Ocular lateral deviation as a vestibular clinical sign of medial posterior inferior cerebellar artery strokes: A case report

Radiographic Horizontal Conjugate Gaze Deviation: Clinical Correlates

Purpose of Review

The potential diagnostic value of radiographic, horizontal, conjugate gaze deviation (Rad h-CGD) was first recognized in 2003 by Simon et al. Thereafter, interest grew related to its potential use as a marker of different neurologic and vestibular disorders. Over the past 20 years, we have identified clinical correlates of Rad h-CGD including those caused by supratentorial and infratentorial lesions. We propose clinicians and radiologists will better diagnose and manage patients by knowing the different diagnostic possibilities for Rad h-CGD.

Findings

We report different clinical correlates of Rad h-CGD relevant for localizing and lateralizing lesions. We measured the angle of deviation and correlated it with the clinical findings and underlying mechanisms. We then reviewed important data from the previous literature relevant to the localization of each lesion and combined it with our experience into the design of a practical algorithm to interpret Rad h-CGD.

Summary

Using Rad h-CGD provides useful information about the diagnosis and localization and may reveal subtle ocular findings not clear on physical examination. However, Rad h-CGD alone cannot distinguish between supratentorial and infratentorial lesions, and therefore, the clinical context is critical. Moreover, although Rad h-CGD occurs with strokes due to large vessel occlusion, it could also be seen with an acute vestibular syndrome, secondary to a peripheral vestibular neuritis. Other possibilities include ischemic events in the cerebellum, brainstem, and labyrinth.

Diagnosis of Isolated Central Vertigo: Report for a Series Cases

Vertigo, including central and peripheral causes, is one of the common symptoms in patients who are admitted to neurological outpatient and emergency rooms. Despite the advancements in imaging techniques in recent years, central vertigo is difficult to identify and is often misdiagnosed in clinical practice. In this study, 4 patients were admitted to the hospital with complaints of dizziness or vertigo. Information about their symptoms, physical examinations and imaging were collected. Two patients were accurately diagnosed using diffusion-weighted imaging (DWI), a specific type of brain MRI. They received targeted treatments, which led to significant improvement, and were discharged nearly cured within a week. One patient with dorsolateral medullary infarction was misdiagnosed due to atypical symptoms, such as vertigo without the typical lateral medullary syndrome signs, and was discharged with a mild swallowing disorder after 2 weeks of treatment. One patient was diagnosed with both central and peripheral vertigo. It was observed that the symptoms of isolated vertigo caused by an acute lacunar infarction resolved more quickly than the accompanying physical symptoms. In summary, more attention should be paid to the diagnosis of isolated central vertigo, as early identification and intervention can improve a patient's prognosis and reduce medical expenses.

Dynamic changes of the direction and angle of radiographic ocular lateral deviation in patients with lateropulsion after stroke onset

OBJECTIVE

To examine if radiographic ocular lateral deviation (rOLD) could be provoked in stroke patients with mild-to-moderate lateropulsion according to vertical perception.

METHODS

In this single-center, retrospective study, acute stroke patients with mild-to-moderate lateropulsion assessed by the Scale for Contraversive Pushing were enrolled. Computed tomography or magnetic resonance imaging was performed on all patients on admission and then according to their conditions. The direction and angle of rOLD were compared among three groups according to the responsible lesion: lateral medullary (LM), pontine (P), and hemispheric (H).

RESULTS

Sixty-six patients (male, 47; average age, 67 years) were enrolled and divided into the LM (n = 37), P (n = 8), and H (n = 21) groups. All patients had body tilt. Patients in the LM group showed body tilt to the ipsilesional side during hospitalization, while those in the P and H groups tilted to the contralesional side. All patients had rOLD at the final assessment at an average of 13 days after onset; patients in the P and H groups showed contralateral rOLD, while those in the LM group showed ipsilateral rOLD if they did not have cerebellar or pontine lesions. Significant decreases in the angle and changes in direction of rOLD according to lesion site were observed during hospitalization.

CONCLUSION

Serial changes in rOLD findings after stroke onset are different according to the responsible lesion. The direction of rOLD in most patients is in accordance with vertical perception after the acute stage of stroke.