Skew Deviation Revisited

Brodsky, Michael C.; Donahue, Sean P.; Vaphiades, Michael S.; Brandt, Thomas

doi:10.1016/j.survophthal.2005.12.008

Cited by 232 publications

(177 citation statements)

References 173 publications

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“…41 Tests for vertical ocular alignment primarily assess central otolithic pathways in the brainstem. 42 Not surprisingly, the HINTS rule performs as expected when tested empirically. It is nearly perfect with the more common strokes affecting the lateral medulla or inferior cerebellum (posterior inferior cerebellar artery territory) that do not directly affect the labyrinth or eighth cranial nerve inputs.…”

Section: Discussionsupporting

confidence: 58%

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Newman‐Toker

Kerber

Hsieh

et al. 2013

Academic Emergency Medicine

307

351

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ObjectivesDizziness and vertigo account for about 4 million emergency department (ED) visits annually in the United States, and some 160,000 to 240,000 (4% to 6%) have cerebrovascular causes. Stroke diagnosis in ED patients with vertigo/dizziness is challenging because the majority have no obvious focal neurologic signs at initial presentation. The authors sought to compare the accuracy of two previously published approaches purported to be useful in bedside screening for possible stroke in dizziness: a clinical decision rule (head impulse, nystagmus type, test of skew [HINTS]) and a risk stratification rule (age, blood pressure, clinical features, duration of symptoms, diabetes [ABCD2]).MethodsThis was a cross‐sectional study of high‐risk patients (more than one stroke risk factor) with acute vestibular syndrome (AVS; acute, persistent vertigo or dizziness with nystagmus, plus nausea or vomiting, head motion intolerance, and new gait unsteadiness) at a single academic center. All underwent neurootologic examination, neuroimaging (97.4% by magnetic resonance imaging [MRI]), and follow‐up. ABCD2 risk scores (0–7 points), using the recommended cutoff of ≥4 for stroke, were compared to a three‐component eye movement battery (HINTS). Sensitivity, specificity, and positive and negative likelihood ratios (LR+, LR–) were assessed for stroke and other central causes, and the results were stratified by age. False‐negative initial neuroimaging was also assessed.ResultsA total of 190 adult AVS patients were assessed (1999–2012). Median age was 60.5 years (range = 18 to 92 years; interquartile range [IQR] = 52.0 to 70.0 years); 60.5% were men. Final diagnoses were vestibular neuritis (34.7%), posterior fossa stroke (59.5% [105 infarctions, eight hemorrhages]), and other central causes (5.8%). Median ABCD2 was 4.0 (range = 2 to 7; IQR = 3.0 to 4.0). ABCD2 ≥ 4 for stroke had sensitivity of 61.1%, specificity of 62.3%, LR+ of 1.62, and LR– of 0.62; sensitivity was lower for those younger than 60 years old (28.9%). HINTS stroke sensitivity was 96.5%, specificity was 84.4%, LR+ was 6.19, and LR– was 0.04 and did not vary by age. For any central lesion, sensitivity was 96.8%, specificity was 98.5%, LR+ was 63.9, and LR– was 0.03 for HINTS, and sensitivity was 99.2%, specificity was 97.0%, LR+ was 32.7, and LR– was 0.01 for HINTS “plus” (any new hearing loss added to HINTS). Initial MRIs were falsely negative in 15 of 105 (14.3%) infarctions; all but one was obtained before 48 hours after onset, and all were confirmed by delayed MRI.ConclusionsHINTS substantially outperforms ABCD2 for stroke diagnosis in ED patients with AVS. It also outperforms MRI obtained within the first 2 days after symptom onset. While HINTS testing has traditionally been performed by specialists, methods for empowering emergency physicians (EPs) to leverage this approach for stroke screening in dizziness should be investigated.

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Section: Discussionsupporting

confidence: 58%

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Newman‐Toker

Kerber

Hsieh

et al. 2013

Academic Emergency Medicine

307

351

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“…The triad of head tilt, skew deviation, and abnormal torsion seen in ocular tilt reaction represents a righting response, the goal of which is to realign the vertical axes of both the head and the eyes to the internal estimate of, albeit erroneous, absolute earth-vertical. 4,46 Abnormal static ocular torsion has been demonstrated in patients with skew deviation when they look straight ahead; however, it is unknown whether, or how, torsion is altered during dynamic eye movements or during different gaze directions and whether the relationship of ocular torsion with horizontal and vertical eye position (ie, Listing's law) is intact in skew deviation. We found that in skew deviation, torsion was abnormal during fixation and dynamic eye movements (saccades) to different gaze directions.…”

Section: Pathophysiologymentioning

confidence: 99%

“…9 Skew deviation and ocular tilt reaction are most commonly caused by ischemia, infarction, multiple sclerosis, tumor, trauma, abscess, hemorrhage, syringobulbia, and neurosurgical procedures. [4][5][6] They can also be a finding in the setting of raised intracranial pressure. 16 …”

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confidence: 99%

“…[1][2][3][4] Skew deviation is often the initial manifestation of diseases that affect the brainstem, cerebellum, or peripheral vestibular system. [4][5][6][7][8][9][10] Because both skew deviation and trochlear nerve palsy may result from intracranial lesions or trauma, and because some skew deviations may clinically mimic trochlear nerve palsy, differentiating these 2 conditions can be challenging. Understanding skew deviation remains difficult, partly because it requires knowledge of the underlying anatomy and pathophysiology.…”

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confidence: 99%

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Understanding skew deviation and a new clinical test to differentiate it from trochlear nerve palsy

Wong¹

2010

Journal of American Association for Pediatric Ophthalmology and

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SUMMARYSkew deviation is a vertical strabismus caused by a supranuclear lesion in the posterior fossa. Because skew deviation may clinically mimic trochlear nerve palsy, it is sometimes difficult to differentiate the 2 conditions. In this review we compare the clinical presentations of skew deviation and trochlear nerve palsy and examine the pathophysiology that underlies skew deviation. We then describe a novel clinical test-the upright-supine test-to differentiate skew deviation from trochlear nerve palsy: a vertical deviation that decreases by ≥50% from the upright to supine position suggests skew deviation and warrants investigation for a lesion in the posterior fossa as the cause of vertical diplopia.Skew deviation is a vertical strabismus caused by supranuclear lesions. It is often associated with ocular torsion and head tilt, which together constitute the ocular tilt reaction. [1][2][3][4] Skew deviation is often the initial manifestation of diseases that affect the brainstem, cerebellum, or peripheral vestibular system. [4][5][6][7][8][9][10] Because both skew deviation and trochlear nerve palsy may result from intracranial lesions or trauma, and because some skew deviations may clinically mimic trochlear nerve palsy, differentiating these 2 conditions can be challenging. Understanding skew deviation remains difficult, partly because it requires knowledge of the underlying anatomy and pathophysiology. In this review, we first compare the clinical presentation of skew deviation versus trochlear nerve palsy. We then focus on the pathophysiologic mechanism of skew deviation and examine some current evidence that shows that skew deviation results from an imbalance of the utriculo-ocular pathway. We then present a novel upright-supine test that can be used clinically to differentiate skew deviation from trochlear nerve palsy at the bedside. Clinical PresentationSkew deviation was first induced experimentally in animals by Magendie 11 and later Hertwig, 12 who produced skew deviation in cats by sectioning the middle cerebellar peduncle. It was first observed in humans with cerebellar tumors by Stewart and Holmes in 1904. 13 Skew deviation is a vertical misalignment of the visual axes caused by a disturbance of supranuclear inputs as a result of lesions in the brainstem, cerebellum, or peripheral CIHR Author ManuscriptCIHR Author Manuscript CIHR Author Manuscript vestibular system (ie, the inner ear and its afferent projections). The vertical misalignment may be comitant or incomitant. Rarely, it alternates with eye position (eg, right hypertropia on right gaze and left hypertropia on left gaze). 14,15 Skew deviation often is associated with other neurologic signs and may be part of the ocular tilt reaction, which consists of a triad of skew deviation, ocular torsion, and head tilt. [1][2][3]10 In ocular tilt reaction, the pathologic head tilt is ipsilateral to the hypotropic eye, and the ocular torsion is such that the upper poles of both eyes rotate in the same direction as that of the head tilt (ie, the h...

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Head Position–Dependent Changes in Ocular Torsion and Vertical Misalignment in Skew Deviation

Parulekar

Dai²,

Buncic³

et al. 2008

Arch Ophthalmol

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To investigate whether ocular torsion and vertical misalignment differ in the upright vs supine position in skew deviation and to compare these findings with those in trochlear nerve palsy. Methods: Ten patients with skew deviation, 14 patients with unilateral peripheral trochlear nerve palsy, and 12 healthy subjects were prospectively recruited. With subjects first in the upright position and then in the supine position, ocular torsion was measured by double Maddox rods and vertical misalignment was measured by the prism and alternate cover test. Results: In patients with skew deviation, the abnormal torsion and vertical misalignment in the upright position decreased substantially with change to the supine position, whereas in patients with trochlear nerve palsy, it changed little between positions. Torsion was decreased by 83% in patients with skew deviation, 2% in patients with trochlear nerve palsy, and 6% in healthy subjects (PϽ.001). Similarly, vertical misalignment was decreased by 74% in patients with skew deviation and increased by 5% in patients with trochlear nerve palsy and 6% in healthy subjects (P Ͻ.001). Conclusions: Our findings provide the basis for additional clinical tests to support the classic 3-step test: ocular torsion and vertical misalignment that decrease from the upright position to the supine position indicate skew deviation, whereas torsion and vertical misalignment that do not change significantly between positions indicate trochlear nerve palsy.

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Skew Deviation Revisited

Cited by 232 publications

References 173 publications

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Understanding skew deviation and a new clinical test to differentiate it from trochlear nerve palsy

Head Position–Dependent Changes in Ocular Torsion and Vertical Misalignment in Skew Deviation

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