Waragai M, Takaya Y, Hayashi M
Department of Neurology, Kofu City Hospital, Yamanashi, Japan.
No To Shinkei. 1996 Apr;48(4):371-6.
We report a patient who presented with complex visual hallucinations in the right hemianopic field following an infarction in the left occipitotemporal base. A 73-year-old right-handed woman developed right homonymous hemianopia. A week after its onset, she noticed a strange man with glasses, or a man wearing a gray hat and a black coat standing in the defective visual field. Such visual images later included a nurse, a large hand extending from the right side to the center, and many pieces of cloth descending from the roof. Most of these objects were unfamiliar to her, but may have been related to previous experiences. Her hallucinations were usually black and white singular and motionless, and sometimes consisted of multiple identical replications of objects. All of the hallucinations vanished when the patient tried looking directly at them. An EEG failed to showed any epileptic discharges. T1-weighted MRI with gadolinium-DTPA performed nine days after the onset revealed a localized high-signal-intensity region suggesting an infarction around the left collateral sulcus that included part of the lingual gyrus and the fusiform gyrus. 123I-IMP SPECT showed hypoperfusion of the left occipitotemporal base. The hallucinations gradually resolved a month after the onset, but the right homonymous hemianopia persisted. The enhanced lesion on T1-weighted images was no longer visible on MRI performed a month after the onset but, remained high-intensity on the T2-weighted images. There have been reports of complex visual hallucinations in hemianopic fields, but there have been only a few reports in which the responsible lesion was discussed on the basis of the CT and MRI findings. The findings in our patient suggest that lesions of the occipitotemporal base are one of the possible causes of this symptom. Taken together with earlier reports, not only pure release phenomena but irritative phenomena in the association visual cortex may be involved in the complex visual hallucinations in the hemianopic field, as Lance and Kölmel suspected.
我们报告一名患者，其在左侧枕颞底部梗死之后，右侧偏盲视野中出现复杂的视幻觉。一名73岁右利手女性出现了右侧同向性偏盲。发病一周后，她注意到一个戴眼镜的陌生男子，或者是一个戴着灰色帽子、穿着黑色外套的男子站在缺损的视野中。这样的视觉影像后来还包括一名护士、一只从右侧伸向中央的大手，以及许多从屋顶飘落的布料。这些物体大多她并不熟悉，但可能与既往经历有关。她的幻觉通常是黑白的、单一且静止的，有时由物体的多个相同复制品组成。当患者试图直视这些幻觉时，它们都会消失。脑电图未显示任何癫痫放电。发病九天后进行的钆喷酸葡胺增强T1加权磁共振成像显示，左侧侧副沟周围有一个局限性高信号强度区域，提示梗死，累及舌回和梭状回的一部分。123I-异碘安非他明单光子发射计算机断层扫描显示左侧枕颞底部灌注不足。幻觉在发病一个月后逐渐消退，但右侧同向性偏盲仍持续存在。发病一个月后进行的磁共振成像中，T1加权图像上的强化病灶已不可见，但在T2加权图像上仍为高强度。已有关于偏盲视野中出现复杂视幻觉的报道，但仅有少数报道根据CT和磁共振成像结果讨论了责任病灶。我们患者的发现提示，枕颞底部病变是该症状的可能病因之一。与早期报道一起考虑，如兰斯和科尔梅尔所怀疑的，不仅纯粹的释放现象，而且联合视觉皮层的刺激性现象可能都与偏盲视野中的复杂视幻觉有关。
