Sudden darkness, silent infarction: a case of bilateral painless visual loss in otherwise healthy patient

Abstract Background Acute bilateral painless visual loss is an uncommon presentation and poses a significant diagnostic challenge. Without overt neurological deficits or significant vascular risk factors, stroke may not be the initial consideration. However, infarctions in the occipitoparietal regions can result in profound visual impairment, despite normal early CT head findings. Case presentation We present the case of a 59-year-old male with no known comorbidities who developed acute bilateral painless visual loss, reducing his vision to hand motion in one eye and finger counting at 30 cm in the other. His neurological and ophthalmological examinations were otherwise unremarkable, and initial CT head and cerebral CT angiography were normal. Due to the absence of vascular risk factors and normal early neuroimaging, bilateral retrobulbar neuritis was suspected. However, a delayed MRI obtained the next day revealed bilateral occipitoparietal ischemic infarctions. The patient was treated with dual antiplatelet therapy and statins. He showed slight improvement in visual acuity, although significant deficits remained. Conclusion This case highlights the importance of considering posterior circulation strokes in patients with acute bilateral painless visual loss, even in the absence of traditional stroke risk factors. It emphasizes the role of advanced neuroimaging, particularly MRI, in diagnosing cortical strokes when initial CT head is unremarkable.