Ocular lateral deviation with brief removal of visual fixation differentiates central from peripheral vestibular syndrome

Kattah, Jorge C.; Badihian, Shervin; Pula, John H.; Tarnutzer, Alexander A.; Newman‐Toker, David E.; Zee, David S.

doi:10.1007/s00415-020-10100-5

Cited by 14 publications

(11 citation statements)

References 43 publications

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“…Both patients reported vertical double vision. The stroke patient also presented with a laterodeviation, which is considered as a central sign [ 10 ]. Figure 3 shows the box-plots whiskers and the outliers of vertical ocular misalignment in patients with AUVP and stroke.…”

Section: Resultsmentioning

confidence: 99%

Acute vestibular syndrome: is skew deviation a central sign?

et al. 2021

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Objective Skew deviation results from a dysfunction of the graviceptive pathways in patients with an acute vestibular syndrome (AVS) leading to vertical diplopia due to vertical ocular misalignment. It is considered as a central sign, however, the prevalence of skew and the accuracy of its test is not well known . Methods We performed a prospective study from February 2015 until September 2020 of all patients presenting at our emergency department (ED) with signs of AVS. All patients underwent clinical HINTS and video test of skew (vTS) followed by a delayed MRI, which served as a gold standard for vestibular stroke confirmation. Results We assessed 58 healthy subjects, 53 acute unilateral vestibulopathy patients (AUVP) and 24 stroke patients. Skew deviation prevalence was 24% in AUVP and 29% in strokes. For a positive clinical test of skew, the cut-off of vertical misalignment was 3 deg with a very low sensitivity of 15% and specificity of 98.2%. The sensitivity of vTS was 29.2% with a specificity of 75.5%. Conclusions Contrary to prior knowledge, skew deviation proved to be more prevalent in patients with AVS and occurred in every forth patient with AUVP. Large skew deviations (> 3.3 deg), were pointing toward a central lesion. Clinical and video test of skew offered little additional diagnostic value compared to other diagnostic tests such as the head impulse test and nystagmus test. Video test of skew could aid to quantify skew in the ED setting in which neurotological expertise is not always readily available.

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Section: Resultsmentioning

confidence: 99%

Acute vestibular syndrome: is skew deviation a central sign?

et al. 2021

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“…Pontine infarctions, however, can induce Bruns’ nystagmus [ 14 ]. Some patients with AVS and Wallenberg's syndrome may have a tonic deviation of the eye away from straight ahead gaze but only when fixation is removed [ 15 ].…”

Section: Discussionmentioning

confidence: 99%

“…Note the data were mirrored for direction for comparison. Patients # 1 and 2 had shifts of the null to the right, Patient # 3 and 4# to the left with AVS and Wallenberg's syndrome may have tonic deviation of the eye away from straight ahead gaze but only when fixation is removed [15].…”

Section: F I G U R Ementioning

confidence: 92%

Bruns' nystagmus revisited: A sign of stroke in patients with the acute vestibular syndrome

Mantokoudis

Korda

Zee

et al. 2021

Euro J of Neurology

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Pathologic gaze-evoked nystagmus (GEN) is a central sign in patients with acute dizziness, however, the discrimination between a pathologic and physiologic GEN is challenging. Neurology textbooks [1] suggest that physiologic GEN is not sustained and beats at a lower frequency. The direction and intensity of GEN is more difficult to discern in patients with an acute vestibular syndrome (AVS), since they have spontaneous nystagmus (SN).We have not found a study quantifying GEN in the acute phase of patients with the AVS either from peripheral or central causes. The slow-phase velocity (SPV), frequency (beats per second), and direction of eye drift of GEN can be quantified using mobile eye tracking

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“…1 At the same time, the sensitivity of OLD for a central cause was 39.9% (11/29) when focusing on lateral medullary stroke patients with isolated acute vestibular syndrome (i.e., had no non-vestibular eye signs nor general neurologic signs other than imbalance) and 12% (12/100) when including all central AVS cases in a recent case series. 1 In this 75-year-old-patient with new-onset dizziness, gait imbalance, nausea and dysphagia complete OLD to the left (Supplemental Video 1) was accompanied by right-beating spontaneous nystagmus, horizontal gaze-evoked nystagmus and severe truncal ataxia. MR-imaging identified a left-sided lateral medullary stroke (Figure 1AB) with accompanying radiologic OLD to the left (Figure 1C).…”

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confidence: 89%

“…Noteworthy, radiologic OLD is usually seen in the context of continuous eyelid closure for several minutes 3 and therefore does not allow a distinction between central (usually ischemic) and peripheral (i.e., acute vestibular neuropathy) causes. 1 Thus, whenever OLD is detected in CT-or MR-imaging, brief eye-lid closure testing at the bedside should be applied also to allow such a distinction.…”

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confidence: 99%

Ocular Lateral Deviation in Severe Gait Imbalance Pointing to Lateral Medullary Stroke

Spiegelberg

Morel

Beer

et al. 2021

The Neurohospitalist

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Complete ipsilesional ocular-lateral-deviation (OLD) after brief (3-5 sec) eyelid closure is highly specific for a central (usually ischemic medullary) lesion, with a specificity of 100% in patients with acute vestibular syndrome (AVS). 1 At the same time, the sensitivity of OLD for a central cause was 39.9% (11/29) when focusing on lateral medullary stroke patients with isolated acute vestibular syndrome (i.e., had no non-vestibular eye signs nor general neurologic signs other than imbalance) and 12% (12/100) when including all central AVS cases in a recent case series. 1 In this 75-year-old-patient with new-onset dizziness, gait imbalance, nausea and dysphagia complete OLD to the left (Supplemental Video 1) was accompanied by right-beating spontaneous nystagmus, horizontal gaze-evoked nystagmus and severe truncal ataxia. MR-imaging identified a left-sided lateral medullary stroke (Figure 1AB) with accompanying radiologic OLD to the left (Figure 1C). Whereas the H.I.N.T.S-battery (Head-Impulse,

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Ocular lateral deviation with brief removal of visual fixation differentiates central from peripheral vestibular syndrome

Cited by 14 publications

References 43 publications

Acute vestibular syndrome: is skew deviation a central sign?

Acute vestibular syndrome: is skew deviation a central sign?

Bruns' nystagmus revisited: A sign of stroke in patients with the acute vestibular syndrome

Ocular Lateral Deviation in Severe Gait Imbalance Pointing to Lateral Medullary Stroke

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