Case History #153
Date of Consultation: 11-7-1989
HISTORY OF PRESENT ILLNESS:
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.
NEUROLOGICAL
EXAMINATION:
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.
Questions:
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?
Answers
