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Identifier 010-1
Title Palinopsia
Ocular Movements Normal
Creator Shirley H. Wray, M.D., Ph.D., FRCP, Professor of Neurology Harvard Medical School, Director, Unit for Neurovisual Disorders, Massachusetts General Hospital
Contributor Primary Amy Pruitt, M.D., University of Pennsylvania, Philadelphia, PA.
Subject Palinopsia; Prosopometamorphopsia; Migraine visual aura with headache; Falx meningioma; Occipital Lobe; Visual Phenomena
Presenting Symptom Episodic visual disturbance
History The patient is a healthy 59 year old woman who presented in 1978 with transiet visual symptoms. The first visual disturbance occurred in December 1978 when suddenly she noted: • Fluttering of vision in the left eye (OS) • The appearance of a central black spot • Around the edge of the black spot lights like "jagged lightening bolts". • Persisting for 20 to 30 minutes and • Associated with a severe headache Her husband thought she was having a migraine and the visual hallucination she described is consistent with a scintillating scotoma characteristic of migraine visual aura. Subsequently, she had three similar attacks of migraine headache with aura. The second attack occurred in January 1979 and the third in February 1979. The second visual disturbance occurred one evening when she was eating dinner and watching the evening news with Walter Cronkite on TV. Suddenly, she saw a miniaturized TV with Walter Cronkite's face in her dinner plate when she looked down. When she moved her eyes to look elsewhere in the room, the same miniaturized image of Walter Cronkite appeared everywhere on the walls and objects that she looked at. She got up immediately and turned off the TV and the room lights but even in the darkened room she continued to see the image of Walter Cronkite. This visual disturbance lasted for 15 to 20 minutes. The episode was followed by a visual aura of fluttering lightening bolts and accompanied by headache. She had been nauseated prior to sitting down for dinner and nausea persisted during the headache. The positive visual phenomena finally stopped shortly before she went to bed. The whole attack lasted for approximately 3 1/2 hours. In May 1979, she had a similar episode of visual perseveration watching TV, but was unable to recall the TV image that kept reappearing when she looked away from the screen. This time the episode frightened her and she immediately called her doctor. The third visual disturbance occurred when she was out shopping with her mother. They were sitting together at a counter and she turned to look at her mother and observed that her mother's head and the top of her face appeared blurred and distorted. The distortion of her mother's face lasted for a period of seconds to minutes and did not reoccur. In May 1979, she was referred for a neurovisual evaluation. The history of late onset migraine and visual perseveration prompted full investigation. The neurovisual examination documented: Visual acuity 20/30 OU Goldmann perimetry: full visual fields OU to threshold target and to 4 mm. red and green targets Confrontation fields: no extinction to double simultaneous stimuli Ocular motility full OU with no nystagmus Optokinetic nystagmus symmetric with horizontal rotation of the drum No deviation of the eyes on forced eye closure Stereopsis normal 7/9 Fundus examination: normal optic discs and fundi OU. General neurological examination: no abnormality. Investigations CT brain scan showed: A high contrast enhancing mass in the region of the falx between the occipital lobes. A vertebral arteriogram showed: A vascular tumor in this position, consistent with a meningioma. In July 1979, she had a craniotomy and total excision of a meningioma. Post operatively she made an excellent recovery. The neuro-visual examination showed: Visual acuity 20/30 OU and on Goldmann perimetry A small highly congruous scotoma pointing to fixation in the left homonymous field Her migraine headaches stopped. Then, in July 1979 when turning over in bed, she suddenly noted flashes of light and "little wiggly bright lights" for an instant only. A second similar episode of photposia also occurred when turning over in bed. This time she saw flashes like Venetian blind-like lines instantaneously for seconds only. Diagnosis: Late onset Symptomatic Migraine Palinopsia and Metamorphopsia Falx Meningioma
Clinical This patient was interviewed by Dr. Amy Pruitt, Chief Resident in Neurology at the Massachusetts General Hospital in 1979. The patient gives an excellent description of: 1. A scintillating scotoma consistent with migraine visual aura 2. A unique episode of palinopsia characterized by the repetitive reappearance of an image of Walter Cronkite on a TV screen and 3. Prosopometamorphopsia, transient visual distortion of her mother's face and head. Comment: Three positive visual phenomena are associated with focal posterior hemisphere lesions. 1. Visual perseveration - palinopsia 2. Hallucinations 3. Distortions - dysmetria These phenomena are also associated with diverse pathologies including: • Drugs Prescription e.g. trazadone (6), interleukin II, Clomiphene • Addiction marijuana, mescaline, lysergic acid diethylamide (5) • Seizures • Jakob-Creutzfeldt Disease • Migraine (9) • Psychiatric diseases including psychotic depression Visual perseveration is the persistence, reoccurrence, or duplication of a visual image. In 1951 Critchley named the disorder paliopsia (from Greek palin, again(2)). The term was changed to palinopsia in the intervening years. Palinopsia is the perseveration of the visual image in time. There are two forms of abnormal persistence of a visual image in time, an immediate and a delayed type. With the immediate type of palinopsia, an image persists after the disappearance of the actual scene, usually fading after a period of several minutes. This type of palinopsia bears some similarity to the normal phenomenon of an after image experienced after prolonged viewing of a bright object. With the delayed type of palinopsia, an image of a previously seen object reappears after an interval of minutes to hours, sometimes repeatedly for days or even weeks (8). Some patients have both immediate and delayed palinopsia. The features are: • A perseverated image can assume almost any location in the visual field • Persist in the same retinal location as the original image • Move as the eyes move • Sometimes the image is located into a co-existing visual field defect • On rare occasions the location of palinopsic images is contextually specific, as when patients report, after viewing a face on television, everyone else in the room has the same face as the person on television. Some of these images may represent a complex form of palinopsic polyopia. Others may also be consistent with a constant foveal or perifoveal perseverative image that repeatedly manifests itself when the context is appropriate. Critchley, however, believed that palinopsia was only one component of a wider spectrum of disorders - the metamorphopsias, a variety of perceptual distortions involving the size of objects (macropsia and micropsia), the fragmentation of lines, the waviness of contours, the apparent movement of stationary objects and a distortion specific to faces (prosopo-metamorphopsia) (2). Bender considered palinopsia to be a rare transient phase in either the resolution or progression of a visual field defect, which usually lasted for days to months (1) An associated homonymous hemianopia is reported in some patients.
Neuroimaging Cerebral lesions associated with palinopsia are always in the non-dominant posterior hemisphere although they can be on either side or bilateral. (1, 10). Cerebral localization with brain CT is reported in three patients with palinopsia (10). Unfortunately, our patient's neuroimaging studies are not available for publication.
Anatomy In man, as in the monkey, the visual brain consists of multiple map-like cortical representations for external space, each specialized for a different visual attribute (12, 14). The specialized cortical regions are interconnected, forming a hierarchy, with low level areas projecting to higher level ones. The hierarchy divides into two pathway streams, one ventral leading to the ventral temporal lobe and one dorsal leading to the parietal lobe (11, 12). A third projection along the superior temporal sulcus is connected to both streams (13). For review see ref (4). Palinopsia implies functional abnormality within parietal reference frames and relates to pathological increases of activity in the parietal projection of the dorsal visual pathway. (Figure 1 yellow (4)). There is further evidence to link hallucinatory syndromes and visual pathway streams. (See ID#926-4). A well-described organizational feature of the dorsal projection to the parietal lobe in the monkey is the predominant representation of the peripheral visual field while, in contrast, the ventral temporal lobe contains a predominant representation of the central visual field. If the hypothesis is correct, one would expect the dorsal stream hallucinatory syndrome to be associated with a peripheral visual field and the ventral stream hallucinatory syndrome to be associated with the central visual field. This is exactly what has been found - perseveration and delayed palinopsia were located in the peripheral field while hallucinations of figures, vehicles and landscapes were located in the central visual field. The hypothesis that palinopsia -- the third visuopsychosyndrome relates to the parietal projection of the dorsal stream is supported by the fact that delayed palinopsia and visual perseveration are associated with lesions in the parietal lobe (2,4).
Pathology Meningioma
Etiology Meningioma
Disease/Diagnosis Meningioma
Treatment Surgical excision of the tumour
References 1. Bender MB, Feldman M, Sobin AJ. Palinopsia. Brain 1968, 91:321-338. 2. Critchley M. Types of visual perseveration: "palinopsia" and "illusory visual spread". Brain 1951;74:267-299. 3. Critchley M. The parietal lobes. New York: Hafner 1953. 4. ffytche DH, Howard RJ, Brammer MJ, David A, Woodruff, P, Williams S. The anatomy of conscious vision: an fMRI study of visual hallucinations. Nat Neurosci 1998;1:738-742. 5. Grof S, Realms of the human unconscious. Observations from LSD research. New York: Dutton; 1976. 6. Hughes MS, Lessell S. Trazodone-induced palinopsia. Arch Ophthalmol 1990;18:399-500. 7. Kanwisher N. McDermott J, Chun MM. The fusiform face area: a module in human extrastriate cortex specialized for face perception. J Neurosci 1997; 17:4302-4311. 8. Kinsbourne M. Warrington EK. A study of visual perseveration. J Neurol Neurosurg Psychiatry 1963, 26;468-475. 9. Klee A, Willanger R. Disturbances of visual perception in migraine. (Review) Acta Neurol Scan 1966; 42:400-414. 10. Michel EM, Troost BT. Palinopsia: Cerebral localization with computed tomography. Neurology 1980, 30:887-889. 11. Ungerleider LG, Haxby JV. "What" and "where" in the human brain. (Review). Curr Opin Neurobiol 1994; 4:157-165. 12. VanEssen DC, Felleman DJ, Deyoe EA, Knierim JJ. Probing the primate visual cortex: pathways and perspectives. In: Gulyas B, Ottoson D, Roland PE, editors. Functional organization of the human visual cortex. Oxford: Pergamon Press 1993; 29-41. 13. Young MP. Objective analysis of the topological organization of the primate cortical visual system. Nature 1992;358:152-155. 14. Zeki S, Watson JD, Lueck CJ, Friston KJ, Kennard C, Frackowiak RS. A direct demonstration of functional specialization in human visual cortex. J Neurosci 1991; 11:641-649.
Relation is Part of 926-4, 932-5, 939-4, 947-1
Contributor Secondary ; Shirley H. Wray, MD, PhD, FRCP, Professor of Neurology, Harvard Medical School; Director, Unit for Neurovisual Disorders, Massachusetts General Hospital; Ray Balhorn, Video Compressionist; Steve Smith, Videographer
Reviewer D. H. ffytche, BSc, MBBS MRCP. Institute of Psychiatry, London
Publisher Spencer S. Eccles Health Sciences Library, University of Utah
Date 1979
Type Image/MovingImage
Format video/mp4
Source 3/4" Umatic master videotape
Rights Management Copyright 2002. For further information regarding the rights to this collection, please visit:
Holding Institution Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E, SLC, UT 84112-5890
Collection Neuro-ophthalmology Virtual Education Library: NOVEL
Language eng
ARK ark:/87278/s6mp80ts
Setname ehsl_novel_shw
Date Created 2005-06-08
Date Modified 2017-11-27
ID 188502
Reference URL
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