Homonymous Hemianopia With Normal Neuroimaging

Abstract

A 46-year-old man presented with a 2-week history of a persistent blurred area in his right lower visual field of both eyes. He noticed colors surrounding the dark area that lasted 2 to 3 minutes at a time and occurred multiple times per day. His medical history was significant for dyslipidemia for which he took rosuvastatin. He also reported feeling lethargic, with polydipsia and a dull mild holocephalic headache during this period. Ophthalmological examination revealed a visual acuity of 20/20 OU, pupils were equal and reactive to light with no relative afferent pupillary defect, and color vision was normal. Dilated fundus examination was normal. Humphrey 24-2 Swedish interactive threshold algorithm fast visual field testing revealed a right homonymous hemianopia denser inferiorly (Figure , A). An urgent noncontrast computed tomography (CT) scan of the head was obtained and was normal (Figure, B). Magnetic resonance imaging (MRI) of the brain was initially reported as normal but revealed subtle abnormal T2/fluid-attenuated inversion recovery hyperintensity involving the left occipital cortex after further review (Figure , B).

Clinical Reasoning: An 80-Year-Old Woman With a Homonymous Hemianopsia

“…An HH without a structural lesion on brain MRI has a short but important differential diagnosis that includes the Heidenhain variant of Creutzfeldt-Jacob disease (CJD), posterior cortical atrophy (PCA) syndrome, nonketotic hyperglycemia, seizures, subtle occipital ischemia, or a functional visual disorder. 5,6 In our patient, the duration of symptoms and lack of diffusion restriction on the brain MRI made CJD unlikely. Normal laboratory evaluation and the progressive nature of the symptoms made hyperglycemia or a vascular etiology unlikely.…”

“…Copyright © 2022 American Academy of Neurology. Unauthorized reproduction of this article is prohibited A congruent HH without a structural lesion on brain MRI often localizes to the occipital cortex and has a short but important differential diagnosis that includes the Heidenhain variant of Creutzfeldt-Jacob disease (CJD), posterior cortical atrophy (PCA) syndrome, non-ketotic hyperglycemia, seizures, subtle occipital ischemia or a functional visual disorder 5,6 . In our patient, the duration of symptoms and lack of diffusion restriction on the brain MRI made CJD unlikely.…”