Teaching Neuro Images Neurology Resident and Fellow Section 2017 American Academy of Neurology Vignette An 82yearold man with atrial fibrillation nonadherent to Rivaroxaban presented with sudden bilateral ptosis ID: 784725
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Acute bilateral ptosis in an 82-year old manTeaching NeuroImagesNeurologyResident and Fellow Section
© 2017 American Academy of Neurology
Slide2VignetteAn 82-year-old man with atrial fibrillation, non-adherent to Rivaroxaban, presented with sudden bilateral ptosisExamination 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 nystagmusMRI showed infarction of bilateral third nerve nuclei and mesial thalami (Figure 2)Swinkin, et al.
© 2017 American Academy of Neurology
Slide3ImagingSwinkin, et al.
© 2017 American Academy of Neurology
Figure 1.
Figure 2.
Slide4Infarction 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
Swinkin, et al.
Acute Parinaud’s Syndrome
© 2017 American Academy of Neurology