Acute bilateral ptosis in an 82-year old man Teaching NeuroImages Neurology Resident and Fellow Section © 2017 American Academy of Neurology

Vignette An 82-year-old man with atrial fibrillation, non-adherent to Rivaroxaban, presented with sudden bilateral ptosis Examination was notable for bilateral complete ptosis (Figure 1), pupils midline, fixed midsize, not reactive to light but constricting to accommodation, impaired vertical eye movements with paresis of superior greater than inferior rectus and upgaze convergence nystagmus MRI showed infarction of bilateral third nerve nuclei and mesial thalami (Figure 2) Swinkin, et al. © 2017 American Academy of Neurology

Imaging Swinkin, et al. Figure 1. Figure 2. Figure 1. Bilateral ptosis Bilateral ptosis with forehead corrugator activation on attempted eyelid opening. Figure 2. MRI Brain MRI DWI sequence demonstrates infarction of the bilateral CN III nuclei and mesial thalami corresponding to the artery of Percheron territory. Figure 1. Figure 2. Swinkin, et al. © 2017 American Academy of Neurology

Acute Parinaud’s Syndrome Infarction of the bilateral third nerve nuclei and mesial thalami is consistent with an artery of Percheron infarct Given the patient’s history of atrial fibrillation and non-compliance with anticoagulation, the etiology of the infarct was presumably cardioembolic Artery of Percheron is a single P1 branch that supplies the bilateral paramedian thalami and rostral midbain including the central caudal subnucleus which innervates the bilateral levator palpebrae superioris. Infarcts may present with vertical gaze palsy, memory impairment, and altered mental status1 References 1. Lazzaro N, Wright B, Castillo M, et al. Artery of Percheron infarction: imaging patterns and clinical spectrum. Am J Neuroradiol 2010;31:1283–9. Swinkin, et al. © 2017 American Academy of Neurology