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A 56-year-old woman presented to the emergency department with sudden onset of left-sided ptosis, perioral paraesthesias and dizziness, without imbalance or vertigo, after getting up from bed. She had hyperlipidaemia and was a smoker. General examination was normal. On neurological examination there was asymmetric bilateral ptosis, more on the left, without pupillary or eye movement abnormalities (figure 1). Other cranial nerves, motor and sensory examination, coordination, posture and gait were unremarkable. The Cogan lid-twitch test and eyelid ice-pack test were normal.