Case Presentation by Dr. Debia Kim
CC: “My eyes are blurry”
HPI: 31 y/o M reports 2 weeks of worsening headaches and 2 days of double vision after being hit in the back of the head with a metal napkin ring holder by his fiancee. Since being hit in the head, he has been having intermittent, occipital, throbbing headaches which are partially alleviated by Motrin. In addition to the headaches, he began experiencing double vision that began a day ago. He tried to “sleep it off,” but on waking today he was still seeing double. He denies pain in his eyes, denies red eyes, denies discharge, denies any new medications. He states that when he closes one eye, the double vision does go away. He can’t say which eye is worse. He does not wear contacts or glasses, does not use eye drops. Denies any numbness or tingling in his face, denies trouble with chewing, swallowing, or moving his facial muscles. Denies change in hearing. States he can walk “just fine” but prefers not to write and drive because of the blurry vision. Denies nausea, vomiting, fever, neck ache, sick contacts.
REVIEW OF SYSTEMS: EYES: Positive for double vision. Negative for eye pain. Negative for decreased vision. Negative for photophobia. ENT: Negative for neck pain. GASTROINTESTINAL: Positive for nausea, but negative for vomiting. MUSCULOSKELETAL: No pain elsewhere in his body. No trauma anywhere else in his body from the altercation with his girlfriend. NEUROLOGIC: Positive for throbbing headache that waxes and wanes.
PAST MEDICAL, FAMILY, AND(OR) SOCIAL HISTORY:
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
MEDICATIONS: Motrin p.r.n. ALLERGIES: NONE.
SOCIAL HISTORY: Daily smoking, occasional ethanol, occasional marijuana, but he did not report any use of ethanol or drugs within the last few days. He is currently unemployed.
PRIMARY CARE PHYSICIAN: None.
EXAMINATION OF ORGAN SYSTEMS-BODY AREAS:
VITAL SIGNS: Blood pressure 131/70, heart rate 65, respirations 16, temperature 36.6, and pulse ox is 97% on room air. CONSTITUTIONAL: This is a well-nourished, adult gentleman, in no acute cardiopulmonary distress, sitting calmly on the stretcher.
HEENT: Head is normocephalic and atraumatic. Nontender over the face and scalp. The patient has a slight right ptosis, but his facies are otherwise symmetric. He has anisocoria with right pupil that is enlarged nearly 8 mm. The left pupil that is normal about 4. Both pupils are reactive with no afferent defect. His vision is 20/100 in the right eye and 20/20 in the left. He does have some binocular double vision; however, when each eye is covered independently, he has monocular vision restored. His extraocular movements are restricted. His right eye cannot abduct completely to the right and he has trouble looking up; however, he is able to look down and to the left without difficulty on my examination. Funduscopic exam is incomplete, but normal vasculature is visualized in both eyes. The optic disks are incompletely visualized. Sensation to light touch in the face is symmetric. The patient is nontender over the bony prominences of his face. Posterior pharynx is clear.
NECK: Throat supple. Trachea midline with no meningismus.
CARDIOVASCULAR: Regular rate and rhythm. Positive S1 and S2. No tachycardia. LUNGS: Clear bilaterally.
ABDOMEN: Soft, flat, nondistended, and nontender.
MUSCULOSKELETAL: Nontender over the arms and legs.
SKIN: Warm and dry.
NEUROLOGIC: Alert and oriented. Speech fluent and appropriate. Sensation to light touch intact over his facies symmetrically. He can demonstrate a symmetric smile. Midline tongue on protrusion. He can lift his eyebrows and close his eyes. He can shrug against resistance. He can puff out his cheeks. He demonstrates symmetric grip strength with normal finger-to-nose. He has a normal gait and balance when walking through the emergency department.
1) Which cranial nerve(s) is(are) affected?
2) What is the patient’s most likely diagnosis?
a) Bell’s Palsy
b) Multiple Sclerosis
c) PCA Aneurysm
d) Horner Syndrome
e) Brain bleed!
3) Which imaging study would best provide a diagnosis?
1) CN III palsy
2) C – PCA Aneurysm
3) MRI/MRA brain
Neuro-ophthalmologic diagnoses are often challenging to sort out. In this young patient with headache, a CN III palsy with ipsilateral pupillary dilatation is a posterior communicating artery aneurysm until proven otherwise.
PCOM aneurysms are the second most common Circle of Willis aneurysms (the first being ACOM). PCOM aneurysms arise from the internal carotid artery near the PCOM origin. Expansion here causes compression of the outer fibers of CN III as it travels out of the brain– which cause the nerve palsy and pupillary dilatation.
New onset diplopia is the most common presentation of CN III and VI palsies. It can be painful or painless. EOM testing will be abnormal with lateral gaze preserved in pure CN III palsy (unlike CN VI palsy, which will have abnormal lateral gaze with worsening diplopia on the affected side). This patient presents with mixed EOM findings. He also has decreased visual acuity in the R eye, which was thought to be secondary to his pupillary constriction problems (can’t focus) rather than an additional CN I issue. This patient’s upward and medial gaze is preserved, which points away from a stroke or a demyelinating disease (such as multiple sclerosis) causing intranuclear ophthalmoplegia from lesion of the medial longitudinal fasciculus. CN VII palsy (such as Bell’s palsy) can also present with ptosis but will classically be associated with problems of facial expression — it should not cause anisocoria or EOM issues. Lastly, Horner syndrome also presents with ptosis and pupillary abnormalities. In a Horner syndrome, the problem is interruption of the sympathetic inputs to the eye. The classic physical findings would be ipsilateral ptosis, miosis (rather than dilatation as in our patient), and anhydrosis in a patient with a history of zoster, tumor, or trauma (to the ipsiliateral neck where the sympathetic plexus surrounds the carotid artery). Lastly, this is a young nondiabetic and nonhypertensive patient. Patients who do have such vasculopathies (diabetics especially) can develop acute CN III palsy due to vascular compromise of the nerve. In vascular compromise of CN III, the central nerve fibers are most often infarcted first, which will cause a nerve palsy with pupillary sparing (EOM problems WITHOUT anisocoria).
The best imaging choice to diagnose a posterior circulation abnormality such as aneurysm is an MRI/MRA of the brain. Given the broad differential for neuro-ophthalmologic emergencies and history of (relatively) recent trauma in our patient, a non-contrast head CT was the first test performed to rule out the possibility of an already bleeding significant aneurysm. MRA of the neck was also done to assess the carotids and evaluate for Horner syndrome. Neurosurgery, neurology, and ophthalmology services were consulted. Blood pressure control was strictly monitored.
The patient underwent emergent coiling of the aneurysm, did well, recovered, and was discharged home. He and his fiancee have cancelled their wedding plans.