PMC6202048_01
Primary position shows mild ptosis of the left eyelid with orthotropic ocular alignment.
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Ophthalmic examination was significant for mild ptosis of the left eyelid with anisocoria (smaller pupil in the left eye) as shown in Figure 1.
Pupillary examination shows anisocoria.. Notes: (A) In bright light, the right and left pupil diameters are 3 and 2 mm, respectively. (B) The degree of anisocoria is greater in a dark environment, in which the right pupil dilates to 4.0 mm compared with 2.5 mm of the left pupil. (C) After 10% cocaine instillation to both eyes, the difference between the pupils' diameters is 2.5 mm. The positive 10% cocaine test confirms diagnosis of left Horner syndrome.
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In bright light, the right and left pupils were 3 and 2 mm, respectively (Figure 2A). Under dim light, however, the right pupil dilated to 4 mm, whereas the left pupil was almost unchanged (2.5 mm), as shown in Figure 2B. A Horner syndrome confirmatory test (the 10% cocaine test) was positive; the difference in pupillary diameter increased to 2.5 mm (6.0 mm on the right and 3.5 mm on the left) after the instillation of 10% cocaine bilaterally (Figure 2C). This was accompanied by right upper eyelid retraction (Figure 2C).
Emergent computed tomography angiography of the neck, including the base of the skull.. Notes: Contrast-enhanced (A) axial and (B) coronal studies show long segmental luminal narrowing of the petrous part of the left ICA (arrows) compared with the normal luminal size of the right ICA (arrowheads). Left ICA dissection is suspected.. Abbreviation: ICA, internal carotid artery.
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Emergent computerized tomography angiography (CTA) of the neck, including the skull base, revealed long segmental luminal narrowing of the petrous part of the left internal carotid artery (ICA), and left ICA dissection was suspected (Figure 3A and B).
Magnetic resonance imaging of the brain, orbit, and neck.. Notes: (A) Axial T1-weighted imaging with gadolinium injection shows a large infiltrative lesion with strong enhancement encasing the left ICA (arrowhead) and causing segmental luminal narrowing with invasion to the left Meckel cave and left sphenoid wing (arrow). (B) Coronal T1-weighted imaging with gadolinium injection shows that the epicenter of the enhancing infiltrative lesion involves the central skull, and the lesion extends to the medial left middle cranial fossa and left Meckel cave (arrowheads) with extensions to the pterygopalatine fossa and lateral wall of the nasopharynx (not shown).. Abbreviation: ICA, internal carotid artery.
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The lesion encased the left ICA with extensions to the left Meckel cave, left sphenoid wing, and lateral wall of the nasopharynx (Figure 4A and B).