Binocular Visual Loss Caused by Acute Cardioembolic Stroke(5)

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Binocular visual loss, acute visual loss, cardioembolic stroke, cerebral angiography, DSA, selective intraarterial thrombolysis, visual pathway infarction, posterior circulation stroke, occipital lobe infarction, cortical blindness, visual pathway ischemia, neuro-ophthalmology, emergency stroke imaging, interventional neuroradiology


PART 5 — QUIZ + ADVANCED INTERPRETATION

Binocular Visual Loss Caused by Acute Cardioembolic Stroke

QUIZ

Q1. A 43-year-old woman developed sudden deterioration of consciousness accompanied by acute binocular visual loss during percutaneous mitral balloon valvuloplasty. Digital subtraction angiography (DSA) revealed distal occlusion of both posterior cerebral arteries (PCAs). Which diagnosis best explains this patient’s clinical presentation?


A. Hemi-neglect

B. Paratonic rigidity
C. Urinary incontinence
D. Binocular visual loss
E. Verbal agnosia

Answer: D. Binocular visual loss. Explanation: Bilateral distal PCA occlusion → bilateral occipital lobe ischemia → damage to the primary visual cortex → cortical blindness → binocular visual loss

  • Pupillary light reflex: preserved

  • Funduscopic examination: normal

  • Sudden onset of visual loss

These findings are characteristic of typical cortical blindness.

Q2. Which of the following investigations is essential for the fastest and most accurate etiologic diagnosis in a patient presenting with acute binocular visual loss?


A. Fundus photography
B. Visual evoked potential
C. EEG
D. CT angiography + DSA
E. Fluorescein angiography

Answer: D. CT angiography + DSA. Explanation: Acute binocular visual loss strongly suggests vascular occlusion involving the occipital lobes or brainstem, making vascular imaging the top priority.

  • CTA: Rapid evaluation of large-vessel occlusion

  • DSA: Gold standard; enables simultaneous diagnosis and therapeutic intervention

Q3. Which factor is the most important prognostic determinant in cortical blindness caused by cardioembolic stroke?


A. Patient age
B. Hypertension
C. Time to reperfusion
D. Diabetes mellitus
E. Lesion laterality

Answer: C. Time to reperfusion. Explanation: “Time is brain, time is vision.”

The time elapsed until reperfusion is the single most critical determinant of visual recovery.

  • Within 2 hours → more than 80% chance of recovery

  • Beyond 6 hours → dramatic increase in risk of permanent blindness

REFERENCES

  1. Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke. Stroke, 2019;50(12):e344–e418.
  2. Powers WJ, et al. 2018 Guidelines for the early management of acute ischemic stroke. Stroke, 2018;49:e46–e110.
  3. Saver JL. Time is brain—quantified. Stroke, 2006;37:263–266.
  4. Rizzo JF, Lessell S. Cortical blindness. Ophthalmology, 1994;101(10):1778–1783.
  5. Broderick JP, et al. Endovascular therapy after intravenous t-PA versus t-PA alone. N Engl J Med, 2013;368:893–903.
  6. Goyal M, et al. Endovascular thrombectomy after large-vessel ischemic stroke. Lancet, 2016;387:1723–1731.
  7. Biousse V, Newman NJ. Neuro-ophthalmology of stroke. Lancet Neurol, 2015;14:1168–1180.
  8. Campbell BCV, et al. Imaging selection in ischemic stroke. N Engl J Med, 2015;372:1009–1018.


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