Acute Stroke: writes but cannot read

The patient is a 63 year old right handed woman with history of hypertension and non-insulin dependent diabetes mellitus, who complained of episodic right arm parasthesia and inability to read.

On neurologic examination, she was an alert, oriented middle-aged woman. She had a fluent anomic aphasia (occasional word-finding difficulty and paraphasias, intact repetition). She could write a grammatically complex sentence, but was unable then to read it back. She had difficulty recognizing some letters of the alphabet, but if she could spell out the individual letters verbally, she had no difficulty in recognizing the word, i.e., alexia without agraphia. She had hemi-achromatopsia (loss of color vision) in the right visual field, and a right homonymous superior quadrantanopsia. There was a very mild right pronator drift but otherwise normal motor exam, and a slight decrease in pinprick perception in the right hemibody. She had symmetric reflexes and flexor plantar responses.

Initial work-up included a CT demonstrating a medial left occipital infarct involving the left side of the splenium of the corpus callosum. Cardiac workup was normal and MR angiogram revealed only mild narrowing of the left posterior cerebral artery. Despite anticoagulation and increased BP, the patient progressed to a complete right homonymous hemianopsia, with a mild right hemiparesis, and right hemibody sensory abnormalities. She developed a mild anomic aphasia in addition to continued alexia without agraphia. Subsequent imaging with MR revealed extension of the infarct into the left posterior cerebral artery territory.

Some details have been altered to protect confidentiality.
Keith A. Johnson (, J. Alex Becker (