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Higher Visual Function Deficits Post Stroke

A 62-year-old right-handed woman with history of type 2 diabetes mellitus and hypertension noticed sudden loss of vision loss in the temporal field of the right eye along with paresthesias in the right side of the face. Noncontrast CT head in the emergency department showed acute infarction. MRI brain confirmed diffusion restriction in the territory of left posterior cerebral artery (Figure 1A,B). On examination, vision was 20/ 30 and 20/40 with mild right relative afferent pupillary defect (RAPD). Ocular motility was full. Ophthalmoscopy revealed mild diabetic retinopathy in each eye. Automated perimetry demonstrated right homonymous hemianopia (Figure 1C). She struggled reading Ishihara plates and was unable to identify the control plate, reading the numerical figures as letters; however, she was able to correctly identify the colors of the objects presented to her. She was able to correctly describe the Boston Cookie theft picture. This patient’s ability to recognize objects’ color but inability to identify the control Ishihara plate indicated that her problem was not due to color vision deficit. Her ability to correctly describe Boston Cookie theft picture confirmed that she did not suffer from simultanagnosia. When asked to write a sentence, she was able to do so easily; however, she could not read it back 15 seconds later, indicating the presence of pure alexia or alexia without agraphia and localizing the lesion to the occipital lobe of the dominant hemisphere as well as splenium of the corpus callosum (Figure 1B). The subtle right RAPD indicated extension of the lesion to also involve the left optic tract as it enters the thalamus.