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September 14, 2021; 97 (11) Resident & Fellow Section

Teaching Video NeuroImage: Pupil-Sparing Infranuclear Third Nerve Palsy Pattern Caused by a Mesencephalic Stroke

View ORCID ProfilePaulo Eduardo Lahoz Fernandez, Vanessa de Sousa Brito, Coralia Gabrielle Vieira Silveira, Guilherme Diogo Silva, Eduardo Genaro Mutarelli
First published May 13, 2021, DOI: https://doi.org/10.1212/WNL.0000000000012189
Paulo Eduardo Lahoz Fernandez
From the Neurology Department (P.E.L.F., V.d.S.B., C.G.V.S., G.D.S., E.G.M.), Syrian Lebanese Hospital; and Neurology Department (G.D.S., E.G.M.), University of São Paulo, Brazil.
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  • ORCID record for Paulo Eduardo Lahoz Fernandez
Vanessa de Sousa Brito
From the Neurology Department (P.E.L.F., V.d.S.B., C.G.V.S., G.D.S., E.G.M.), Syrian Lebanese Hospital; and Neurology Department (G.D.S., E.G.M.), University of São Paulo, Brazil.
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Coralia Gabrielle Vieira Silveira
From the Neurology Department (P.E.L.F., V.d.S.B., C.G.V.S., G.D.S., E.G.M.), Syrian Lebanese Hospital; and Neurology Department (G.D.S., E.G.M.), University of São Paulo, Brazil.
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Guilherme Diogo Silva
From the Neurology Department (P.E.L.F., V.d.S.B., C.G.V.S., G.D.S., E.G.M.), Syrian Lebanese Hospital; and Neurology Department (G.D.S., E.G.M.), University of São Paulo, Brazil.
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Eduardo Genaro Mutarelli
From the Neurology Department (P.E.L.F., V.d.S.B., C.G.V.S., G.D.S., E.G.M.), Syrian Lebanese Hospital; and Neurology Department (G.D.S., E.G.M.), University of São Paulo, Brazil.
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Teaching Video NeuroImage: Pupil-Sparing Infranuclear Third Nerve Palsy Pattern Caused by a Mesencephalic Stroke
Paulo Eduardo Lahoz Fernandez, Vanessa de Sousa Brito, Coralia Gabrielle Vieira Silveira, Guilherme Diogo Silva, Eduardo Genaro Mutarelli
Neurology Sep 2021, 97 (11) e1166-e1167; DOI: 10.1212/WNL.0000000000012189

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A 27-year-old obese woman, a smoker, presented diplopia. She showed ptosis, impaired adduction, supraduction, and infraduction of the left eye with pupil-sparing (figure, A–C and video 1). Brain MRI showed restricted diffusion in the left midbrain, revealing ischemia (figure, D–F). Pupil-sparing third nerve palsy is usually associated with microvascular diabetic ischemia of central fibers in the cisternal segment, but is also related to partial fascicular lesions in brainstem stroke, ophthalmoplegic migraine, and, rarely, aneurysm. Although microvascular and brainstem ischemia have a better prognosis, regardless of pupillary involvement, the investigation is important for secondary stroke prevention, particularly in young patients, as in this case.1,2

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Figure Photograph and Brain MRI

(A, B) Left eye ptosis and pupil-sparing pattern. (C) Nine cardinal positions of gaze show impairment of adduction, supraduction, and infraduction of the left eye. (D–F) Brain MRI reveals a lesion in the left midbrain in fluid-attenuated inversion recovery, diffusion-weighted, and apparent diffusion coefficient sequences.

Video 1

Pupil-sparing third nerve palsy. Nine cardinal positions of gaze show impairment of adduction, supraduction, and infraduction of the left eye with preserved pupillary function.Download Supplementary Video 1 via http://dx.doi.org/10.1212/012189_Video_1

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The authors report no disclosures. Go to Neurology.org/N for full disclosures.

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  • 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/B422

  • © 2021 American Academy of Neurology

References

  1. 1.↵
    1. Lee SH,
    2. Lee SS,
    3. Park KY,
    4. Han SH
    . Isolated oculomotor nerve palsy: diagnostic approach using the degree of external and internal dysfunction. Clin Neurol Neurosurg. 2002;104(2):136-141.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Breen LA,
    2. Hopf HC,
    3. Farris BK,
    4. Gutmann L
    . Pupil-sparing oculomotor nerve palsy due to midbrain infarction. Arch Neurol. 1991;48(2):105-106.
    OpenUrlCrossRefPubMed

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