 months of episodic migrainous headache with associated “dizziness.” Her physical examination was notable only for a blood pressure of 160/100, subtle left facial weakness of the upper motor neuron type, relatively slowed fine motor movements in the left hand, mild weakness to direct testing of the left hand intrinsics and triceps and a suggestion of a slight left arm reflex preponderance. Brain magnetic resonance imaging (MRI) demonstrated a small T2 hyperintensity within the right thalamus (felt to be consistent with her previous lacunar stroke). Brain MRI demonstrated a sacular aneurysm involving the right middle cerebral artery trifurcation and a smaller aneurysm involving the intracranial right internal carotid in its cavernous portion (Figure).