title: Bilateral ptosis: Lesion in the oculomotor nuclei or supranuclear lesion?
abstract: BACKGROUND
  Bilateral ptosis is a very interesting clinical challenge for doctors because of the multiple possible localizations of a lesion which can lead to this neurological sign.
  
  
  OBJECTIVE
  Through this case report, we aim to determine the difference between an apraxia of lid opening (ALO) with difficulty in initiating the act of lid elevation, in spite of adequate understanding, motor control and cranial nerve pathways, and a bilateral ptosis with a lesion in the oculomotor nucleus or blepharospasm.
  
  
  METHODS
  The case report of a 50-year-old patient presenting bilateral ptosis and multiple ischemic lesions in the brainstem and bilateral frontal lobe lesions after the emergency removal of a large frontal tumor.
  
  
  RESULTS
  Our patient had an ALO according to the neurological follow-up and showed the ability, after a few weeks, of initiating the act of opening her eyes with her hand. The ophthalmic evaluation confirmed that in her case the ALO was associated with a nuclear lesion of the oculomotor nerve secondary to a midbrain lesion.
  
  
  CONCLUSIONS
  Our case report confirms multiple differential diagnoses in bilateral ptosis and the importance of clinical examination in spite of good neurological imaging.
authors.affiliation: Département des Neurosciences cliniques, Service de Neurochirurgie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
authors.forename: Julien
authors.initials: J
authors.lastname: Dimitriou
authors.affiliation: Département des Neurosciences cliniques, Unité de Neuro-Réhabilitation Aigüe, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
authors.forename: Timothy
authors.initials: T
authors.lastname: Montoute
authors.affiliation: Département des Neurosciences cliniques, Service de Neurochirurgie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
authors.forename: Marc
authors.initials: M
authors.lastname: Levivier
authors.affiliation: Unité de Neuro-Ophtalmologie, Hôpital Ophtalmique Jules Gonin, Lausanne, Switzerland.
authors.forename: François-Xavier
authors.initials: FX
authors.lastname: Borruat
authors.affiliation: Département des Neurosciences cliniques, Unité de Neuro-Réhabilitation Aigüe, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
authors.forename: Karin
authors.initials: K
authors.lastname: Diserens
mesh_terms: D001763:Blepharoptosis / Q000175:diagnosis* / Q000209:etiology / Q000534:rehabilitation*; D001932:Brain Neoplasms / Q000150:complications / Q000175:diagnosis / Q000534:rehabilitation; D003937:Diagnosis, Differential; D005260:Female; D005500:Follow-Up Studies; D005625:Frontal Lobe / Q000473:pathology; D006801:Humans; D008279:Magnetic Resonance Imaging; D008636:Mesencephalon / Q000473:pathology*; D008875:Middle Aged; D009802:Oculomotor Nerve / Q000473:pathology*
keywords: Ptosis; apraxia; coma; consciousness