Phantom Visions in the Dark: Ictal hallucinations and postictal homonymous hemianopsia
Abstract number :
3.283
Submission category :
4. Clinical Epilepsy / 4B. Clinical Diagnosis
Year :
2025
Submission ID :
418
Source :
www.aesnet.org
Presentation date :
12/8/2025 12:00:00 AM
Published date :
Authors :
Presenting Author: Sahibjot Saini, DO – Michigan State University/UMH-Sparrow
Serena Soleimani, DO – Michigan State University/UMH-Sparrow
Vikram Dhillon, DO – Michigan State University/UMH-Sparrow
Abdulaziz Al-Abdulghani, MD – Michigan State University/UMH-Sparrow
Abdullah Alshammaa, MD – Michigan State University/UMH-Sparrow
Rationale: To describe an atypical presentation of occipital lobe seizures.
Methods: Clinical case study presentation.
Results: A 70-year-old male with diabetes, hypertension, hyperlipidemia, coronary artery disease and remote history of treated malaria infection presented to the ER with acute onset transient visual disturbances along with persistent headache ongoing for one week and imbalance for one day. Visual changes were noted in both eyes and characterized as colorful, criss-crossed lines in the left half of his visual fields; lasting seconds up to a minute and occurring numerous times per day. His headache was described as a holocephalic, throbbing headache with photophobia. Family also noted insidious cognitive decline over 1-2 years. Neurological exam revealed a left homonymous hemianopsia (LHH), overlapping with the area of the patient's visual disturbances. Labs were significant for glucose 419 with unremarkable UA, CBC, CMP. CT Head without contrast showed no acute process with global cerebral atrophy. MRI Brain with/without contrast showed diffuse cortical microhemorrhages, confluent white matter disease and right occipital subcortical T2 FLAIR hypointensity (Fig. 1, left). EEG revealed seizures arising from the right occipital region which coincided with the patient's visual disturbances, proving them to be an epileptic phenomenon (Fig.2). The transient visual symptoms resolved after the patient was started on 2 anti-seizure medications with gradual improvement of his LHH and full resolution after 1 month. Follow-up MRI Brain showed resolution of right occipital subcortical T2 FLAIR hypointensity (Fig 1, right).
Conclusions: We present an atypical case of occipital lobe epilepsy with ictal hallucinations and postictal visual fields suppression. The patient’s initial presentation and MRI findings were concerning for an ischemic stroke with subsequent development of Charles Bonnet syndrome; however, an ischemic stroke would not demonstrate resolution of T2 FLAIR signal changes on repeat MRI. Additionally, migraines with visual aura can also present with similar features, though the persistence of visual hallucinations and homonymous visual field defects would be unusual particularly following headache resolution. EEG conclusively demonstrated electroclinical right occipital lobe seizures corresponding with the patient’s visual disturbances. This case demonstrates an unusual presentation of occipital lobe seizures, with visual hallucinations in the left visual field, and subsequent postictal visual field deficit akin to postictal Todd’s paralysis. Of note, the patient’s clinical symptoms and MRI findings resolved following initiation of ASMs.
Funding: No relevant sources of funding to report.
Clinical Epilepsy