Abstract: Objective To analyze the images features of acute bilateral paramedian thalamic infarction syndrome. Methods: From October 2014 to January 2017, 8 patients with acute bilateral paramedian thalamic infarction syndrome confirmed clinically in our hospital were enrolled, and the clinical and images data were retrospectively analyzed. All patients underwent the first CT of the brain examination within 24 h, the first MRI examination of the brain was performed within 5 d. 3 cases had MRA examination data. Results Initial CT of the brain was unremarkable in 3 cases, suspicious bilateral paramedian thalamic infarcts in 4 case (presenting as suspicious or small low-density lesions), clear bilateral paramedian thalamic infarcts in 3 cases (presenting as somewhat symmetrical low-density lesions). MRI showed that the bilateral paramedian thalamus symmetrical distribution of the butterfly low or slightly low signal in T1 WI, high or slightly high signal in T2 WI, high or slightly high signal in FLAIR, high signal in DWI, and low signal in ADC. The lesion was characterized by high signal in DWI images on MRI. Follow-up of images showed the lesion was progressing in 4 cases. "V" shaped infarction of the midbrain could be seen in the course of the disease in 4 cases. Unilateral or bilateral posterior cerebral artery and its branched vessels stenosis could be seen on the images of the three patients underwent MRA examination. Conclusion Imaging examination methods, especially MRI, are of great value in the early diagnosis and differential diagnosis of acute bilateral paramedian thalamic infarction syndrome.