What is the diagnosis and management for a patient with hyperalgesia on the left side of the forehead and scalp, and lateral rectus (LR) palsy on the right eye, who has a history of hypertension and previous neurological symptoms?

Diagnosis: Likely Bilateral Cranial Neuropathy Requiring Urgent Neuroimaging and Giant Cell Arteritis Workup

This patient presents with contralateral cranial nerve involvement (left trigeminal hyperalgesia and right abducens palsy), which is highly concerning for a brainstem or skull base lesion and requires immediate MRI brain with and without contrast, along with urgent ESR/CRP to rule out giant cell arteritis given the hypertension history. 1, 2

Critical Diagnostic Considerations

Why This Pattern Demands Urgent Action

• Bilateral but asymmetric cranial nerve involvement (left CN V1 distribution hyperalgesia + right CN VI palsy) localizes to either:

  • Brainstem pathology (pontine lesion affecting both nerve nuclei)
  • Skull base/cavernous sinus pathology affecting nerves bilaterally
  • Systemic vasculitis (giant cell arteritis) causing multiple cranial neuropathies 1

• This is NOT an isolated sixth nerve palsy, which would be the most common scenario in a hypertensive patient. The addition of contralateral trigeminal hyperalgesia elevates concern dramatically for structural or inflammatory pathology 1

Immediate Workup Algorithm

Step 1: Obtain stat laboratory studies (do not delay imaging for results):

• ESR and CRP immediately to assess for giant cell arteritis 2, 3
• Complete blood count (severe anemia with bilateral sixth nerve palsy can mimic increased intracranial pressure) 4
• Hemoglobin A1c and fasting glucose (vasculopathic risk stratification) 1

Step 2: Urgent MRI brain and brainstem with and without gadolinium contrast:

• Evaluate for pontine lesions (stroke, demyelination, tumor) 1
• Assess cavernous sinus and skull base for masses, inflammation, or vascular lesions 1
• Look for signs of elevated intracranial pressure if bilateral sixth nerve involvement suspected 1, 4

Step 3: If ESR/CRP elevated or high clinical suspicion for GCA:

• Initiate high-dose corticosteroids immediately before any further testing to prevent vision loss 2, 3
• Arrange temporal artery biopsy within days (can be done up to 2 weeks after starting steroids) 2, 3
• Consult neuro-ophthalmology urgently 2, 3

Differential Diagnosis by Localization

Brainstem Lesion (Most Likely)

• Pontine stroke, demyelination (multiple sclerosis), or tumor affecting:
  • Abducens nucleus or fascicle (right CN VI palsy)
  • Trigeminal sensory pathways (left facial hyperalgesia) 1
• Key point: Hypertension increases stroke risk, making ischemic pontine lesion a primary concern 1

Skull Base/Cavernous Sinus Pathology

• Meningioma, schwannoma, or metastatic lesion
• Inflammatory conditions (sarcoidosis, IgG4-related disease)
• Less likely given the contralateral distribution but must be excluded 1

Giant Cell Arteritis

• Multiple cranial neuropathies can occur
• Critical pitfall: In elderly with hypertension, never assume isolated vasculopathic sixth nerve palsy when additional neurologic signs present 2, 3
• Jaw claudication, scalp tenderness, or temporal artery abnormalities would strongly support this diagnosis 2, 3

Increased Intracranial Pressure

• Can cause bilateral sixth nerve palsies
• Trigeminal involvement less typical but possible with skull base compression
• Look for papilledema on funduscopic exam 1, 4

Management Algorithm After Diagnosis

If Neuroimaging Shows Structural Lesion

• Neurosurgery consultation for tumor/mass effect 1
• Neurology consultation for stroke or demyelination 1
• Treatment directed at underlying cause 1

If Giant Cell Arteritis Confirmed

• Continue high-dose corticosteroids (typically prednisone 1 mg/kg/day or IV methylprednisolone) 2, 3
• Temporal artery biopsy for confirmation 2, 3
• Rheumatology co-management for long-term steroid taper 3

If Vasculopathic (Microvascular) Sixth Nerve Palsy Confirmed

• Only after excluding structural pathology and GCA 1
• Optimize blood pressure and glucose control 1
• Monitor for spontaneous resolution over 3-6 months 1
• Prisms or occlusion for diplopia management during recovery 1

Symptomatic Diplopia Management (After Acute Workup)

• Occlusion with patch or Bangerter filter over affected eye 1
• Base-out Fresnel prism if deviation stable and patient can fuse 1
• Consider botulinum toxin injection to ipsilateral medial rectus if deviation persists beyond 6 weeks to prevent contracture 1

Critical Pitfalls to Avoid

Never assume "vasculopathic sixth nerve palsy" with multiple cranial nerve involvement: The presence of contralateral trigeminal hyperalgesia absolutely mandates neuroimaging regardless of vascular risk factors 1

Do not delay corticosteroids if GCA suspected: If ESR/CRP elevated or clinical suspicion high (elderly, hypertension, headache, jaw claudication), start steroids immediately before biopsy 2, 3

Do not perform lumbar puncture before neuroimaging: With focal neurologic signs, always obtain MRI first to exclude mass lesion before LP 1

Do not wait for "spontaneous resolution" without imaging: Isolated vasculopathic sixth nerve palsy in elderly with risk factors may be observed initially, but this patient has bilateral cranial nerve involvement requiring immediate investigation 1

Prognosis and Follow-Up

• If vasculopathic: 70-80% resolve spontaneously within 3-6 months 1
• If no improvement by 6 weeks or worsening at any time: repeat neuroimaging mandatory 1
• Surgical management (medial rectus recession, lateral rectus resection, or vertical rectus transposition) reserved for persistent deviation after 6 months with no recovery 1, 5