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Stroke. 2008;39:1355-1357
Published online before print February 28, 2008, doi: 10.1161/STROKEAHA.107.504761
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(Stroke. 2008;39:1355.)
© 2008 American Heart Association, Inc.

Case Report

Complete Ophthalmoplegia

An Unusual Sign of Bilateral Paramedian Midbrain-Thalamic Infarction

Matthew J. Thurtell, MBBS, FRACP G. Michael Halmagyi, MD, FRACP

From the Department of Neurology, Institute of Clinical Neurosciences, Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia.

Correspondence to Dr Matthew J. Thurtell, Department of Neurology, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW 2050, Australia. E-mail matthewt{at}icn.usyd.edu.au

Background and Purpose— Complete ophthalmoplegia, the combination of bilateral ptosis with loss of all extraocular movements, is rarely a consequence of ischemic stroke. We describe 3 patients who had complete ophthalmoplegia as a manifestation of bilateral paramedian midbrain-thalamic infarction, and we discuss possible pathophysiologic mechanisms.

Summary of Cases— Three patients presented with coma. All had complete ophthalmoplegia that initially persisted despite improvement or fluctuation in their other deficits. MRI revealed bilateral paramedian midbrain-thalamic infarction. Two patients died, with the ophthalmoplegia remaining unchanged before death. The surviving patient had a progressive improvement in ocular abduction but persisting third nerve and vertical gaze palsies.

Conclusions— Complete ophthalmoplegia is an unusual sign of bilateral paramedian midbrain-thalamic infarction. The ophthalmoplegia could result from combined third nerve, pseudoabducens, and vertical gaze palsies.


Key Words: ophthalmoplegia • mesencephalon • thalamus • infarction






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