Bilateral ptosis caused by patent foramen ovale-associated stroke

A 39-year-old woman presented with sudden onset bilateral ptosis and binocular diplopia for 3 days. The double vision was horizontal and most prominent when she was looking to the left side. The severity of symptoms does not vary over the day. She denied vertigo, headache, ocular pain, limb weakness, paresthesia, alcohol usage and botulinum toxin injection. Past medical history and family history were unremarkable. Neurological examination revealed bilateral ptosis, limited adduction in the right eye and normal pupils (Figure  1A). Other cranial nerves, extremity strength, coordination and sensory tests were intact. Deep tendon reflexes were rated 2+ throughout four limbs. Ice bag and neostigmine tests were negative. Initial blood tests including complete blood cell count, electrolytes, liver and renal functions, lipid, oral glucose tolerance test, thyroid functions and vitamins were normal.
Source: QJM - Category: Internal Medicine Source Type: research