CASE OF THE MONTH: JULY 2019
Title: MORE THAN MEETS THE EYE
This 28 years old male patient presented with chief complaints of diplopia on left lateral gaze, and restriction of left eyeball movements towards left since the past 1year. There was no history of diminution of vision on either side, sudden onset vision loss, headache, vomiting, altered sensorium, seizures, no history of facial sensory loss, or difficulty while chewing, no history of DM/HTN, or any other co-morbidity.
The patient was moderately built, nourished. There were no neuro-cutaneous markers suggestive of any syndromic pathology. His vitals were stable. Higher Mental Function – Patient was conscious, alert and oriented. Cranial Nerves – were within normal limits except VA- right 6/6, left 6/9, left VI nerve palsy, no jaw deviation or sensory loss of the face. Motor – Bulk and Tone normal. Power is 5/5 in all groups Sensory – Touch, Pain and temperature was normal. Rest of the examination was unremarkable.
Clinical picture of the patient with VI cranial nerve palsy of the left eye
(Informed consent obtained)
Preoperative contrast enhanced Computed tomography (a) and MRI with gadolinium contrast,T1 and T2 (b,c,d) images showing T2 hypointense-isointense lesion, T1 isointense with heterogenous contrast enhancing, at the petrous apex and medial sphenoid wing, Ipsilateral ICA is seen pushed towards right side and superiorly.
Management: The patient underwent a left fronto-temporal craniotomy and excision of lesion, lesion was completely inside cavernous sinus, and was firm, moderately vascular, Intraoperative squash/frozen section was suggestive of a schwannoma
Follow up: Patient is conscious, obeying, oriented, moving all 4 limbs, pupils 3mm BERL, left VI nerve palsy no fresh deficits.
Postoperative contrast enhanced MRI with gadolinium contrast,T2 and T1 (A,B,C) images showing minimal residue in the cavernous sinus and no hematoma with temporal lobe edema
Authors: Dr. Harsh Deora, Dr. Manjul Tripathi, Dr. Abhinith Shashidhar, Dr. Malla Bhaskar Rao