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Background
Our case highlights the importance of prompt assessment and investigations in patients presenting with 'red-flag' symptoms such as sudden-onset visual field loss, including urgent neuroimaging. It also stresses that antiphospholipid syndrome (APS) is relatively common (20-25%) in young patients with cerebrovascular disease.
Case presentation
A woman aged 26 years, a teaching assistant, was referred to the eye casualty by her GP with '24 hours of left homonymous hemianopia'. She reported of losing the left side of her vision for the past 1 day and a right-sided headache, consisting of fluctuations of sharp pain on a background of pain like a 'tight band' around her head.
The patient reported a similar week-long episode of left-sided visual field loss without headache 4 years ago, which spontaneously resolved and was never formally investigated. At presentation, she had been taking the combined oral contraceptive pill (COCP) and gabapentin.
Investigations
On examination, the patient had a blood pressure of 189/112 mm Hg, heart rate 77 bpm and no focal weakness was found. Eye examination revealed discomfort on movement for the left eye. Eye movements were otherwise full with no symptom of diplopia. Visual acuity and pupillary reflexes were normal with no relative afferent pupillary defect. Automated perimetry confirmed the left-sided homonymous hemianopia ( figure 1 ).
Urgent CT head scan performed the same day revealed a right-sided ischaemic parieto-occipital infarct.
Lumbar puncture was performed and the results were unremarkable. Magnetic resonance angiogram...