Pearls & Oy-sters: Isolated oculomotor nerve palsy due to pituitary apoplexy missed on CT scan

Pituitary apoplexy is an important differential diagnosis for acute headache, particularly accompanied by cranial nerve palsies c Apoplexy should be included in the clinician's differential for acute onset third nerve palsy in addition to the more common etiologies of compressive aneurysmal palsy and ischemic microvascular palsy c MRI with dedicated views of the sella turcica is important to detect milder pituitary pathology Oy-sters c Limited presentations of pituitary apoplexy may only involve a single cranial nerve c Patients with new headache of maximal intensity at onset should be admitted for extensive evaluation with a high index of suspicion for a serious intracranial pathology c Headaches from secondary causes may subside by the time patients seek medical attention c Midline lesions like pituitary apoplexy may be easily missed on standard emergency department neuroimaging, especially if findings are early or mild cReviewing the images themselves can help clinicians ensure that important secondary causes are not missed A 70-year-old left-handed man presented to his family physician's office after waking up with a new 10/10 intensity headache and was prescribed acetaminophen and cephalexin for left ankle cellulitis.Over the next 3 days, his headache had improved to 1/10, but he then developed a new horizontal binocular diplopia and right-sided ptosis concurrent with a mild bifrontal headache, for which he presented to the emergency department.He had a medical history of type II diabetes, hypertension, stage IV chronic kidney disease with kidney transplantation for immunoglobulin A nephropathy and immunosuppression, left upper limb deep vein thrombosis, right-sided parotid mass, recurrent but locally limited squamous cell carcinoma (SCC), and dyslipidemia.His medications included amlodipine, bisoprolol, gabapentin, prednisone, tacrolimus, and warfarin.He had an unremarkable cardiovascular, respiratory, and abdominal physical examination.On neurologic examination, he had a mild anisocoria (right pupil: 3 mm, left pupil: 2 mm, worse in bright light vs dim light) but both pupils were briskly reactive to light and accommodation.His visual acuity was 20/20 bilaterally and he had full visual fields on bedside examination and unremarkable funduscopy.In addition to right ptosis (marginal reflex distance of 3 mm to lower lid margin), he had impaired right eye adduction, elevation, and depression (figure 1).No other deficits were identified.We localized these findings to the right oculomotor nerve.The differential diagnoses considered for these findings included a posterior communicating artery aneurysm resulting in a compressive third nerve palsy given the initial severe nature of the patient's headache *These authors contributed equally to this work.

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