Fourth nerve palsy

A 69-year-old Caucasian male presented to the emergency room with acute-onset severe frontal headache, nausea, and acute, binocular diplopia. Past medical history was significant for hypertension, type II diabetes, hyperlipidemia, and an ischemic stroke 10 years prior. The initial blood pressure measured 199/97 mmHg. Computed tomography (CT) of the head without contrast (performed first) and with contrast showed no acute intracranial abnormalities. A subsequent cranial magnetic resonance imaging (MRI) scan with and without contrast was unremarkable except for age-related small vessel ischemic changes. The patient denied any symptoms of giant cell arteritis (e.g., scalp tenderness, temporal nodularity, or jaw claudication), history of eye trauma, strabismus surgery, or lazy eye. Laboratory studies including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), hemoglobin/hematocrit, thyroid-stimulating hormone (TSH), free T3, and free T4 were all within normal limits. Serum glucose was elevated at 154 mg/dL and hemoglobin A1c was elevated at 8.83%. Serum cholesterol and triglycerides were elevated at 194 mg/dL and 179 mg/dL, respectively. The remainder of the medical history was negative. The patient remained in the emergency room until his blood pressure was stabilized. Upon discharge, he was referred to the outpatient neuro-ophthalmology service for evaluation…