Abstract Details

Title Ocular lateral deviation as a clinical sign of medial PICA infarct

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P3 - Poster Session 3 (5:30 PM-6:30 PM)

Poster/Presentation
Number 13-006

Objective NA

Background Ocular motor abnormalities are underappreciated in the context of stroke, but nevertheless can be helpful in differentiating stroke from benign causes. One such ocular sign that is under-utilized is Ocular Lateral Deviation (OLD). OLD is deviation of the eyes, enhanced by eye closure. OLD is seen in a third of lateral medullary infarcts, where it is ipsilesional. Contralesional OLD has only been described radiographically in a stroke involving the medial posterior inferior cerebellar artery (mPICA). To our knowledge, contralesional OLD has not been described clinically in patients. We report a case of a patient with clinical contralesional OLD as one of the main presenting symptoms of her mPICA infarct without medullary involvement.

Design/Methods Patient data were obtained from the electronic medical records at the University of Iowa, Iowa, USA.

Results We report a 73-year-old female with B cell lymphoma admitted for autologous stem cell transplant on whom code stroke was called for sudden onset of left gaze deviation, nausea, and vomiting. Exam also revealed left beating nystagmus with torsional component seen in both eyes in all gaze directions. Head impulse and skew tests were normal. There was dysmetria on finger-to-nose testing, right worse than left (NIHSS 3). Brain MRI showed acute right mPICA infarct without medullary involvement. Left gaze deviation was also appreciated on MRI.

Conclusions This case provides clinical and radiographic evidence of contralesional OLD, as a presenting symptom of mPICA infarct without medullary involvement. This is consistent with the pathophysiology of OLD where vestibulocerebellum (uvula & nodulus in vermis), supplied by mPICA, inhibits ipsilateral vestibular nuclei; therefore, right mPICA stroke results in increased activity of right vestibular nuclei, which tonically push eyes contralaterally (to left). Clinicians should be aware of potential ocular manifestations of posterior circulation strokes, as these syndromes often do not generate significant NIHSS scores.

Authors/Disclosures
Nicole Platti, MD PRESENTER	Dr. Platti has nothing to disclose.
Rami Fakih, MD (University of Missouri)	Dr. Fakih has nothing to disclose.
Joan Maley (The University of Iowa Hospitals and Clinics)	No disclosure on file
Kaancan Deniz, MD (UCSF Department of Neurology)	Dr. Deniz has nothing to disclose.
Busranur Agac, MD (National Institutes of Health)	Dr. Agac has nothing to disclose.
Deema A. Fattal, MD (Univ of Iowa)	An immediate family member of Dr. Fattal has received research support from American transportation center and DOD.

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