Ptosis in patients with hemispheric strokes. Averbuch-Heller L. Leigh RJ. Mermelstein V. Zagalsky L. Streifler JY. Neurology 2002;58:620–624

Abstract

Ptosis caused by lesions of the cerebral hemispheres without involvement of the third cranial nerves or oculosympathetic pathways is considered rare. So-called cerebral ptosis has been most often reported with unilateral, usually right hemispheric lesions. However, the frequency of cerebral ptosis in patients with strokes has not received systematic study. The purpose of this study was to determine the frequency of ptosis in patients with acute hemispheric stroke and to identify stroke features associated with ptosis. Eyelid function was studied in 64 consecutive patients with acute hemispheric stroke and 40 age-matched subjects with no known neurologic disease. All underwent comprehensive neuroophthalmologic and general neurologic examination within 48 hours of admission, including measurement of palpebral fissures, marginal reflex distance, and range of upper lid movement. Only patients who could cooperate with eyelid testing were included Brain CT scans were obtained for all patients. Neurogenic ptosis was found in 24 patients (37.5%) with stroke, which was bilateral in 10 patients and unilateral in 14. None of the control subjects had neurogenic ptosis. All patients with stroke with ptosis had a hemiparesis, most often contralateral to the side of the ptosis in those patients with unilateral or highly asymmetric ptosis. CT evidence of right-sided hemispheric cortical infarction was more common in patients with strokes with ptosis. Rightward gaze deviation and upgaze paresis were more common (P < .05) in the patients with ptosis compared with others who had had strokes. In five patients with large hemispheric infarction, complete bilateral or asymmetric ptosis was the first sign of imminent herniation, preceding pupillary dilatation and ocular motor deficits. The authors conclude that ptosis occurs frequently in patients with hemispheric strokes, especially in association with right hemispheric lesions. Complete bilateral ptosis is usually caused by large infarctions and may be a premonitory sign of an impending herniation.—Nancy J. Newman