Visual hallucination as presenting symptom for acute parieto-occipital cerebrovascular accident

Visual hallucinations are visual perceptions that are not associated with a real object. Visual hallucinations are often associated with dementia, eye disease, visual pathway disease, psychiatric disorders, delirium, migraines, ictal phenomena, or medication effects. We report a case of a 74-year-old woman with a previous cerebrovascular accident(CVA) without residual deficit and no previous psychiatric history presenting for one week of worsening hallucinations progressing from shapes to cats to human figures in the left visual field. She had no focal neurologic deficits nor visual field defects detected on physical exam. CT head without intravenous(IV) contrast demonstrated a nonspecific hypodensity in the right parieto-occipital region. MRI brain with and without IV contrast confirmed an acute stroke. Patient was admitted for risk factor modification and secondary prevention. She continues to have infrequent hallucinations of floating hands and fingers at follow-up appointment 2 weeks after the initial presentation to the Emergency Department. Posterior circulation CVAs can present with subtle or unusual symptoms. CVA should be included in the differential for new onset hallucinations, particularly in elderly patients.