Introduction: Visual hallucinations formed or unformed have been correlated to the occipital and temporal lobes. Isolated episodes with no other focal deficits can cause diagnostic dilemmas. We present 2 cases of formed and unformed visual hallucinations respectively as post-stroke sequelae that were misdiagnosed.

Case Presentations:

Case 1 was a 64-year-old lady with diabetes, hypertension, hyperlipidemia, and a positive covid screen that presented with severe headache and developed daily formed hallucinations 2 days later that persisted for 3 weeks. The patient presented to primary care complaining of bizarre images of people, crawling insects, spaceships, and flashlights all over that raised suspicion of a psychotic episode but otherwise intact mentation. Neurology was consulted, MRI showed occipital stroke, levetiracetam was started for occipital seizures with good response. Case 2 was a 63-year-old male with a prior significant cardiac history, endocarditis, bioprosthetic valvular replacement, and previous left occipital stroke treated by neurology with levetiracetam for occipital seizures. The patient was lost to follow up and antiepileptic medication was replaced with valproic acid with a suspected diagnosis of migrainous headache. The patient then presented to neurology 3 years later with almost daily episodes of unformed visual hallucinations with confusion and headaches similar to the initial presentation. Neuro exam revealed right homonymous hemianopia with MRI evidence of left occipital gliosis.

The patient was diagnosed with occipital seizures and restarted on levetiracetam.

Management: In both these cases of occipital strokes the correct diagnosis of post-stroke seizures with management leads to the resolution of symptoms of visual hallucinations.

Conclusion: Isolated occipital seizures presenting with visual hallucinations can be misdiagnosed as a psychotic or a migraine spell. Hence detailed evaluation with a neurology referral is warranted for persisting episodes.