A 44-year-old woman presented to the emergency department with neck pain. She reported that 1 week ago she “tweaked” her neck while coughing and during the intervening days had undergone physical therapy with massage for this mild, isolated neck pain. One hour before her ED arrival, the pain suddenly increased in severity, associated with vomiting and diffuse headache. The physical examination was notable for an inability of the left eye to abduct past the midline (Figure 1).
Figure 1. The bottom photograph shows attempted left lateral gaze.
Diagnosis
Lateral rectus palsy from subarachnoid hemorrhage. Lateral rectus palsy is present in 5.9% of patients with aneurismal subarachnoid hemorrhage.1 This likely occurs because increased intracranial pressure compresses the abducens nerve during its course through the base of the brain, which is relatively long compared with the other cranial nerves.2 When abducens palsy is discovered in the absence of injury, a range of processes should be entertained, such as subarachnoid mass, basilar meningitis, and increased intracranial pressure caused by pseudotumor cerebri or skull base neoplasm.3
Our patient had a vertebral artery aneurysm causing subarachnoid hemorrhage and her initial complaint of neck pain. Computed tomography of the brain revealed acute hemorrhage centered at the suprasellar and ambient cisterns (Figure 2). The patient's eye was covered to relieve diplopia and the neurosurgery team was consulted. Ultimately, transfer was arranged for neuroendovascular management.
Figure 2. Computed tomographic angiogram of brain. Used with permission of Michael Halberg, MD, Maine Medical Center, Department of Emergency Medicine, Portland, ME.
References
1. 1Munakata A, Ohkuma H, Nakano T, et al.Abducens nerve pareses associated with aneurismal subarachnoid hemorrhage (Incidence and clinical features). Cerebrovasc Dis.2007;24:516–519.
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