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Case summary
A 47-year-old male presented with complaints of diplopia upon awakening. He had atrial fibrillation, mitral valve regurgitation, aortic valve regurgitation and a history of spleen infarction 1 year prior. His right eye was hypertrophic and right eye downgaze was limited unilaterally of equal degree in adduction and abduction. Right eye horizontal and upward movements were intact. Left eye movement was intact in all directions. Pupillary light reflex response and convergence test were normal. Nystagmus was not observed. The patient was diagnosed with double depressor palsy of the right eye. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the brain showed an old infarction of the left thalamus and diffusion MRI showed acute infarction of the right thalamus. The patient's daily warfarin dose was 2 mg and was increased to 5 mg with cilostazol 75 mg two times a day. Seven weeks later, the patient's ocular movement revealed near normal muscle action and, subjectively, the patient was diplopia-free.
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Figure 1.
In primary position, hypertropia of the right eye was found and limitation to down gaze of equal degree in adduction and abduction was noted.
Figure 2.
Hess charting was consistent with palsy of superior oblique and inferior rectus of the right eye.
Figure 3.
Axial view of brain MRI. (A-C) Diffusion MRI images show a high signal intensity in a right paramedian thalamus (arrow); acute infarction. Midbrain is intact. (D-F) T2 weighted images show a high signal intensity in left paramedian thalamus (arrow head); old infarction. Midbrain is intact.
Figure 4.
Seven weeks later, hypertropia of the right eye was improved in primary position and limitation to down gaze was subsided completely.
Figure 5.
The thalamoperforating arteries, schematic representation, coronal plane-posterior third ventricle level. The posterior thalamoperforating artery (A-C), (A) the most common variation, there are many small perforating arteries arising from the P1 segments of the PCA. (P1 segment: segment from the basilar artery to the junction with the PCom.) (B) An arcade of perforating branches arising from the PCA. (C) The artery of Percheron is a single perforating blood vessel arising from one P1 segment. (D) The anterior thalamoperforating arteries arising from the Pcom arteries. PCom = posterior communicating; PCA = posterior cerebral artery; MB = midbrain; Th = Thalamus; B = basilar artery; R = red nucleus; S = substantial nigra; P = basis pedunculi.
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