A Rare CN 6 Palsy

Horner's syndrome with ipsilateral CN VI palsy has significant localizing value.

Poster 118 A Rare CN 6 Palsy Menachem Weiss1, Richard Jones1, Frank Scribbick1, John Carter2 1 Department of Ophthalmology, University of Texas Health - San Antonio, San Antonio, Texas, USA, 2Department of Ophthalmology and Neurology, University of Texas Health - San Antonio, San Antonio, Texas, USA Introduction: Horner's syndrome with ipsilateral CN VI palsy has significant localizing value. Description of Case(s): A 71-year-old woman presented with left temporal headache and horizontal diplopia. She had type 2 diabetes mellitus, chronic obstructive pulmonary disease, and hypothyroidism. Ophthalmic exam showed loss of left eye abduction. Initial workup showed erythrocyte sedimentation rate of 100 and C-reactive protein of 92. Complete blood count, comprehensive metabolic panel, and computed tomography scan of her head were normal. Empiric steroid treatment for giant cell arteritis (GCA) was initiated. Magnetic resonance imaging (MRI) of her brain as well as temporal artery biopsy (TAB) were interpreted as normal. Repeat exam 1 week later showed unchanged left eye abduction deficit with development of left upper eyelid ptosis and anisocoria. Right and left pupils measured 3mm and 2mm in dark, and 1.75mm and 1.5mm in light, respectively. This finding prompted re-evaluation of her MRI from 1 week prior, which was then found to have an abnormal enhancing signal in the left petrous apex extending towards the clivus, with possible involvement of the cavernous sinus. Subsequent imaging showed diffuse metastatic disease involving the liver, lungs, kidneys and bone. Liver biopsy confirmed metastatic adenocarcinoma of upper GI origin. Conclusions, including unique features of the case(s): This is a rare presentation of Parkinson syndrome with an isolated CN VI palsy and development of an ipsilateral Horner's syndrome 1 week later. The localizing value of this combination revealed the diagnosis. Parkinson Syndrome occurs with a lesion in the cavernous sinus where sympathetic plexus fibers from the carotid artery join CN VI before joining the ophthalmic division of the trigeminal nerve. It was first described as a theoretical syndrome by Dr. Dwight Parkinson in 1979 and subsequently described only in case reports. Etiology of these lesions include intracavernous carotid artery aneurysm or occlusion, cavernous sinus thrombosis, trauma, and neoplasm. References: 1. Parkinson, Mitchell, Horner syndrome and others?, Surg Neurol., 11(3), 221-3,1979 2. Tamhankar, Biousse, Ying, et al., Isolated third, fourth, and sixth cranial nerve palsies from presumed microvascular versus other causes: a prospective study, Ophthalmology, 120(11), 2264-2269, 2013 Keywords: Ocular motility, Neuroimaging, metastatic carcinoma, Tumors, Skull base Financial Disclosures: The authors had no disclosures. Grant Support: None. Contact Information: Menachem Weiss, MD- 210.567.8406, [e-mail], 7703 Floyd Curl Dr. MSC 6230, San Antonio, TX 78229-3900 172 | North American Neuro-Ophthalmology Society