Abstract:
We report a case of right cerebellopontine (CP) angle tumor presented with bilateral internuclear ophthalmoplegia (INO).A healthy 31-years-old lady presented with two-months history of right sided body weakness associated with blurring of vision and headache. Prior to presentation, she had right-sided hearing impairment and unsteady gait. General examination revealed exotropia with adduction deficit bilaterally and horizontal abducting nystagmus on attempted gaze to the contralateral side. Also, there was right facial palsy with ipsilateral hearing impairment. Other cranial nerves examination was otherwise unremarkable with no relative afferent pupillary defect (RAPD) and both eyes best corrected visual acuity 6/10. Neurological examination showed reduced power over right side with hypertonia and hyperreflexia. Magnetic resonance imaging (MRI) brain showed right CP angle tumor measuring 4.1cmx 5.4cm x 3.7cm with mass effect, hydrocephalus and cerebral edema. It suggested the diagnosis of right schwannoma with severe mass effect to the brainstem and forth ventricle. Left ventriculoperitoneal shunt (VP) was done by neurosurgical team and she was subsequently electively admitted for right retrosigmoid craniotomy and excision of tumor with intraoperative neurophysiological monitoring. Yet, her INO does not improved despite surgical excision of the tumor.The commonest presentation of bilateral INO among young patient is demyelinating disease. However, one important differential to be considered when a patient comes with bilateral INO associated with neurological signs is brain tumor as the treatment plan and prognosis is drastically different.
