Basic Human Neuroanatomy
A Clinically Oriented Atlas 

Case History #177

Date of Consultation: 12-19-1989


This 31-year-old right-handed white female bus driver was referred for neurologic evaluation of her headache problem and visual symptoms.  Her difficulty with headaches began approximately two years prior to consultation (1987), and she knows of no specific circumstances surrounding the onset of the problem.  The frequency of her headaches varies between one to four headaches per week.  There are no well-defined neurologic signs or symptoms occurring either before, during, or in between headache attacks, although she does experience bilateral blurred vision during an attack.  Her headaches are usually bilateral and located in the retro-orbital and supraorbital regions.  She describes the pain as a steady, aching, pressure-like sensation.  The headaches generally last approximately two hours.  Symptoms associated with the headaches include nausea, photophobia, and a desire to lie quietly in a dark room.  They are often triggered by her menstrual periods, exposure to heat, and stress.

In addition to her headaches, the patient was recently discovered to have optic disc atrophy and visual field defects in the right eye on a routine eye examination.  She was not aware of any visual symptoms prior to this examination. 

Aside from the above, the patient denied any other neurologic or systemic signs and symptoms.  Her past history reveals a 15 pack-year history of smoking and a previous rear-end motor vehicle accident a number of years ago without any sequelae.


Mental Status Exam:  Intact.

Cranial Nerves:  Sensation of smell was intact bilaterally.  Visual acuity was J2 in the right eye and J1 in the left eye without glasses.  Funduscopic examination revealed optic atrophy of the right optic disc and a normal left optic disc.  Visual fields by confrontation were unremarkable.  An afferent pupillary defect was present in the right eye, as well as 25 per cent color desaturation on the right.  External ocular movements were full without nystagmus or diplopia.  The right pupil was 5 mm, and the left pupil was 6 mm with normal reactivity, except for the relative afferent pupillary defect in the right eye.  There was no ptosis present.  Sensory and motor functions of the Vth cranial nerve were normal.  There was no facial weakness.  Hearing was intact in the left ear but was diminished in the right ear.  XIth cranial nerve functions were normal.  Tongue and palate appeared normal.  

Motor System:  Intact.
Reflexes:  Intact.  

Sensory System:  Intact.
Cerebellar Function:  Intact.

Gait and Stance:  Intact.


1.  Where in the visual pathway would you localize the lesion in this case (optic nerve, optic chiasma, optic tract, optic radiations, or occipital cortex)?
2.  What is an afferent pupillary defect (Marcus Gunn pupil), what is its anatomical basis, and what localizing significance does it have? 

3.  What side of the nervous system is involved in this case?  What specific structure(s) is involved by the pathologic process?

4.  In general, what type of pathologic process is involved in this case?

5.  Are the visual findings and the patient’s headache problem related in this case? 

6.  How would you classify the patient’s headache problem? 
7.  What diagnostic procedure(s) would you undertake at this point?

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