Neuroimaging biomarkers in migraine with aura mimicking stroke: A qualitative and quantitative analysis of perfusion CT alterations

Objective Our main goal was to describe the clinical, analytical, and neuroimaging characteristics of a large series of patients with migraine with aura (MA) as stroke mimic (SM). As secondary goals, we evaluated factors associated with perfusion computed tomography (PCT) alterations in MA. Background MA is a frequent SM in the acute setting. Increasing our knowledge and awareness of the clinical and radiological characteristics that may occur in the context of a MA as SM may improve diagnosis and reduce unnecessary treatments such as intravenous thrombolysis. Methods We conducted a retrospective observational cross‐sectional study including patients with a final diagnosis of MA who were evaluated at a tertiary hospital and stroke center under the stroke code (SC) protocol activation ‐focal neurological symptoms occurring within 24 h‐ between January 1, 2015, and January 31, 2025. Demographic variables (age, sex), clinical features (history of migraine, vascular risk factors, aura type), and biochemical markers (potassium, glucose, and creatinine levels) were collected. Moreover, we explored factors associated with PCT alterations in MA. Results Among 5513 SC, 68 (1%) were MA, with mean age of 42 (SD: 12.1) years old, 46/68 (68%) females. The most frequent aura symptom was sensory (67%). PCT alterations were found in 15/68 (22%), with a hypoperfusion pattern mainly unilateral, corresponding to a non‐vascular territory. The RAPID automatic software was available in 9/15 (60%) patients. Of these, all patients showed T max > 4 s elevation, and one patient also presented T max > 6 s elevation. The automatic software analysis identified PCT alterations in five patients that did not show alterations in the qualitative analysis. Male sex ( p = 0.003) and aphasic aura ( p = 0.004) were associated with PCT alterations in patients with MA. Conclusion MA as SM forms 1% of SC activation. Automatic RAPID software analysis may help identify PCT alterations that cannot be detected by qualitative analysis. Male sex and aphasia are associated with PCT alterations in MA, which may improve diagnosis in the acute setting.