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A Woman with Headache and Ptosis
The Journal of Emergency Medicine, Vol. 43, No. 6, pp. e483–e484, 2012 Copyright Ó 2012 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
doi:10.1016/j.jemermed.2011.06.053
Visual Diagnosis in Emergency Medicine
A WOMAN WITH HEADACHE AND PTOSIS Mustafa Serinken, MD,* Ibrahim Turkcuer, MD,* Ozgur Karcioglu, MD,† and Ali Kocyigit, MD‡ *Department of Emergency Medicine, Pamukkale University School of Medicine, Denizli, Turkey, †Department of Emergency Medicine, Acibadem University School of Medicine, Bakirkoy, Istanbul, Turkey, and ‡Department of Radiology, Pamukkale University School of Medicine, Denizli, Turkey Reprint Address: Mustafa Serinken, MD, Department of Emergency Medicine, Pamukkale University Medical School, Denizli 20070, Turkey
rior and superior gaze was noted in the motor examination (Figure 1). Isolated third nerve paralysis was considered. Cranial computed tomography (CT) and CT angiographic imaging were interpreted as normal. Magnetic resonance (MR) imaging and MR venography performed to exclude
CASE REPORT A 59-year-old woman with no remarkable medical history was admitted into the Emergency Department due to right frontal headache and ipsilateral ptosis lasting for a month. The patient reported vomiting three to four times a day during the first days of severe, throbbing headache. One week later, the patient had a complaint of diplopia. Ophthalmological examination did not reveal any clue, except for ptosis and right-sided anisocoria detected in the neurological examination. Restricted infe-
Figure 2. Digital subtraction angiography image demonstrates a saccular posterior communicating artery aneurysm (arrow).
Figure 1. The patient exhibited anisocoria and restricted gaze on the right.
RECEIVED: 29 December 2010; FINAL SUBMISSION RECEIVED: 26 April 2011; ACCEPTED: 5 June 2011 e483
e484
M. Serinken et al.
probable peduncular events and cavernous sinus thrombosis were also negative. The patient was diagnosed with isolated oculomotor nerve paralysis. Digital subtraction angiography (DSA) imaging disclosed a saccular aneurysm of 1.5 1 cm with bilobar shape, enlarging towards the posterior in the level of the right distal internal carotid artery and posterior communicating artery (Figure 2). The aneurysm was embolized with interventional radiological technique and the patient was discharged on the 7th day after an uneventful course in the hospital. DISCUSSION Cerebral artery aneurysm should be considered in the differential diagnosis in patients presenting with isolated oculomotor nerve paralysis and headache (1). Aneurysms are often located at the junction of the internal carotid and posterior communicating arteries (2). Emergency physicians should distinguish between patients who require emergent neuroimaging and those who can wait for it.
MR and CT angiography imaging of the brain and cerebral vessels is generally the preferred method of imaging third nerve palsies (1). Advanced radiological investigation such as DSA should be employed in the work-up. In the present case, DSA was also useful to plan the treatment modalities, that is, endovascular or surgical interventions to employ for the patient. Therefore, DSA was to be performed regardless of the interpretation of the CT angiogram as positive or negative. In summary, the present findings suggest that clinicians employ a higher-level diagnostic modality to evaluate a patient with suspected aneurysm even if the initial assessment is negative.
REFERENCES 1. Woodruff MM, Edlow JA. Evaluation of third nerve palsy in the emergency department. J Emerg Med 2008;35:239–46. 2. Chaudhary N, Davagnanam I, Ansari SA, Pandey A, Thompson BG, Gemmete JJ. Imaging of intracranial aneurysms causing isolated third cranial nerve palsy. J Neuroophthalmol 2009;29:238–44.
doi:10.1016/j.jemermed.2011.06.053
Visual Diagnosis in Emergency Medicine
A WOMAN WITH HEADACHE AND PTOSIS Mustafa Serinken, MD,* Ibrahim Turkcuer, MD,* Ozgur Karcioglu, MD,† and Ali Kocyigit, MD‡ *Department of Emergency Medicine, Pamukkale University School of Medicine, Denizli, Turkey, †Department of Emergency Medicine, Acibadem University School of Medicine, Bakirkoy, Istanbul, Turkey, and ‡Department of Radiology, Pamukkale University School of Medicine, Denizli, Turkey Reprint Address: Mustafa Serinken, MD, Department of Emergency Medicine, Pamukkale University Medical School, Denizli 20070, Turkey
rior and superior gaze was noted in the motor examination (Figure 1). Isolated third nerve paralysis was considered. Cranial computed tomography (CT) and CT angiographic imaging were interpreted as normal. Magnetic resonance (MR) imaging and MR venography performed to exclude
CASE REPORT A 59-year-old woman with no remarkable medical history was admitted into the Emergency Department due to right frontal headache and ipsilateral ptosis lasting for a month. The patient reported vomiting three to four times a day during the first days of severe, throbbing headache. One week later, the patient had a complaint of diplopia. Ophthalmological examination did not reveal any clue, except for ptosis and right-sided anisocoria detected in the neurological examination. Restricted infe-
Figure 2. Digital subtraction angiography image demonstrates a saccular posterior communicating artery aneurysm (arrow).
Figure 1. The patient exhibited anisocoria and restricted gaze on the right.
RECEIVED: 29 December 2010; FINAL SUBMISSION RECEIVED: 26 April 2011; ACCEPTED: 5 June 2011 e483
e484
M. Serinken et al.
probable peduncular events and cavernous sinus thrombosis were also negative. The patient was diagnosed with isolated oculomotor nerve paralysis. Digital subtraction angiography (DSA) imaging disclosed a saccular aneurysm of 1.5 1 cm with bilobar shape, enlarging towards the posterior in the level of the right distal internal carotid artery and posterior communicating artery (Figure 2). The aneurysm was embolized with interventional radiological technique and the patient was discharged on the 7th day after an uneventful course in the hospital. DISCUSSION Cerebral artery aneurysm should be considered in the differential diagnosis in patients presenting with isolated oculomotor nerve paralysis and headache (1). Aneurysms are often located at the junction of the internal carotid and posterior communicating arteries (2). Emergency physicians should distinguish between patients who require emergent neuroimaging and those who can wait for it.
MR and CT angiography imaging of the brain and cerebral vessels is generally the preferred method of imaging third nerve palsies (1). Advanced radiological investigation such as DSA should be employed in the work-up. In the present case, DSA was also useful to plan the treatment modalities, that is, endovascular or surgical interventions to employ for the patient. Therefore, DSA was to be performed regardless of the interpretation of the CT angiogram as positive or negative. In summary, the present findings suggest that clinicians employ a higher-level diagnostic modality to evaluate a patient with suspected aneurysm even if the initial assessment is negative.
REFERENCES 1. Woodruff MM, Edlow JA. Evaluation of third nerve palsy in the emergency department. J Emerg Med 2008;35:239–46. 2. Chaudhary N, Davagnanam I, Ansari SA, Pandey A, Thompson BG, Gemmete JJ. Imaging of intracranial aneurysms causing isolated third cranial nerve palsy. J Neuroophthalmol 2009;29:238–44.