Imagery without perception--a case study of anosognosia for cortical blindness

A patient with complete cortical blindness after bilateral posterior cerebral artery infarctions denied her blindness. Her pretended visual experiences could frequently be traced back to synaesthetic translations of acoustic or tactile perceptions into mental visual images. Possibly, the belief to see resulted from a confusion of mental visual images with real percepts. The patient manifested preserved visual imagery also by correct responses to questions concerning the shapes of letters and the shapes and colours of objects. MRI showed an almost complete destruction of primary visual cortex with sparing of only small remainders of cortex at the occipital tip of the left upper calcarine lip. In the literature there are a few cases of denial of blindness with similarly severe damage to primary visual cortex but none with unequivocal evidence of complete destruction of primary visual cortex. We conclude that severe damage to primary visual cortex is compatible with visual imagery but that there is a possibility that islands of visual cortex must be spared to permit the generation of mental visual images.