A 58-year-old male patient with history of hypertension and diabetes mellitus presented to the ER with 2 days history of visual perception disturbances characterized by distortion of the size and shape of objects, which he described as perceiving a basketball player's hand as larger than normal when visualized in the left visual field. The altered visual perception lasted 2 days. He also complained of bifrontal headache and transient horizontal diplopia, which had subsequently resolved. In the ER the patient did not present with headache, scintillating scotomas, vision loss, nausea, or vomiting. He did not refer to twitching of face or extremities and had no loss of consciousness.
Neurological examination revealed full visual fields. Visual acuity was 20/20 in both eyes. Pupils are equal, round, and reactive to light and accommodation, and extra ocular movements are intact. There was no hemianopia or diplopia. EEG showed slowing to 6 Hz in the right occipital region but no spike wave discharges suggesting an interictal epileptic focus.
Magnetic resonance imaging of the brain showed an acute occipitotemporal ischemic injury corresponding to the PCA territory, affecting Brodmann areas 18 and 19 involving the cuneus (Figure 1). An angiomagnetic resonance revealed approximately 50% luminal stenosis involving the proximal right internal carotid artery. Surface echocardiogram was normal. Transesophageal echocardiogram was unremarkable except for a 2 mm x 6.8 mm layered immobile plaque involving the aortic arch without thrombus. The etiology of the stroke was thought to be cryptogenic at that point. Patient received 325 mg of ASA (aspirin) for 2 days while he was in the hospital and was then discharged on 81 mg of ASA (aspirin) and a simvastatin 20 mg daily. Six months later he had an acute infarct in the right parietal lobe.