65F with Isolated Bilateral Occulomotor Nerve Palsy

 

 

PRESENTING COMPLAINTS:

  A 65 yr old female presented with complaints of inability to open eyes since 1 day

 

HISTORY OF PRESENTING ILLNESS:

 

The patient was apparently asymptomatic 1 day back when she developed an inability to open both her eyes which was sudden in onset and static in progression, associated with blurring of vision. Not associated with diurnal variation, loss of consciousness, dizziness, chest pain, shortness of breath, palpitations. Right eye adduction and Right LPS function improved on day 2.

 

No h/o  head trauma fall from height, lifting heavy objects on the head/back/ spinal anaesthesia

No h/o headache, vomiting, diarrhoea

No h/o bed sores, dark coloured urine

H/o diminution in vision in right eye since 1 year

Not associated with alteration in smell

Not associated with colour blindness or night blindness

Not associated with facial numbness or inability to chew food

Not associated with deviation of angle of mouth, drooling of saliva, unable to taste

Not associated with hard of hearing, tinnitus, vertigo

Not associated with difficulty in speech, nasal twang to speech, regurgitation of feeds, difficulty in swallowing

Not associated with inability to move limbs or weakness of limbs

Not associated with wasting or thinning of muscles, pain, fatigue, muscle cramps, or involuntary movements

           

Not associated with loss of sensation, numbness, tingling. Unsteadiness (?)

Not associated with altered sensorium, speech disturbances, emotional disturbances.

Not associated with clumsiness, unsteadiness (?), or swaying while walking

Not associated with difficulty in passing urine and stool, or involuntary micturition and defecation

Not associated with sweating, palpitations

Not associated with fever, vomiting, stiffness of neck

 

Not associated with sob, chest pain

No h/o calf tenderness

H/o antihypertensives intake since 2 years Tab. Telma H 40/12 mg PO/OD.

PAST HISTORY:

No h/o Similar illness in the past

K/c/o HTN since 2 years - Tab. Telma H 40/12 mg PO/OD.

N/K/C/O Diabetes, Hypertension, coronary artery disease, thyroidal illness, Tuberculosis, HIV, malignancy

 

PERSONAL HISTORY:

Married

Non-veg

Adequate Sleep

No h/o smoking, alcohol, drug abuse

 

FAMILY HISTORY:

Non consanguineous marriage

No h/o similar complaints in family

 

MENSTRUAL HISTORY AND OBSTETRIC HISTORY – FEMALES:

Menarche at age of 16

Regular

No. of children - 2

Menopause 1 year back

 

TREATMENT HISTORY:

Tab. Telma H 40/12 mg PO/OD.

 

SUMMARY:

Onset – acute

Progression – static

Disease – b/l 3rd CN palsy

Structures involved –muscles, midbrain

Levels – Single

Etiology –vascular

PHYSICAL EXAMINATION

 

GENERAL EXAMINATION:

Patient is Conscious, coherent, and cooperative

Moderately built and moderately nourished.

Afebrile

No visible signs of Palor, Icterus, Cyanosis, Clubbing, Pedal edema, regional lymphadenopathy

or Significant lymphadenopathy

Right Handed Individual

No Neurocutaneous Markers

 

VITAL SIGNS

PULSE: 84 bpm regular in rhythm, normal in volume, character, and condition of vessel wall, no radioradial/radiofemoral delay,

 

BLOOD PRESSURE: 130/80 mm of Hg measured in the right Upper limb with the patient in sitting position and 120/80 mm of Hg in the standing position.

 

RESPIRATORY RATE: 18 cpm, regular, thoracoabdominal

 

TEMPERATURE: 98.6F measured in the Axilla

NEUROLOGICAL EXAMINATION

 

HIGHER MENTAL FUNCTIONS:

Conscious

Oriented to time, place and person

Speech and language – normal

Memory – immediate-retention and recall, recent and remote intact

No Delusions, hallucinations

Emotional lability – Present

MMSE score (28/30)

Orientation: 10/10

Registration: 3/3

Attention and Calculation  4/5

Recall 2/3

Language 9/9

 

CRANIAL NERVES

CRANIAL NERVE	TEST	RIGHT	LEFT
I	Sense of smell Coffee	+	+
II	Visual acuity – Rosenbaum Chart Field of vision – Confrontation test Colour vision – Ishihara chart Fundus	Counting Fingers 1 m	Unable to Test Unable to Test Unable to Test Unable to Test
III, IV, VI	Extra-ocular movements   Pupil – Size Direct Light Reflex Consensual Light Reflex Accommodation Reflex Ptosis Nystagmus Horners syndrome	Weak adduction   Mid dilated on presentation Present  Present  Present Present Present     Absent	absent abduction Normal  Present Present Present Present Present Present Absent
V	Sensory -over face and buccal mucosa Motor – masseter, temporalis, pterygoids Reflex	Normal  Normal	Normal Normal

	Corneal Reflex Conjunctival Reflex Jaw jerk	Absent Absent Present	Absent Absent Present
VII	Motor – nasolabial fold hyeracusis occipitofrontalis orbicularis oculi orbicularis oris buccinator platysma Sensory – Taste of anterior 2/3rds of tongue(salt/sweet) Sensation over tragus Reflex – Corneal Conjunctival Secretomotor – Moistness of the eyes/tongue and buccal mucosa	Present Absent  Good   Good  Good  Good  Good   Normal   Normal   Present Present   Normal	Present Absent Good Good Good Good Good   Normal   Normal   Present Present   Normal
VIII	Rinnes Test Webers Test     Nystagmus	Positive  Not lateralised   Absent	Positive     Absent
IX, X	Uvula, Palatal arches, and movements     Gag reflex Palatal reflex	Centrally placed and symmetrical   Present Present	Present Present
X1	trapezius sternocleidomastoid	Good  Good	Good Good
XII	Tone Wasting Fibrillation Tongue Protrusion to the midline and either side	Normal  No No  Normal	Normal No No Normal

 

MOTOR SYSTEM

TEST	RIGHT	LEFT
I – BULK Inspection Palpation Measurements Upper limb – 10cm above and below acromion Lower limb 18 cm above and 10 cm below tibial tubercle	Normal Normal   cms  cms	Normal Normal   cms  cms
II – TONE

Upper limbs Lower limbs	Normal Normal	Normal Normal
III – POWER Neck muscles Upper limbs Shoulder Flexion-Extension Lateral Rotation-Medial Rotation Abduction -Adduction Elbow Flexion-Extension Wrist Dorsi flexion-Palmar flexion Abduction-Adduction Pronation-Supination small muscles of hand Hand grip   Lower limbs Hip Flexion-Extension Abduction-Adduction Lateral Rotation-Medial Rotation Knee Flexion-Extension Ankle Dorsi flexion-Plantar flexion Inversion-Eversion Small muscles of foot   Trunk muscles Beevor’s sign	Good  5/5 5/5 5/5 5/5   5/5   5/5 5/5 5/5 Good  Good     5/5 5/5 5/5   5/5   5/5 5/5 Good   Good  Absent	Good  5/5 5/5 5/5 5/5   5/5   5/5 5/5 5/5 Good  Good     5/5 5/5 5/5   5/5   5/5 5/5 Good   Good  Absent
IV – REFLEXES SUPERFICIAL REFLEXES Corneal Conjunctival Pharyngeal Reflex Palatal Reflex Abdominal Reflex Cremasteric Reflex Perianal Reflex Plantar Reflex DEEP TENDON REFLEXES Jaw jerk Trapezius jerk Pectoralis jerk Biceps jerk Triceps jerk	Absent Absent Present Present Present Present Present Flexor   Present Present Present Present Present	Absent Absent Present Present Present Present Present Flexor   Present Present Present Present Present

Supinator jerk Finger flexion reflex Knee jerk Ankle jerk Clonus   C. PRIMITIVE REFLEXES   D. OTHERS Hoffmans sign Wartenbergs sign Rossalimos sign	Present Present Present Present Absent   Absent     Absent Absent Absent Absent	Present Present Present Present Absent   Absent     Absent Absent Absent Absent
V – COORDINATION TESTED ALONG WITH THE CEREBELLUM	Romberg sign – Absent
VI – GAIT	Normal
VII – INVOLUNTARY MOVEMENTS A – Athetosis, Asterexis B – Ballismus C – Chorea D – Dystonia E – Essential tremors F – Fasciculations M - Myoclonus	Absent

 

 

SENSORY SYSTEM

TEST	RIGHT	LEFT
– SPINOTHALAMIC Crude touch Pain Temperature – POSTERIOR COLUMN Fine touch Vibration Position sense Romberg’s sign III – CORTICAL Two point discrimination Tactile localisation Graphaesthesia Stereognosis	Normal Normal Normal   Normal Normal Normal Absent   Normal Normal Normal Normal	Normal Normal Normal   Normal Normal Normal Absent   Normal Normal Normal Normal

 

 

CEREBELLAR SIGNS

Titubation – Absent

Gait – Normal

Nystagmus – Present. More prominent in right eye than left eye

Dysarthria – Absent

Hypotonia—Absent

Rebound phenomenon – Absent

Intention tremor – Absent

Pendular knee jerk – Absent

Tandem Walking – Absent

Coordination – Normal

 

AUTONOMIC NERVOUS SYSTEM – Normal

 

SIGNS OF MENINGEAL IRRITATION – Normal

 

EXAMINATION OF THE SPINE AND CRANIUM  -- Normal

PERIPHERAL NERVES No Thickened nerves

No Trophic ulcers

No Wrist drop

 No Foot drop

 

CAROTID PULSES AND BRUIT -- Normal

EXAMINATION OF OTHER SYSTEMS CARDIOVASCULAR SYSTEM:

JVP, Apex normally placed, no Palpable P2, Heart sounds – normal, No thrills/murmurs

 

 

RESPIRATORY SYSTEM:

Chest symmetrical, No paradoxical movements, Normal vesicular breath sounds heard, No abnormal/added sound

 

ABDOMEN:

Abdomen is soft, No organomegaly, No ascites, Per-rectal examination

PROVISIONAL DIAGNOSIS

B/L 3rd Cranial Nerve Palsy secondary to Acute CVA 

K/c/o HTN 

INVESTIGATIONS

Complete Urine Examination (CUE): Normal

 

- Renal Function Tests (RFT):

  - Urea: 18 mg/dl

  - Creatinine: 1.2 mg/dl

  - Uric Acid: 4.8 mmol/L

  - Calcium: 10.0 mg/dl

  - Phosphorous: 4.8 mg/dl

  - Sodium: 139 mmol/L

  - Potassium: 4.1 mmol/L

  - Chloride: 104 mmol/L

 

Liver Function Tests (LFT):

  - Total Bilirubin: 0.87 mg/dl

  - Direct Bilirubin: 0.20 mg/dl

  - SGOT(AST): 27 IU/L

  - SGPT(ALT): 16 IU/L

  - Alkaline Phosphatase: 99 IU/L

  - Total Proteins: 7.2 gm/dl

  - Albumin: 4.2 gm/dl

  - A/G Ratio: 1.42

 

- HBsAg and Anti HCV Antibodies: Negative

- Post Lunch Blood Sugar: 127 mg/dl

 

Thyroid Function Tests (T3, T4, TSH):

  - T3: 1.14 ng/ml

  - T4: 8.35 micro g/dl

  - TSH: 1.62 micro IU/ml

- Serum Electrolytes (Na, K, Cl):

  - Sodium: 139 mmol/L

  - Potassium: 4.0 mmol/L

  - Chloride: 103 mmol/L

 

MRI Brain:

  - Diffusion restricted multiple T2/FLAIR hyperintense acute infarcts seen at right medial thalamus, midbrain, right centrum semiovale, right frontoparietal lobes.

  - Chronic lacunar infarct seen at bilateral capsuloganglionic regions and corona radiata.

  - Multiple small T2/FLAIR hyperintensities with no diffusion restriction seen at bilateral corona radiata, centrum semiovale, subcortical white matter of bilateral frontoparietal lobes, suggestive of likely small vessel ischemic changes.

  - Diffuse cerebral atrophy.

  - Focal absent flow signals with severe narrowing of lumen (stenosis) seen at the junction of M1 and M2 segments of the right MCA.

  - Correlate clinically.

 

 

Carotid Doppler:

  - Plaques in bilateral CCA causing <50% stenosis.

  - Calcified plaque in left ICA causing up to 50% stenosis.

  - Right branching of CCA on the right side.

 

2D Echo:

  - Moderate aortic regurgitation (AR) and trivial tricuspid regurgitation (TR).

  - No mitral regurgitation (MR).

  - No regional wall motion abnormalities (RWMA).

  - No aortic stenosis (AS) or mitral stenosis (MS).

  - Sclerotic aortic valve (AV).

  - Good left ventricular (LV) systolic functions.

  - Grade I diastolic dysfunction.

  - No pulmonary arterial hypertension (PAH), pericardial effusion (PE), or LV clot.

 

FINAL DIAGNOSIS:

Bilateral Third Cranial Nerve Palsy Secondary to Acute Cerebrovascular Accident (CVA) with Infarcts in the Midbrtain, Right Medial Thalamus, and Right Parieto-Frontal Lobes. Known Case of Hypertension since 2 years. 

TREATMENT

The patient was given

1.  Tab. Ecosprin Gold 75/75/20 mg PO HS

2.  Inj. Optineuron 1 amp in 100 NS IV OD

On Day 2, her ptosis of right eye improved.