Headaches and double vision in a 68-year-old woman
The present case appears in the journal Neurology. A 68-year-old woman presented with increased frequency of headaches accompanied by double vision. The patient had a history of migraines, which she typically experienced on a monthly basis. In the month prior to presentation, the frequency of her headaches gradually increased to daily and had become more common at night and upon waking from sleep.

She also noted the recent development of double vision with vertical and horizontal gaze. Finally, she reported associated nausea, light, and noise sensitivity, which was typical of her usual migraines, as well as generalized fatigue and a feeling of being “off-kilter.” Her medical history was significant for right-sided breast cancer treated with radical mastectomy, since then in remission.

On physical examination, the patient was afebrile with normal vital signs. Her mental status and language function were normal. Visual fields were intact and pupils were reactive to light without anisocoria. There was no evidence of papilledema.

Extraocular movement examination demonstrated a mild elevation and adduction deficit consistent with a partial pupil sparing right-sided oculomotor nerve palsy. There was no ptosis. Cranial nerve examination was otherwise unremarkable. She had a normal motor and sensory examination, and symmetrically reduced deep tendon reflexes throughout. Her gait examination was significant for astasia-abasia.

Head CT and follow-up MRI demonstrated a right-sided, homogenously enhancing extra-axial frontotemporal mass with minimal associated right-to-left midline shift. A CSF cleft was visible around the margins of the lesion and there was no evidence of nearby sulcal effacement. The patient was initiated on oral dexamethasone after discovery of the mass with no effect on the intensity of her headaches.

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