DR. SHREE LEKHA VADDE

DR. RAMAN YENUGANDULA

Abstract

A 40yr old male came with complaints of drooping of (RE) upper lid associated with right sided headache from 2 days. On examination there was (RE)ptosis, exotropia, restricted extra ocular movements ,mid dilated and sluggishly reacting pupil. Other cranial nerve examination were normal thus presenting as isolated 3rd nerve palsy with pupillary involvement making the diagnosis highly suspicious of surgical causes and most probably PCA aneurysm. He was advised MRI and MRA to rule out PCA aneurysm but MRI revealed thickened right cavernous sinus showing iso to hypo intense signal suggesting Tolosa Hunt Syndrome. He was started on tapering dose of steroids and the follow up showed improved ptosis, extra ocular movements and anisocoria. Thus all the cases of isolated 3rd nerve palsy with anisocoria need not always be a surgical cause and there are rare exceptions like this which has pathology in cavernous sinus but presenting with isolated 3rd nerve palsy with pupillary involvement.