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

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Abstract

Objective

Ocular lateral deviation (OLD) is a conjugate, ipsilesional, horizontal ocular deviation associated with brief (3–5 s) closing of the eyes, commonly linked to the lateral medullary syndrome (LMS). There is limited information regarding OLD in patients with the acute vestibular syndrome (AVS). In one case series 40 years ago OLD was suggested to be a central sign. Recently, horizontal ocular deviation on imaging (RadOLD) was frequently associated with anterior circulation stroke and horizontal gaze palsy. Similarly, RadOLD has been associated with posterior circulation stroke, e.g., LMS and cerebellar stroke, but without clinical correlation with OLD.

Methods

This is a prospective, cross-sectional diagnostic study of 151 acute AVS patients. Patients had spontaneous nystagmus. Horizontal gaze paralysis was an exclusion criterion. We noted the effect of brief 3–5 s eyelid closure on eye position, and then used the HINTS algorithm (the head-impulse test, nystagmus characteristics and skew deviation) and RadOLD, to establish a correlation between clinical and radiologic findings

Results

Of the 151 AVS patients, 100 had a central lesion and 51 a peripheral lesion; 29 of the central lesions were LMS, and 11 had OLD. Additionally, one lateral pontine syndrome had OLD. On opening the eyes 11 patients with OLD and LMS made multiple, hypometric corrective saccades to bring gaze back to straight ahead. 10/11 patients with LMS showed RadOLD.

Conclusions

OLD with multiple hypometric corrective saccades on opening the eyes was infrequent but highly localizing and lateralizing. We emphasize how simple it is to test for OLD, with the caveat that to be specific, it must be present after just brief (3–5 s) eyelid closure.

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Abbreviations

AVS:

Acute vestibular syndrome

OLD:

Ocular lateral deviation

LMS:

Lateral medullary syndrome

RadOLD:

Radiographic ocular lateral deviation

HIT:

Head-impulse test

HINTS:

Head impulse, nystagmus and tests of skew

OTR:

Ocular tilt reaction

OMV:

Oculomotor vermis

FOR:

Fastigial oculomotor region

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Author information

Authors and Affiliations

  1. Department of Neurology. Illinois Neurologic Institute, University of Illinois College of Medicine, Peoria, IL, USA

    Jorge C. Kattah

  2. Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Shervin Badihian, David E. Newman-Toker & David S. Zee

  3. Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Shervin Badihian, David E. Newman-Toker & David S. Zee

  4. Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Shervin Badihian & David E. Newman-Toker

  5. Department of Ophthalmology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    David S. Zee

  6. Northshore University Health System, Evanston, Il, USA

    John H. Pula

  7. Neurology, Cantonal Hospital of Baden, Baden, Switzerland

    Alexander A. Tarnutzer

  8. Faculty of Medicine, University of Zurich, Zurich, Switzerland

    Alexander A. Tarnutzer

Authors
  1. Jorge C. Kattah
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  2. Shervin Badihian
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  3. John H. Pula
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  4. Alexander A. Tarnutzer
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  5. David E. Newman-Toker
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  6. David S. Zee
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Corresponding author

Correspondence to Jorge C. Kattah.

Ethics declarations

Conflicts of interest

Jorge C. Kattah, M.D. Disclosure: Otometrics Corporation loaned us research equipment in 2012, this equipment is no longer in use. Evaluates legal cases related to vestibular disorders in thiamine deficiency. Sherwin Badihian, M.D. has no disclosures. John H. Pula, M.D. has no disclosures. Alexander A. Tarnutzer, M.D. had no disclosures. David E. Newman-Toker, M.D., PhD Evaluates media legal cases and conducts funded research related to dizziness and stroke diagnosis. He had equipment leases by two commercial companies: Otometrics and Interacoustic. David S. Zee has no disclosures.

Ethical approval

This study is part of an “on-going” prospective investigation of patients with acute vestibular syndrome. The study was approved by the University of Illinois College of Peoria IRB. We follow the tenets of the Declaration of Helsinki.

Electronic supplementary material

Below is the link to the electronic supplementary material.

415_2020_10100_MOESM1_ESM.mp4

Supplementary file1Video 1 (patient 12, Table 1). Video obtained from a patient with a left dorsolateral medullary-cerebellar stroke. The first section obtained during the acute stroke phase shows an OLD to the left with brief eyelid closure and corrective hypometric saccades to the right on opening the eyes. The second section, obtained three months later show oblique saccades, as the patient refixate between vertical targets. The trajectory of these vertical saccades shows ipsilesional, horizontal lateropulsion. Horizontal saccades (not shown) were hypermetric to the left and hypometric to the right. The patient also a left head tilt. (MP4 75369 kb)

415_2020_10100_MOESM2_ESM.docx

Supplementary file2Supplementary Table1. Clinical findings in lateral medullary syndrome without OLD. Supplementary table 2. Previous literature describing location of lesions with OLD, cause, fixation block technique and clinical course. Supplementary Figure 1 OLD Study Diagram: The Diagram provides a graphic comparison between HINTS/HINTS plus (associated with hearing loss) and OLD in AVS patients. Supplementary Figure 2 Axial DWI MRI in the patient with left-sided pontine stroke (Patient 3, see also Table 1). The left panel illustrates the rostral extent of the infarction, partially affecting the left superior cerebellar peduncle (SCP), and the right panel shows the caudal extent of the infarction including partial DWI signal in the flocculus. The middle panels show restricted signal in the left pons. (DOCX 2852 kb)

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Kattah, J.C., Badihian, S., Pula, J.H. et al. Ocular lateral deviation with brief removal of visual fixation differentiates central from peripheral vestibular syndrome. J Neurol 267, 3763–3772 (2020). https://doi.org/10.1007/s00415-020-10100-5

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  • DOI: https://doi.org/10.1007/s00415-020-10100-5

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