Differential Diagnosis

The patient's symptoms of absent pupillary reaction, ptosis, affected eye movements, headache, and vomiting suggest a serious underlying condition. Here's a categorized differential diagnosis:

• Single most likely diagnosis

  • Third Cranial Nerve (Oculomotor Nerve) Palsy: This condition is characterized by ptosis, outward and downward deviation of the eye, and a dilated pupil that is unresponsive to light. The symptoms can be caused by an aneurysm compressing the nerve, which could also explain the headache and vomiting due to increased intracranial pressure.

• Other Likely diagnoses

  • Increased Intracranial Pressure (ICP): Symptoms such as headache and vomiting can be indicative of increased ICP, which could be due to various causes including tumors, hemorrhage, or hydrocephalus. The pupillary changes and eye movement abnormalities could be signs of herniation.
  • Cavernous Sinus Thrombosis: This condition can cause multiple cranial nerve palsies, including the third nerve, leading to ptosis, pupillary dysfunction, and eye movement abnormalities. It is often associated with headache and can lead to more severe neurological deficits.

• Do Not Miss

  • Subarachnoid Hemorrhage: Although less directly linked to the specific combination of eye findings, a subarachnoid hemorrhage can cause sudden severe headache, vomiting, and if an aneurysm is compressing the third cranial nerve, the described eye symptoms. Missing this diagnosis could be fatal.
  • Pituitary Apoplexy: This condition involves sudden hemorrhage or infarction of the pituitary gland and can cause acute headache, visual disturbances, and cranial nerve palsies, including the third nerve. It's a medical emergency requiring prompt treatment.

• Rare diagnoses

  • Tolosa-Hunt Syndrome: A rare condition characterized by painful ophthalmoplegia (eye pain and weakness or paralysis of extraocular muscles), which could explain some of the patient's symptoms. It is due to nonspecific inflammation of the cavernous sinus or superior orbital fissure.
  • Miller Fisher Syndrome: A rare variant of Guillain-Barré Syndrome, characterized by ophthalmoplegia (weakness or paralysis of extraocular muscles), ataxia, and areflexia. While it doesn't directly explain all symptoms like headache and vomiting, it's a rare condition that affects eye movements.