A young woman with severe bilateral visual loss and putaminal infarcts

A 19-year-old woman was referred with poor vision in each eye. Two years previously, while living in Bangladesh, she had woken up feeling very unwell and confused. She vomited several times and her parents took her to a local emergency department. While there she could not see well in either eye and this progressed throughout the day. MR scan of the brain and orbits with contrast showed acute bilateral putaminal infarcts but no white matter lesions; the anterior visual pathway appeared normal and did not enhance with contrast. An extensive stroke work-up was normal, including CT angiogram from aortic arch to the vertex, Holter ECG monitoring and transthoracic echocardiogram. Serum neuromyelitis optica antibody titres were normal. She was presumed to have bilateral optic neuritis and treated with intravenous methylprednisolone (1 g daily for 3 days), followed by a long oral prednisone taper. Her vision subsequently improved only slightly.

On current examination, her visual…

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