Ipsilateral third nerve palsy with early pupillary enlargement is an important sign of transtentorial herniation from a supratentorial mass lesion. A case of frontal, intraparenchymal haemorrhage is reported in which the first ocular manifestation of transtentorial herniation was enlargement of the contralateral pupil. The ipsilateral pupil dilated only after complete oculomotor palsy of the contralateral eye. After partial frontal lobectomy and removal of blood clot, the ipsilateral third nerve recovered before the contralateral third nerve. Clinical findings localised the contralateral third nerve lesion to an extra-axial site. The possible mechanisms of contralateral third nerve compression are discussed. This seems to be the first example of pupillary enlargement as a false localising sign from a contralateral, supratentorial, intraparenchymal mass lesion.
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