A 45-year-old woman developed acute diplopia on looking down or to the right. She had a history of migraine with aura, prior Hodgkin lymphoma treated with thoracic irradiation 26 years earlier, epilepsy, smoking, hypertension, hyperlipidemia, and a left middle cerebral artery territory transient ischemic attack 5 years earlier. She previously had surgery, chemotherapy, and radiotherapy for recurrent breast carcinoma. She was taking 200 mg of carbamazepine slow-release formulation daily, 150 mg of aspirin daily, 10 mg of amlodipine daily, 2.5 mg of bendrofluazide daily, 20 mg of tamoxifen daily, and 50 μg of thyroxine daily.
Photographs show primary position, head tilt to side of midbrain lesion (A); normal right superior oblique action (B); and impaired left eye depression in adduction (C).
A, Axial T2-weighted magnetic resonance imaging through the midbrain shows a hyperintense lesion (arrow) anterolateral to cerebral aqueduct. B, Diffusion-weighted magnetic resonance imaging shows high signal intensity (arrow), with low signal on apparent diffusion coefficient map (not shown) consistent with discrete acute right trochlear fasciculus infarction. C, Normal midbrain anatomy illustrates cerebral peduncles (1), trochlear nuclei and fasciculi decussating in the dorsal midbrain (red), medial longitudinal fasciculi (2), inferior colliculi (3), and periaqueductal gray matter (4).
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