Case History #49

Date of Admission: 11-16-1978

This 31-year-old right-handed white male construction worker was admitted to the hospital for evaluation of headache and diplopia.  Approximately 2 weeks prior to admission, the patient noted difficulty with visual blurring and the new onset of occipital headaches.  Over the next 2 weeks, both the headaches and visual blurring gradually increased in severity until he noted diplopia (double vision), mainly of a vertical or oblique nature, during the few days prior to admission.  He described the headaches as being bilateral, occipital in location, and throbbing and bursting in character.  They increased in intensity in the early morning hours and also with coughing, stooping, and straining.  In the 5 days prior to admission, he experienced 3 episodes of nausea and vomiting with the headaches.

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact.

Cranial Nerves:  Cranial nerve examination was normal except for the following.  Visual acuity was 20/20 in the right eye and 20/40 in the left eye.  Visual field testing was entirely normal.  Funduscopic examination revealed a moderate degree of papilledema in both eyes.  Pupillary light reflex testing revealed a slow and sluggish constriction of the pupils to light stimulation (direct light reflex).  The pupils responded more completely and more quickly to accommodation (the near reflex).  The pupils were 5 mm, equal, and round, however.  External ocular movements were full with horizontal smooth pursuit movements, but dysconjugate with upgaze.  Diplopia was present in upgaze.  Saccadic eye movements were full horizontally and in downgaze.  Saccades on upgaze were slowly executed, somewhat dysconjugate, and wavering or vermiform in trajectory.

Motor System:  Intact. 

Reflexes:  Intact. 

Sensory System:  Intact. 

Cerebellar Function:  Intact.

Questions

1.  Indicate the level of the neurologic lesion in this case as precisely as possible and the structures involved by the pathologic process. 

Signs or Symptoms                                                    Site of Lesion
Impaired vertical upgaze eye movements                      

”Light-near dissociation” of pupillary reflexes     

Diplopia in vertical upgaze                                             

2.  The findings in this case (difficulty with vertical upgaze eye movements, especially with saccadic movements, impaired pupillary light reflexes with intact accommodation [“light-near dissociation”], diplopia in vertical gaze) represent a classic neurologic syndrome.  What is the name of that syndrome?  A lesion of or damage to what specific area(s) of the brain classically causes this syndrome?
            

3.  What is the significance and possible cause of the patient’s recent onset of bursting headaches aggravated by coughing and straining?  Does the patient’s papilledema relate to this process?
            

4.  If the pathologic process in this case were a tumor or mass lesion, where would it be located, from what structure would it be originating, and by what mechanism could it be producing headache and papilledema?