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A patient’s very scary ski vacation

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By Dr. Jeff Daniels EBS Medical Columnist

In between the torn ACLs and fractured shoulders suffered on the slopes, occasionally an unusual and previously unseen medical oddity presents itself to the clinic. When that happens, we muster all of our resources and try to get to the bottom of it.

One such case presented in February, when a young man visiting Big Sky looked in the mirror and noticed that one of his eyelids was drooping, and the pupil of that eye was a lot smaller than his other pupil. To say that this scared him would be putting it mildly!

He came into the office and I had all of the medical students and residents working with me examine him and give their opinion. None of us could find any other neurological abnormality aside from the droopy eyelid (ptosis) and the constricted pupil (meiosis).

His history didn’t give us any clues either: He was from the East Coast, but had never had a problem at this elevation. He was here skiing, but hadn’t experienced head trauma. He was traveling with friends, and he may have had more to drink than usual, but that commonly occurs on a ski vacation. His vision was 20/20 on the affected side, and his only other complaint was a mild headache on the same side of his head as the ptosis and meiosis.

All of the emergency medicine residents wanted him to immediately get a CT scan of the brain, as well as a CT angiogram, looking for aneurysms and bleeding near the nerves that go to the eye. We were able to arrange for these tests immediately at the Big Sky Medical Center, and the CT angiogram suggested that the blood vessels in a certain part of the brain were inflamed.

It so happened that a frequent guest lecturer for the students and residents, who happened to be a neurosurgeon, was coming to talk to us about interesting cases that evening. Our patient was only too happy to come in and get an opinion, so we all crowded into an examination room as a very careful and thorough neurological examination was done.

Finding no other abnormalities, our neurosurgeon ruled out many terrible problems, but couldn’t pinpoint a diagnosis. He didn’t think that the CT angiogram findings were that significant, but agreed that giving a steroid to treat vasculitis would be appropriate.

Our patient left for home the next day, and within a week was able to see the head of neurology at Johns Hopkins Hospital in Baltimore, Maryland. The patient emailed me that he was told he had a condition called “reversible cerebral vasoconstriction syndrome” or RCVS, with an emphasis on “reversible.” He was told to avoid alcohol for three months, take two Aleve twice a day, and not to come back to altitude for a while—and his symptoms have slowly been resolving.

Reading more about RCVS, it sounds a lot worse than what our patient experienced. “Thunderclap” headaches and seizures could be part of the syndrome, along with a variety of neurological findings. Thunderclap headaches are described as being felt on both sides of the head, reaching a very severe degree within one minute of onset. This is supposed to be a symptom in 95 percent of cases of RCVS, but fortunately not in our case!

The good news is that the syndrome usually resolves in about three weeks, as it appears to be happening for our patient. I texted the diagnosis to our neurosurgeon, who responded “interesting!”

Dr. Jeff Daniels was the recipient of the 2016 Big Sky Chamber of Commerce Chet Huntley Lifetime Achievement Award and has been practicing medicine in Big Sky since 1994, when he and his family moved here from New York City. A unique program he implements has attracted more than 700 medical students and young doctors to train with the Medical Clinic of Big Sky.

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