Dados do Trabalho

Título

Cerebral bilateral monocular polyopia: an unusual presentation of an ischaemic stroke

RESUMO

A 58-year-old man presented to our emergency unit with a history of a sudden low visual acuity 2 days prior to the admission followed by a polyopia up to four images in both eyes, in all 9 positions of gaze which did not improve with monocular vision. His medical history included type 2 diabetes and ischemic stroke with a mild left hemiparesis.
The patient had an otherwise normal ophthalmological exam, except for visual acuity of 20/40 in the left eye and 20/30 in the right eye, besides two hard exudates in the right eye at the direct fundoscopy. Visual field testing was unreliable due to the fluctuating diplopia.
On examination, he had a mild sequelae left hemiparesis and simultanagnosia. The patient elaborated better that his double vision involved persisting images in his visual field, indicating palinopsia. The remainder of the neurological exam was normal. A CT scan showed chronic watershed right frontoparietooccipitall hypodensities and subacute watershed left parietooccipital hypodensities, later confirmed the same infarct areas by magnetic resonance imaging. The patient was diagnosed with a new ischemic stroke and started dual antiplatelet therapy. His clinical presentation was attributed to cerebral polyopia with palinopsia.
Discussion: Diplopia is a frequent complaint in the neurology clinic. Unilateral monocular diplopia is secondary to intraocular pathology in most cases. Bilateral monocular diplopia can occur due to an intraocular process, but that's unusual to happen simultaneously in both eyes.
Polyopia is the visualization of multiple images, often due to an intraocular or a functional disorder. Regardless, it can be a rare manifestation of cortical and subcortical ischemic stroke at the non-dominant or bilateral occipital lobe and even in the dominant parietal lobe. Palinopsia is the persistent visualization of visual images after the stimulus ceased and occur due to cortical non-dominant occipital lesions
Final considerations: Bilateral monocular polyopia is a rare manifestation of ischemic stroke. In the presence of this symptom, a complete evaluation of higher order visual function is mandatory, such as visual agnosia, simultagnosia and palinopsia. We report an illustrative case of watershed ischemic stroke manifesting as polyopia and palinopsia associated with a simultagnosia.

Palavras Chave

diplopia, AVC