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Título

Unilateral Oculomor Palsy Secondary Idiopathic Intracranial Hypertension: a rare case report

RESUMO

Case report: A 38 years-old-woman, caucasian, civil engineer, residing in Belo Horizonte, Minas Gerais State, Brazil. She has a depressive disorder and has been orally using Sertraline daily. She denied using hormonal contraceptives. She reported chronic headaches for 10 years characterized by monthly episodes of moderate holocranial pressure starting two days before menstruation and lasting up to three days after, and episodes of bilateral frontal pressure headache of severe intensity three to four times per year. Arose in December 2020 with incipient right eyelid ptosis. In August 2021, she had a headache episode that lasted about 30 days. Vitamin D on June 2021 was 31.8 ng/dL. On January, 10th 2022 presented a new episode with exacerbation. Presented to the neurological examination with a medial deviation of the right eye when looking up vertically and looking centered, right pupil mydriatic and photoreactive, and right eyelid ptosis without worsening of the deficit to repetition stimulation. Magnetic Resonance Imaging of the brain on January 17th without relevant abnormalities. On March 04th during clinical reassessment, she reported spontaneous improvement of the headache. She had symmetrical pupils but maintained right eyelid ptosis. Intracranial Pressure non-invasive monitoring by Brain4 Care on March 30th showed normal oscillation of pressure levels, however, the P2/P1 ratio altered the change to decubitus, reaching a value of 1.8, compatible with intracranial hypertension. Magnetic Resonance angiography of the intracranial venous system on April 27th revealed a slight volumetric reduction of the lateral ventricles associated with elongation and tortuosity of optic nerves, notably on the left. A lumbar puncture with opening pressure of 31cm H20 was performed. Ophthalmoscopy of May 19th without abnormalities. Optical coherence tomography this day showed a borderline reduction of the inferior temporal thickness of both eyes and a reduction of the superior temporal area of the left eye. On May, 25th started oral polyvitamin supplement weekly, cholecalciferol weekly, and acetazolamide twice a day. Discussion: The sixth cranial nerve is most commonly affected. Third cranial nerve involvement is distinctly unusual. Final Comments: Systematic review of cases of ophthalmoplegia in the setting of idiopathic intracranial hypertension published last year identified only one case report of unilateral oculomotor palsy.

Palavras Chave

Oculomotor Nerve Palsy . Pseudotumor Cerebri . Headache