PJNNS 329 1–3 neurologia i neurochirurgia polska xxx (2017) xxx–xxx Available online at www.sciencedirect.com ScienceDirect journal homepage: http://www.elsevier.com/locate/pjnns 1 2 3 Case report Visual and somatosensory phenomena following cerebral venous infarction 4 5 6 7 8 9 10 Q1 Aleksandra Loster-Niewińska a, Edyta Dziadkowiak a, Justyna Chojdak-Łukasiewicz a,*, Anna Zimny b, Bogusław Paradowski a a Department of Neurology, Wroclaw Medical University, st. Borowska 213, 50-556 Wroclaw, Poland Department of General Radiology, Interventional Radiology and Neuroradiology, Wroclaw Medical University, st. Borowska 213, 50-556 Wroclaw, Poland b article info abstract Article history: Background: The most frequent clinical presentation of occipital or visual tract lesion is Received 28 September 2016 hemianopsia or quadrantanopsia. However, damage to the primary or secondary visual Accepted 6 July 2017 cortex can also manifest as visual hallucinations (photopsiae or complex phenomena). We Available online xxx report visual and somatosensory phenomena following cerebral venous infarction based on a study of a patient with a history of recent head injury. Keywords: Case presentation: We report a 61-year-old man with a history of recent head injury presented Visual/somatosensory with a headache of two weeks duration. He was complaining of transient visual abnormali- hallucinations ties, which he described as impaired ability to recognize faces, dark spots moving in the Visual/somatosensory illusions visual field and distorted contours of an objects. Clinical examination showed a balance Venous stroke disorder with no evidence of visual deficit. During further observation the patient started to Q2 Irritation of cortical centers experience more complex visual and sensory phenomena of: waving of the ceiling, clouds that he could form and feel, he had an impression of incorrect sizes of given objects, he could see a nonexistent pack of cigarettes and the character from the arcade game Pac-Man ‘‘eating’’ an existing drip stand. Conclusions: The patient mentioned above possessing simple and complex visual and somatosensory hallucinations and illusions in the course of venous stroke. A possible mechanism involves irritation of cortical centers responsible for visual processing. © 2017 Published by Elsevier Sp. z o.o. on behalf of Polish Neurological Society. 13 11 12 14 15 16 17 18 1. Background Hemianopsia or quadrantanopsia is the most frequent clinical presentation of occipital or visual tract lesion. However, damage to the primary or secondary visual cortex can also manifest as visual hallucinations. It can present as elementary (photopsia) or complex phenomena. Photopsiae, consisting of bright lights (points, flashes, sparks) are more likely to appear with occipital pathologies, whereas complex hallucinations, defined as formed images of objects or persons, are combined * Corresponding author. E-mail addresses: olaloster@poczta.onet.pl (A. Loster-Niewińska), ebkow@esculap.pl (E. Dziadkowiak), justyna.chojdak@wp.pl (J. Chojdak-Łukasiewicz), abernac@wp.pl (A. Zimny), bogusparad@poczta.onet.pl (B. Paradowski). http://dx.doi.org/10.1016/j.pjnns.2017.07.007 0028-3843/© 2017 Published by Elsevier Sp. z o.o. on behalf of Polish Neurological Society. Please cite this article in press as: Loster-Niewińska A, et al. Visual and somatosensory phenomena following cerebral venous infarction. Neurol Neurochir Pol (2017), http://dx.doi.org/10.1016/j.pjnns.2017.07.007 19 20 21 22 23 24 PJNNS 329 1–3 2 neurologia i neurochirurgia polska xxx (2017) xxx–xxx Fig. 1 – CT image (A) showing hemorrhagic venous infarction within right occipital lobe (white arrow) and hyperdense superior sagittal sinus indicating CVT (black arrow). T1-weighted (B) and T2-weighted (C) MR images showing hyperintense right occipital hematoma surrounded by edema without hyperperfusion on perfusion map (D). FLAIR MR image (E) showing hyperintense right transverse sinus indicating CVT (arrows) and post contrast T1-weighted image (F) showing a filling defect in the confluence of the sinuses and in the right transverse sinus indicating thrombus (arrows). 25 26 with abnormalities of the occipitotemporal and occipitoparietal region. 27 2. 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 treated with a weight-adjusted dose of heparin. The visual phenomena lasted for about two weeks and then resolved completely. 45 46 47 3. 48 Case presentation A 61-year-old man with a history of recent head injury presented with a headache of two weeks duration. He also reported occasional visual disturbances such as: impaired facial recognition, dark spots moving in the visual field and distorted contours of the observed objects. Clinical examination revealed a balance disorder with no evidence of visual deficit. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated cerebral venous sinus thrombosis (CVT) complicated by right-sided occipital hemorrhagic infarction (Fig. 1). During further observation the patient started to experience more complex visual and sensory phenomena of: waving of the ceiling, clouds that he could form and feel, he had an impression of incorrect sizes of given objects, he could see a nonexistent pack of cigarettes and the character from the arcade game Pac-Man ‘‘eating’’ an existing drip stand (Fig. 2). Except for the head trauma, no other pathologies contributing to CVT were found. The patient was Conclusion The most frequent clinical presentation of an occipital or visual tract lesion is hemianopsia or quadrantanopsia. Damage to the primary or the secondary visual cortex can also manifest as visual hallucinations often localized to the affected part of the visual field [1,2]. It can present as elementary (photopsia) or complex phenomena. Photopsiae, consisting of bright lights (points, flashes, sparks), are more likely to appear with occipital pathologies, whereas complex hallucinations, defined as formed images of objects or persons, are related to abnormalities of the occipitotemporal and occipitoparietal regions [3]. The patient described above presented with coexisting simple and complex visual and somatosensory hallucinations and illusions in the course of venous stroke [4]. A possible mechanism involves irritation of cortical centers responsible for visual processing [1,3]. Please cite this article in press as: Loster-Niewińska A, et al. Visual and somatosensory phenomena following cerebral venous infarction. Neurol Neurochir Pol (2017), http://dx.doi.org/10.1016/j.pjnns.2017.07.007 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 PJNNS 329 1–3 neurologia i neurochirurgia polska xxx (2017) xxx–xxx 3 Fig. 2 – Drawings of the patient's hallucinations. (A) Pac-Man (arrow) ‘‘eating’’ a drip stand. (B) Clouds-like structures that the patient could form and feel. references 65 Consent 66 67 68 69 Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal. 70 Conflict of interest 71 None declared. 72 Acknowledgement and financial support 73 [1] Beniczky S, Keri S, Voros E, et al. Complex hallucinations following occipital lobe damage. Eur J Neurol 2002;9:175–6. [2] Brzecki A, Podemski R, Kobel-Buys K, Buys G. Illusions and hallucinations in posterior cerebral artery thrombosis — a case study. Udar Mózgu 2001;3(2):71–6. [3] Menon GJ, Rahman I, Menon SJ, Dutton GN. Complex visual hallucinations in the visually impaired: the Charles Bonnet Syndrome. Surv Ophthalmol 2003;48(1):58–72. [4] Saposnik G, Barinagarrementeria F, Brown Jr RD, et al. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42(4):1158–92. 74 Q4 75 76 77 78 79 80 81 82 83 84 85 86 87 Q3 None declared. 88 Please cite this article in press as: Loster-Niewińska A, et al. Visual and somatosensory phenomena following cerebral venous infarction. Neurol Neurochir Pol (2017), http://dx.doi.org/10.1016/j.pjnns.2017.07.007