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We report the case of a patient with acute painless horizontal diplopia and partial right oculomotor palsy characterized by impaired adduction, mild vertical limitation, partial ptosis, and mildly impaired convergence, with equally reactive pupils. On left gaze, the right eye failed to adduct and the contralateral eye did not demonstrate abducting nystagmus. Brain magnetic resonance imaging revealed a small dorsal paramedian midbrain infarction on diffusion-weighted imaging, and diffusion-tensor tractography demonstrated reduced integrity of the ipsilateral medial longitudinal fasciculus. The patient received dual antiplatelet therapy for 21 days, followed by aspirin, high-intensity statin therapy, and intensive glycemic control. Diplopia resolved within 4 weeks and remained absent at the 3-month follow-up. This case broadens the clinico-radiological spectrum of midbrain infarction and underscores that pupil-sparing third-nerve palsy does not exclude a central lesion. The combination of adduction deficit, impaired convergence, and absent contralateral abducting nystagmus should lower the threshold for urgent brain magnetic resonance imaging with diffusion-weighted imaging; diffusion-tensor tractography may be helpful where available.<\/jats:p>","DOI":"10.1177\/03000605251405100","type":"journal-article","created":{"date-parts":[[2025,12,27]],"date-time":"2025-12-27T10:42:18Z","timestamp":1766832138000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Pupil-sparing partial oculomotor palsy with ipsilateral medial longitudinal fasciculus involvement: A novel midbrain infarct phenotype\u2013a case report"],"prefix":"10.1177","volume":"53","author":[{"given":"Li-Chao","family":"Zhou","sequence":"first","affiliation":[{"name":"Department of Radiology, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Qiong","family":"Wu","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yu-Jing","family":"Liu","sequence":"additional","affiliation":[{"name":"Department of Radiology, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wei","family":"Xu","sequence":"additional","affiliation":[{"name":"Department of Neurology, The Second Hospital of Changsha, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tie-Qiao","family":"Feng","sequence":"additional","affiliation":[{"name":"Department of Neurology, The Second Hospital of Changsha, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zhen","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Neurology, The Second Hospital of Changsha, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fang-Yi","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Neurology, The Second Hospital of Changsha, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7085-6291","authenticated-orcid":false,"given":"Wen-Gao","family":"Zeng","sequence":"additional","affiliation":[{"name":"Department of Neurology, The Second Hospital of Changsha, China"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"179","published-online":{"date-parts":[[2025,12,27]]},"reference":[{"key":"e_1_3_9_2_2","doi-asserted-by":"publisher","DOI":"10.54029\/2022utv"},{"key":"e_1_3_9_3_2","doi-asserted-by":"publisher","DOI":"10.1159\/000435954"},{"key":"e_1_3_9_4_2","doi-asserted-by":"publisher","DOI":"10.4103\/ijo.IJO_216_19"},{"key":"e_1_3_9_5_2","doi-asserted-by":"publisher","DOI":"10.1097\/NRL.0000000000000302"},{"key":"e_1_3_9_6_2","doi-asserted-by":"publisher","DOI":"10.1159\/000070129"},{"key":"e_1_3_9_7_2","doi-asserted-by":"publisher","DOI":"10.12659\/AJCR.893875"},{"key":"e_1_3_9_8_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jstrokecerebrovasdis.2016.11.119"},{"key":"e_1_3_9_9_2","doi-asserted-by":"publisher","DOI":"10.1212\/01.wnl.0000335267.63332.2c"},{"key":"e_1_3_9_10_2","doi-asserted-by":"publisher","DOI":"10.4103\/0028-3886.55579"},{"key":"e_1_3_9_11_2","doi-asserted-by":"publisher","DOI":"10.18203\/2349-3291.ijcp20243870"},{"key":"e_1_3_9_12_2","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.120.030568"},{"key":"e_1_3_9_13_2","doi-asserted-by":"publisher","DOI":"10.1177\/1971400917700671"},{"key":"e_1_3_9_14_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ophtha.2013.04.009"},{"key":"e_1_3_9_15_2","doi-asserted-by":"publisher","DOI":"10.3109\/01658107.2014.963252"},{"key":"e_1_3_9_16_2","doi-asserted-by":"publisher","DOI":"10.1111\/head.12246"},{"key":"e_1_3_9_17_2","doi-asserted-by":"publisher","DOI":"10.25259\/JCIS_49_2020"},{"key":"e_1_3_9_18_2","doi-asserted-by":"publisher","DOI":"10.1002\/hbm.25670"},{"key":"e_1_3_9_19_2","doi-asserted-by":"publisher","DOI":"10.1097\/WNO.0000000000000208"},{"key":"e_1_3_9_20_2","doi-asserted-by":"publisher","DOI":"10.4103\/ijo.IJO_1482_22"},{"key":"e_1_3_9_21_2","doi-asserted-by":"publisher","DOI":"10.3389\/fneur.2025.1601434"},{"key":"e_1_3_9_22_2","first-page":"e36835","article-title":"Wall-eyed bilateral internuclear ophthalmoplegia as an early presentation of multiple sclerosis","volume":"15","author":"Zainal Abidin N","year":"2023","unstructured":"Zainal Abidin N, Tuan Jaffar TN, Ahmad Tajudin LS. 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