Great case today about headache and diplopia. My feeling about the case was that this represented a lacunar stroke that just wasn't seen on the MRI. Treatment would involve modification of the vascular risk factors.
The discussant very methodically went over an approach to diplopia. I think his anatomical approach was excellent:
- Neurological -- i.e. ischemia/vasculitis, demyelination, tumour (including leptomenegeal), infection (TB, syphilis, listeria, lyme), toxic/metabolic (alcohol/wernike's)
- NMJ - mysesthenia and other myesthenic syndromes
- Muscular/Structural - Graves, masses in the muscles, muscular impingement
- Opthomologic -- monocular diplopia -- think corneal or lens problem
In this case I think it was important to think about temporal arteritis because of the diplopia and headache. Temporal arteritis will lead to blindness if not diagnosed and treated.
Clues on history and physical include:
- Diplopia
- Jaw/Tongue claudication
- Temporal artery beading and tenderness
Excluding subarachnoid hemorrhage is important given the right clinical context (i.e. in the context of the characteristic thunderclap headache). A normal CT scan and negative lumbar puncture are sufficient to exclude with high sensitivity and low negative likelihood ratio provided there are no gross neurological deficits.
Also, remember syphilis is the 'great mimicker' and in "young" patients with stroke/stroke-like syndromes one should think about excluding this diagnosis.
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