A 60-year-old patient who comes to the emergency room because, according to the family, when waking up after 15 hours of sleep, presents with disorientation, difficulty in articulating language, with blurred emission and vertical comprehension.
She did not present loss of consciousness, fever episodes, chest pain or fever.
The patient had a history of smoking for 15 years, hypertension treated with enalapril and dyslipidemia treated with simvastatin.
Examination revealed paresis of the fourth cranial pair of the right eye, as well as incomplete involvement of the third bilateral pair and VI right pair of inferior predominance manifested as binocular vertical diplopia.
The rest of the cranial nerves are normal.
There is no evidence of associated motor or sensory deficit, negative Romberg, no dysmetria and no meningeal signs.
There is evidence of gait disturbance with tendency to the right side.
In addition to the basic emergency protocol, complete blood count, biochemistry, coagulation study, simple chest X-ray and electrocardiogram were normal, a 64-channel computed tomography (CT) was performed without any apparent pathological findings.
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During admission, diplopia persists and is corrected with alternating monocular occlusion, persisting instability and gait disorder.
On the third day of admission, a 1.5 T MRI scan revealed a solitary microinfarction in the deep white matter, as well as acute ischemic lesions of paramedian location in both arteries.
Flair sequences and the use of diffusion are especially useful for observing these lesions.
1.
After consulting the case with the cardiology department and, given the embolic origin of the condition, it was decided to initiate oral anticoagulation with Dabigatran due to the high risk of recurrence.
The evolution of the patient was favorable and, with the rehabilitation treatment, progressive autonomy of gait was achieved, she presented improvement of diplopia.
