PMC7287175_01
A case of left ptosis, difficulty in seeing inward (A), and left pupil enlargement (C). The case had normal left abduction (B).
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F1
Neurological examination revealed a complete paralysis of the left third cranial nerve (Figure 1).
Axial T1 contrast-enhanced MRI (44 days after headache) and DWI (30 days after headache) through the point at which the oculomotor nerve emerges from the midbrain in this patient with left oculomotor ophthalmoplegic migraine. (A-C) Acute phase. The MRI shows a nodular, enhancing lesion in the cisternal segment of the left third nerve (arrow) in (A). In (B,C), a signal was demonstrated at the midbrain of the left-sided third cranial nerve on DWI and ADC. (D-F) Quiescent phase, taken 7 weeks after the left ptosis and diplopia had resolved. (D) Demonstrates the decreased enhancement. (E,F) Demonstrate that the signal had disappeared at this point on DWI and ADC.
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F2
MRI revealed focal enhancement of the cisternal segment of the left oculomotor nerve (Figure 2A). Meanwhile, the affected nerve was isointense to the midbrain on DWI and apparent diffusion coefficient (ADC) maps (Figures 2B,C). Repeated MRI revealed relatively weaker enhancement with no signal visible on DWI and ADC maps (Figures 2D-F).
Relatively dilated left pupil (C) with recovered extra-ocular movement (A,B).
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F3
Gradually, over the course of the next 3 months, the patient's left-sided ptosis and diplopia showed complete resolution although the left pupil remained relatively dilated and poorly reactive to light (Figure 3).
Unenhanced MRI from 9 years prior showing minor thickening of the distal cisternal portion of the left-sided third cranial nerve on T2 FLAIR. See arrow (B). The signal on T1 is obvious, during both the attack and remission. See arrow (C,D) although it is not visible on the T1 image from 9 years ago (A).
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F4
A review of a previous MRI performed at another hospital 9-years earlier, when the patient was aged 15, showed slight thickening of the left third cranial nerve at the site of exit from the midbrain, especially on T2 FLAIR (Figure 4B). During the past 15-years, although the symptoms resolved completely each time except for this attack, the lesion had increased in size on T1 since his initial presentation (Figures 4A,C,D).