Title : Upside down words as initial clinical presentation of an underlying acute ischemic stroke
Abstract:
Background: Reversal of vision metamorphopsia is a transient form of metamorphopsia described as an upside-down alteration of the visual field in the coronal plane. Patients would describe objects, such as cups, upside down but the tea would not spill; and people would walk on their heads. It is extremely rare as a stable finding, lasting days or weeks. We report a case wherein this type of metamorphopsia occurred only in written words and lasting for six months.
Objective: To the best of our knowledge, we report the first rare occurrence reversal of vision metamorphopsia described as inverted words as the sole initial presentation of an underlying stroke.
Case Presentation: We report a 59-year-old male with poorly controlled hypertension and diabetes mellitus who presented with a 3-day history of difficulty of reading, described as the words were turned upside down, as if the words were inverted horizontally then with progression of deficits such as right homonymous hemianopia and achromatopsia, prosopagnosia. Cranial magnetic resonance imaging (MRI) revealed an acute infarct on the left posterior cerebral artery territory. Follow up after 6 months revealed improvement of the visual field cut but with persistence of the higher cortical function deficits.
Conclusion: We report the first rare occurrence metamorphopsia described as purely inverted words as the sole initial presentation of an underlying stroke. Stroke in the occipitotemporal areas should be included in the differential diagnoses of a patient presenting with text reversal metamorphopsia. It further expands the landscape of metamorphopsias due to its exclusivity to written words and prolonged duration. Knowing these clinical features will help in identifying the lesion locus and may improve subsequent stroke care, especially in time-bound management like intravenous thrombolysis.
Audience Take Away Notes:
- We report the first rare occurrence metamorphopsia described as purely inverted words as the sole initial presentation of an underlying stroke
- Stroke in the occipitotemporal areas should be included in the differential diagnoses of a patient presenting with text reversal metamorphopsia
- Knowing these clinical features will help in identifying the lesion locus and may improve subsequent stroke care, especially in time-bound management like intravenous thrombolysis
