Bilateral middle cerebral artery
haemorrhagic infarcts
presenting only as
cortical blindness
A 70-year-old woman presented with sudden onset headache
and vomiting followed by bilateral vision loss within the next
30 min while she was brushing in the morning. She did not have
any seizures or focal deficit. On examination, she was found
to be hypertensive with systolic blood pressure of 220 mm Hg
and only perception of hand movement in bilateral eyes. Pupils
were bilaterally 2 mm and reacting to light. Fundus examination
showed grade 3 hypertensive retinopathy. Power in all four limbs
was 5/5 at all joints. Sensory examination was not suggestive
of any cortical sensory deficits. Cerebellar and extrapyramidal
system examination revealed no abnormality. Aphasia testing
was also normal. Visual evoked potentials by flashlight were
normal. MRI of the brain revealed bilateral middle cerebral arterial (MCA) territory haemorrhagic infarcts with angiography
showing blockage of inferior division of left MCA (figures 1–5).
ECG revealed left ventricular hypertrophy that was confirmed
on echocardiography. There was no evidence of atrial fibrillation. Her vision loss was attributed to the involvement of both
temporal and parietal optic radiations in MCA territory. Doppler
examination of the carotids showed multiple soft plaques along
the entire length of bilateral internal carotid artery with increased
intimal thickness. Hypertension leading to arterial sclerosis and
thrombus formation was considered as the cause of stroke in
this patient. She was started on dual antiplatelet, antihypertensives and supportive treatment for headache. She had complete

Figure 1 Diffusion-weighted images showing diffusion restriction in
right parieto-temporal and left temporal region.

Figure 2 Susceptibility-weighted images showing blooming in the
areas of diffusion restriction.
recovery of vision in both eyes on follow-up at 3 months. Her
Mini-Mental State Examination score was 29/30. She lost 1
point in drawing complex diagrams. On detailed neurological
examination, she had left-sided hemineglect but there was no
evidence of simultagnosia. Language examination did not reveal
any abnormality. We could not do diffusion tensor imaging
to look for optic radiation involvement in this patient due to

Figure 3 T2-weighted images showing increased hyperintensity in
right parieto-temporal and left temporal region suggestive of infarct
with surrounding oedema.

Das A, Anand S. Postgrad Med J Month 2019 Vol 0 No 0

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Figure 6 Diagram showing blood supply of optic radiation. MCA,
middle cerebral artery; PCA, posterior cerebral artery.

Figure 4 Axial T1 contrast images showing contrast take-up in the
area of infarct.
technical issues. This could have helped in understanding the
precise injury and recovery pattern of optic radiations in MCA
stroke. Figure 6 is a diagram showing blood supply of optic

radiations. This is the first case in literature illustrating parieto-temporal infarcts and resulting cortical blindness as the only
presentation of MCA territory stroke.1
Animesh Das,‍ ‍ Sucharita Anand‍ ‍
Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical
Sciences, Lucknow, Uttar Pradesh, India
Correspondence to Dr Animesh Das, Department of Neurology, Sanjay Gandhi
Post Graduate Institute of Medical Sciences, Lucknow, 226014, India;
​animeshdas05@​gmail.​com
Acknowledgements The authors acknowledge the patient for giving her consent
for publication of her MRI images and clinical information.
Contributors AD managed the patient and wrote the manuscript. SA provided
technical help in the preparation of the manuscript.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and
permissions. Published by BMJ.

To cite Das A, Anand S. Postgrad Med J Epub ahead of print: [please include Day
Month Year]. doi:10.1136/postgradmedj-2018-135962
Received 28 June 2018
Revised 11 January 2019
Accepted 16 January 2019
Postgrad Med J 2019;0:1–2.
doi:10.1136/postgradmedj-2018-135962

Figure 5 MR angiography (MRA) images showing occlusion of
inferior division of left middle cerebral artery.

2

Reference

1 Kahana A, Rowley HA, Weinstein JM. Cortical blindness: clinical and radiologic findings
in reversible posterior leukoencephalopathy syndrome: case report and review of the
literature. Ophthalmology 2005;112:e7–11.

Das A, Anand S. Postgrad Med J Month 2019 Vol 0 No 0

Postgrad Med J: first published as 10.1136/postgradmedj-2018-135962 on 5 February 2019. Downloaded from http://pmj.bmj.com/ on 21 February 2019 by guest. Protected by copyright.

Images in medicine