| Identifier |
walsh_2019_s3_c3-slides |
| Title |
Fooled Thrice |
| Creator |
Jonathan A. Micieli, MD, CM |
| Subject |
3rd Nerve Palsy; Radiation |
| History |
A 40-year-old healthy man presented with a one-month history of left ptosis and binocular horizontal diplopia. Examination revealed normal afferent visual function. He had left ptosis and there was limitation of elevation, depression, adduction and a dilated, sluggishly reactive pupil in the left eye. CT angiogram was normal and MRI of the brain with contrast revealed an enhancing mass extending along the course of the left oculomotor nerve suggestive of a schwannoma. Lumbar puncture was normal and neurosurgery advised against biopsy. He received fractionated radiation therapy (50Gy) and a short-course of dexamethasone for a presumed left oculomotor nerve schwannoma and his ptosis and diplopia started to improve two weeks after treatment. Follow-up MRI six months after treatment showed further decrease in the size of the lesion and his diplopia in primary position resolved. Eighteen months after treatment, his double vision returned and repeat MRI demonstrated stability in the size of the cisternal portion, but an increase in the size of the cavernous and intra-orbital portion of the left oculomotor nerve mass. Due to the relatively prompt response to radiation and dexamethasone, the possibility of an inflammatory lesion was considered. An extensive workup including CT of the chest/abdomen/pelvis was normal. He was also started on mycophenolate mofetil as he did not tolerate corticosteroids well. One month later, he suddenly lost vision in his left eye and examination revealed hand motions vision with a left relative afferent pupillary defect, left ptosis and complete left ophthalmoplegia. The right eye had normal visual acuity and motility. Repeat MRI demonstrated interval enlargement of the mass with compression of the left optic nerve at the orbital apex. Repeat lumbar puncture was normal and after 5 days of high-dose intravenous methylprednisolone, his vision in the left eye worsened to no light perception. A diagnostic procedure was performed. |
| Disease/Diagnosis |
Malignant oculomotor nerve sheath tumor |
| Date |
2019-03 |
| References |
1. Kozic D, Nagulic M, Ostolic J, et al. Malignant peripheral nerve sheath tumor of the oculomotor nerve. Acta Radiol 2006;47(6):595-8. 2. Fard MA, Montgomery E, Miller NR. Complete, pupil-sparing third nerve palsy in a patient with a malignant peripheral nerve sheath tumor. Arch Ophthalmol 2011;129(6):813-4. |
| Language |
eng |
| Format |
application/pdf |
| Type |
Text |
| Source |
2019 North American Neuro-Ophthalmology Society Annual Meeting |
| Relation is Part of |
NANOS Annual Meeting 2019: Frank B. Walsh Session 3 |
| Collection |
Neuro-Ophthalmology Virtual Education Library - Walsh Session Annual Meeting Archives https://novel.utah.edu/Walsh/index3.html |
| Publisher |
Spencer S. Eccles Health Sciences Library, University of Utah |
| Holding Institution |
Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E SLC, UT 84112-6005 |
| Rights Management |
Copyright 2019. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright |
| ARK |
ark:/87278/s61z8nnw |
| Setname |
ehsl_novel_fbw |
| ID |
1431989 |
| Reference URL |
https://collections.lib.utah.edu/ark:/87278/s61z8nnw |
