----- Original Message -----
From: "John Ryan"
Subject: Isolated 6th nerve palsy
> A 48 year old, cigarette smoking, otherwise well, lady presents with a 3
day
> history of diplopia which was preceded by unilateral headache for 2 days,
> resolving with onet of diplopia. Examination reveals a marked lateral
> rectus palsy on the right side and she has already patched the eye to
> prevent diplopia. Examination is otherwise completely normal. Blood
sugar
> and BP normal, nothing to suggest demyelination or auto immune pathology.
> Would you ?
> 1) Arrange urgent CT
> 2) Arrange urgent MRI
> 3) Referr to neurology OPD, (next available appointment in a future era)
> 4) Discharge her telling her many of these resolve after 3 months (as per
> Tintanelli !)
> 5) Some other bright idea ?
In the first instance I would've thought you should rule out berry aneurysm,
so some sort of imaging is in order, either CT or MRI. I'm not sure it
matters much which, although combined angiography will probably also be
required to delineate the aneurysm properly. This is when I would quite
happily accept the radiologist's advice (although a neurologist may also
have a view at this point) and I'm fortunate that I can get opinions fairly
quickly from either specialist where I work.
I don't think temporal arteritis produces cranial nerve palsies, although
clearly it affects vision via involvement of the central retinal artery. I
wouldn't do any blood tests. Am I on the right track?
Adrian Fogarty
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