Right putamen hemorrhage manifesting as apraxia of eyelid opening
A 91-year-old right-handed woman with a history of hypertension was admitted to the medical ward due to pneumonia. She was independent in daily life and without a documented neurological deficit.\nOne day following admission, a sudden onset of chest discomfort was noted and non-ST elevated myocardial infarction was diagnosed. She was transferred to the intensive care unit, where clopidogrel and aspirin were used continually, followed by heparinization for 3 days. After 7 days of this dual antiplatelet therapy, she was found to have an acute onset of difficulty in opening her eyes. A nasogastric (NG) tube was put in place to avoid choking and because she could not walk steadily. A neurologist was consulted for the eye-opening problem.\nThe neurological exam revealed she had difficulty in bilateral eyelid opening, left central facial palsy, mild dysarthria, and left-side hemiparesis. Pursuit and saccadic eye movements were intact. Her eye opening was especially difficult after closing her eyes tight, but she could open her eyelid after a light touch to her forehead. No ptosis or blepharospasm was noted. Brain computed tomography scans revealed an acute hemorrhage at the right putamen () and surface electromyography revealed persistent contraction of the frontalis muscle and relaxation of the orbicularis oculi muscles on trying to open the eyes (). AEO was suspected.\nHer eyelid opening and dysphagia had not improved 2 weeks after the hemorrhage. Half a Sinemet® (carbidopa-levodopa, 25/100 mg) tablet (Merck & Co., Inc, Whitehouse Station, NJ, USA) was given twice daily for 6 weeks. Her NG tube was removed 1 month later. Her eyelid problem had subsided after 2 months of hemorrhage being identified, while brain computed tomography scans revealed that the hemorrhage had resolved.