Safety and Efficacy of Ketamine Without Intubation in the Management of Refractory Seizures: A Case Series.

BACKGROUND: Continuous infusion ketamine has demonstrated efficacy in the management of refractory seizures yet does not suppress respiratory drive like other continuous infusion anesthetics (CIAs) used for this indication. The aim of this study is to describe the safety and efficacy of ketamine infusions in patients with refractory seizure without intubation. METHODS: We analyzed a retrospective cohort of adult patients who were not intubated at the time of initiation of a ketamine infusion for refractory seizures. Seizure onset was determined to be the first clinical seizure or nonconvulsive seizure reported on electroencephalography (EEG) or the start time of EEG for patients with seizures at EEG initiation. Responders were defined as patients with resolution of seizures within 24 h of initiation without the need for intubation or an additional CIA. RESULTS: A total of 28 patients were analyzed (median age 62 years, 64.3% female, 82.1% African American, 82.1% with structural seizure etiology, and 85.7% focal seizures). Of patients, 78.5% received an initial bolus averaging 0.9 mg/kg, and the majority (89.3%) were initiated on an infusion at 10 µg/kg/minute; median duration was 39.8 h. Maximum infusion rates were 10 µg/kg/minute in 16 patients, 20 µg/kg/minute in seven patients, and 30 µg/kg/minute in five patients. Of patients, 71.4% were assessed to be ketamine responders; six of the eight nonresponders required intubation and an additional CIA. Responders were 80% more likely to have received ketamine 5 or more hours earlier than nonresponders. Hypotension (systolic blood pressure < 90 mmHg) occurred in 31.8% of patients receiving only ketamine, which did not correlate with duration or maximum dose of ketamine; hypertension (systolic blood pressure > 180 mmHg) occurred in 39.3%. CONCLUSIONS: Ketamine represents a safe and effective treatment option for refractory seizures and has potential to reduce morbidity associated with intubation in a carefully selected patient population. Early initiation may increase the likelihood of success.

A Rare Case of Progressive Encephalopathy in a Sickle Cell Trait Patient: A Case Report.

Fat embolism syndrome (FES) is one of the underdiagnosed and underrecognized complications that can happen in multiple medical and surgical conditions. FES can manifest in a broad spectrum of signs and symptoms and affect multiple organ systems in the human body. One of the most commonly involved is the central nervous system (CNS), mainly the brain, which can be involved in different ways, and the presenting symptoms can vary in type and severity. One of the most common causes of FES is trauma, mainly a long bone fracture or any orthopedic injury. However, one of the rare causes of FES is sickle cell disease (SCD) and thalassemia. Generalized and vague presenting symptoms, the rarity of FES, and the absence of well-defined diagnostic criteria make it a challenging diagnosis for healthcare practitioners. FES diagnosis is usually made after having a high index of suspicion in patients with underlying risk factors that can precipitate and contribute to the pathophysiology of FES. Moreover, the diagnosis is usually reached after excluding other more common and treatable conditions.

Evaluation of the Safety of Rapid Administration of Undiluted High-Dose Intravenous Levetiracetam.

Background: Intravenous (IV) levetiracetam (LEV) is an antiseizure medication traditionally given as an intermittent infusion to mitigate potential adverse effects given its acidic formulation. The process of compounding may lead to delays in treating status epilepticus, which is why administration of undiluted doses is of interest. Prior studies have shown safety of IV doses from 1000 mg to 4500 mg; however, assessments of adverse side effects outside IV site reactions have not been studied. Methods: A retrospective analysis was completed with patients who received 1500 mg doses of undiluted IV LEV. We included patients ≥ 18 years old that received at least 1 dose of IV LEV 1500 mg from January 2018 to February 2021. Study end points included assessment of hemodynamic disturbance (bradycardia [HR less than 50 beats per minute] or hypotension [SBP less than 90 mmHg] within 1 hour or documented infusion reaction within 12 hours of LEV. Descriptive statistics were utilized. Results: A total 213 doses of 1500 mg of IV LEV were administered to 107 patients. Peripheral lines were used for 85.9% of doses. Approximately half of doses (57) were administered to patients on the general wards, with the remainder in the intensive care unit or emergency department. Two patients (1.9%) experienced bradycardia; however, 1 patient had pre-existing bradycardia. Three patients (3.8%) experienced hypotension; however, those patients were receiving vasopressors prior to the dose. There were no cases of infusion reaction. Conclusion: Undiluted, rapid administration of IV LEV 1500 mg was well tolerated and safe.

Neurological manifestations and complications of coronavirus disease 2019 (COVID-19): a systematic review and meta-analysis.

BACKGROUND: The spectrum of neurological involvement in COVID-19 is not thoroughly understood. To the best of our knowledge, no systematic review with meta-analysis and a sub-group comparison between severe and non-severe cases has been published. The aim of this study is to assess the frequency of neurological manifestations and complications, identify the neurodiagnostic findings, and compare these aspects between severe and non-severe COVID-19 cases. METHODS: A systematic search of PubMed, Scopus, EBSCO, Web of Science, and Google Scholar databases was conducted for studies published between the 1st of January 2020 and 22nd of April 2020. In addition, we scanned the bibliography of included studies to identify other potentially eligible studies. The criteria for eligibility included studies published in English language (or translated to English), those involving patients with COVID-19 of all age groups, and reporting neurological findings. Data were extracted from eligible studies. Meta-analyses were conducted using comprehensive meta-analysis software. Random-effects model was used to calculate the pooled percentages and means with their 95% confidence intervals (CIs). Sensitivity analysis was performed to assess the effect of individual studies on the summary estimate. A subgroup analysis was conducted according to severity. The main outcomes of the study were to identify the frequency and nature of neurological manifestations and complications, and the neuro-diagnostic findings in COVID-19 patients. RESULTS: 44 articles were included with a pooled sample size of 13,480 patients. The mean age was 50.3 years and 53% were males. The most common neurological manifestations were: Myalgia (22.2, 95% CI, 17.2 to 28.1%), taste impairment (19.6, 95% CI, 3.8 to 60.1%), smell impairment (18.3, 95% CI, 15.4 to 76.2%), headache (12.1, 95% CI, 9.1 to 15.8%), dizziness (11.3, 95% CI, 8.5 to 15.0%), and encephalopathy (9.4, 95% CI, 2.8 to 26.6%). Nearly 2.5% (95% CI, 1 to 6.1%) of patients had acute cerebrovascular diseases (CVD). Myalgia, elevated CK and LDH, and acute CVD were significantly more common in severe cases. Moreover, 20 case reports were assessed qualitatively, and their data presented separately. CONCLUSIONS: Neurological involvement is common in COVID-19 patients. Early recognition and vigilance of such involvement might impact their overall outcomes.

A retrospective, observational study of perampanel in refractory and super-refractory status epilepticus.

INTRODUCTION: The outcomes of administration of Perampanel (PER) which is a ß-amino-3-(5-methyl-3-oxo-1,2-oxazol-4-yl)propionic acid (AMPA) receptor antagonist for the treatment of refractory status epilepticus (RSE) and Super-refractory (SRSE) were previously reported in small cohort studies and case reports. We report efficacy and side effect results of an observational cohort of 75 patients treated with PER for RSE and SRSE. METHODS: This was a single-center, retrospective, observational study of patients with RSE admitted to the neurocritical care unit between April 2017 and September 2019 who received treatment with PER. The primary outcome was the occurrence of a definite response to PER, which was defined as clear resolution of the ictal pattern and/or seizures within 72 h of delivery of PER which was the last administered antiseizure medication (ASM). Secondary outcomes included the percentage of patients other response types (partial responder or non-responder), as well as the rate of adverse effects. RESULTS: A total 75 patients were included in our analysis. PER was initiated as the median sixth ASM at a median initial dose of 12 mg. For the primary outcome, 31 (41.3%; 95% confidence interval 31.0%-53.0%) patients were classified as a definite responder. Seven patients (9.3%) experienced an adverse effect that was attributed to PER, with the most common being sedation in four patients. CONCLUSIONS: In our retrospective cohort of RSE, we observed a definite response rate of 41.3% within 72 h of PER initiation. PER was well tolerated with few documented adverse effects. Further prospective studies are needed to confirm the role of PER in treating patients with RSE.

Prognostication via early computed tomography head in patients treated with targeted temperature management after cardiac arrest.

BACKGROUND: We evaluated computed tomography head (CTH) imaging obtained prior to targeted temperature management (TTM) in patients after cardiac arrest, and its role in prognostication. METHODS: In this retrospective cohort study in a tertiary-care hospital, 341 adults presenting with out-of-hospital cardiac arrest received a CTH prior to TTM. Associations between outcomes and neuroimaging variables were evaluated with Chi-square analysis for significant associations that yielded a composite neuroimaging score-Tennessee Early Neuroimaging Score (TENS). Univariable and multivariable logistic regression analysis including TENS as an independent variable and the four outcome dependent variables were analyzed. RESULTS: Four of the neuroimaging variables-sulcal effacement, partial gray-white matter effacement, total gray-white matter effacement, deep nuclei effacement-had significant associations with each of the four outcome variables and yielded TENS. In multivariable logistic regression models adjusted for potential confounders, TENS was associated with poor discharge CPC (OR 2.15, 95%CI 1.16-3.98, p = .015), poor disposition (OR 2.62, 95%CI 1.37-5.02, p = .004), in-hospital mortality (OR 1.99, 95%CI 1.09-3.62, p = .024), and ICU mortality (OR 1.89, 95%CI 1.12-3.20, p = .018). CONCLUSION: Imaging prior to TTM may help identify post-cardiac arrest patients with severe anoxic brain injury and poor outcomes.

Cerebellar Hippocampal and Basal Nuclei Transient Edema with Restricted diffusion (CHANTER) Syndrome.

BACKGROUND: Abnormal restricted diffusion on magnetic resonance imaging is often associated with ischemic stroke or anoxic injury, but other conditions can present similarly. We present six cases of an unusual but consistent pattern of restricted diffusion in bilateral hippocampi and cerebellar cortices. This pattern of injury is distinct from typical imaging findings in ischemic, anoxic, or toxic injury, suggesting it may represent an under-recognized clinicoradiographic syndrome. Despite initial presentation with stupor or coma in the context of obstructive hydrocephalus, patients may have acceptable outcomes if offered early intervention. METHODS: We identified an ad hoc series of patients at our two institutions between years 2014 and 2017 who presented to the neurocritical care unit with severe, otherwise unexplained cerebellar edema and retrospectively identified several commonalities in history, presentation, and imaging. RESULTS: Between two institutions, we identified six patients-ages 33-59 years, four male-with similar presentations of decreased level of consciousness in the context of intoxicant exposure, with acute cytotoxic edema of the cerebellar cortex, hippocampi, and aspects of the basal nuclei. All patients presented with severe cerebellar edema which led to obstructive hydrocephalus requiring aggressive medical and/or surgical management. The five patients who survived to discharge demonstrated variable degrees of physical and memory impairment on discharge and at follow-up. CONCLUSIONS: We present findings of a potentially novel syndrome involving a distinct pattern of cerebellar and hippocampal restricted diffusion, with imaging and clinical characteristics distinct from ischemic stroke, hypoxic injury, and known toxidromes and leukoencephalopathies. Given the potential for favorable outcome despite early obstructive hydrocephalus, early identification and treatment of this syndrome are critical.

Minimally invasive endoscopic hematoma evacuation vs best medical management for spontaneous basal-ganglia intracerebral hemorrhage.

BACKGROUND: We conducted a case-control study to assess the relative safety and efficacy of minimally invasive endoscopic surgery (MIS) for clot evacuation in patients with basal-ganglia intracerebral hemorrhage (ICH). METHODS: We evaluated consecutive patients with acute basal-ganglia ICH at a single center over a 42-month period. Patients received either best medical management according to established guidelines (controls) or MIS (cases). The following outcomes were compared before and after propensity-score matching (PSM): in-hospital mortality; discharge National Institutes of Health Stroke Scale score; discharge disposition; and modified Rankin Scale scores at discharge and at 3 months. RESULTS: Among 224 ICH patients, 19 (8.5%) underwent MIS (mean age, 50.9±10.9; 26.3% female, median ICH volume, 40 (IQR, 25-51)). The interventional cohort was younger with higher ICH volume and stroke severity compared with the medically managed cohort. After PSM, 18 MIS patients were matched to 54 medically managed individuals. The two cohorts did not differ in any of the baseline characteristics. The median ICH volume at 24 hours was lower in the intervention group (40 cm3 (IQR, 25-50) vs 15 cm3 (IQR, 5-20); P<0.001). The two cohorts did not differ in any of the pre-specified outcomes measures except for in-hospital mortality, which was lower in the interventional cohort (28% vs 56%; P=0.041). CONCLUSIONS: Minimally invasive endoscopic hematoma evacuation was associated with lower rates of in-hospital mortality in patients with spontaneous basal-ganglia ICH. These findings support a randomized controlled trial of MIS versus medical management for ICH.

Predictors for Tracheostomy with External Validation of the Stroke-Related Early Tracheostomy Score (SETscore).

BACKGROUND AND PURPOSE: Ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) patients often require endotracheal intubation (EI) and mechanical ventilation (MV). Predicting the need for prolonged EI and timing of tracheostomy (TR) is challenging. While TR is performed for about 10-15% of patients in the general intensive care unit (ICU), the rate in the neurological ICU and for stroke patients ranges between 15 and 35%. Thus, we performed an external validation of the recently published SETscore. METHODS: This is a retrospective review for all patients with IS, non-traumatic ICH, and SAH who required intubation within 48 h of admission to the neurological ICU. We compared the SETscore between tracheostomized versus successfully extubated patients, and early TR (within 7 days) versus late TR (after 7 days). RESULTS: Out of 511 intubated patients, 140 tracheostomized and 105 extubated were included. The sensitivity for a SETscore > 10 to predict the need for TR was 81% (95% CI 74-87%) with a specificity of 57% (95% CI 48-67%). The score had moderate accuracy in correctly identifying those requiring TR and those successfully extubated: 71% (95% CI 65-76%). The AUC of the score was 0.74 (95% CI 0.68-0.81). Multivariable logistic regression models were used to identify other independent predictors of TR. After including body mass index (BMI), African American (AA) race, ICH and a positive sputum culture in the SETscore, sensitivity, specificity, overall accuracy, and AUC improved to 90%, 78%, 85%, and 0.89 (95% CI 0.85-0.93), respectively. In our cohort, performing early TR was associated with improvement in the ICU median length of stay (LOS) (15 vs 20.5 days; p = 0.002) and mean ventilator duration (VD) (13.4 vs 18.2 days; p = 0.005) in comparison to late TR. CONCLUSIONS: SETscore is a simple score with a moderate accuracy and with a fair AUC used to predict the need for TR after MV for IS, ICH, and SAH patients. Our study also demonstrates that early TR was associated with a lower ICU LOS and VD in our cohort. The utility of this score may be improved when including additional variables such as BMI, AA race, ICH, and positive sputum cultures.

Safety and Efficiency of Intravenous Push Lacosamide Administration.

BACKGROUND/OBJECTIVE: Intravenous (IV) lacosamide use for status epilepticus has increased in recent years and is recommended for refractory status epilepticus by current guidelines. Per the lacosamide package labeling, the preferred route of administration is diluted and infused over 30-60 min; however, administration undiluted is also acceptable and recent literature demonstrated safety at a maximum rate of 80 mg per minute (Kellinghaus et al. in Acta Neurol Scand 123:137-141, 2011). Undiluted administration as an IV push has potential to increase efficiency of administration to patients needing urgent seizure control since it may be dispensed from automatic dispensing cabinets in patient care areas. This study aims to compare safety outcomes and efficiency of administration in patients receiving lacosamide IV push compared to IV piggyback. METHODS: We present a single-center, retrospective cohort study of patients receiving lacosamide via IV piggyback or IV push from June 2016 to July 2017. Baseline characteristics, data related to potential safety concerns and timing of ordering, verification, and administration were collected. The primary safety outcomes were incidence of infusion site reactions, hypotension (systolic blood pressure [SBP] < 90 mm Hg), and bradycardia (heart rate [HR] < 50 beats per minute) documented within 2 h of each lacosamide dose. Secondary safety outcomes included the incidence of PR interval prolongation in patients with at least one electrocardiogram measured. The primary efficiency outcome was the time between order verification and administration. RESULTS: Patients in the IV piggyback (n = 88) and IV push (n = 78) groups had similar baseline characteristics, initial dose, SBP, and HR. Hypotension (8 vs. 10.3%) and bradycardia (2.3 vs. 2.6%) rates were similar among both groups (p > 0.05). Only one patient in each group had documented PR prolongation, and no documented infusion reactions occurred. Median time from order verification to administration was significantly reduced in the IV push group (35 min vs. 1 h 49 min; p < 0.001). CONCLUSIONS: Administration of lacosamide via IV push results in similar adverse effect rates to IV piggyback preparations with more efficient time to administration.

Serum Magnesium Levels and Outcomes in Patients With Acute Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Magnesium (Mg) has potential hemostatic properties. We sought to investigate the potential association of serum Mg levels (at baseline and at 48 hours) with outcomes in patients with acute spontaneous intracerebral hemorrhage (ICH). METHODS AND RESULTS: We reviewed data on all patients with spontaneous ICH with available Mg levels at baseline, over a 5-year period. Clinical and radiological outcome measures included initial hematoma volume, admission National Institutes of Health Stroke Scale and ICH scores, in-hospital mortality, favorable functional outcome (modified Rankin Scale scores, 0-1), and functional independence (modified Rankin Scale scores, 0-2) at discharge. Our study population consisted of 299 patients with ICH (mean age, 61±13 years; mean admission serum Mg, 1.8±0.3 mg/dL). Increasing admission Mg levels strongly correlated with lower admission National Institutes of Health Stroke Scale score (Spearman's r, -0.141; P=0.015), lower ICH score (Spearman's r, -0.153; P=0.009), and lower initial hematoma volume (Spearman's r, -0.153; P=0.012). Higher admission Mg levels were documented in patients with favorable functional outcome (1.9±0.3 versus 1.8±0.3 mg/dL; P=0.025) and functional independence (1.9±0.3 versus 1.8±0.3 mg/dL; P=0.022) at discharge. No association between serum Mg levels at 48 hours and any of the outcome variables was detected. In multiple linear regression analyses, a 0.1-mg/dL increase in admission serum Mg was independently and negatively associated with the cubed root of hematoma volume at admission (regression coefficient, -0.020; 95% confidence interval, -0.040 to -0.000; P=0.049) and admission ICH score (regression coefficient, -0.053; 95% confidence interval, -0.102 to -0.005; P=0.032). CONCLUSIONS: Higher admission Mg levels were independently related to lower admission hematoma volume and lower admission ICH score in patients with acute spontaneous ICH.

Blood pressure levels post mechanical thrombectomy and outcomes in non-recanalized large vessel occlusion patients.

OBJECTIVE: Permissive hypertension may benefit patients with non-recanalized large vessel occlusion (nrLVO) post mechanical thrombectomy (MT) by maintaining brain perfusion. Data evaluating the impact of post-MT blood pressure (BP) levels on outcomes in nrLVO patients are scarce. We investigated the association of the post-MT BP course with safety and efficacy outcomes in nrLVO. METHODS: Hourly systolic BP (SBP) and diastolic BP (DBP) values were prospectively recorded for 24 hours following MT in consecutive nrLVO patients. Maximum, minimum, and mean BP levels were documented. Three-month functional independence (FI) was defined as modified Rankin Scale (mRS) scores of 0-2. RESULTS: A total of 88 nrLVO patients were evaluated post MT. Patients with FI had lower maximum SBP (160±19 mmHg vs 179±23 mmHg; P=0.001) and higher minimum SBP levels (119±12 mmHg vs 108±25 mmHg; P=0.008). Maximum SBP (183±20 mmHg vs 169±23 mmHg; P=0.008) and DBP levels (105±20 mmHg vs 89±18 mmHg; P=0.001) were higher in patients who died at 3 months while minimum SBP values were lower (102±28 mmHg vs 115±16 mmHg; P=0.007). On multivariable analyses, both maximum SBP (OR per 10 mmHg increase: 0.55, 95% CI 0.39 to 0.79; P=0.001) and minimum SBP (OR per 10 mmHg increase: 1.64, 95% CI 1.04 to 2.60; P=0.033) levels were independently associated with the odds of FI. Maximum DBP (OR per 10 mmHg increase: 1.61; 95% CI 1.10 to 2.36; P=0.014) and minimum SBP (OR per 10 mmHg increase: 0.65, 95% CI 0.47 to 0.90; P=0.009) values were independent predictors of 3-month mortality. CONCLUSIONS: Our study demonstrates that wide BP excursions from the mean during the first 24 hours post MT are associated with worse outcomes in patients with nrLVO.

Stimulus-Induced Rhythmic, Periodic, or Ictal Discharges in Coma-Incidence and Interrater Reliability of Continuous EEG After a Standard Stimulation Protocol: A Prospective Study.

PURPOSE: Stimulus-induced rhythmic, periodic, or ictal discharges (SIRPIDs) are often seen during continuous electroencephalographic (cEEG) monitoring in coma. Given their uncertain clinical significance, our prospective study evaluated incidence of SIRPIDs in comatose patients in the neuroscience intensive care unit (NSICU) who underwent a standard stimulation protocol and defined interreader reliability for cEEG. METHODS: Of 146 patients prospectively screened who underwent cEEG during a 6-month period, 53 patients were included and 93 patients were excluded. Our protocol used a sequence of auditory, mild tactile, and painful stimuli tested in a quiet room. Continuous electroencephalogram were then reviewed offline by blinded experts, with interrater agreement assessed by kappa statistic. By Pearson χ and Wilcoxon rank-sum tests, we then compared binary and numerical clinical features between those with and without SIRPIDs. RESULTS: Of 53 patients who underwent our protocol, one patient with a corrupt cEEG file was excluded. Traumatic brain injury was the most common diagnosis. Moderate interrater agreement was observed for 66 total stimulations: 20 patients (38.5%) had possible or definite SIRPIDs by minimum one reviewer. For 19 stimulations reviewed by a third reviewer, consensus was reached in 10 cases making the incidence of SIRPIDs 19.3% in our cohort. There was a moderate interrate agreement with kappa of 0.5 (95% confidence interval: 0.1, 0.7). Median intensive care unit stay was 15 days in patients with SIRPIDs versus 6.5 days in those without (P = 0.021). CONCLUSIONS: Our prospective study of SIRPIDs in the neuroscience intensive care unit found a 19% incidence by cEEG using a standard stimulation protocol, most often rhythmic delta activity, and showed a moderate interrater agreement.

Admission systolic blood pressure and outcomes in large vessel occlusion strokes treated with endovascular treatment.

BACKGROUND AND PURPOSE: High admission blood pressure (BP) levels have been associated with lower recanalization rates after endovascular treatment (EVT) for patients with acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO). We sought to evaluate the association of admission BP with early outcomes in patients with ELVO treated with EVT. METHODS: Consecutive patients with AIS presenting with ELVO in a tertiary stroke center during a 4-year period were prospectively evaluated. Admission systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured using automated cuff recordings. A blinded neuroradiologist calculated the final infarct volume (FIV) using standardized ABC/2 methodology. A favorable functional outcome (FFO) at 3 months was defined as modified Rankin Scale score of 0-2. RESULTS: Our study population consisted of 116 patients with AIS (mean age 63±13 years, median NIH Stroke Scale score 17 points (IQR 14-21), median FIV 30 cm3 (IQR 8-94)). Higher admission SBP correlated with higher FIV (r +0.225; p=0.020). Patients with FFO had lower admission SBP (151±24 mm Hg vs 165±28 mm Hg; p=0.010), while admission SBP levels were higher in patients who died during hospitalization (169±34 mm Hg vs 156±24 mm Hg; p=0.043). A 10 mm Hg increment in admission SBP was independently (p=0.010) associated with an increase of 12 cm3 in FIV (95% CI 3 to 21) in multiple linear regression models adjusting for potential confounders. A 10 mm Hg increment in admission SBP was independently (p=0.012) associated with a lower likelihood of FFO at 3 months (OR 0.64; 95% CI 0.45 to 0.91) in multiple logistic regression models adjusting for potential confounders. CONCLUSIONS: Higher admission SBP is an independent predictor of increased FIV and lower likelihood of 3-month FFO in patients with ELVO treated with EVT.

A rare midbrain infarction presenting with plus-minus lid syndrome with ataxia: a case report.

INTRODUCTION: We present the case of a patient with midbrain infarction with an unusual clinical presentation, where clinical diagnosis and anatomical localization were valuable tools in deciding treatment. CASE PRESENTATION: Our patient was a 59-year-old, right-handed Caucasian man with hypertension who presented to our facility with acute diplopia that persisted until he developed complete right-sided ptosis. He also had difficulty walking and coordinating movements of his upper extremities bilaterally, but this was worse on his left side. CONCLUSIONS: Plus-minus lid syndrome with ataxia is a rare presentation of midbrain infarction with a unique localization and anatomical description. This case highlights the importance of clinical skills for making a diagnosis in the absence of imaging to confirm the findings.