J Clin Neurol.  2019 Apr;15(2):228-234. 10.3988/jcn.2019.15.2.228.

Conjugate Eye Deviation in Unilateral Lateral Medullary Infarction

• Teufel J
• Strupp M
• Linn J
• Kalla R
• Feil K

• KMID: 2467737
• DOI: http://doi.org/10.3988/jcn.2019.15.2.228

Abstract

BACKGROUND AND PURPOSE
The initial diagnosis of medullary infarction can be challenging since CT and even MRI results in the very acute phase are often negative.
METHODS
A retrospective, observer-blinded study of horizontal conjugate eye deviation was performed in 1) 50 consecutive patients [age 58±15 years (mean±SD), 74% male, National Institutes of Health Stroke Scale 2±1] with acute unilateral lateral medullary infarction as seen in MRI (infarction group), 2) 54 patients with transient brainstem symptoms [transient ischemic attack of brainstem (TIA) group; age 69±16 years, 59% male], and 3) 53 patients (age 59±20 years, 49% male) with diagnoses other than stroke (control group).
RESULTS
Conjugate eye deviation was found in all patients in the infarction group [n=47 (94%) with ipsilesional deviation and n=3 (6%) with contralesional deviation] compared to 41% (n=22) in the brainstem TIA group and 15% (n=8) in the control group (p<0.0001). Within all groups mean deviation and range were similar for both sides (to the right vs. to the left side 26.6°±12.3 vs. 26.1°±12.3 in the infarction group, 10.5°±5.8 vs. 8.4°±6.3 in the brainstem TIA group and 4.5°±3.2 vs. 7.5°±3.2 in the control group). The extent of eye deviation was significantly greater in the infarction group (p<0.05).
CONCLUSIONS
All patients with MRI-demonstrated unilateral medullary infarction showed conjugate eye deviation. Therefore, conjugate eye deviation in patients with suspected acute lateral medullary infarction is a helpful sensitive sign for supporting the diagnosis, particularly if the deviation is >20°.

Keyword

dorsolateral medullary syndrome; eye motility disorders; cerebral stroke; transient ischemic attack; neurological examination; orthoptics

MeSH Terms

Brain Stem
Diagnosis
Humans
Infarction*
Ischemic Attack, Transient
Lateral Medullary Syndrome
Magnetic Resonance Imaging
Male
National Institutes of Health (U.S.)
Neurologic Examination
Ocular Motility Disorders
Orthoptics
Retrospective Studies
Stroke

Figure

• 

  Fig. 1 CT and MRI scan of patients. A: CT scan of a middle-aged patient with right dorsolateral medulla infarction, which was later demonstrated in MRI (eye deviation angle α of 47° on the right side and 38° on the left side), with the eyes closed. B: MRI scan of a middle-aged patient with right dorsolateral medulla infarction (eye deviation angle β of 37° on the right side and 35° on the left side), with the eyes closed.

• 

  Fig. 2 Overview of study results. A: Results of conjugate eye deviation in the three compared groups (lateral medullary infarction, demonstrated in MRI; brainstem TIA group; and control group). B: Comparison of mean of conjugate eye deviation. *In MRI, purely medullary infarction was found in 31 patients (19 right-sided, 12 left-sided); 19 patients had an additional ipsilateral cerebellar infarction (8 right-sided, 11 left-sided). NIHSS: National Institutes of Health Stroke Scale, TIA: transient ischemic attack of brainstem.

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