“Sentinel Oculomotor Nerve Palsy”: A Harbinger of Subarachnoid Hemorrhage

TL;DR

A rare case shows that oculomotor nerve palsy can be an early warning sign of subarachnoid hemorrhage, even before typical headaches appear.

Contribution

This case report introduces isolated oculomotor nerve palsy as a potential sentinel sign of nonaneurysmal subarachnoid hemorrhage.

Findings

A 64-year-old woman developed oculomotor nerve palsy before experiencing nonaneurysmal SAH.

Isolated oculomotor nerve palsy may serve as an early, atypical warning sign of SAH.

Atypical headaches can delay diagnosis, making alternative signs like nerve palsy clinically significant.

Abstract

Subarachnoid hemorrhage (SAH) is a life-threatening condition most commonly caused by aneurysmal rupture. Sentinel headaches, often described as the “worst headache of life” or a “thunderclap headache,” are critical warning signs that may precede SAH. However, atypical headaches can complicate early diagnosis. Oculomotor nerve palsy, though rare, may occur as a complication of both aneurysmal and nonaneurysmal SAH. We report a unique case of a 64-year-old woman who initially presented with atypical headache followed by isolated oculomotor nerve palsy, preceding the onset of a nonaneurysmal SAH. This case highlights isolated oculomotor palsy as a potential unrecognized sentinel sign of SAH.

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