Mystery Case: Bilateral Claude syndrome

A 59-year-old man with hypertension, hyperlipidemia, and type 2 diabetes presented with sudden-onset, bilateral ptosis, ataxia, and confusion. Examination showed bilateral ophthalmoparesis sparing minimal adduction and abduction, poorly reactive and dilated pupils, and global ataxia (video). The oculocephalic reflex revealed normal bilateral abduction. Bell phenomenon and convergence were absent. MRI brain showed bilateral paramedian mesencephalic ischemic stroke (figure). Here in a bilateral variant, clinical presentation and imaging closely follow the description of Henri Claude's first case,1 where pathologic examination revealed a paramedian midbrain stroke involving the superior cerebellar peduncle, red nucleus, and medial longitudinal fasciculus (MLF).1