A 65-year old woman started experiencing headaches which increased in severity over two weeks. She eventually sought care in the emergency department. Neurological examination was reported as normal. Unenhanced CT of the brain was performed and reported as normal. Headaches continued and she was prescribed oral morphine by her family physician to control the pain without a definite diagnosis. 1 week later she developed oblique binocular diplopia and left upper lid ptosis. She saw her family physician again who referred her for neuro-ophthalmological consultation. On exam, central acuities were normal in each eye, there was obvious left upper lid ptosis, left pupil was 2 mm larger than the right, there was no relative afferent pupillary defect, there were obvious supra-, infra- and adduction motility deficits in the left eye. A diagnosis of partial pupillary involving left third cranial nerve palsy was made. Urgent admission for CT angiogram (CTA) was arranged. After arrival to the hospital the patient collapsed in the cafeteria but regained consciousness in less than a minute which was felt to be a vaso-vagal episode. CT demonstrated smooth, homogeneously hyperdense abnormal thickening along the dura of the falx, tentorium cerebellum, clivus, and floor of the posterior fossa (Figure 1). The distribution was felt to be unusual for subdural hemorrhage and the possibility of inflammatory (IgG-4 disease) or neoplastic infiltrate was raised. Long-standing dural venous thrombosis was also entertained. No aneurysm was identified on CTA. CT of the chest, abdomen and pelvis was performed and was interpreted as unremarkable. A diagnostic procedure was performed.
Relation is Part of
NANOS 2020: Frank B. Walsh Session 3
Trishal Jeeval-Patel, MD
Spencer S. Eccles Health Sciences Library, University of Utah
2020 North American Neuro-Ophthalmology Society Annual Meeting