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Teaching Video NeuroImages: Alternating skew deviation with abducting hypertropia following superior colliculus infarction

June 7, 2018 By

Teaching Video NeuroImages: Alternating skew deviation with abducting hypertropia following superior colliculus infarction
Damien Biotti, Marianne Barbieux and David Brassat
Neurology. March 01, 2016; 86 (9) RESIDENT AND FELLOW SECTION

A 63-year-old patient was admitted with acute ataxia and binocular oblique diplopia. Neuro-ophthalmologic examination revealed abducting hypertropia on lateral gaze, better seen during upgaze, mimicking bilateral inferior oblique palsy (Figure A, video). There was no ocular cyclotorsion. Brain MRI revealed focal ischemic lesions in the right cerebellar hemisphere and left superior colliculus (Figure B). The diagnosis of alternating abducting hypertrophic skew deviation was made. This rare type of skew deviation is related to central otolithic dysfunction. Similar cases have been described with cerebellar, pretectal, or cervico-medullary junction lesions.1,2 Orthoptic management can help and patients can slowly improve over months.


Figure  Ocular motor examination and MR images
(A) Ocular motor examination (right gaze, straight gaze, left gaze).
(B) Diffusion-weighted imaging (left) and apparent diffusion coefficient images (right) reveal a focal and acute ischemic stroke.

AUTHOR CONTRIBUTIONS D. Biotti: principal author, corresponding author. M. Barbieux: contributor, neurologic management. D. Brassat: contributor.

STUDY FUNDING No targeted funding reported.

DISCLOSURE The authors report no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.

Footnotes
  ● Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
● Supplemental data at Neurology.org
  ● Download teaching slides: Neurology.org

REFERENCES
1. Versino M, Hurko O, Zee D. Disorders of binocular control of eye movements in patients with cerebellar dysfunction. Brain 1996;119:1933–1950.
2. Hamed LM, Maria BL, Quisling RG, Mickle JP. Alternating skew on lateral gaze: neuroanatomic pathway and relationship to superior oblique overaction. Ophthalmology 1993;100:281–286.