DOI: https://doi.org/10.36347/sjmcr.2026.v14i09.006

Pages: 1964-1968

Acute bilateral ptosis due to brainstem infarction is an exceptionally rare manifestation of ischemic stroke and may indicate involvement of the oculomotor nuclear or fascicular structures in the rostral midbrain. We report the case of a 60-year-old woman who presented with acute diplopia, impaired consciousness, marked gait ataxia, complete bilateral ptosis, mydriasis, and bilateral downward and outward deviation of the eyes. Brain magnetic resonance imaging revealed acute bilateral paramedian infarctions of the rostral mesencephalon, predominantly involving the dorsal mesencephalic tegmentum and periaqueductal gray matter, associated with bilateral paramedian thalamic infarctions. Additional ischemic lesions of different ages involving cortical and cortico-subcortical territories, including a left middle cerebral artery infarction with hemorrhagic transformation, suggested an embolic mechanism. Magnetic resonance angiography demonstrated occlusion of the distal basilar artery extending to the left P1 segment. Extensive investigations for vascular, inflammatory, immunological, infectious, toxic, and metabolic causes were negative. Cardiac evaluation revealed a large patent foramen ovale with spontaneous right-to-left shunt, associated with an atrial septal aneurysm and massive passage of microbubbles during the Valsalva maneuver, supporting a cardioembolic mechanism.