Abstract
Horizontal gaze deviation (HGD) on computed tomography (CT) is considered a useful finding for detecting ischemic stroke. To enhance its availability, we studied the criterion suitable for visual determination and lesion characteristics. The clinical records of 327 ischemic stroke patients and 193 non-stroke controls were reviewed with measurements of eye deviation angles on CT. Initially, the HGD criterion defined by the minimum angle in unidirectionally deviated eyes was determined from control data. Subsequently, patients were classified by infarcted arterial territory and stroke subtype, and compared with controls in HGD frequency using Fisher’s exact test. In patients with middle cerebral artery (MCA) stroke, ipsilesional HGD during a week from symptom onset was modeled in a mixed-effects logistic regression analysis. Among the controls, 4.9% were categorized as pathological with a cutoff of 14°. HGD frequency was significantly increased in most stroke subgroups and prominent in MCA cardioaortic embolism (odds ratio and 95% confidence interval, 24.2 [9.6, 66.3]) and posterior inferior cerebellar artery (PICA) stroke (15.6 [3.2, 76.2]). In MCA stroke, ipsilesional HGD probability decreased daily (0.62 [0.48, 0.78]) and increased with cardioaortic embolism (4.12 [1.05, 16.16]) and lenticular nucleus lesions (3.36 [1.18, 9.58]). HGD is judged pathological if both eyes are unidirectionally deviated by ≥ 14°. This CT sign is frequent in MCA cardioaortic embolism and PICA stroke but does not necessarily indicate specific lesions. In MCA stroke, HGD is influenced by time, stroke subtype, and lesion location. The criterion and basic information on lesion characteristics may enhance the availability of HGD.
Similar content being viewed by others
References
Leigh RJ, Zee DS (2015) The neurology of eye movements, 5th edn. Oxford University Press, New York
Tijssen CC, Schulte BP, Leyten AC (1991) Prognostic significance of conjugate eye deviation in stroke patients. Stroke 22:200–202
Tijssen CC, van Gisbergen JA, Schulte BP (1991) Conjugate eye deviation: side, site, and size of the hemispheric lesion. Neurology 41:846–850
Fruhmann-Berger M, Karnath HO (2005) Spontaneous eye and head position in patients with spatial neglect. J Neurol 252:1194–1200
Ringman JM, Saver JL, Woolson RF, Adams HP (2005) Hemispheric asymmetry of gaze deviation and relationship to neglect in acute stroke. Neurology 65:1661–1662
Singer OC, Humpich MC, Laufs H, Lanfermann H, Steinmetz H, Neumann-Haefelin T (2006) Conjugate eye deviation in acute stroke: incidence, hemispheric asymmetry, and lesion pattern. Stroke 37:2726–2732
Schwartz KM, Ahmed AT, Fugate JE, Diehn FE, Eckel LJ, Hunt CH, Kallmes DF (2012) Frequency of eye deviation in stroke and non-stroke patients undergoing head CT. Neurocrit Care 17:45–48
Payabvash S, Qureshi I, Qureshi AI (2016) Clinical implications of eye deviation on admission CT examination of acute ischaemic stroke patients. Clin Radiol 71:1314.e11–1314.e15
Shah NH, Bhatt N, Tipirneni A, Condes D, Khandelwal P, Romano JG (2017) Conjugate eye deviation on CT associated With worse outcomes despite IV thrombolysis. Neurohospitalist 7:74–77
Mahajan V, Minshew PT, Khoury J, Shu PP, Muzaffar M, Abruzzo T, Leach JL, Tomsick TA (2008) Eye position information on CT increases the identification of acute ischemic hypoattenuation. AJNR Am J Neuroradiol 29:1144–1146
Simon JE, Morgan SC, Pexman JH, Hill MD, Buchan AM (2003) CT assessment of conjugate eye deviation in acute stroke. Neurology 60:135–137
Spokoyny I, Chen JY, Raman R, Ernstrom K, Agrawal K, Modir RF, Meyer DM, Meyer BC (2016) J Stroke Cerebrovasc Dis 25:2809–2813
Kaditis DG, Zintzaras E, Sali D, Kotoulas G, Papadimitriou A, Hadjigeorgiou GM (2016) Conjugate eye deviation as predictor of acute cortical and subcortical ischemic brain lesions. Clin Neurol Neurosurg 143:80–85
Lesley WS, Rangaswamy R, Smith KH, Watkins DM (2009) Predicting acute ischemic stroke by measuring the degree of ocular gaze deviation (Prevost’s sign) on CT. J Neurointerv Surg 1:32–34
Coffman CR, Raman R, Ernstrom K, Herial NA, Schlick KH, Rapp K, Modir RF, Meyer DM, Hemmen TM, Meyer BC (2015) The DeyeCOM Sign: predictive Value in Acute Stroke Code Evaluations. J Stroke Cerebrovasc Dis 24:1299–1304
Cordonnier M, Van Nechel C (2013) Neuro-ophthalmological emergencies: which ocular signs or symptoms for which diseases? Acta Neurol Belg 113:215–224
Nishimura K, Ohara T, Nagatsuka K, Minematsu K, Toyoda K (2015) Radiographic conjugate horizontal eye deviation in patients with acute cerebellar infarction. J Neurol Sci 355:68–71
Tatu L, Moulin T, Vuillier F, Bogousslavsky J (2012) Arterial territories of the human brain. In: Caplan LR, van Gijn J (eds) Stroke syndromes, 3rd edn. Cambridge University Press, Cambridge, pp 329–343
Ay H, Furie KL, Singhal A, Smith WS, Sorensen AG, Koroshetz WJ (2005) An evidence-based causative classification system for acute ischemic stroke. Ann Neurol 58:688–697
Puetz V, Dzialowski I, Hill MD, Demchuk AM (2009) The alberta stroke program early CT score in clinical practice: what have we learned? Int J Stroke 4:354–364
R Core Team (2016) R: a language and environment for statistical computing. R Foundation for Statistical Computing. https://www.r-project.org. Accessed 18 Feb 2016
Bates D, Maechler M, Bolker B, Walker S (2015) Fitting linear mixed-effects models using lme4. J Stat Softw 67:1–48
Kheradmand A, Zee DS (2011) Cerebellum and ocular motor control. Front Neurol 2:53
Yamazaki A, Zee DS (1979) Rebound nystagmus: EOG analysis of a case with a floccular tumour. Br J Ophthalmol 63:782–786
Djulejić V, Marinković S, Georgievski B, Stijak L, Aksić M, Puškaš L, Milić I (2016) Clinical significance of blood supply to the internal capsule and basal ganglia. J Clin Neurosci 25:19–26
Anagnostou E, Sporer B, Steude U, Kempermann U, Büttner U, Bötzel K (2001) Contraversive eye deviation during deep brain stimulation of the globus pallidus internus. Neurology 56:1396–1399
Hinduja A (2014) Imaging predictors of outcome following intravenous thrombolysis in acute stroke. Acta Neurol Belg 114:81–86
Papadopoulou A, Ahlhelm FJ, Lyrer P, Kuhle J (2015) Decision for intravenous thrombolysis in a young patient with acute vertical gaze palsy. Acta Neurol Belg 115:445–447
Dekker L, Hund H, Lemmens R, Boiten J, van den Wijngaard I (2017) Unknown onset ischemic strokes in patients last-seen-well> 4.5 h: differences between wake-up and daytime-unwitnessed strokes. Acta Neurol Belg 117:637–642
Beckers V, De Smedt A, Van Hooff RJ, De Raedt S, Van Dyck R, Putman K, De Keyser J, Brouns R (2012) Prediction of hospitalization duration for acute stroke in Belgium. Acta Neurol Belg 112:19–25
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The author declares that he has no conflict of interest.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent
For this type of study formal consent is not required.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Kobayashi, M. Horizontal gaze deviation on computed tomography: the visual criterion and lesion characteristics in ischemic stroke. Acta Neurol Belg 118, 581–587 (2018). https://doi.org/10.1007/s13760-018-0949-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13760-018-0949-1