Clinical Reasoning: a woman with recurrent aphasia and visual field defects

A 73-year-old woman with a history of hypertension and a recent stroke presented with recurrent nonsensical speech and visual problems. One month prior, she had been diagnosed with a stroke, after sudden-onset speech and visual difficulties that resolved after a few hours. Thirteen days before, she had had a second episode of similar symptoms. She was seen in our institution after a few hours of sudden-onset unintelligible speech. Her vital signs were within normal limits. She was not in distress, but appeared frustrated. Her general physical examination was unremarkable. She had no carotid, ophthalmic, or cranial bruits. Her neurologic examination was notable for fluent aphasia, with paraphasic errors and inability to name, read, or write. She also had right homonymous hemianopia, right-sided sensory loss, and generalized brisk deep tendon reflexes. The rest of her neurologic examination showed no abnormalities.