Indirect Light Reflex Research Articles

CASE REPORT : OLFACTORY GROOVE MENINGIOMA

Abstract
 Background: Olfactory Groove Meningiomas (OGM) are a rare cause of olfactory dysfunction. OGMs are benign, slow-growing tumors that cause non-specific symptoms, such as headaches, olfactory impairment, and psychiatric symptoms, such as depression, personality changes, decreased cognitive function, visual problems, or seizures.
 Aim: In this case report we would like to discuss about a rare case of olfactory groove meningioma with non-spesific symptoms presented in 47-year old female patient
 Case report: A 47-year old female with progressive blurred vision in the right eye for 3 months. Negative light perception in the right eye and fundus of the right eye indicated papillary atrophy. The direct and indirect light reflexes were negative in the right eye. We found Strong homogenous contrast enhancement extraaxial lesion accompanied by multiple dural tails in the left frontal convexity UK approximately 3.2 x 2.8 x 3.1 cm, Tuberculum sellae approximately 2.7 x 2.9 x 3 cm. Cranial decompression, frontal bone reconstruction, and tumor removal were performed. It was found that there was microcystic growth of tumor tissue, consisting of proliferation of meningoethelial cells, round to oval nuclei, smooth chromatin, visible intranuclear inclusions
 Discussion: OGM is a rare, benign tumor. Female patients were more likely to develop OGM than male patients. The ciliary ganglion of cranial nerve III may be affected by compression of the tumor, resulting in the absence of direct and indirect pupillary reflexes in the affected eyes.
 Conclusion: OGM is a slow-growing tumor that does not show significant symptoms at an early stage, making early detection difficult.
 Keyword: Olfactory Groove Meningioma, Blurred Vision, Meningioma

Septic Cavernous Sinus Thrombosis (CST) with Blindness Caused by Odontogenic Infection – A Case Report

Introduction: Septic cavernous sinus thrombosis (CST) is a rare thrombosis, but severe, causing damage to all nerves inside the cavernous sinus. The incidence rate of CST is estimated at two to four per million people per year. The symptom usually varies, gradually worsening, making diagnosis harder and potentially making permanent disability. Early detection and prompt treatment are very important to lower the morbidity rate. Case: Tn. M had complained of multiple headaches attacks since 8 months ago before being admitted followed by diplopia. Complaints had worsened 3 months before with the loss of vision in the left eye. MRI showed left thrombosis sinus cavernous. The terrible headache was scaled 8-9 with VAS score. The patient’s left eye was found proptosis palpebra, with anisocoria and mydriasis followed by no direct light reflex also indirect light reflex, visual acuity of the left eye is no light response, whereas the patient’s right eye is normal. On the patient’s left eye was found gaze palsy sinistra. The abnormal blood result was leucocytosis and thrombocytosis. The patient was given fondaparinux once a day with a dose of 6000 units subcutaneously for 5 days. After that, the headache was decreased significantly. The patient underwent 5 tooth extraction done by mouth surgeon after being discharged. The patient was given 20 mg rivaroxaban per day for three weeks, then 10mg per day for three months, and evaluated with MRV again. Conclusion: CST is still very rare but very lethal and makes permanent disability on the patient. Through this case, we demonstrate the potential of tooth infection which leads to septic CST and caused ophthalmoplegia and blindness.

Severe Hyponatremia and Cerebral Edema after Laparoscopic Salpingectomy, Hysteroscopy Myomectomy, and Adenomyosis Resection

Abstract The usage of hypotonic irrigation solution during hysteroscopy and laparoscopy can cause systemic fluid absorption and complications such as hyponatremia, fluid overload, and cerebral edema. Moreover, Trendelenburg position on gynecologic laparoscopy with a long duration can increase intracranial pressure and decrease cerebral perfusion pressure. A woman, 39 years old, suffered from severe hyponatremia and cerebral edema after hysteroscopy myomectomy, laparoscopic salpingectomy, adenomyosis resection, and adhesiolysis procedure. Water for injection was used as an irrigation solution during the procedure, totaling 20 L. The position of the procedure was supine, Trendelenburg, with a procedure duration of 4 h 50 min. A spontaneous respiratory trigger was not found for about 1 h during extubation. We found anisochoric pupil 5/4 mm without direct and indirect light reflex on physical examination. From the laboratory result, the sodium level was 118. Brain CT scan with contrast showed cerebral edema. Sodium correction was given using NaCl 3%, 500 mL/24 h IV drip. Sodium was corrected slowly and cautiously to prevent cerebral pontine myelinolysis. In the ICU, the sodium level was increased to a normal level. But, the light reflex was still absent, and the pupil was anisochoric. Brain MRI showed diffuse cerebral edema.

A Novel Method for Measuring the Pupil Diameter and Pupillary Light Reflex of Healthy Volunteers and Patients With Intracranial Lesions Using a Newly Developed Pupilometer.

Background: Physicians currently measure the pupil diameter and the pupillary light reflex with visual observations using a ruler and a traditional penlight, leading to possibly inaccurate and subjective assessments. Although a mobile pupillometer has been developed and is available in clinical settings, this device can only assess one pupil at a time. Hence, an indirect pupillary light reflex, including those under irradiation to the opposite side of pupil, cannot be evaluated. Consequently, we have developed a new automatic mobile pupilometer, the Hitomiru®, with Hitomiru Co., Ltd. (Tokyo, Japan). This device is a two-glass type pupilometer with a video recording system. The pupil diameter and light reflex of both pupils can be measured simultaneously; therefore, both indirect and direct light reflexes can be assessed.Purpose: To evaluate the clinical ability of the Hitomiru® pupilometer to assess the pupil diameter and the pupillary light reflex of healthy volunteers and patients with intracranial lesions in an intensive care unit (ICU).Methods: Twenty-five healthy volunteers and five ICU patients with intracranial lesions on only the left side were assessed using the Hitomiru® pupilometer. The protocol was as follows: infrared light was applied to both pupils, followed by visible light to the right pupil, infrared light to both pupils, visible light to the left pupil, and then infrared light to both pupils. All the intervals were 2 s, and the dynamics of pupil diameters on both sides were continuously recorded.Results: The healthy adults had approximately 0.5 mm anisocoria, miosis was harder, and mydriasis was less with increased age. There were several differences in miosis rates, miosis times, and mydriasis rates between the healthy adults and the patients with intracranial lesions with both direct irradiation and indirect irradiation.Conclusions: The initial trial estimated and digitally recorded direct and indirect light reflexes, including rapidity of miosis after direct and indirect lights on, and mydriasis after direct and indirect lights off. The Hitomiru® pupilometer was a useful device to digitally record and investigate the relationship between pupil reflexes and intracranial diseases.

Mezensefalondaki Hematomdan Kaynaklanan İzole Tek Taraflı Okülomotor Sinir Felci

Oculomotor nerve palsy causes reduced adduction, supraduction, infraduction, and ptosis with or without mydriasis. We report a case of isolated unilateral oculomotor nerve palsy due to hematoma in mesencephalone. A 30-years- old male patient presented with sudden onset of left ptosis, vertical diplopia, and difficulty in reading with his left eye that had persisted for one week. Direct and indirect light reflexes were negative on his left eye. There was incomplete ptosis on his left eyelid. In primary position, the left eye was deviated outward and downward. Supraduction of the left eye was absent, infraduction and adduction were reduced. MRI demonstrated hematoma in mesencephalone. Three months later, patient?s symptoms decreased, MRI demonstrated resolution of the hematoma and cavernoma in pons and gamma knife therapy was recommended. Isolated unilateral oculomotor nerve palsy due to hematoma related to cavernoma in mesencephalone is seen rarely and complete or incomplete recovery may be observed.

Atypical Growth Pattern of an Intraparenchymal Meningioma.

Meningiomas are the most common primary nonneuroglial extra-axial neoplasms, which commonly present as spherical or oval masses with a dural attachment. Meningiomas without dural attachment are rare and, according to their locations, are classified into 5 varieties, including intraventricular, deep Sylvain fissure, pineal region, intraparenchymal, or subcortical meningiomas. To the best of our knowledge, intraparenchymal meningioma with cerebriform pattern has never been reported. In this paper, we report a 34-year-old Chinese male patient who presented with paroxysmal headaches and progressive loss of vision for 10 months and blindness for 2 weeks. A thorough physical examination revealed loss of bilateral direct and indirect light reflex. No other relevant medical history and neurologic deficits were noted. Computed tomography and magnetic resonance imaging scans showed an irregular mass with a unique cerebriform pattern and extensive peritumoral edema in the parietal-occipital-temporal region of the right cerebral hemisphere. The initial diagnosis was lymphoma. Intraoperatively, the tumor was completely buried in a sulcus in the parietal-occipital-temporal region without connecting to the dura. The histological diagnosis was intracranial meningioma based on pathological examination. Therefore, when an unusual cerebriform growth pattern of a tumor is encountered, an intraparenchymal meningioma should be considered as a differential diagnosis.

Severe Pure Acute Motor Axonal Neuropathy

Acute motor axonal neuropathy (AMAN) is a subtype of Guillain-Barre syndrome. Characteristic electrophysiological features of AMAN are reduced amplitude or absence of muscle action potentials. Our patient described progressive weakness in his leg and was not able to independently walk; he had a feeling weakness in his arms within 24 h after the onset of symptoms. He was diagnosed with AMAN according to the clinical and electrophysiological features. He could independently walk after two years following intensive physical therapy and monitoring. Neurologists and physiatrist should conduct long term monitoring and rehabilitation for patients with AMAN because neurological deficits may persist for a long time. AMAN was first reported to occur in patients having peripheral axonal dysfunction without demyelinating findings in the electroneuromyograph (ENMG) and is seen mostly during summers in the rural areas of China. Some cases were reported from some countries out of Asia, such as Mexico, in spite of the absence of seasonal predisposition. AMAN is characterized by acute motor paralysis, loss of reflexes or hyporeflexia, and peripheral axonal involve- ment without demyelinating findings in ENMG. In a study the median age of patients with AMAN in China was found to be 10 years (3). In this study, it was aimed to present an 8-year-old patient with AMAN and who had muscle weakness in the lower extremity at the beginning and then developed tetraplegia as a result of pure motor involvement without sensory involvement in a short time. The patient was treated with intravenous immunoglobulin (IVIG) therapy. CASE REPORT An 8-year-old male patient presented to our outpatient clinic with complaints of incapability of walking and moving his hands and arms. The patient who had not experienced such a complaint before complained about loss of strength that had suddenly occurred in his right leg a week ago. He stated that the weakness spread to the other leg and arms within the first 24 h after the onset of the symptoms. He told that he did not have any pain at the onset of symptoms but that he began to feel pain as the weakness progressed. The investigation of his medical history revealed no previous infection, surgical intervention, or vaccination. Moreover, he did not have a history of fever, vomiting, and diarrhea before the illness; no serious pathological history was found in his family and relatives. The patient was conscious, and he was completely oriented and cooperative. His systemic examination results were normal. The eyes were at the midline and moving to every direction. The patient could count fingers at 6 m. His pupils were isocoric; direct and indirect light reflexes were positive, and the examination of the fundus was normal. No pathological changes were detected on cranial nerve examination.

Glycine induced acute transient postoperative visual loss.

INTRODUCTION Hysteroscopic surgeries, which require use of irrigating fluids like glycine can rarely be associated with significant complications.[12] We report a case of transient postoperative blindness following use of large quantities of glycine delivered through a rotatory pump set at an inappropriately high pressure. CASE REPORT A 27-year-old nulliparous female patient, American Society of Anesthesiologists grade I physical status with a history of menorrhagia and severe progressive dysmenorrhea, resistant to medical management, was scheduled for a hysteroscopic myomectomy under general anaesthesia, after ultrasound study revealed multiple submucous fibroids. Routine preoperative blood investigations were normal. Premedication included intramuscular glycopyrrolate 0.2 mg given half an hour before surgery, intravenous ranitidine 50 mg and intravenous ondansetron 4 mg. Anaesthesia was induced with intravenous thiopentone 250 mg, intravenous fentanyl 100 μg and intravenous atracurium 25 mg. After endotracheal intubation, 60% nitrous oxide in oxygen and isoflurane 0.8–1% was used for maintenance of anaesthesia with controlled ventilation. A 22F Karl Storz™ (Germany) resectoscope was used for hysteroscopy. To facilitate distension of the uterine cavity and better visualization during hysteroscopy, glycine 1.5% was infused at 200 mmHg pressure through the side port of Karl Storz endomat roller pump. 33 L glycine was infused and the outflow container collected 27 L. The procedure lasted for approximately 40 min. Haemodynamic parameters stayed within 20% of baseline values throughout the procedure. Neuromuscular blockade was reversed and the patient had an uneventful recovery from anaesthesia. On awakening, the patient complained of visual loss which was initially attributed to either residual effects of anaesthetic agents or the eye ointment. An hour after recovery in the postanaesthesia care unit (PACU), she was fully awake but complained of nausea, vomiting and had complete bilateral blindness. There were no other neurological deficits. On ophthalmic examination, the patient had normal eye movements, no light perception, mildly dilated pupils, normal intraocular pressures and absent direct and indirect light reflexes. Fundal examination revealed normal vasculature with no signs of the optic disc or macular oedema. A presumptive clinical diagnosis of glycine toxicity was made, and the patient was reassured that the blindness was a transient phenomenon. In the PACU, serum electrolytes, osmolality, urea, glucose, and ammonia were checked an hour after the procedure. Serum osmolality (282 mOsm/kg), serum potassium (4.3 mmol/L) and glucose were within normal limits. Serum ammonia was 137 μg/dl (reference range 27–102 μg/dl) and serum sodium was 127 mmol/L. Serum creatinine, liver function tests and blood urea nitrogen were within normal limits. 8 h after the procedure, serum ammonia was 234 μg/dl, serum sodium was 130 mmol/L and serum potassium was 2.3 mmol/L. Her vision showed signs of improvement and returned to normal within 20 h of the procedure. Serum ammonia level, checked 26 h after the procedure, was normal (52 μg/dl). Her remaining hospital stay was uneventful. She was discharged on the 3rd day after the surgery. DISCUSSION Glycine, a low-viscosity fluid, is favoured for uterine distension during hysteroscopies for its good optical image, poor electrical conduction, and minimal haemolysis.[3] Visual disturbances correlate with plasma glycine concentration of 5–8 mmol/L when glycine, an inhibitory neurotransmitter in the retina, slows down the transmission of impulses from the retina to the cerebral cortex resulting in prolonged visual evoked potentials and absent oscillatory potentials on the electroretinogram.[45] Transient blindness, which resolves within 24 h, following glycine absorption, has been reported.[6] Though blood ammonia (an intermediate product in glycine metabolism) concentration of more than 100 μmol/L (normal range 10–35) is associated with neurological symptoms,[7] inter-individual variability is great and patients may show neurological symptoms with normal blood ammonia concentration after absorbing large amounts of 1.5% glycine. There is a vague correlation between hyperammonaemia and visual disturbances.[8] There have been reports of transient blindness with high levels of ammonia after hysteroscopy, one case of temporary complete blindness, and several cases where visual acuity was temporarily reduced to perception of light after transurethral resection of prostate using glycine as the irrigation fluid.[9] In our patient, the increase in blood ammonia level corresponded with the period of blindness. For a better view, gynaecologists prefer a well-distended uterus. In our case, this was achieved by increasing the pressure (200 mmHg) to infuse glycine, which was higher than the safe standards suggested by Vulgaropulos et al.[10] (35–75 mmHg) which would have contributed to rapid absorption resulting in toxicity. CONCLUSION Large quantities of glycine, when used under higher than recommended pressures can result in excessive absorption and toxicity. With the increasing numbers of hysteroscopic procedures performed on a more routine basis, a more judicious use of irrigating solutions like glycine is necessary to avoid complications.

A case that developed orbital apex syndrome after strabismus surgery

In our study, we present a case that developed orbital apex syndrome after strabismus surgery. Nineteen years old female patient referred to our clinic with a decrease of vision, ptosis, limitation of eye movements and pain on left eye that began 5 days ago. There was a strabismus surgery history about 4 months ago on left eye. With ophthalmologic examination, best corrected visual acuity was 10/10, intraocular pressure was 15 mmHg, eyelids, eye movements, anterior segment and fundus was normal on the right eye. On the left eye, best corrected visual acuity was 5/10, intraocular pressure was 23 mmHg. There was ptosis that close approximately 2/3 of pupil field. At the evaluation of extraocular muscle movements, there was limitation while looking up, down, in, and out. At the examination of the anterior segment, pupil was dilated; there was no direct and indirect light reflex. Fundus examination of left eye was normal. With remaining findings, we diagnosed the object as orbital apex syndrome and planned the treatment. Orbital apex syndrome after strabismus surgery has not been described yet. For this reason, this case report has been found worth to present.

Endoscopic Endonasal Transsphenoidal Resection of Solitary Extramedullary Plasmacytoma in the Sphenoid Sinus with Destruction of Skull Base

Solitary extramedullary plasmacytomas are isolated plasma cell tumors of soft tissue that typically do not metastasize. They are rare and account for 4% of all plasma cell tumors. To our knowledge, only 14 cases of solitary extramedullary plasmacytomas in the sphenoid sinus have been reported. A 32-year-old man presented to our department with complaint of ocular pain in the right eyeball and diplopia. Physical and neurological examinations revealed intact and prompt direct and indirect light reflexes in both pupils and limitation of extraocular muscle movement seen with the lateral gaze of the right eyeball. Magnetic resonance imaging suggested the presence of mucocele or mycetoma, therefore surgical resection was performed with endoscopic endonasal transsphenoidal approach. Histopathology was consistent with plasmacytoma. Systemic work-up did not show any evidence of metastasis and the sphenoid sinus was the sole tumor site, and therefore the diagnosis of solitary extramedullary plasmacytoma was confirmed. We report a rare case of solitary extramedullary plasmacytoma in the sphenoid sinus with successful treatment using the endoscopic endonasal transsphenoidal resection and adjuvant radiotherapy.

Establishing a cat model of acute optic nerve injury

Background In order to investigate the progress in optic nerve injury and the following regeneration and repair, many kinds of animal models of optic nerve injury have been established, such as models of acute and chronic ocular hypertension, compression, amputating wound, ischemia reperfusion or hypoxia, intravitreal injection of excitatory amino acids, etc. However, most of these models are established by squeezing intraorbital optic nerve, and suitable for ophthalmology, and there are fewer models suitable for the acute cranial contusion in neurosurgery. Objective To observe the changes of optic nerve after acute injury, and the characteristics of methods for establishing model of acute optic nerve injury in cats. Design A complete randomized grouping and controlled animal trial. Setting Department of Neurosurgery, General Hospital of Ji'nan Military Area Command of Chinese PLA. Materials Twenty-eight healthy adult cats, common degree, either sex, weighing 2.0–3.5 kg, were provided by the animal experimental center of Fudan University. The cats were randomly divided into control group ( n =3) and model group ( n =25), and 5 cats in the model group were observed at 6 hours and 1, 3, 7 and 14 days after injury respectively. JX-2000 biological signal processing system (Department of Physiology, Second Military Medical University of Chinese PLA, Shanghai); Inverted phase contrast microscope (Olympus); Axioplan 2 imaging microgram analytical system (Labsystems). Methods The experiments were carried out in the Department of Neurosurgery, General Hospital of Jinan Military Area Command of Chinese PLA from June 2004 to June 2005. The cats in the model groups were made into models of acute optic nerve injury: The cats were anesthetized, then the limbs were fixed in a lateral recumbent position. Pterion approach in human was imitated, the operative incision was made along the line between lateral canthus and tragus, and it could be seen deep along the skull base that white optic nerve (about 3 mm) went through optic foramen and entered into brain tissue. It was squeezed with noninvasive vascular clip for 20 seconds, then the clip was removed, and then the skull was closed after it was examined to be no bleeding. The size of bilateral pupils, direct and indirect light reflexes were observed postoperatively. Successfully established models were judged by larger operated pupil than controlateral one, disappearance of direct light reflex and the existence of indirect light reflex. No model establishment was performed in the control group. Each cat was tested with flash visual evoked potential (F-VEP) to observe the electrophysiological changes before and after experiment. All the cats in the control group and model groups were killed under anesthesia before model establishment and at 6 hours, 1, 3, 7 and 14 days after model establishment respectively, and the pathological changes of the optic nerve after injury were observed under electron microscope and light microscope. Main outcome measures VEP and the ultrastructural changes of optic nerve after acute optic nerve injury in both groups. Results All the 28 cats were involved in the analysis of results. ▪ VEP results: The VEP latencies were obviously different between the control group and model group at each time point ( P < 0.05), whereas there were no obvious differences among different time points in the model group ( P > 0.05). The VEP amplitudes were obviously different between the control group and model group at each time point ( P < 0.05), whereas there were no obvious differences among different time points in the model group ( P > 0.05). ▪ Ultrastructural changes of the optic nerve: Under electron microscope, normal optic nerve myelin sheath had complete structure, tramal plates were clear and arranged tightly, axolemma was complete, whereas the structures of endoneurium, myelin sheath, tramal plates, axolemma and axon were in disorders after optic nerve injury. Conclusion Models of acute optic nerve injury established by squeezing intracranial optic nerve with noninvasive vascular clip can be applied in studying intracranial acute optic nerve injury.

Changes in vitreous amino acid concentrations in a rabbit model of cataract surgery

We previously reported marked elevation of glutamate, gamma-aminobutyric acid (GABA) and alanine in the vitreous after combined cataract surgery and vitrectomy for macular disorder. Photo-stimulation by the operating microscope and increased intraocular pressure (IOP) are possible causes of postoperative increases in amino acids. An animal model was used to verify this hypothesis. Forty-five coloured rabbits were studied; stress was applied to simulate cataract surgery. Simultaneous photic and pressure stress, photic stress alone, or pressure stress alone were exerted for 20 mins. The vitreous was extracted at the end of the stress period, or 10 mins or 30 mins later. Levels of six amino acids (asparate, glutamate, glycine, taurine, alanine and GABA) in the vitreous were analysed quantitatively. Significant increases in vitreous glutamate concentrations in treated eyes were observed following simultaneous photic and pressure stress, as well as after pressure stress alone, whereas no difference was found after photic stress alone. The mean glutamate concentrations in treated eyes and fellow eyes, respectively, were 5.59 +/- 2.03 microM and 4.36 +/- 2.09 microM (p < or = 0.05) 10 mins after simultaneous photic and pressure stress, and 4.32 +/- 0.97 microM and 2.29 +/- 0.51 microM (p < 0.05) 10 mins after pressure stress alone. Taurine concentration was elevated by pressure stress alone at 0 min and at 10 mins post-stress. Alanine concentration was reduced by photic stress alone at 10 mins post-stress. In all protocols, no significant differences between treated and fellow eyes were observed at 30 mins after stress. Time-dependent changes were observed not only in the treated eyes, but also in untreated fellow eyes. Elevations of vitreous glutamate in cataract surgery may be caused by pressure stress due to irrigation. Photic stress caused by the operating microscope has little influence. Sympathetic response may be involved in amino acid changes due to stress in cataract surgery.

Bilateral Complete Avulsion of Ocular Globes in a Le Fort III Maxillofacial Fracture: A Case Report and Review of the Literature

The purpose of this paper is to demonstrate a case of bilateral complete avulsion of the globes following maxillofacial trauma. A 23-year-old man with bilateral complete globe avulsion following a maxillofacial trauma. Both globes were luxated out of the orbit and suspended on the skin of the upper lid below the brows. No direct or indirect light reflexes or any eye movements could be noted. Computerized tomography showed complete lacerations of both optic nerves at a level just anterior to the optic canal. There were also multiple fractures corresponding to Le Fort III fracture with Le Fort II components. The brain parenchyma was normal with an exception of brain edema. As the globes were unsuitable for repositioning, both were enucleated. The maxillofacial fractures were immobilized with plates and screws. Although the patient gained consciousness with normal vital signs in the early postoperative period, he died on the ninth day due to Pseudomonas aeruginosa infection, despite invasive antibiotic treatment. The optic nerve and the globes are very resistant to mild and moderate trauma. The avulsion of the nerve at the canalicular or more posterior level may demonstrate central nervous system complications resulting in life-threatening conditions. The most critical issue in complete globe avulsions with a transected optic nerve is to rescue the vision. In total transected optic nerves the final eyes could only have had cosmetic benefits. In spite of promising experimental research on optic nerve regeneration, there are unknowns, such as the methods to eliminate the risk of anterior segment ischemia and phthisis bulbi. Globe avulsions with a complete optic nerve cut remain a challenging problem. More research is required to better understand the pathophysiology of optic nerve repair.

The Unusually Shaped Bifrontal Hematoma

To the Editor: We present a rare case of bifrontal hematoma resulting in death caused by a spontaneously ruptured aneurysm of the anterior communicating artery (ACoA). The hematoma was in the shape of a thick crescent, and the aneurysm was revealed on computerized tomography (CT) and CT angiography. A 60-year-old man suffering from hypertension and diabetes mellitus was admitted to the emergency service after having lost consciousness following vomiting and urinary incontinence. Examination revealed a systolic blood pressure of 220 mm Hg and a diastolic blood pressure of 120 mm Hg. He had a tachypneic and irregular respiration. His score on the Glasgow Coma Scale was 5 (E1M3V1). Both of his pupils were middilated, and direct and indirect light reflexes were decreased; deep tendon reflexes were decreased in all extremities, and he had a bilateral positive Babinski sign. He was admitted directly to …