The case

A 67-year-old man presented with acute onset severe generalised headache and diplopia. He had membranous glomerulonephritis, had failed immunosuppressant therapy, and had started haemodialysis 3 months before presentation. He was on three antihypertensive agents and had missed a few doses in the week before his admission. He had no other illness and no recent change of medication.

On examination, his blood pressure was 201/95 mm Hg. He reported diplopia on all eye movements, although with no clinically obvious ophthalmoplegia. Visual acuity was 6/6 bilaterally and fundoscopy was normal. The rest of the neurological examination was normal. CT scan of head was normal.

His blood pressure control was difficult, requiring intravenous labetalol, and his symptoms persisted despite blood pressure lowering.

On day 3, he developed dysconjugate eye movements with incomplete right eye abduction. A MR scan of brain was reported as showing a small haemorrhage in the right basal ganglia (figure 1).