HPI: 24 year old health woman presents to Emergency Department with difficulty with concentration, headaches, pressure and photophobia in the left eye. These symptoms have been persistent for the last 5 months after she was involved in a car accident. She did not have any significant injuries at that time but did have a head CT which, per her report, was normal (the films are not available for review). She feels that she has some blurry vision but has prescription lenses which she has not been wearing recently. She has no other complaints at this time.
Social Hx:Patient has not been able to work or go to school since her trauma due to her inability to concentrate for more than 10 minutes at a time secondary to her intense headaches. She denies tobacco history and drinks alcohol only socially. No history of illicit drug use. She has one healthy 3 year old boy. Denies any tobacco, alcohol or
illicit drug use.
Family Hx: Non-contributory.
Physical exam: Vital signs are normal.
PERRL, EOMI. Fundoscopic exam reveals mild atrophy of the left optic disc with corresponding temporal hemianopsia. The right optic disc is slightly hyperemic. Visual acuity: 20/20 in right eye and 20/25 in left eye. Her cranial nerves are intact but smell is not tested. The remainder of her physical and neurological exam is unremarkable.
The emergency department physician consults Neurology first, who obtain an MRI as part of their workup.
Figure 1. Axial T2 weighted MRI
Figure 2. Sagittal T1 weighted MRI
Figure 3. Axial post-contrast T1 MRI
Figure 4. Axial diffusion weighted MRI
Figure 5. Axial T1 weighted MRI
1. What is the most likely diagnosis?
2. Are her symptoms likely related to her trauma?
3. What is the next likely step in her management?
4. You are suspicious she has a tumor and she is anxious to undergo open biopsy with resection. What approach should be taken for resection?
5. Please add any suggestions or comments regarding this case:
Could be good to know sings of CSL nasal fistula
Dermoid tumor ruptured.