Hemorrhagic Intracranial Cavernoma Presenting as a Homonymous Horizontal Sectoranopia

Photo and Video Essay Section Editors: Melissa W. Ko, MD Dean M. Cestari, MD Peter Quiros, MD Hemorrhagic Intracranial Cavernoma Presenting as a Homonymous Horizontal Sectoranopia Fiona E. Costello, MD, FRCPC, Yves P. Starreveld, MD, PhD, FRCPS FIG. 1. Cranial MRI scan showing a hemorrhagic cavernoma in the right temporal lobe, including: (A) T1 axial post-gadolinium, (B) axial fluid-attenuated inversion recovery sequence (FLAIR), (C) T1 sagittal post-gadolinium, and (D) T1 coronal post-gadolinium images. Abstract: Hemorrhagic lateral geniculate nucleus (LGN) insults are rare but have been reported in association with tumors, vascular malformations, and trauma. The localization of LGN lesions is facilitated by recognition of pathognomonic visual field defects. A 21-year old woman developed a sudden onset painless left homonymous horizontal sectoranopia. Magnetic resonance imaging revealed a hemorrhagic cavernous malformation of the right temporal lobe. Optical coherence tomography (OCT) and Humphrey perimetry findings localized the lesion to the right LGN. Specifically, OCT testing revealed Departments of Clinical Neurosciences (FEC) and Surgery (YPS), Cumming School of Medicine, University of Calgary, Calgary, Canada. The authors report no conflicts of interest. Address correspondence to Fiona E. Costello, MD, FRCPC, Foothills Medical Centre, Clinical Neurosciences 12th Floor, 1403-29th Street SW, Calgary, AB T2N 2T9, Canada; E-mail: [e-mail] Costello and Starreveld: J Neuro-Ophthalmol 2021; 41: e225-e227 a right homonymous sectoranopia pattern of hemi-retinal macular ganglion layer-inner plexiform layer (mGCIPL) thinning contralateral to the left sided visual field defect. The OCT pattern reflected retrograde neuroaxonal degeneration from the right LGN lesion. This case highlights a unique pattern of mGCIPL thinning characteristic for a posterior lateral choroidal artery injury, affecting the LGN. These findings illustrate how functional eloquence correlates with topographical elegance in the afferent visual pathway. Journal of Neuro-Ophthalmology 2021;41:e225–227 doi: 10.1097/WNO.0000000000001014 © 2020 by North American Neuro-Ophthalmology Society A previously well, 21-year-old woman presented with a history of acute, painless vision loss “in the left eye,” lasting 24 hours. Initially, the patient assumed she had a migraine and did e225 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Photo and Video Essay FIG. 2. A. Humphrey perimetry 30-2 central threshold testing demonstrated a congruous left horizontal sectoranopia. B. Spectral domain optical coherence tomography (OCT) ganglion layer analysis (macular cube 200 · 200 testing) showed a congruous pattern of right hemi-retinal thinning in both eyes (arrows), corresponding to the left-sided visual field defect. C. The fundus examination revealed normal appearing optic nerves, with no features of optic disc edema or band atrophy. not seek medical attention. Notably, she lacked a previous history of migraine, and she also denied headache, nausea, phonophobia, or light sensitivity in association with her vision loss. After her symptoms persisted for 24 hours, she presented to a local emergency department. On further inquiry, she described difficulty seeing the left side of people’s faces and not being able to read the beginning of sentences. Her neurological examination was normal except for the finding of a left homonymous hemianopsia, detected with confrontation testing. Owing to concerns about a focal intracranial lesion, an urgent cranial CT scan was arranged, which revealed a hemorrhagic lesion in the right temporal lobe. The patient was subsequently admitted to the inpatient neurosurgical service for additional investigations. A cranial MRI study demonstrated intralesional hemorrhage within a cavernoma of the right mesial temporal lobe, with associated perilesional edema (Fig. 1). One month later, the patient was evaluated in the neuroophthalmology clinic to check for interval resolution of her visual field defect. On examination, blood pressure was 120/70 mm Hg, heart rate was 70 beats per minute (regular), and she was afebrile. Best-corrected visual acuity (Snellen equivalent) was 20/ 20 in both eyes. Pupils measured 6 mm in darkness constricting to 3 mm in bright light, with no relative afferent pupil defect. Ocular motility showed normal ocular ductions and versions, with no nystagmus or ocular misalignment. Intraocular pressures were 14 mm Hg in each eye with applanation tonometry. Color vision was within normal limits, and the patient identified 10/10 Hardy Rand and Rittler pseudoisochromatic plates with each eye. Humphrey perimetry 30-2 central threshold testing demonstrated a congruous, left homonymous horizontal sectoranopia (Fig. 2). The fundus examination revealed normal appearing optic nerves, with no features of optic disc edema or band atrophy (Fig. 2). Spectral domain optical coherence tomography (OCT) ganglion layer analysis (macular cube 200 · 200 testing) e226 showed a congruous pattern of right hemi-retinal macular ganglion layer–inner plexiform layer (mGCIPL) thinning in both eyes (Fig. 2), corresponding to the left homonymous horizontal sectoranopia visual field defect. The remaining details of the neurological examination were normal. In this case, the pathognomonic visual field defect, corresponding homonymous pattern of hemi-retinal mGCIPL thinning, and MRI lesional characteristics localized the afferent visual pathway lesion to the right lateral geniculate nucleus (LGN). 2Hemorrhagic lesions of the LGN are quite rare, representing only 1 in 2,763 cerebral hemorrhage cases enrolled in a stroke registry, with data captured over a decade-long period (1). The most commonly reported causes of hemorrhage in this anatomical region include tumors, vascular malformations, and trauma (1–5). A variety of visual field abnormalities have been attributed to LGN lesions, including relative defects, incongruous homonymous defects, and even monocular patterns of visual field loss (4); yet, the classic homonymous horizontal and quadruple sectoranopias, associated with lateral and anterior choroidal infarcts, respectively, are strongly associated with vascular lesions of the LGN. In the case presented, the hemorrhagic cavernoma manifested with a left homonymous horizontal sectoranopia, with features consistent with a posterior lateral choroidal artery insult, or what Frisen referred to as a “lateral choroidal artery syndrome” (4). As a relatively novel reported finding, OCT testing revealed a homonymous “sectoranopia” pattern of hemi-retinal mGCIPL thinning, ipsilateral to the LGN Lesion, and contralateral to the visual field defect. The OCT pattern reflected retrograde neuroaxonal degeneration in the afferent visual pathway that was evident 1 month after the symptom onset. The extent of neuroaxonal injury caused by the LGN lesion will likely determine the potential, or lack thereof, for visual recovery. This case highlights a unique Costello and Starreveld: J Neuro-Ophthalmol 2021; 41: e225-e227 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Photo and Video Essay pattern of mGCIPL thinning that localizes lesions to the LGN. Moreover, the findings illustrate how functional eloquence (visual field loss) correlates with topographical elegance (OCT measured neuroaxonal structure), in the afferent visual pathway. STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: F. E. Costello and Y. P. Starreveld; b. Acquisition of data: F. E. Costello and Y. P. Starreveld; c. Analysis and interpretation of data: F. E. Costello and Y. P. Starreveld. Category 2: a. Drafting the manuscript: F. E. Costello and Y. P. Starreveld; b. Revising it for intellectual content: F. E. Costello. Category 3: a. Final approval of the completed manuscript: F. E. Costello and Y. P. Starreveld. Costello and Starreveld: J Neuro-Ophthalmol 2021; 41: e225-e227 REFERENCES 1. Tokida H, Kanaya Y, Shimoe Y, Yamori S, Tagawa K, Kuriyama M. Lateral geniculate body presenting only hemorrhage homonymous hemianopia-a case report. 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