A 42-year-old young lady presented with acute onset of dizziness, drooping of 
left eye with binocular diplopia and inability to walk unassisted. She had past 
history of uncontrolled diabetes mellitus and hypertension. On examination, she 
had left fascicular type of third nerve palsy, vertical one and half syndrome 
(VOHS), left internuclear ophthalmoplegia and skew deviation with ipsilesional 
hypertropia. She also had thalamic astasia and right unilateral asterixis. Her 
MRI revealed T2 and Flair hyper intense signal changes with restricted diffusion 
in the left thalamus, subthalamus and left midbrain. MR Angiography was normal. 
Thalamic-subthalamic paramedian territory infarct is relatively uncommon. It can 
present with oculomotor abnormalities including vertical one and half syndrome, 
skew deviation, thalamic astasia and asterixis. This case is reported for the 
rarity of the presenting clinical findings in unilateral thalamo-mesencephalic 
infarcts.