Double Double, Toil and Trouble

Our patient initially presented in 2013 (age 66 years) with progressive subacute blurry vision, that progressed to double vision. She has history notable for remote breast cancer status post chemoradiation, in remission since 2001. She reported binocular double vision, worsened when looking left or down, included both horizontal and diagonal components, and generally worse with distance. She did not have headache or other neurologic symptoms. Neurologic examination showed mild left exophthalmos and deficits consistent with left trochlear and abducens nerve palsies. Brain MRI with and without contrast (Image 1) showed an enhancing left cavernous sinus mass, which was thought to be a meningioma. Biopsy was deferred due to concern for neurologic morbidity, and she underwent empiric radiation with improvement. In 2018 she reported jaw numbness. Brain MRI showed progression of the previously described lesion in the left cavernous sinus (Image 2). She was again treated with radiation and her symptoms improved. In late 2022, she reported horizontal double vision and lower motor neuron pattern left facial weakness. Imaging showed significant disease progression compared to 2018 with multiple new lesions and interval development of pachymeningeal enhancement (old lesion Image 3; new lesions 4, 5, 6); spinal imaging showed epidural enhancement and a L5 osseus lesion (Image 7). Extensive evaluation for malignancy (CT chest/abdomen/pelvis, PET scan, bone scan, serologic studies including flow cytometry) was completed without evidence of systemic illness. The patient had two biopsies in 2022 and early 2023 of the two peripheral lesions, which were read as having chronic inflammatory changes without clear disease. Throughout this time, the patient has continued to experience symptoms and morbidity related primarily to her double vision.