Isolated Inferior Rectus Paresis in a Patient with a History of Lymphoma

Isolated inferior rectus paresis due to a midbrain lesion is very uncommon.To the best of our knowledge, there are only three cases of infarction in the literature.[1][2][3] It seems that selective oculomotor fascicular lesions may be more common than selective oculomotor nucleus lesions, possibly due to complicated perforating arteries 4 or wider distribution in fascicular arrangement.5 The possible stroke etiology was small vessel disease.[1][2][3] We present a patient with a tiny infarction in the oculomotor nucleus.The lesion in this case is illustrative because it was very selective and only detected by brain diffusion-weighted magnetic resonance imaging (DWI).The patient had a history of previous transient ischemic attacks (TIAs) and Hodgkin's lymphoma with complete remission.In this case, the possible stroke mechanism may be different from that identified in previous reports. CASE REPORTA 46-year-old woman with two previous TIAs was admitted for evaluation of painless diplopia and dizziness with acute onset.She did not have hypertension, diabetes mellitus, hyperlipidemia or a history of smoking, and had no family history of stroke.Fifteen years prior, she had been diagnosed with Hodgkin's lymphoma and treated with radiotherapy at a different hospital.She indicated that the radiation field included the neck and inguinal area, but not the head.She reported that there was no relapse with regular follow-ups.Her diplopia was more severe when she gazed to the right.The neurological examination was normal except for right isolated rectus paresis.The maximal limitation of right eye movement was associated with a right downward gaze (Figure A).Her right eye was not depressed on abduction and there was no ptosis.Pupils were symmetric and reactive to light stimulation.Nystagmus was not observed.She had no head tilt.A 1.5 Tesla MRI scan (Intera, Philips Medical Systems, Best, The Netherlands) was performed (5 mm slice thickness; 2.5 mm interslice gap; 23 axial slices; 230 mm field of view).Brain diffusion-weighted magnetic resonance imaging (DWI, TR 4,032 msec, TE 80 msec; matrix number of 192 x 192; two b values of 0 and 1,000 sec/mm 2 ) and an apparent diffusion coefficient (ADC) map showed a focal infarct in the right median midbrain ventral to the aqueduct at the level of superior colliculus, presumably involving the right dorso-lateral subnucleus of the oculomotor nuclear complex (Figure B,C).Magnetic resonance angiography, routine laboratory tests, electrocardio-graphy, transthoracic (TTE) and transesophageal echocardiography (TEE) were performed with normal results.Additional laboratory tests were all normal and included analysis of protein C, protein S,

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