Headache and Visual Deficits: Ironing Out the Details

A 67-year-old woman with hypertension, hyperlipidemia, and diabetes developed posterior-predominant, non-positional headaches associated with nausea and vomiting. Two weeks after headache onset, she developed significant visual hallucinations. She described seeing "graphics," consisting of formed and unformed images and words coming and going throughout her field of vision. She noticed that faces looked distorted, but she did not have difficulty recognizing familiar people. She could not read the time on a clock or use her phone despite being able to see both. She had difficulty navigating unfamiliar settings, needing to hold onto walls or furniture to get around. She denied frank vision loss or double vision. She denied recent fever, rash, insect bites, unintentional weight loss, night sweats, or fatigue. Examination demonstrated normal level of arousal, comprehension, fluency of speech, repetition, reading, and writing. Visual acuity and color vision were normal. Visual field testing demonstrated a dense, congruous, left homonymous hemianopsia. She had impaired visual search within the intact field, but naming of visually presented objects was normal. On the Navon figure, she described the local elements but not the global form. She did not demonstrate left-sided neglect for tactile stimuli or with line cancellation testing. Pupils were equal and briskly reactive, with no relative afferent pupillary defect. Slit lamp and funduscopic exam were unremarkable. Efferent exam was normal. Cranial nerve, motor, sensory, cerebellar and gait exams were normal. Reflexes were 2+ and symmetric throughout, except the left plantar response was extensor.