Delayed complete bilateral ptosis associated with massive infarction of the right hemisphere

. Objective: To characterize the phenomenon of complete bilateral ptosis associated with massive infarction of the right cerebral hemisphere, particularly with respect to its time course and relationship to herniation syndromes. . Patients. and Methods: In May through July 2002, consecutive patients admitted to the neurology/neurosurgery intensive care unit at the Mayo Clinic in Rochester, Minn, with massive infarction of the right cerebral hemisphere, and later, complete bilateral ptosis, underwent serial neurologic examinations and neuroimaging. . Results: Six patients with massive infarction of the right cerebral hemisphere developed complete bilateral ptosis. All had normal eyelid opening at initial examination and later developed ptosis, which clearly preceded signs of herniation. Three patients died after herniation syndromes developed. In the 3 survivors, improvement in ptosis closely followed resolution of midbrain distortion seen on computed tomographic scans. . Conclusion: The precise anatomical explanation for complete bilateral ptosis is unclear, but upper brainstem involvement seems most likely. Complete bilateral ptosis is a valuable clinical sign in patients with a massive hemispheric infarction that precedes herniation and could provide an opportunity for early intervention.