unilateral fixed dilated pupil trauma

unilateral mydriasis A 40-year-old female gardener presented with a 1-day history of a dilated left pupil (figure 1). Ped Anaesth 2005; 15: 1120-1123 6. Physiologic control of pupillary function is dictated by sympathetic and parasympathetic innervation to the pupillary dilator and the pupillary sphincter muscles, respectively. Thank you very much for your imput. In a non-traumatic setting approximately 25% of cases of a unilateral dilated pupil … 2012;114:295-9 o 36 patients with unilateral fixed dilated pupils admitted to a neurosurgical unit. Particulary, anisocoria and … trauma patient with an irregular pupil with significant visual loss must include intraorbital foreign body and ... matic setting approximately 25% of cases of a unilateral dilated pupil are idiopathic [9]. ... (CT) of the brain and multiple fractures of face and thigh. We however, encountered a patient in our intensive therapy unit who had a more benign reason. All these factors highly affect the consensual reactivity of the eyes to light and cause fixed and dilated pupils after trauma. 4. These often increase intracranial pressure, which can put pressure on and affect the eye system. Drugs, eg Adrenaline Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. Symptoms Of Pupil Dilation. The objectives of this study were to determine the underlying condition responsible, the natural history of recovery of third nerve palsy and the ultimate clinical outcome in 60 patients admitted to a regional neurosurgical centre with a diagnosis of TBI and unilateral or bilateral fixed, dilated pupils … Pinpoint pupils or bilateral fixed pupils for more than 5 minutes are indicative of brainstem damage. There was no history of topical eye-drops or trauma. A pupil that does not constrict when light is directed at the pupil but constricts when light is directed into the contralateral pupil (intact consensual response) is indicative of a traumatic optic nerve injury. She denied headaches, vomiting, double vision, eye pain or discharge. 5. The AED was discharged once, with return of spontaneous circulation. We report a case of unilateral fixed dilated pupil induced by a Datura inoxia plant product. Neuro: IntraCranial Pressure (ICP) – Answers. The objectives of this study were to determine the underlying condition responsible, the natural history of recovery of third nerve palsy and the ultimate clinical outcome in 60 patients admitted to a regional neurosurgical centre with a diagnosis of TBI and unilateral or bilateral fixed, dilated pupils (FDP). A unilateral fixed dilated pupil suggests injury or compression of the third cranial nerve and the upper brain stem. A fast or slowly developing SOL causes pressure on the brain stem areas that control pupil constriction or on the oculomotor nerve (cranial nerve III). The pupil constricts or dilates (enlarges) according to the amount of light that enters the eyes, with both pupils normally dilating in dim light and constricting in bright light. Brodie T, Adalat S. Unilateral fixed dilated pupil in a well child. Keywords: pupil; herniation; complication; prognosis Fixed and dilated pupils in comatose patients are well known to be related to a poor progno-sis, especially when present bilaterally.1–5 If not caused by local trauma or drug action, this symptom indicates injury or … A 34-year-old man was referred to our hospital for management of multiple trauma in consequence of a car accident. We present such a case, outline the physiology of this Determine whether one or both pupils are abnormal in size; Localize the lesion responsible for anisocoria. Overview. Causes include: A unilateral fixed dilated pupil suggests injury or compression of the third cranial nerve and the upper brain stem. A unilaterally dilated pupil is often viewed as an ominous sign. What are some causes of an abnormally large (dilated or mydriatic) pupil? The pupils are evenly affected for 360 degrees, unlike the irregular pupil seen in the tonic pupil or iris trauma. Arch Dis Child 2006; 91: 961 5. Brain injury or disease. Mydriasis has already been observed following the use of a scopolamine patch in many clinical situations: motion sickness [ 4 ], nausea and vomiting [ 2] drooling [ 6 ], dizziness [ 7 ]. due to closed-angle glaucoma; Hutchinson pupil: pupillary abnormalities that lead to a fixed dilated pupil in 3 stages as a result of increased intracranial pressure (typically uncal herniation). Fixed and dilated pupils in comatose patients are well known to be related to a poor prognosis, especially when present bilaterally.1-5If not caused by local trauma or drug action, this symptom indicates injury or compression of the third cranial nerve and the upper brain stem, mainly caused by an extending intracranial mass lesion or by diffuse brain injury.6-12 A recently suggested … The objectives of this study were to determine the underlying condition responsible, the natural history of recovery of third nerve palsy and the ultimate clinical outcome in 60 patients admitted to a regional neurosurgical centre with a diagnosis of TBI and unilateral or bilateral fixed, dilated pupils (FDP). haemorrhagic, penetrating eye trauma, and inadvertent instillation of α-adrenergic or anticholinergic agents in the eye.4 It is, therefore, not surprising that the finding of a dilated pupil in the postoperative period can lead to considerable alarm, anxiety and investigations. Enlarged pupils will be the result of dilation, while pinpoint pupils are the result of constriction. The change occurs when the iris, which is commanded by two muscle groups, either lessens or increases the pupil’s size. Rarely delays in diagnosis of this cause have resulted in angle-closure glaucoma.2 Pilocarpine test using 0.1% and 1% drops on the eye produces pupillary constriction in Adie’s pupil … This report focus on a rare side effect due to Datura inoxia. The patient had a reduced Glasgow Coma Scale (GCS) and a unilateral fixed, dilated pupil. The oculomotor nerve supplies efferent fibers to the extraocular muscles of the eye. This may be caused by an injury, psychological factors, or when someone takes certain drugs or medications. Doctors sometimes refer to more pronounced mydriasis, when the pupils are fixed and dilated, as "blown pupil." This condition can be a symptom of an injury to the brain from physical trauma or a stroke. Interruption of both divisions can lead to ptosis, mydriasis, and ophthalmoplegia. Fixed and dilated pupils in comatose patients are well known to be related to a poor prognosis especially when present bilaterally1-5If not caused by local trauma or drug action this symptom indicates injury or compression of the third cranial nerve and the upper brain stem mainly caused by an extending intracranial mass lesion or by diffuse brain injury6-12 A recently suggested alternative or … Non-physiological causes of mydriasis include disease, trauma, or the use of drugs.. In other words, there’s pressure on the brain. This is the American ICD-10-CM version of H57.04 - other international versions of ICD-10 H57.04 may differ. Bilateral fixed dilated pupils has been defined as a pupillary diameter >4 mm and non-reactivity to light [7]. After trauma to the eye, the colored part of the eye (i.e. Am J Ophthalmol. Causes. Various symptoms depend on the causes including drug use and poisoning. Mydriasis. A unilateral, ipsilateral (on the same side as the lesion), fixed dilated pupil is the initial focal sign, followed by bilateralfixed dilated pupils, occurring anything from minutes to hours later. Sometimes drops (1% pilocarpine) are used to make it small but then it stays small and does not dilate in the dark. An aneurysm of the posterior communicating artery presents with a CN III palsy 30% to 60% of the time. 4. A dilated pupil may be caused by any kind of trauma such as a damage of the nerves controlling the activities of the iris, an injury to the head or the eye, and iris sphincter. It may be up to 6 months before it can be said to be permanent. She denied headaches, vomiting, double vision, eye pain or discharge. However, a majority of patients with a neurologically isolated unilateral mydriasis have a … Roper DL, Hale L. A case report: unilateral cycloplegia resulting Atropinic drugs are competitive antagonists of pilocarpine. Udy A. 2012;114:295-9 o 36 patients with unilateral fixed dilated pupils admitted to a neurosurgical unit. A 75-year-old man collapsed on a golf course and received cardiopulmonary resuscitation from a bystander, including the use of a public automated external defibrillator (AED). A fixed dilated pupil in an awake patient is NOT due to herniation. Suspect herniation due to an intracranial mass lesion as a cause of fixed dilated pupil in an unconscious patient. Survival of patients with severe trauma presenting with Glasgow Coma Score (GCS) 3 and bilateral fixed dilated pupils is uncertain. Pre-hospital management of these patients affects the true measurement of the GCS and other factors may affect pupillary status. John C Hagan III, MD, FACS, FAAO. Feline dilated pupil syndrome or Key-Gaskell syndrome. You have perhaps 20% chance of the pupil ending up larger than the other eye. That is called traumatic iridoplegia. It may be up to 6 months befor... If a trivial head injury without unconsciousness leads to third nerve palsy, think of ICSOL (intracranial space occupying lesion). It has been taught that the pupils go through two reactive phases in cases of damage to the brain or hemorrhage. the iris tissue) can be injured causing the pupil to not get small (or constrict) to bright light normally. 4. • Helmy, A et al, Fixed, Dilated Pupils Following Traumatic Brain Injury: Historical Perspectives, Causes and Ophthalmological Sequelae, Acta Neurochir Suppl. Some of the common symptoms include fixed, dilated, or unequal-sized pupils. When light enters the eye, it activates the retinal photoreceptors. Sympathetic stimulation Fixed dilated pupils can be associated with excessive endogenous catecholamine release from a phaeochromocytoma or from an overdose of sympatho-mimetic drugs including phenylephrine, ephedrine, Pupil evaluation may help narrow the differential, as the pupillary fibers reside on the dorsomedial aspect of the oculomotor nerve and are affected in 90% of compressive pathologies, causing a fixed, dilated pupil. While a fixed dilated pupil is an alarming sign, if it is caused by ocular instillation of ipratropium bromide the condition will resolve, although it may take up to 24 hours. Case report ... compression to these structures may cause a dilated and fixed pupil… Background. A 69 year old woman was referred by her primary care doctor to the eye emergency department with a dilated left pupil and ptosis of her right upper lid. H57.04 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Weir REP, Whitehead DEJ, Zaidi FH, Greaves BBG. It always requires a careful, thorough evaluation. Survival of patients with severe trauma presenting with Glasgow Coma Score (GCS) 3 and bilateral fixed dilated pupils is uncertain. Typically blown pupils occur as a response to a brain injury, such as head trauma or stroke. All patients on admission who fulfilled the inclusion criteria of GCS 3 and bilateral fixed dilated pupils were included. A 10-year-old child with status asthmaticus, hypercapnia and a unilateral dilated pupil. A pupil that is permanently damaged and still dilated 4-6 months after an injury cannot be made "normal". The most common cause of red eye presenting in a primary care setting is conjunctivitis. This information travels along cranial nerve (CN) II via th… Surgery will not make the pupil work normal. It can make it smaller but it won't dilate and it makes seeing into the back of the eye more difficult... It has usually been my experience to find a hemorrhage on the side of the dilated pupil regardless of other neurologic aspects, and it is my purpose to report the following cases to emphasize the importance of "following the pupil." The age, gender and mechanism of injury were recorded. Topical pilocarpine 1% can be used as a simple test for pharmacologic blockade. The signs and symptoms occur on the same side (ipsilateral) as it is a lesion of the sympathetic trunk. A dilated pupil can be a cause of any serious injury or occur out of other symptoms. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. Slight compression of the pial blood vessels and the superficially located pupillary fibers could result in dilation of the pupil . And that’s usually a bad thing. • Helmy, A et al, Fixed, Dilated Pupils Following Traumatic Brain Injury: Historical Perspectives, Causes and Ophthalmological Sequelae, Acta Neurochir Suppl. Traumatic iritis typically presents with unilateral ocular involvement in the context of recent history of blunt ocular trauma. is the constriction that normally occurs in a pupil when light is shown into the opposite eye.6 Because of this response, the trauma nurse should wait for several sec-onds before assessing pupillary light reflex in the second eye, as that pupil may be temporarily constricted. To be able to prognosticate, we need to breakdown the causes of fixed dilated pupils. e.g., unilateral, fixed, dilated pupil e.g., hemiparesis Hemodynamic dysfunction OR e.g., hypertension, bradycardia, and respiratory variation (Cushing’s reflex) Deterioration despite maximal medical management AND Neurosurgeon not available within 4 hours transport time EWS Traumatic Brain Injury Brain injury, Pupil, Trauma Traumatic brain injury (TBI) affects more than 1.4 mil-lion Americans annually.1 These injuries, defined as a blow or penetrating injury to the head that disrupts normal brain function,2 occur as a result of falls (28%), motor vehicle crashes (20%), … It’s exactly what it sounds like, just think about what each word (or word part) in the name means. In contrast, the tonic pupil is usually unilateral and mydriatic. An estimated 2% of patients with major trauma have associated ... occupying lesion–such as intracranial bleeding–can cause a unilateral dilated and non-reactive (“blown” ) pupil… Miosis refers to smaller than normal pupil size, while mydriasis refers to larger than normal pupil size.. NEUROANATOMY Visual Pathway. The left pupil was Unilateral dilated pupil in a critical patient under sedation is an important clinical sign that requires prompt evaluation. Dilated Pupils is the change in size of the pupil as physiological response towards a stimulus. For instance if it is dark or dim, the pupils can dilate (increase in size) so that persons can have a good view of the objects surrounding them. and multiple sclerosis can cause fixed dilated pupils, as can trauma due to brain injury or local damage of the ciliary nerves. Horner's syndrome, also known as oculosympathetic paresis, is a combination of symptoms that arises when a group of nerves known as the sympathetic trunk is damaged. Doctors sometimes refer to more pronounced mydriasis, when the pupils are fixed and dilated, as “blown pupil.” This condition can be a symptom of an injury to the brain from physical trauma … I was hit by a car at the age of two and car accident hitting my head at the age of thirty. Now after going to my eye doctor he tells me I have nar... He had anisocoria of 3 mm, with the left pupil measuring 3 mm in diameter and reactive to light, while the right pupil remained fixed at 6 mm. to mydriasis, a fixed dilated pupil, and when affected on one side leads to anisocoria. It appears that depression of consciousness is mainly related to a lateral brain shift at the tentorium. A “blown” pupil is the colloquial term used by medics to refer to a fixed unilateral mydriasis. To the Editor.— The appearance of a patient with unilateral or bilateral fixed, dilated pupils is usually a matter of grave concern, making one consider angle closure glaucoma, cerebral aneurysm, brain tumor, subdural or subarachnoid hemorrhage, or other conditions. Fixed dilated pupil followed by ophthalmoplegia. 4. The visual pathway (Figure 2) is composed of the retina, optic nerve (also known as cranial nerve II), lateral geniculate nuclei (LGN) in the thalamus, and occipital cortex in the cerebrum. Hi im 15, and I was hit my a baseball 4 days ago and i saw a eye specialist. They said there were no damage to the eye and they are unsure why it w... Brodie T, Adalat S. Unilateral fixed dilated pupil in a well child. He exhibited trismus and occasional decorticate posturing. When a doctor shines a light into your eyes after an injury or illness, it’s to see if your pupils are reacting normally to light. In contrast, microvascular ischemia causes an infarct in the center of the nerve, which spares the pupil in 70% of ischemic cases. Dilated pupils were noted earlier than fixed pupils. Your pupils can be large for variety of reasons including dilation, household chemical, drugs, or a dark room. Fixed dilated pupils, can be considered under the headings: Parasympathetic paralysis, sympathetic stimulation and a miscellaneous group, in which the mechanism of fixed dilated pupils is uncertain (Table 1). The initial evaluation of the pupils is critical in the emergency room in evaluating any patients with head trauma. 1) What is ICP? Anisocoria is a condition in which the pupils of the cat's eyes are different sizes. This large, dilated pupil is much greater than the mydriasis usually seen in typical third nerve palsy or tonic pupil syndromes. The 15 point GCS was used 23 and bilateral fixed dilated pupils was defined as: pupillary diameter >4 mm and non-reactivity to light. Young cats under three years old are most commonly affected. My son has had an eye injury from a bb gun. end result is like the person above his vision is cleared for far away but his pupil will not constric... A pupil that is permanently damaged and still dilated 4-6 months after an injury cannot be made "normal". Sometimes drops (1% pilocarpine) are used... 23 In addition, other causes such as tumors and trauma must also be ruled out in pupil-involving CN III palsies. On examination, her left pupil was 8 mm compared with her right pupil at 3 mm. For the neurosurgeon, a FDP following trauma is one of the most meaningful focal finding in the neurological examination in the emergency room. So…ICP is: An applied force inside the skull. A single fixed dilated (mydriatic) pupil can be caused by: The 2021 edition of ICD-10-CM H57.04 became effective on October 1, 2020. A 40-year-old female gardener presented with a 1-day history of a dilated left pupil (figure 1). Mydriasis can occur in people with traumatic brain injuries. Pupil dilation and cortical localization were presented by several authors, including Mills. Pupillary abnormalities are commonly seen in patients presenting with severe traumatic brain injury (TBI). These plant products may be the cause of fixed and unilateral dilated pupil. The more seriously injured victim had obvious right-sided facial and thoracic injuries, had a blown right pupil and a GCS 3 (with no external signs of head trauma). Fixed dilated pupil resulting from transdermal scopolamine. His symptoms were relieved only by draping a towel over his eyes and head while avoiding movement. ‘Anisocoria' (a unilateral dilated pupil) in critical care patients is a point of concern, which warrants a thorough examination and often, also, costly investigations to rule out a serious cause. Non-reactive pupil. effect of the toxins. She denied headaches, vomiting, double vision, eye pain or discharge. The largely dilated pupil may affect one eye (unilateral) or both eyes (bilateral). Its occurrence is normal and as a result of involuntary reflex actions. On examination, her left pupil was 8 mm compared with her right pupil at 3 mm. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain. Adie Pupil is the most likely diagnosis with the lesion in the ciliary ganglion. So we can see that especially for extradurals fixed dilated pupils are certainly not a death sentence. Almost two-thirds of patients with extradural haematoma and bilateral fixed dilated pupils survived after surgery, with over half having a good outcome Neurosurgeon, HEMS doctor, and all round good egg Mark Wilson was on the RAGE podcast recently and mentioned favourable outcomes from neurosurgery in patients with extradural (=epidural) haematomas who present with bilateral … Case: Our HEMS team was called to a rural trauma involving two motocross riders. If troublesome you can use mild drops to keep the pupil small or … Causes of a unilateral non-reactive pupil. A head injury, stroke or brain tumor can affect how your pupils react to light … CN III palsy with fixed dilated pupil, it is important to recall that pupillary fibers occupy a peripheral location and receive more collateral blood supply that the main trunk of the nerve. Sympathetic stimulation. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are indicative of brainstem damage. Fixed and dilated pupils in comatose patients indicate a poor prognosis, especially when present bilaterally. Another possible cause is Adie’s tonic pupil syndrome. A rare condition first discovered in 1982 caused by a dysfunction of the autonomic nervous system. Pupil blown by a puffer. [] A small proportion of red eye cases are serious and need urgent treatment. This is why they are susceptible to compression (e.g. 3 A dilated, oval pupil can also be seen secondary to ophthalmic procedures like cataract surgery, though the pupil may still react to light in that situation. On examination, her left pupil was 8 mm compared with her right pupil at 3 mm. aneurysm). The most common known etiology is a posterior communicating artery aneurysm. The unilaterally dilated pupil can be explained by stretching of the oculomotor nerve over the clivus or by its compression by a bulging hemispheric mass or haemorrhage. The differential diagnosis of a unilateral dilated pupil includes partial third nerve palsy, tonic pupil, direct trauma to … Arch Dis Child 2006; 91: 961 5. However, in view of the discouraging outcomes in patients with bilateral fixed dilated pupils and a low GCS score (usually <5), it is still unclear whether these patients should undergo DC. Causes of Fixed Dilated Pupils. Thank you for your previous response. They now see that my son has a tear in his muscle at the top of the pupil. Can that ever heal itself or be re... The American Association of Neurological Surgeons and the Brain Trauma Foundation guidelines recommend that severe TBI patients be evaluated for asymmetry in pupil size or reactivity to light, as well as fixed and/or dilated pupils. Simple analgesia proved ineffective. Post-traumatic iridocyclitis - eg, direct facial trauma. The sympathetic pathway is a three-orde… Thomas(2000), suggests a simple structure for differentiate the possible causes. Lancet 2004; 363: 1853 7. Sometimes your pupils can dilate without any change in the light. The medical term for it is mydriasis. Medicines, injuries, and diseases can all cause this eye condition. A few medicines can affect the muscles that control your pupils and prevent them from getting smaller when light shines in. These meds include: Primary DC, in which mass lesions and a large bone flap are removed in an early stage of trauma, is a critically important method in the treatment protocol . Red eye is a common presentation in primary care and is a sign of inflammation. She had visited her primary care doctor because of an upper respiratory tract infection and was unconcerned about her unequal pupil size (anisocoria), stating that she “has had odd pupils and a droopy right lid since being a teenager.” [2 4 5 10] An exhaustive assessment must be performed, including neurological examination and imaging tests, and pharmacological causes must be ruled out. There was no history of topical eye-drops or trauma. Weir REP, Whitehead DEJ, Zaidi FH, Greaves BBG. All these factors affect the activities of the Eyes to Light and cause fixed and dilated Pupil after Trauma. Most cases will be due to relatively benign problems. It has a delayed response to light and near, with tonicity to a near target. A unilateral fixed (unresponsive) and dilated pupil has many potential causes. The “ blown pupil “, a fixed dilated pupil next to a normal-size reacting pupil is an ominous neurological sign and strongly suggests elevated intracranial pressure and a need for immediate intervention and scanning of the brain. Unilateral non-reacting dilated Pupil: ... Trauma is the second commonest cause for third nerve involvement (after vascular). While a fixed dilated pupil is an alarming sign, if it is caused by ocular instillation of ipratropium bromide the condition will resolve, although it may take up to 24 hours. Anisocoria is a sign of an underlying disease condition and therefore there are several different causes. Lasting bilaterally dilated and unreactive pupils after a severe traumatic brain injury (TBI) are usually considered a sign of irreversible brainstem damage and have been strongly associated with a very poor outcome (death, vegetative state, or severe disability) in the majority of patients. Pharmacologic blockade is the most common cause of a fixed dilated pupil in an otherwise normal healthy patient. The focused FRAM model of WAI for the ISS management of a standardised scenario of a 7-year-old child presenting with evolving signs of raised intracranial pressure, a unilateral fixed dilated pupil and a depressed level of consciousness, following a road traffic accident (RTA) is shown in Fig. Patients with severe head injury with bilateral dilated unreactive pupils are considered to have a grave prognosis. identify mydriasis induced by anticholinergic drugs [10]. Pupillary function is autonomic, largely occurring in response to light stimulation and adrenergic tone. To simplify the terminology, Fisher coined the term oval pupil. An air ambulance crew found the patient haemodynamically stable, with Lancet 2004; 363: 1853 7. Mydriasis is the dilation of the pupil, usually having a non-physiological cause, or sometimes a physiological pupillary response. A pupil dilated due to a 3rd nerve palsy will also be supersensitive to pilocarpine 0.125%, however other signs of a 3rd nerve palsy would be present (ptosis, reduced ocular movements, or ocular misalignment). Our clinical information is certified to meet NHS England's Information Standard.Read more. Signs of significant head trauma were apparent, with bilateral periorbital echymosis and blood visible in the right external auditory meatus. Accommodation is the constriction of pupils that occurs You have perhaps 20% chance of the pupil ending up larger than the other eye. That is called traumatic iridoplegia. The nurse should immediately report this finding. Ped Anaesth 2005; 15: 1120-1123 6. This system controls parts of the body not consciously operated such as heartbeat, digestive system, and pupillary response. A 10-year-old child with status asthmaticus, hypercapnia and a unilateral dilated pupil. A unilateral fixed dilated pupil suggests injury or compression of the third cranial nerve and the upper brain stem. Cathy, please see my post http://www.medhelp.org/posts/show/763012 to see if any information there may help you, as well. Mitch, I know it's bee... 1982;93(6):803–4. The differential diagnosis of a unilateral dilated pupil includes partial third nerve palsy, tonic pupil, direct trauma to … Fixed dilated pupil: dilated, unresponsive pupil, e.g. A 40-year-old female gardener presented with a 1-day history of a dilated left pupil (figure 1). Udy A. Unilateral cases, where only one pupil is dilated and fixed, is known as anisocoria, meaning unequal pupil size. a clue to an underlying disorder. Pupil blown by a puffer. It tends to happen on just one side, and this type of mydriasis is called unilateral fixed mydriasis, or a blown pupil. There was no history of topical eye-drops or trauma. In case of severe injury, the pupil may appear in unequal size. History from the patient’s wife (via telephone) was that earlier in the morning he had slipped on some ice and fallen over, hitting his head, but had decided that he was well enough to play golf. Trauma A dilated Pupil can be caused due to any sort of Trauma like damage of Nerves controlling the activities of Iris, injury to head or Eye and Iris Sphincter. A 45 year old man was referred to the medical team with a one week history of unilateral headache associated with nausea and photophobia.

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