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62 year old male with left occipital stroke

  • 1.  62 year old male with left occipital stroke

    Posted 09-16-2025 22:25
    Seeking your advice and education on this patient

    This is one of my optometrists that works for me. He is a 62 year old white male, not a hypertensive,not a diabetic, who experienced a left sided headache about 10 days ago, went to bed, and the next morning woke up and had trouble processing words, couldn't really say certain words, even though he could read the letters. Ended up at ER with diagnosis of left occipital hematoma after MRI brain. CTA head and neck normal, echocardiogram normal, cholesterol 200 so now on a statin. No history of thromboses. Visual acuity has been fine, not on any other meds, i think they gave him a low dose antihypertensive med

    Exam today
    1. Formal visual field shows right homonymous vf defect just right of midline, left side a little more dense than the right, but confined to the right of central about 5 degrees. Decibel loss about 4-8 decibels.
    2. Visual acuity normal, color vision normal, stereo vision normal , normal saccades and pursuit. 
    3. When he looks at a word, like the word "middle" ,he has to point with his fingers the individual letters m,i, d,d and says them, but the letters "le" he doesn't see right away. He describes it as seeing certain objects in front of him but doesn't see all of the objects in his view. He can name objects fine, it is the reading he has difficulty with,

    This type of finding is new to me. I am calling it visual agnosia, (not sure if i am correct)

    My questions:
    1. What should i tell him the expected recovery time wise to be?
    2. Should he expect full recovery?
    3. What work up should I do? I ordered esr, CRP, hypercoagulable work up and SPEP.
    4. Not sure how soon he will get to see neurology
    5. They don't know what caused the stroke, no aneurysm on angiogram

    Hopefully I have given enough information to you all.

    Thank you very much
    --

    Robert Bellinoff, MD

    Division Head, Eye Department, Mercy Medical Group

    Site Medical Director of Midtown Medical and Surgical Specialties

     

    Mercy Medical Group

    3000 Q Street

    Sacramento, CA 95816

    (916) 733-3311 (O)

    (916) 733-3307 (F)

     

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  • 2.  RE: 62 year old male with left occipital stroke

    Posted 09-16-2025 22:53
    Is his writing grammatically correct?




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  • 3.  RE: 62 year old male with left occipital stroke

    Posted 09-16-2025 23:01
    Yes, i just asked him to write down a few things--

    Robert Bellinoff, MD

    Division Head, Eye Department, Mercy Medical Group

    Site Medical Director of Midtown Medical and Surgical Specialties

     

    Mercy Medical Group

    3000 Q Street

    Sacramento, CA 95816

    (916) 733-3311 (O)

    (916) 733-3307 (F)

     

    Caution: This email is both proprietary and confidential, and not intended for transmission to (or receipt by) any unauthorized person(s). If you believe that you have received this email in error, do not read any attachments. Instead, kindly reply to the sender stating that you have received the message in error. Then destroy it and any attachments. Thank you.



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  • 4.  RE: 62 year old male with left occipital stroke

    Posted 09-16-2025 23:12
    Sounds like alexia without agraphia syndrome. Perhaps the visual cortex became disconnected from the angular gyrus by the hematoma




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  • 5.  RE: 62 year old male with left occipital stroke

    Posted 09-17-2025 06:09
    I am sure the hematoma extends anteriorly to the splenium from your description and I would simply have him Write a few sentences and ask him to read what he just wrote. When he can't, you will have your diagnosis.



    Sent via the Samsung Galaxy S21 5G, an AT&T 5G smartphone




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  • 6.  RE: 62 year old male with left occipital stroke

    Posted 09-17-2025 11:19
    My answers( I am no great authority on it , answering because you asked :)- all of us)
    1. What should i tell him the expected recovery time wise to be?- Depends on the cause of haemorrhage/ hematoma.BTW -no h/o a fall or head trauma that he doesn't remember?
    If it was a missed aneurysm on the CTA, I suppose it will take a couple of months to clear the hematoma. But if there's a progressive cause like vasculitis , it's going to brew and blast.
    2. Should he expect full recovery?-to some extent but again depends on the cause
    3. What work up should I do? I ordered esr, CRP, hypercoagulable work up and SPEP.
    Vasculitis work up and if negative a cerebral angiogram
    4. Not sure how soon he will get to see neurology- Hmm
    5. They don't know what caused the stroke, no aneurysm on angiogram- Vasculitis work up and if negative a cerebral angiogram


    ------------------------------
    Shikha
    ------------------------------

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  • 7.  RE: 62 year old male with left occipital stroke

    Posted 09-17-2025 11:27
    Posterior hemispheric hemorrhage almost always puts Amyloid Angiopathy in differential dx in his age  group




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  • 8.  RE: 62 year old male with left occipital stroke

    Posted 09-17-2025 11:56


    Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu) should also be in the differential diagnosis.  I cared for one patient with HHT and occipital hemorrhage in whom the diagnosis wasn't made until he was well into his sixties.

    I'd suggest:
    1)  Inquiring about a family history of bleeding disorders.
    2)  Asking the patient about frequent nosebleeds.
    3)  Examining the face, lips, and tongue for reddish-purple spots and/or telangiectasias

    Steve

    Stephen C. Pollock, M.D.






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  • 9.  RE: 62 year old male with left occipital stroke

    Posted 09-17-2025 19:42
    Thank you all for your valuable input regarding this patient's case. I wanted to provide an update based on further evaluation.

    Firstly, there is no history to suggest hereditary hemorrhagic telangiectasia in this patient, which addresses one of the excellent points raised.

    I brought the patient back in today for a follow-up. He is able to write, but continues to experience difficulty with reading. He finds it necessary to spell out certain words before he can vocalize them.

    I also had the radiologist review the MRI, and they did not identify any involvement of the splenium, however as has been mentioned, the splenium is responsible for the symptoms we are seeing. We plan to repeat the MRI in approximately four months for further assessment. Additionally, there was no evidence of an aneurysm or amyloid angiopathy found in the imaging studies. We are currently awaiting the results of blood tests for vasculitis.

    The patient will be commencing rehabilitation therapy shortly. This is indeed my first time encountering a patient with alexia without agraphia, and I truly appreciate all the insights shared.

    Again, thank you all for your contributions.

    bob

    Robert Bellinoff, MD

    Division Head, Eye Department, Mercy Medical Group

    Site Medical Director of Midtown Medical and Surgical Specialties

     

    Mercy Medical Group

    3000 Q Street

    Sacramento, CA 95816

    (916) 733-3311 (O)

    (916) 733-3307 (F)

     






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  • 10.  RE: 62 year old male with left occipital stroke

    Posted 09-17-2025 20:09
    I wonder whether a neuroquant volumetric mri might be employed for that planned 4-month follow-up study to see whether there is the expected damage to the splenium or others areas that might currently be obscured by edema and hemorrhage. 



    Sent via the Samsung Galaxy S23 Ultra 5G, an AT&T 5G smartphone
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  • 11.  RE: 62 year old male with left occipital stroke

    Posted 09-17-2025 20:28
    Look at extension of edema/heme/ischemia into the left fusiform area- in our study we found majority had left fusiform gyrus lesions rather than the disconnection lesion in splenium.


    Shapiro JN, Sharma A, Trobe JD, Walsh RD, Khanna S. Brain MRI Lesions in Alexia Without Agraphia: A Case-Control Study. J Neuroophthalmol. 2024 Nov 25;45(3):316-320. doi: 10.1097/WNO.0000000000002263. PMID: 39582117.

    S



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  • 12.  RE: 62 year old male with left occipital stroke

    Posted 09-18-2025 15:52

    Hi All,

    I am caring for a 23YO college student who suffered a severe TBI 2 yrs ago.  He has made great strides in rehab, but suffers from lingering alexia w/o agraphia.

    My question to the group – what specific therapies help to rehabilitate alexia, and what kind of therapist offers them?  

    Thank you, Jane

    -------

    JANE C. EDMOND, M.D.

    Professor & Chair,  Department of Ophthalmology

    Wong Family Distinguished University Chair

    Director, Mitchel and Shannon Wong Eye Institute

    Interim Vice Dean for Professional Practice

    Past President, American Academy of Ophthalmology


    Dell Medical School  |  The University of Texas at Austin 

     




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  • 13.  RE: 62 year old male with left occipital stroke

    Posted 09-18-2025 17:14
    Hello,

    I agree that this is alexia without agraphia from a left occipital stroke and this is typically described after ischemic stroke and not hemorrhage but that is splitting hairs.  I would ask the radiologist to make sure there is no vascular malformation in the area of hemorrhage and he may need follow up imaging to make sure that he is not at risk for more hemorrhage.  If this is amyloid angiopathy then he should have up to 3 different radiographic findings including the lobar hemorrhage which are other microhemorrhages and superficial siderosis.  

    Prognosis for recovery in my experience is a little better with ICH than ischemic stroke but not that much better so you may be able to suggest that.  Now unfortunately you get to have the conversation about driving...

    Robert




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  • 14.  RE: 62 year old male with left occipital stroke

    Posted 09-17-2025 20:20
    What you describe is Alexia without Agraphia which is seen with left sided lesions (occipital temporal) affecting left fusiform gyrus  in addition to left occipital or splenium in addition to left occipital. 

    It is an agnosia but visual word form.
    May get better with time.
    That is rather hard for the patient - harder than just hemianopia related reading difficulties.

    Sangeeta 





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