Visual Disturbance as the Sole Presentation of Stroke

Introduction to Visual Disturbances in Stroke

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, according to the International Journal of Stroke guidelines 1, 2, 3

Monocular vision loss can be a manifestation of retinal ischemia, which is considered an ocular form of TIA or stroke, with a high risk of subsequent stroke events 3, 4
Binocular diplopia can indicate brainstem or cranial nerve involvement from stroke, suggesting a need for urgent evaluation 2
Hemianopsia suggests posterior cerebral artery territory involvement, which is a concerning sign for stroke risk 2

Patients presenting with isolated visual disturbances within 48 hours of symptom onset are considered at increased risk for stroke and should be urgently evaluated, as recommended by the International Journal of Stroke guidelines 1, 2
Patients with visual symptoms occurring between 48 hours and 2 weeks ago are considered at moderate risk for recurrent stroke, according to the International Journal of Stroke guidelines 2, 6

Urgent brain imaging and noninvasive vascular imaging should be completed within 24 hours for patients with acute visual symptoms, as recommended by the International Journal of Stroke guidelines 1, 2
MRI with diffusion-weighted imaging 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, highlighting the importance of prompt imaging 3

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, as recommended by the Ophthalmology guidelines 3, 4
For patients with central retinal artery occlusion presenting within 4.5 hours of symptom onset, intravenous thrombolysis may be considered, with a 50% rate of clinical recovery when treated within this timeframe, according to the Stroke guidelines 7
Secondary stroke prevention measures should be initiated, including antithrombotic therapy, statins for hyperlipidemia, and blood pressure control, as recommended by the Ophthalmology guidelines 4

Even if visual symptoms have resolved, patients should still undergo urgent stroke evaluation as they remain at risk for subsequent stroke, emphasizing the need for prompt assessment and management 3, 4