Reversible hemianopia and complex visual hallucinations-A case of non-ketotic hyperglycemia

A 65-year-old hypertensive and diabetic presented to the Emergency Department with a sudden onset of decreased vision, altered behavior, and elevated blood sugars without ketones, indicating non-ketotic hyperglycemia (NKH). Initial brain MRI was normal, but the patient later developed continuous motor and complex visual epileptic hallucinations along with left homonymous hemianopia. A repeat MRI [Figure 1a-d] showed subcortical T2, flair hypointense signals in the right striate and extrastriate occipital cortex, indicative of NKH. This was the reason for his visual hallucinations. Glycemic control and hydration led to normalized sugars and resolution of his symptoms. The MRI features possibly relate to reversible iron deposition in NKH.¹ Differential diagnoses such as meningoencephalitis, leptomeningeal metastases, venous infarct, and hypoxic damage were excluded through clinical and relevant investigation.

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Figure 1:

(a) Axial T2 weighted magnetic resonance imaging of brain demonstrating right occipital subcortical hypo intensities (yellow arrow), (b) Normal apparent diffusion coefficient map, (c) Fluid-attenuated inversion recovery, demonstrating abnormal hypointense signal changes seen involving both striate (white arrow) and extra striate cortex (orange arrow), (d) Normal diffusion weighted magnetic resonance imaging of brain.

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Occipital epilepsies are often missed in emergencies, but recognition of these subtle MRI changes in the right clinical context is critical for management, emphasizing glycemic control over escalating antiseizure medications.