Alice in Wonderland Syndrome as a Rare Presentation of Cryptogenic Stroke: A Case Report

Abstract

Alice in Wonderland syndrome (AIWS) is a rare neurological disorder characterized by perceptual distortions, including alterations in body image perception and time perception. This case report presents a 94-year-old female patient who exhibited visual and auditory hallucinations, including macropsia (perception of objects as larger than their actual size), suggestive of AIWS, following an ischemic stroke. Despite initial suspicions of AIWS, imaging revealed chronic infarcts in the posterior right parietal lobe and the left occipital lobe, suggesting a stroke etiology. Management focused on symptomatic treatment with quetiapine, which effectively alleviated visual and auditory hallucinations, paranoia, and psychosis. This case explores the importance of thorough diagnostic evaluation to distinguish between post-stroke hallucinations versus those associated with AIWS. Additionally, it highlights the need for further research to expand on the mechanisms and optimal management strategies for AIWS, particularly in the context of stroke and other neurological conditions.

Keywords: alice in wonderland syndrome (aiws); antipsychotics; auditory hallucinations; ischemic stroke; macropsia; neurological disorders; perceptual distortions; post-stroke symptoms; quetiapine treatment; visual hallucinations.

Figure 1. Right occipital lobe encephalomalacia

Non-contrast axial CT scan of the brain showing an area of encephalomalacia in the right occipital lobe (red arrow), suggestive of a remote infarct.

Figure 2. Left occipital lobe encephalomalacia

Non-contrast axial CT scan of the brain demonstrating focal encephalomalacia in the left occipital lobe (red arrow), suggestive of a remote infarct.

Figure 3. Microvascular ischemic changes

Axial CT scan of the brain revealing mild, nonspecific low-attenuation white matter changes bilaterally (red arrows), likely representing chronic small vessel ischemic disease.