Basic Human Neuroanatomy
A Clinically Oriented Atlas 

Case History #153

Date of Consultation: 11-7-1989


This 39-year-old right-handed white male consultant was referred for neurologic evaluation of the recent onset of left-sided headache.  Approximately one month prior to consultation, the patient noted the gradual onset of a constant, aching headache in the left periorbital, retro-orbital, and frontotemporal regions.  Occasionally, the headache was also throbbing in nature, but the patient denied any nausea, vomiting, photophobia, or sonophobia.  Approximately one week after the onset of the headache, a friend of the patient's indicated to him that his left eyelid was drooping.  He went to his ophthalmologist, and his visual acuity was unchanged from prior examinations.  However, the ophthalmologist noted that his left pupil was small and referred him for neurologic consultation.  Several photographs of the patient from the past were reviewed, and, at least as recently as one year prior to consultation, no ptosis or miosis was noted.  The patient denied any change or asymmetry of the sweating pattern on his face.  In fact, his neurologic review of systems was entirely unremarkable, except for the left-sided headache, ptosis, and miosis. 


Mental Status Exam:  Intact.

Cranial Nerves:  Cranial nerve examination was unremarkable except for the following.  The right pupil was 6 mm in diameter, and the left pupil was 4 mm in diameter, but both reacted normally to light and accommodation.  There was a 2 mm ptosis of the left eyelid.  On clinical examination, no difference in sweating on either side of the face was noted. 

Motor System:  Intact.

Reflexes:  Intact.

Sensory System:  Intact.

Cerebellar Function:  Intact.

Gait and Stance:  Intact.


1.  Which part of the nervous system controls the size of the pupils? 
2.  List two mechanisms that can cause asymmetry in the size of the pupils (anisocoria). 
3.  List two parts of the nervous system that control the resting state or tone of the upper eyelid.
4.  Of the above possibilities, what do you think was the cause of this patient's ptosis and miosis?  Can these findings be more objectively evaluated?  If so, how would you do that?
5.  With the information presented, how precisely can the lesion be localized? 
6.  Indicate the specific structure(s) possibly involved by the pathologic process to produce this patient’s ptosis and miosis, including the side of involvement.
7.  How would you classify the headache in this case?  This patient’s findings represent a specific neurologic syndrome.  What is the name of that syndrome?
8.  In general, what type of pathologic process is involved in this case?
9.  What diagnostic procedure(s) would you undertake at this point to try to further localize the lesion?


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