A 40-year-old female presented with a 3-day history of headaches and difficulty closing her right eye. Her symptoms progressed to include nausea, vomiting, dizziness, and transient visual disturbances in the right eye. Examination found right lower facial droop, weaker right eye closure, and limited ability to raise the right eyebrow, indicating a seventh nerve palsy. Brain imaging showed a stenosis in the transverse sinus and mild papilledema. A lumbar puncture found elevated opening pressure and protein levels. She was diagnosed with pseudotumor cerebri (also called benign intracranial hypertension or idiopathic intracranial hypertension) and started on steroids and acetazolamide, which

1. INTERESTING CASE
PRESENTATION
Presented by : Dr Shaz Pamangadan
Chair : Prof . Sudeep .K

2. • 40/F
• Housewife
• presenting complaints :
Headache - 3 days
Difficulty in closing right eye – 3 days

3. • Her headache started insidiously, had a
progressive course, squeezing nature , mainly
bifrontal distribution and was associated with
nausea, vomiting, dizziness, transient visual
disturbances in her right eye, and a feeling of
both her ears being clogged.
• A day prior to the presentation, she started to
feel numbness and weakness of the right side of
her face, along with an inability to close her right
eye properly.

4. • No h/o diplopia, loss of vision, photophobia,
tinnitus, or any feeling of weakness,
numbness, or tingling in other locations of her
body.
• She had no history of migraine headaches, tick
bite, or any recent illness or fever, trauma .
• She was not taking oral contraceptive pills at
the time.

5. Past History
• History of Obesity, BMI  of 32
• Systemic Hypertension  10 years
• No h/o T2dm , dyslipidemia or significant
medical or surgical history in the past .

6. Family history
• No significant illnesses in family

7. Personal history
• Mixed diet.
• Normal bowel bladder.
• No addictions.
• Sleep and appetite adequate.

8. To summarize …

9. On examination
• Conscious , oriented , co-operative .
• BP – 140/90 mmHg
• PR – 88/mt regular .
• T – Afebrile
• RR – 18/mt
• GRBS- 97mg/dl.

10. General examination
• No pallor ,icterus , cyanosis , clubbing , lymph
node enlargement , oedema .
• Skin , hair , nails appear normal .
• No thyroid swelling

11. CNS Examination
• HMF  fully alert and oriented, fluent speech
and intact comprehensive abilities.
• CN  3–4 mm pupils, PEARL & Accommodation;
intact extra-ocular movements, no nystagmus,
saccadic movement or skew, full visual fields.
• No signs of abducent nerve palsy were present.
• There was facial asymmetry evident by right
lower facial droop, weaker right eye closure, and
limited ability to raise the right eyebrow.

12. • Facial sensation  equal on both sides, with a
strong jaw opening and a midline tongue of
good power. shoulder shrug was symmetrical,
and hearing was intact.
• A fundus examination revealed bilateral grade
I–II papilledema.
• No signs of meningeal irritation.
• motor function, sensation, gait analysis, skull
and spine -wnl

13. Other systems
• CVS – S1S2 heard . No murmur
• RS – NVBS b/l . No added sounds
• P/A – soft ; No HSM

14. investigations
• Blood r/e ,
• lft ,
• rft ,
• se ,rbs
• ur/e ,
• cxr-pa view ,
• ecg ,
• s.ca , s.mg , s.ph , s.uric acid  normal

15. Eventually ???
• She underwent a computed tomography (CT)
scan of her head that showed right-sided
pontomedullary hypodensity.
• Brain magnetic resonance imaging (MRI) with
magnetic resonance venography (MRV)
revealed a stenosis in the lateral aspect of the
transverse sinus, a partially empty sella
turcica, and a picture of mild papilledema.

16. Lumbar puncture :
• opening pressure  28 cm of csf
• The cytological and chemical findings of the LP
WBCs  2
• lymphocytes 100%
• protein 24
• RBCs 13
• Glucose 58
• c/s ,gram stain, ada , normal

17. Differential diagnosis
• Migraine variants.
• Meningitis/meningoencephalitis.
• Subarachnoid hemorrhage.
• Intracranial hemorrhage .
• Hydrocephalus.
• Intracranial epidural abscess.
• Lymes disease.
• Pseudotumour cerebri.

18. Diagnosis ???
• Pseudotumour cerebri
Or
• Benign intracranial hypertension
Or
• Idipathic intracranial hypertension.

19. • She was started on prednisone 60 mg daily
for 5 days and 500 mg of acetazolamide twice
daily.
• Two days later, she reported a dramatic
improvement in both the headache and the
facial nerve palsy. A week later, right facial
nerve examination was done, which was
completely normal.

36. In our patient …?
• Why seventh nerve palsy ??? Not sixth ???

39. Thank you .