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A 45-year-old woman with Coffin–Lowry syndrome, but without risk factors for cerebrovascular disease, awoke with double vision and unsteadiness on her feet. Examination revealed a skew deviation of the eyes and diplopia on downgaze due to a “double depressor” palsy of the inferior rectus and superior oblique muscles. Her gait was unsteady with a tendency to veer left. Brain computed tomography (CT) and MRI confirmed bilateral paramedian thalamic infarcts (figs 1, 2). CT angiogram of the aortic arch and extracranial and intracranial …
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