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A 54-year-old, right-handed man presented with a 2-week history of stabbing headache, located at the right frontal and temporal regions. Headache intensity was quantified by the patient as 10 out of 10 and was associated with an excruciating ocular pain and right ptosis. The patient was a former smoker who quit 10 years previously. No other relevant medical history was reported. The general physical examination was unremarkable: blood pressure was 110/74 mm Hg, pulse was 78 bpm and temperature was 36.7°C. The neurological exam showed complete right ptosis and palsy of extraocular muscles and an ipsilateral conjunctival injection (see video). The right pupil was 2 mm in diameter and the left 3 mm; both were reactive to light. Funduscopic examination and visual acuity were both normal. Hypoesthesia in the territory of the first division of the trigeminal nerve was also noted. No periorbital murmurs were auscultated. A complete blood count, chemistry panel, and levels of serum electrolytes were normal. The erythrocyte sedimentation rate was 35 mm per hour. Complement levels and results of assays for autoantibodies (antinuclear antibodies, antineutrophil cytoplasmic antibodies, and antibodies to anti-extractable nuclear antigens [anti-Sm, anti-Ro, anti-La, anti-ribonucleoprotein]) were all within normal ranges. Chest x-ray and noncontrast head computed tomography scans were normal. What is the most likely diagnosis in this case? Submit your answer in our poll.
The diagnosis for this case has been published. Click here to read the diagnosis and discussion.