ARTICLE IN PRESS Case Studies Ipsilateral Ptosis and Contralateral Ataxic Hemiparesis as Initial Symptoms of Combined Tuberothalamic and Paramedian Artery Infarction Yi Liu, MD, PhD,*,1 Jianwen Lin, MD,* Lin Zhang, MD,* Anand Karthik Sarma, MD,† Hongling Zhao, MD,* Cui Wang, MD,* Jing Bing, MD,‡ Xin Pan, MD,* Xunming Ji, MD, PhD,§,1 and Suping Wang, MD* Thalamic infarcts, accounting for approximately 14% of lacunar infarcts, exhibit varied clinical manifestations due to complex anatomy of nuclei and varying blood supply. Pure and combined types of thalamic infarctions have been summarized in some paper, but information of cerebral angiography was not mentioned. Here we report a rare case of combined tuberothalamic and paramedian artery occlusion presenting with ipsilateral ptosis and contralateral ataxic hemiparesis. Key Words: Ptosis—ataxic hemiparesis—thalamic infarction—blood supply variation. © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved. Case Report An 84-year-old male with chronic hypertension was admitted to our hospital with symptoms of right-sided ptosis and left ataxic hemiparesis, which began about 16 hours ago. Computed tomography scan confirmed a spheroid of low density in thalamus suspicious for infarction. On examination, patient was noted to have somnolence, exFrom the *Department of Neurology, Dalian Municipal Central Hospital, Affiliated Hospital of Dalian Medical University, Dalian, China; †Department of Neurology, Wake Forest University, Winston Salem, North Carolina; ‡Department of Radiology, Dalian Municipal Central Hospital, Affiliated Hospital of Dalian Medical University, Dalian, China; and §Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China. Received January 22, 2018; revision received February 9, 2018; accepted February 17, 2018. Grant support: This work was supported by National Natural Science Foundation of China (81200915). 1, Co-corresponding author. Address correspondence to Yi Liu, MD, PhD, Dalian Municipal Central Hospital, Affiliated Hospital of Dalian Medical University, 826 Xi’nan Road, Dalian, Liaoning Province, 116033, China. E-mail: letaliu@bjmu.edu.cn. 1052-3057/$ - see front matter © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.02.035 ecutive dysfunction, amnesia, hypophonia, decreased verbal fluency, and left-sided weakness with sensory ataxia. On the right side patient had ophthalmoplegia: ptosis, pupillary dilation, loss of adduction, absent pupillary light, and accommodation reflexes. No vertical palsy was observed. National Institutes of Health Stroke Scale score was 6. Abnormal laboratory examination included high homocysteine (32.6 µmol/L) and low-density lipoprotein (3.13 mmol/L). Diffusion-weighted imaging indicated infarction of right polar thalamus and right mesencephalon while computed tomography angiography further confirmed stenosis of proximal part of right posterior cerebral artery (PCA) and absence of posterior communicating artery (PCoA) (Fig 1). No further surgical intervention was performed. Patient was prescribed aspirin, atorvastatin, Vitamin B12, and folate. On discharge (7 days later), patient had fluent speech with other symptoms unchanged. On 1-year follow-up, patient’s symptoms completely resolved. Discussion The thalamus contains multiple cerebral nuclei and axonal tracts, which makes clinical manifestations more complicated with variant blood supply. This paper is the first to demonstrate a rare case of combined right polar Journal of Stroke and Cerebrovascular Diseases, Vol. ■■, No. ■■ (■■), 2018: pp ■■–■■ 1 ARTICLE IN PRESS Y. LIU ET AL. 2 Figure 1. Diffusion-weighted imaging revealed acute infarction of right polar thalamus (A) and mesencephalon (B). Computed tomography angiography (C) showed stenosis of proximal part of right posterior cerebral artery (arrow) and missing posterior communicating artery. Illustration of normal anatomy of tuberothalamic and paramedian artery (D).1 thalamus and mesencephalon infarction with ptosis and ataxic hemiparesis as initial symptoms. Combined tuberothalamic and paramedian thalamic infarction have been reported without involvement of mesencephalon.2-4 Rare case with ptosis was identified as an initial clinical manifestation of thalamic paramedian artery infarction5 or thalamic-mesencephalon infarction.6 Weber syndrome, typically presenting with ipsilateral oculomotor nerve palsy and contralateral hemiparesis, is mostly caused by thalamic paramedian artery occlusion.7 Patient in this case did not show vertical palsy, which was nuclear oculomotor nerve palsy and could be differentiated from Weber syndrome. Thalamic paramedian artery originates from PCA, whereas tuberothalamic artery derives from PCoA (Fig 1, D), and they irrigate thalamus and mesencephalon.1 One third of the population has an absent tuberothalamic artery, which is alternatively supplied by the thalamic paramedian artery.8 Patient in this study had absent PCoA and combined infarction of right polar thalamus and mesencephalon, which suggest combined blood supply for tuberothalamic and paramedian artery arising from the same source. Computed tomography angiography showed stenosis of proximal part of right PCA, which helped to identify Trial of Org 10172 in acute stroke treatment (TOAST) subtype as large artery atherosclerosis.9 References 1. Schmahmann JD. Vascular syndromes of the thalamus. Stroke 2003;34:2264-2278. 2. Kumral E, Deveci EE, Çolak AY, et al. Multiple variant type thalamic infarcts: pure and combined types. Acta Neurol Scand 2014;131:102-110. 3. Perren F, Clarke S, Bogousslavsky J. 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