Evaluation of Third Nerve Palsy in the Emergency Department

Terson's Syndrome with Roth Spot-Resembling Features and Third Nerve Palsy without Radiologically Diagnosed Subarachnoid Haemorrhage

We report an unusual case of pupil-involving third nerve palsy associated with Terson's syndrome that resulted in the diagnosis of a right posterior communicating artery aneurysm. Interestingly, Terson's syndrome presented with Roth spot-resembling features, accompanied by third nerve palsy in a patient without any disturbance of consciousness. To our knowledge, the association of Terson's syndrome with third nerve palsy has not been described before in the absence of radiologically diagnosed subarachnoid haemorrhage. We present the case of a 48-year-old woman who presented in the Department of Emergencies of the University Hospital of Patras with right-sided complete-pupil-involving third nerve palsy combined with bilateral Terson's syndrome. More precisely, fundoscopy revealed multiple scattered intra- and pre-retinal haemorrhages in both eyes, while some retinal haemorrhages had a white-centred pattern resembling Roth spots. Neurological examination revealed no nuchal rigidity or any other neurological signs. The Glasgow coma scale score was 15/15. A cerebral computed tomography angiography revealed a 5 mm aneurysm of the right posterior communicating artery and the patient underwent a microvascular clipping operation after craniotomy. The significant contribution of the ophthalmological consultation to the appropriate and timely diagnosis and management of a life-threatening condition is highlighted.

Posterior Communicating Artery Aneurysm With Referred Tooth Pain: A Case Report

Oculomotor nerve (CN III) palsy (ONP) has multiple etiologies, with aneurysms and ischemic injury being the two leading causes. The presentations of these conditions differ, as aneurysms commonly manifest with pupillary involvement, while ischemic-related ONP often leads to a pupil-sparing presentation. We present a 63-year-old African American male with a history of sickle cell trait, ocular sickle cell disease, and untreated hypertension that develops "down and out" left eye with a mid-dilated pupil unresponsive to light. However, the patient developed severe left upper tooth pain after the onset of the eye pain, which progressed to ONP. The patient's dental and radiographic evaluation did not indicate any obvious source for his tooth pain. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the head revealed a 7-mm saccular aneurysm with a 2-mm neck arising from the left posterior communicating artery (PCOM) aneurysm, and neurovascular surgical intervention was initiated. This case highlights the potential of referred tooth pain as an early symptom in patients with PCOM aneurysm, which physicians should be vigilant about and consider as a potential indicator of the condition. Therefore, collaboration between different specialties, including ophthalmology, neurology, neurosurgery, and dental care, is necessary to formulate a comprehensive treatment plan that effectively addresses the patient's specific needs and challenges.

Neuro-Ophthalmology in Emergency Medicine

Understanding the anatomy and physiology of the eye, the orbit, and the central connections is key to understanding neuro-ophthalmologic emergencies. Anisocoria is an important sign that requires a systematic approach to avoid misdiagnosis of serious conditions, including carotid dissection (miosis) and aneurysmal third nerve palsy (mydriasis). Ptosis may be a sign of either Horner syndrome or third nerve palsy. An explanation should be pursued for diplopia since the differential diagnosis ranges from the trivial to life-threatening causes.

Isolated oculomotor nerve palsy as a paraneoplastic manifestation of gastric diffuse large B-cell lymphoma: A case report

Isolated oculomotor nerve palsy (ONP) is rare. The major causes are aneurysm of the posterior communicating artery, microvascular ischemia, neoplasm, inflammation and trauma. The present study reports the case of a 72-year-old female with left isolated pupil-sparing ONP and severe anemia as the initial manifestations of gastric diffuse large B-cell lymphoma (DLBCL). Systemic chemotherapy without any central nervous system (CNS)-directed treatment led to a complete resolution of the ONP, suggesting that it was most likely to be a paraneoplastic phenomenon. If CNS involvement cannot be demonstrated by brain magnetic resonance imaging and cerebrospinal fluid assessment, the present case suggests that it may be acceptable to omit CNS-directed therapy in such cases of ONP, since it may be paraneoplastic in nature and may resolve following successful treatment of the underlying malignancy.