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Show Complex Visual Manifestations of Posterior Cortical Atrophy Ramon Reñé, MD, PhD, Silvia Muñoz, MD, Jaume Campdelacreu, MD, PhD, Jordi Gascon-Bayarri, MD, Imma Rico, MD, Montserrat Juncadella, MD, PhD, Jordi Arruga, MD, PhD Abstract: We describe 5 patients with complex visual disturbances in the absence of ocular pathology who were ultimately diagnosed with posterior cortical atrophy (PCA). The presence of visual cortical symptoms, neuroimaging findings and clinical evolution led to the diagnosis 1-5 years after the onset of visual symptoms. Age of onset ranged from 50-66 years. In 3 cases, magnetic resonance imaging (MRI) of the brain demonstrated predominantly right posterior cortical atrophy. The other 2 patients had nonspecific MRI findings but the diagnosis was established given the findings on clinical examination and positron emission tomography (PET). All progressed to global dementia and an autopsy confirmed the diagnosis of Alzheimer disease in one patient. The possibility of PCA should be considered when a patient presents with complex visual symptoms in the absence of ocular pathology. Early neurological assessment may avoid diagnostic delay. Journal of Neuro-Ophthalmology 2012;32:307-312 doi: 10.1097/WNO.0b013e31826b9454 © 2012 by North American Neuro-Ophthalmology Society Posterior cortical atrophy (PCA) is a progressive neu-rodegenerative syndrome, usually of presenile onset, associated with atrophy of the occipital and parieto-occipital cortex (1,2) and clinically characterized by symptoms and signs of cortical visual dysfunction (3,4). Diagnostic criteria have been proposed (Table 1) (1,4). The initial symptoms are usually nonspecific visual com-plaints that prompt the patient to visit an ophthalmolo-gist (1). When ocular pathology is not found, the diagnosis often is delayed until cognitive deficits are detected or further testing is performed. METHODS Five patients were diagnosed with PCA in the Dementia Unit of the Hospital de Bellvitge in the past 10 years. A retrospective review was done of their medical records. Extensive neuropsychological examination, structural neuro-imaging (magnetic resonance imaging and/or computed tomography [CT]), and functional neuroimaging (99Tc- HMPAO single-photon emission computed tomography [SPECT] and/or 18FDG positron emission tomography [PET]) were performed in all patients, and, in 1 patient, neuropathological study was available. RESULTS Three men and 2 women aged 50-66 years were included. None of them had a family history of dementia. Clinical findings and examination results are summarized in Table 2. Detailed description of 3 cases is presented. Case 1 A 65-year-old woman described problems with her vision over the previous 5 years. She reported difficulty threading a needle, thought there was not enough light in her home and wanted to use brighter light bulbs. Two years later, she began using her left hand less and gave up cooking because she dropped food out of the frying pan. She could not recognize people's faces and identified her own children only by their voices. She could not find or organize her clothing. Two years ago, the patient decided to see an ophthalmologist. Visual acuity was normal, but a left homonymous hemianopia was found. Visual evoked potentials were normal. Brain CT revealed asymmetric enlargement of the lateral ventricles (Fig. 1). One year ago, she was unable to write, tell time on her watch, Departments of Neurology-Dementia Unit (RR, JC, JGB), Neuro-psychology (IR, MJ), and Ophthalmology (SM, JA), Hospital Uni-versitari de Bellvitge, L'Hospitalet de Llobregat, Spain. The authors report no financial or conflicts of interest to disclose. Address correspondence to Ramon Reñé, MD, PhD. Neurology Service. Hospital Universitari de Bellvitge. Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Spain; E-mail: ramonrenye@hotmail.com Reñé et al: J Neuro-Ophthalmol 2012; 32: 307-312 307 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. make the bed, dress herself, grasp an object, and easily got lost, but she did not complain about her memory. On seeing a neurologist, she reported feeling depressed because she was aware of her deficits. Examination revealed a left homonymous hemianopia, left upper limb neglect and deafferentation, alexia, agraphia, right-left confusion, finger agnosia, bilateral stereoagnosia, sensory extinction, optic ataxia, and mild parkinsonism (Table 2). SPECT showed severe right parietotemporo-occipital hypoperfusion. PCA was diagnosed. She died in an institution 3 years later. Case 2 A 56-year-old man with visual complaints that had started 1 year earlier was seen by his ophthalmologist. He had TABLE 1. Diagnostic criteria of posterior cortical atrophy Core features Visual complaints in the absence of ocular or brain disease (stroke, tumor) explaining the symptoms Insidious onset and progressive disabling visual impairment Absence of parkinsonism or hallucinations and relative preservation of anterograde memory and insight in early stages (to differentiate from Lewy body dementia or Alzheimer dementia) Any of simultanagnosia, optic ataxia, ocular apraxia, constructional dyspraxia, visual field defects, spatial disorientation, and elements of Gerstmann syndrome Supportive features Presenile onset, alexia, apraxia (ideomotor, dressing), prosopagnosia Parietal and/or occipital deficits on neuropsychological examination Parietal and/or occipital (focal or asymmetric) deficits on structural or functional neuroimaging Modified from Tang-Wai et al (4). TABLE 2. Clinical findings and examination results of 5 patients with posterior cortical atrophy Case 1 Case 2 Case 3 Case 4 Case 5 Age of onset (yr) 59 54 57 50 66 Time to diagnosis (yr) 5 2 5 3 1 Most affected side R R R R R Visual field deficits Yes (HH) Yes (HH) No No Yes (HH) Focal atrophy CT/MRI TPO FP PO TPO N SPECT abnormality TPO TP TP TP - PET abnormality - - TP PO PTO Frontal dysfunction No Yes Yes Yes Yes Verbal memory deficit No Yes No NA Yes Progression AD like AD like Dementia LBD like AD like Anosognosia No No No Yes No Visual agnosia (94%-63%) NA NA Yes Yes No Visuospatial deficits (88%-82%) Left neglect Right neglect NA NA Yes Driving difficulty (82%) Yes Yes No - Yes Ideomotor apraxia (76%-81%) Yes Yes Yes Yes No Agraphia (70%-65%) Yes Yes Yes NA Yes Alexia (65%-91%) Yes Yes Yes NA Yes Spatial disorientation (65%-48%) Yes Yes No Yes Yes Gerstmann syndrome (52%-60%) Yes Yes Yes No No Anomia (52%-67%) No No No Yes No Acalculia (41%-46%) Yes Yes Yes Yes Yes Dressing apraxia (35%-46%) Yes Yes Yes Yes No Simultagnosia (29%-49%) Yes NA No NA Yes Optic ataxia (29%-49%) Yes NA Yes NA No Episodic memory loss (29%-45%) No No No Yes Yes Prosopoagnosia (23%-24%) Yes Yes Yes No No Achromatopsia (12%-9%) No No No No Yes Parkinsonism (12%-18%) Yes No No Yes No Visual hallucinations (6%-10%) No No No Yes No Cortical sensory loss Yes NA Yes NA No Frequency of abnormalities reported in the literature given in parentheses. AD, Alzheimer disease; FP, fronto-parietal; HH, homonymous hemianopsia; LBD: Lewy body dementia; N, normal; NA, not available; PET, positron emission tomography; PO, parieto-occipital; R, right; SPECT, single-photon emission computed tomography; TP, temporo-parietal; TPO, temporo-parieto-occipital. 308 Reñé et al: J Neuro-Ophthalmol 2012; 32: 307-312 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. difficulties with reading and writing, laid the dishes upside down, could not tell the time, could drive and read road signs, but mounted the curb and entered the car through the wrong door. Visual acuity was 20/25 in both the eyes. The patient could not read any of the Ishihara color plates. Intraocular pressure and funduscopy were normal. Visual field testing demonstrated an incomplete left homonymous hemianopia (Fig. 2). The patient was referred for neurological assessment. On examination, he had right hemineglect and apraxia, without language or memory alterations and a normal physical examination. While brain CT was normal, MRI revealed parieto-occipital atrophy bilaterally (Fig. 3). SPECT showed right parietotemporal hypoperfusion (Fig. 4). Neuropsychological examination 3 years later showed widespread deficits including complete Gerstmann syndrome and prosopoagnosia (Table 2). In the following year, the patient was unable to read or write and had difficulty shaving, getting dressed, or going out alone. Visual acuity did not change, but visual field defects pro-gressed in both left hemifields and reliability indices wors-ened. Brain MRI showed bilateral fronto-parietal atrophy. The patient also developed disinhibition and personality changes. As a result of the clinical suspicion of Alzheimer disease (AD), he received treatment with donepezil and memantine without improvement. FIG. 1. Case 1. Axial brain computed tomography shows asymmetric enlargement of the lateral ventricles pre-dominantly on the right side secondary to cortical atrophy. FIG. 2. Case 2. An incomplete left homonymous hemianopia with good reliability indices is detected with automated perimetry. Reñé et al: J Neuro-Ophthalmol 2012; 32: 307-312 309 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Case 4 A 56-year-old woman consulted an ophthalmologist because of progressive vision loss. Visual acuity, color vision, funduscopy, electroretinography, and visual evoked potentials were normal. There was a bilateral visual field constriction, but reliability indices were poor. No specific diagnosis was made, and nonorganic visual field loss was a diagnostic consideration. Two years later, she complained of memory loss and disorientation that was attributed to depression. Brain CT showed diffuse cortical atrophy. The patient was referred to a neurologist, and neuro-psychological evaluation detected frontal dysfunction, apraxia, and apperceptive agnosia. Throughout the follow-ing year, she developed memory loss, aphasia, severe depression, anxiety, irritability, and aggressiveness, and she received several antidepressants. SPECT revealed right hemisphere hypoperfusion with the absence of activity in the right parietotemporal region. The following year, she experienced visual hallucinations and cognitive fluctuations. She did not improve with donepezil, and in the last months of her life, there was progressive impairment of memory and orientation, apraxia, aphasia, agnosia, mood disorder, and clinophilia. Neurological examination revealed global rigid-ity, hypomimia, bradykinesia, and parkinsonian gait. The patient did not use her left hand and required nasoduodenal feeding due to severe dysphagia and buccolingual apraxia. PET showed bilateral parieto-occipital hypometabolism, while MRI revealed temporoparieto-occipital atrophy pre-dominantly on the right. With the onset of cortical visual signs and progression to global dementia, she was diagnosed with PCA and progression to presenile AD. She died of respiratory infection, and neuropathology revealed AD (Braak stage VI) with numerous plaques and tangles predominantly in cortical areas, including primary visual cortex, with the absence of alpha-synuclein. DISCUSSION Our patients presented with complex visual symptoms in the absence of ocular pathology. The diagnosis of PCA was made 1-5 years after the onset of symptoms and established by the presence of visual cortical complaints, clinical evolu-tion, and neuroimaging findings, fulfilling many of the clin-ical criteria proposed by Tang-Wai et al (4) (Table 1). The presenting visual complaints were nonspecific, and as in other case series (4,5), patients initially presented to an ophthalmologist. Unlike typical AD, memory, insight, and judgment were relatively preserved until late in the course, resulting in the failure to recognize PCA. This diag-nostic delay has been reported to range between 1 and 9 years (4,5). The differential diagnosis includes Lewy body dementia (LBD), Creutzfeldt-Jakob disease (Heidenhain variant), cerebrovascular disease, and nonorganic visual loss. The mean age of onset of PCA is earlier than in classical AD (4,5). Onset between 40 and 85 years has been reported, but most cases start between 50 and 60 years (4-7). Almost all cases are sporadic. Some have a familial history of late-onset dementia (5,7) but not of PCA, with the exception of 2 sisters reported by Otsuki et al (8). Our patients had onset ages between 50 and 66 years, and none had a family history of AD. The spectrum of clinical signs of PCA reflects dysfunction of the dorsal (occipito-parietal) and/or the ventral (occipito-temporal) visual streams or primary visual cortical dysfunction (4,9). Almost a quarter of the patients with PCA develop visual hallucinations (4-6), and some have LBD at autopsy. In case FIG. 3. Case 2. T1 axial (A) and sagittal (B) magnetic res-onance imaging showing bilateral parieto-occipital atrophy. 310 Reñé et al: J Neuro-Ophthalmol 2012; 32: 307-312 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. 4, despite the presence of hallucinations and spontaneous par-kinsonism, the neuropathological diagnosis was AD. Approximately half of the patients with PCA eventually complain of intermittent memory loss (6), but this is never a prominent initial feature. In most cases, memory loss develops later in the course of the disease. In neuropsycho-logical studies, PCA patients are significantly more impaired in visual perception, spatial memory, visual attention, and FIG. 4. Case 2. Cerebral perfusion single-photon emission computed tomography demonstrating severe right parieto-temporal hypoperfusion. FIG. 5. Case 5. Positron emission tomography demonstrating severe, bilateral parieto-temporo-occipital hypometabolism. Reñé et al: J Neuro-Ophthalmol 2012; 32: 307-312 311 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. visuospatial reasoning compared to AD patients, who are more impaired in episodic memory (9). Hemianopic visual field loss is thought to be under-diagnosed (10), probably because visual fields are either tested only by confrontation techniques or perimetric exam-ination is not fully reliable because of attention deficits and apraxia of PCA patients. MRI typically shows bilateral PCA, predominantly affecting the occipital, parietal, and temporal lobes (11). If MRI appears normal or reveals nonspecific atrophy, voxel-based morphom-etry studies show a pattern of posterior lobe atrophy compared to controls (7). Cortical atrophy is bilateral but more severe on the right side. In studies comparing patients with PCA to those with typical AD, there is greater atrophy in the right visual association cortex and less in the left hippocampus (11). PET studies also show greater parieto-occipital impairment, also with right predominance (Fig. 5) (12). Frontal lobe involvement, although typical of AD, has been reported in PCA, clinically and with functional neuroimaging. This may be because of the degeneration of the afferent input from the parietal-occipital cortices contributing to ocular apraxia (11,12). Autopsy findings of PCA patients usually show AD-type pathology but of posterior distribution and with hippocam-pal preservation (4). More rarely, some cases have shown LBD. PCA is a clinical syndrome and may be considered as a rare focal onset variant of AD or LBD, or alternatively regarded as a distinct entity. No treatments for PCA have been evaluated in clinical trials. Cholinesterase inhibitors are sometimes used, but their effectiveness is unproven. REFERENCES 1. Mendez MF, Ghajarania M, Peeryman KM. Posterior cortical atrophy: clinical characteristics and differences compared to Alzheimer's disease. Dement Geriatr Cogn Disord. 2002;14:33-40. 2. Victoroff J, Ross GW, Benson DF, Verity MA, Vinters HV. Posterior cortical atrophy. Neuropathologic correlations. Arch Neurol. 1994;51:269-274. 3. Pantel J, Schroder J. Posterior cortical atrophy: a new dementia syndrome or a form of Alzheimer's disease. Fortschr Neurol Psychiatr. 1996;64:492-508. 4. Tang-Wai DF, Graff-Radford NR, Boeve BF, Dickson DW, Parisi JE, Crook R, Caselli RJ, Knopman DS, Peterson RC. 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