A 54-year-old woman presented with a 30-year history of worsening left blepharoptosis. Neuro-ophthalmic examination was significant for blepharoptosis, limited levator function, and supraduction in the left eye with left hypotropia, and normal pupils without diplopia. MRI brain/orbits revealed subtle atrophy of the left superior rectus (figure 1, A and B), without any orbital pathology. Superior compression of the left oculomotor nerve by the posterior cerebral artery (PCA) was observed (figure 1, C–E). Given the microanatomy of oculomotor nerve in the cistern space,1,2 this is a rare selective compression of the superolateral oculomotor nerve by the PCA vessel (figure 2), sparing the superomedial parasympathetic limb.
(A, B) Isolated asymmetric atrophy of the left superior rectus muscle (arrows). (C) Left posterior cerebral artery in cross-section (arrow) impinges upon the left CNIII (arrowhead). (D, E) Asymmetric flattening of the left CNIII (arrowheads) by the left posterior cerebral artery (arrows).
Image is constructed based on similar images in Brazis.3
Study funding
No targeted funding reported.
Disclosure
The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.
Appendix Authors
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Teaching slides links.lww.com/WNL/B67
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