Abstract Background and aims Posterior cerebral artery (PCA) infarctions are classically associated with visual field deficits and visuospatial impairments due to occipital and posterior temporal lobe involvement. Less commonly recognized are neuropsychiatric sequelae, such as paranoid ideation, visual hallucinations, and behavioural disturbances, which reflect disruption of posterior cortical networks mediating perception, reality monitoring, and emotional processing.We report two cases: one with acute-onset paranoia and another with delayed-onset, highlighting the uncommon presentation and clinical significance of paranoia as a primary feature of PCA strok Methods We report two cases of PCA infarction presenting with prominent paranoid ideation. Case 1: A 64-year-old male with right PCA infarction developed delayed visual hallucinations, agitation, and paranoia five weeks post-stroke, associated with haemorrhagic transformation and a secondary right parietal infarct. Case 2: An 81-year-old male with left PCA infarction exhibited acute paranoia and aggressive behaviour immediately post-event, concurrent with systemic illness including STEMI and pneumonia. Management incorporated low-dose pharmacologic therapy (antipsychotic or lorazepam) and structured multidisciplinary care. Results Paranoid ideation emerged as the predominant neuropsychiatric phenotype, with delayed manifestation in Case 1 and immediate onset in Case 2. Both cases demonstrated selective disruption of reality monitoring, and symptoms were attenuated via low-dose pharmacotherapy and structured multidisciplinary rehabilitation, enabling functional stabilization. Conclusions Paranoid ideation is an under-recognized neuropsychiatric manifestation of PCA infarction, arising acutely or in a delayed fashion, irrespective of lesion laterality, and may be exacerbated by haemorrhagic transformation, multifocal infarction, or systemic illness. Recognition of paranoia as a primary feature enables timely intervention, safe rehabilitation, and optimized patient outcomes. Conflict of interest Nothing to disclose Figure 1 - belongs to Conclusions
Ali et al. (Fri,) studied this question.