Occipital Lobes

Seminar 11-11-2009
Lakshya J. Basumatary, M.D. DM (Neurology) Trainee
Association areas
Redrawn from Geschwind N: Specializations of
the human brain. Sci Am 241:180, 1979.
 Blood supply
• Posterior cerebral arteries (PCA)
• "fetal" posterior cerebral artery
• Inferior division of the middle cerebral artery
(parietotemporal branch)
• Posterior callosal branch of Anterior cerebral
artery (ACA)
MRA
Superior sagittal sinus

IJV

Hanaway, J, et al: The

Brain Atlas: 1998, p
28.
 Clinical Effects of Occipital Lobe Lesions

• Visual Field Defects

• Cortical Blindness
• Visual Anosognosia (Anton Syndrome)
• Visual Illusions (Metamorphopsias)
• Visual Hallucinations
 The Visual Agnosias

• Visual Object Agnosia

• Visual Simultanagnosia
• Balint Syndrome
• Prosopagnosia
• Visual Agnosia for Words (Alexia Without
Agraphia)
Visual agnosia Vs Amnesic aphasia
– Description of the use of the Object
– Hesitancy and uncertainity
• Color Agnosia
Color naming defect Vs Amnesic aphasia
immediate cognizance
acceptance
 Eye fixation & movement abnormalities

• Psychovisual reflexes
– Fixation reflex
– Optically elicited fixation movement
– Follow movement
– Convergence/divergence
– Corrective fusional movements (Holmes 1938)
 Visual memory,visualization and the visual
elements of dream
Charcot-Wilbrand syndrome
visual agnosia
loss of visualization
loss of visual elements in dreaming
 Effects of unilateral disease, either right or left

A. Contralateral (congruent) homonymous

hemianopia, which may be central (splitting
the macula) or peripheral; also homonymous
hemiachromatopsia
B. Elementary (unformed) hallucinations—
usually because of irritative lesions
 Effects of left occipital disease

A. Right homonymous hemianopia

B. If deep white matter or splenium of corpus

callosum is involved, alexia and color-naming
defect (optic aphasia for color)

C. Visual object agnosia

 Effects of right occipital disease

A. Left homonymous hemianopia

B. With more extensive lesions, visual illusions

(metamorphopsias) and hallucinations (R>>L)

C. Loss of topographic memory and visual

orientation
 Bilateral occipital disease

A. Cortical blindness (pupils reactive)

B. Anton syndrome (visual anosognosia, denial of
cortical blindness)
C. Loss of perception of color (achromatopsia)
D. Prosopagnosia (bilateral temporooccipital
including fusiform gyrus), simultanagnosia
(parietooccipital)
E. Balint syndrome (bilateral dorsal [high]
parietooccipital)
 Anton's syndrome
Anton-Babinski, or denial visual hallucination
syndrome; cortical blindness with denial
 The Balint (Balint-Holmes) syndrome
• “psychic” impairment of visual fixation and
alterations in visual attention.
• optic ataxia
• optic apraxia
• The patient can see only one object and
cannot move his eyes from it, but he
cannot reach out and take it.
• Bilateral parietooccipital lesions.
 Cortical blindness Vs Hysteria

Menace reflex
Optokinetic Reflex
Blink Reflex
EEG
Associated Neurologic deficit
 Tests for Occipital lobe disorders

Color naming,
color form association, and visual memory,
recognition of faces of prominent people,
map drawing
Color matching tests (Nagel cards)
Weigl’s color-form sorting test
Photograph of famous person
Visual field test
 Occipital lobe and Seizure
• Relatively uncommon
• Lacks recruiting response
• 25% of cases (Gibbs 1932, whitty 1955)
• Generalized seizure > focal

Russell & Whitty 1955

 Primary visual cortex (area 17)
• Elementary, unformed visual hallucinations, such as
scotomas and flashes of light
• Experience of moving lights, colored
• From periphery to centre
• Zig-zag or weaving patterns
• Showers of lights
• Darkness

(Penfield & Jasper 1954, Russell & Whitty 1955)

 Area 18,19
• Lights immobile, Intermittent
• Twinkle, pulsate
• Darkness (hemi field/total) commoner
• Formed visual hallucinations.
• Complex visual hallucination-
• OL(anterior part) or
• Posterior temporal or
• Parietal cortex
 D/D Visual hallucination

• Vascular insufficiency (PCA)

• Migraine episode
• Basilar artery insufficiency
• AVA (posterior)
• VA compression in Cxl Spond.
• PCA compression in Tentorial Herniation
 Occipital lobe seizures
• A/w Visual symptoms (Taylor et al,2003)

• Elemental visual sensations (Bien CG, Benninger FD, Urbach H, et al:

Localizing value of epileptic visual auras. Brain 123:244, 2000)

• Red>blue>green>yellow (Gowers WR: Epilepsy and Other Chronic Convulsive

Diseases: Their Causes, Symptoms and Treatment. New York, Dover, 1964 )

• Momentary blindness in both fields

• A sensation of twinkling or pulsating lights.

(lesions on the lateral surface of the OL, BA 18,19)
Occipito-temporal-parietal junction
• complex or formed visual hallucinations
• Macro/micropsia
• Metamorphopsia
• Visual hallc.
• Complex-colorful
• Autoscopy (rare)
Ocular movement abnormalities

– Oculoclonic
– Oculogyric deviation
– Clonic palpebral jerks
– Forced closer of eyelids
– Forced eye turning (parieto-occipitlal)
Childhood epilepsy with occipital paroxysms

• Heterogenous
• Late onset- Gastaut type
• Panayiotopoulos syndrome

Taylor et al, Brain,vol 126, pp 753-769;2006

 Gastaut- type occipital epilepsy

Onset : 3-16 yrs of age

# Visual hallc.
Ictal blindness,amaurosis,Tonic deviation of eyes
Last <1 min.
Hemiclonic/cps/GTCS
Behavioral/Autonomic features- rare
Remits within 2-5 yrs in 50-60%

EEG
Interictal - high amp,2-3 hz SSWc(posterior quadrant)
Ictal-prominent occipital discharge with spread +
 Panayiotopoulos syndrome

Age 3-6 yrs (1-14 yr), Seizures-Infrequent

Seizures during SLEEP
Autonomic (vomiting,palor,sweating etc)
Behavioral features (irritability)
Autonomic epilepsy (Ferrie et al, 2006)
Last for HOURS in 1/3rd
Good prognosis (remit 1-2 yrs)
AED – unnecessary
EEG
Ictal:# posterior slowing
interictal: same as Gautaut-type
Idiopathic photosensitive occipital epilepsy

• Between 5-17 yrs

• Watching TV, video game
• Colorful moving spots in the PFoV
• Tonic head & eye version
• Nausea/vomiting/sharp pain in the orbit,head
• Unresponsiveness
• Cognitive state/neurological exam- normal
• IIEEG: b/l sync or asynch occipital spikes & SWCs
• IEEG: Occp. Epileptiform activity (shifting)
Conditions a/w occipital discharges
• Lafora‘s disease
• Mitochondrial disorders
• Malformation of Occipital cortical
development
• OE with b/l Occipital calcifications
• Celiac disease