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Internuclear ophthalmoplegia as a presentation of procedural stroke: a case report
Norachai Sirisreetreerux1, Krongkamol Ponglikitmongkol2
1Cardiology Center, Chulabhorn Hospital, Chulabhorn Royal Academy, 906 Kamphaengphet 6 Road, Talat Bang Khen, Lak Si, Bangkok, 10210, Thailand. Norachai.sir@cra.ac.th.
Insights
Procedural stroke can present unusually, as seen with internuclear ophthalmoplegia after cardiac catheterization. Early recognition and stroke care are vital for patients experiencing this rare complication.
Area of Science:
- Neurology
- Cardiology
- Vascular Medicine
Background:
- Cardiac catheterization and endovascular procedures are common medical interventions.
- Procedural stroke is a significant complication in catheterization laboratories.
- Timely recognition of stroke symptoms is critical for patient management.
Observation:
- A 60-year-old woman developed dizziness and diplopia post-cardiac catheterization.
- Clinical examination revealed left internuclear ophthalmoplegia with impaired eye movement.
- Neuroimaging confirmed acute infarcts in the midbrain and cerebellum.
Findings:
- The patient's symptoms were attributed to a stroke affecting the medial longitudinal fasciculus.
- The stroke was a rare complication of a diagnostic cardiac catheterization.
- Magnetic resonance angiography showed no significant cerebral artery disease.
Implications:
- Internuclear ophthalmoplegia is an uncommon but important presentation of procedural stroke.
- This presentation may be misdiagnosed, particularly by those unfamiliar with the condition.
- Prompt stroke care is essential due to the risk of multiple brain infarcts, even with a good prognosis for internuclear ophthalmoplegia.
Background:
Cardiac catheterization and endovascular procedures are extensively used in modern medicine, and procedural stroke is one of the major complications that the catheterization laboratory team may face in their everyday work. Recognizing the signs and symptoms of procedural stroke is crucial to ensuring appropriate management. We herein report a case of internuclear ophthalmoplegia that caused blurred vision, diplopia, and dizziness on lateral gaze as an unusual presentation of procedural stroke.
Case Presentation:
A 60-year-old Thai woman underwent right partial colectomy and was diagnosed with stage IV diffuse large B-cell lymphoma. Pre-chemotherapy echocardiography revealed mild left ventricular systolic dysfunction, and she therefore underwent diagnostic catheterization. Coronary angiography revealed normal coronary arteries, leading to a diagnosis of non-ischemic cardiomyopathy. After the procedure, she immediately developed dizziness and diplopia. During the right lateral gaze, she exhibited impaired adduction of the left eye and horizontal nystagmus of the right eye. A diagnosis of left internuclear ophthalmoplegia was made. Magnetic resonance imaging revealed a tiny area exhibiting characteristics of an acute infarct in the left paramedian midbrain, including the left medial longitudinal fasciculus, which explained the clinical picture. Another region of restricted diffusion indicating an acute infarct was detected in the right inferior cerebellar hemisphere. Magnetic resonance angiography revealed no significant cerebral artery disease. The patient achieved full neurological recovery 6 weeks after symptom onset.
Conclusion:
This report describes an uncommon presentation of procedural stroke that is likely to be misdiagnosed, especially by medical staff unfamiliar with internuclear ophthalmoplegia. Despite the good prognosis of internuclear ophthalmoplegia, appropriate stroke care is crucial in patients with procedural stroke because of the risk of multiple brain infarcts.
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