Prolonged Migraine Aura with Complete Symptom Resolution Revealing Unexpected Infarction: A Case Report

Introduction Migrainous infarction is a rare but clinically significant complication of migraine with aura, accounting for a small subset of ischemic strokes. It is characterized by the occurrence of cerebral infarction during a typical migraine aura, most often in young individuals without traditional vascular risk factors. The diagnosis of migrainous infraction is challenging and requires carful consideration of alternative diagnoses. Case Presentation We report the case of a 33-year-old woman with a known history of migraine with aura who presented with sudden-onset right arm paresthesia, visual disturbances, and language difficulties lasting 3 h and 20 min. Her symptoms resolved completely prior to arrival at the emergency department. Neuroimaging revealed a left parietal subcortical infarct corresponding precisely to the distribution of her aura symptoms. Further investigations revealed a 2 mm patent foramen ovale (PFO) with a small right-to-left shunt, and transiently reduced levels of protein C and S, which normalized on repeat testing. The patient’s Risk of Paradoxical Embolism (ROPE) score was calculated as 9, suggesting a high likelihood of PFO-related stroke, although no high-risk anatomical features were identified. Conclusions This case highlights the diagnostic complexity of prolonged migraine aura associated with imaging-confirmed infarction. While the temporal relationship between aura and ischemia fulfills criteria for migrainous infarction, the presence of a patent foramen ovale and other transient abnormalities suggests a potentially multifactorial mechanism. Clinicians should maintain a broad differential diagnosis in similar presentations and ensure comprehensive etiological evaluation.