Can a patient with stroke present with only visual disturbance?

Visual Disturbance as the Sole Presentation of Stroke

Yes, patients with stroke can present with isolated visual disturbances as their only symptom, and these patients should be evaluated urgently as they are at increased risk for subsequent stroke events. 1

Types of Visual Disturbances in Stroke

• Monocular vision loss (transient or permanent) can be a manifestation of retinal ischemia, which is considered an ocular form of TIA or stroke 1
• Binocular diplopia can indicate brainstem or cranial nerve involvement from stroke 1, 2
• Hemianopsia (loss of half of the visual field) suggests posterior cerebral artery territory involvement 1, 2
• Visual disturbances without other neurological symptoms are specifically mentioned in stroke guidelines as potential stroke presentations 1

Risk Stratification for Patients with Isolated Visual Symptoms

• Patients presenting with isolated visual disturbances within 48 hours of symptom onset are considered at increased risk for stroke and should be urgently evaluated 1
• Patients with visual symptoms occurring between 48 hours and 2 weeks ago are considered at moderate risk for recurrent stroke 1
• Visual symptoms including monocular vision loss, binocular diplopia, and hemivisual loss are specifically mentioned in guidelines as concerning for stroke risk 1

Diagnostic Approach

• Urgent brain imaging (CT or MRI) and noninvasive vascular imaging (CTA or MRA from aortic arch to vertex) should be completed within 24 hours for patients with acute visual symptoms 1
• MRI with diffusion-weighted imaging (DWI) is particularly valuable, as studies have shown that 11.8% to 30.8% of patients with transient monocular visual loss have evidence of acute cerebral infarctions on DWI-MRI 1
• For patients with retinal arterial occlusions (central or branch), DWI-MRI abnormalities are found in 27% to 76.4% of cases, indicating concurrent cerebral infarctions 1

Management Recommendations

• Patients with acute visual disturbances suspected to be vascular in origin should be immediately referred to the closest emergency department affiliated with a stroke center 1
• For patients with central retinal artery occlusion (CRAO) presenting within 4.5 hours of symptom onset, intravenous thrombolysis may be considered, as observational data shows a 50% rate of clinical recovery when treated within this timeframe 1
• Secondary stroke prevention measures should be initiated, including antithrombotic therapy, statins for hyperlipidemia, and blood pressure control 1

Common Pitfalls and Caveats

• Visual disturbances are often overlooked as potential stroke symptoms, with studies showing they are among the most common symptoms in stroke patients not correctly identified by emergency medical services 3
• Adult stroke screening tools like FAST (Face, Arms, Speech, Time) may miss strokes presenting with isolated visual symptoms 1, 3
• Visual disturbances can have many non-stroke causes, so ophthalmologic evaluation is important to differentiate vascular from non-vascular etiologies 1
• Even if visual symptoms have resolved (transient monocular vision loss), patients should still undergo urgent stroke evaluation as they remain at risk for subsequent stroke 1

Conclusion

Isolated visual disturbances can indeed be the sole manifestation of stroke or TIA and should be taken seriously. Current guidelines specifically recognize visual symptoms as potential stroke presentations and recommend urgent evaluation and management to prevent subsequent, potentially more devastating stroke events 1.