Conjugate Eye Deviation Research Articles

Olfactory Neuroblastoma with Intracranial Extension

Background: Olfactory Neuroblastoma (ONB), so called esthesioneuroblastoma, is a rare malignant tumor of the sinonasal tract. ONB represents 6.3% of all sinonasal tract malignancies, with a prevalence of 0.4 cases per million population. These tumors are slow-growing and there may be intracranial extension of the tumor. Nasal obstruction, anosmia, recurrent epistaxis and pain are typical early manifestations. Imaging studies are essential in determining tumor extension and surgical planning of ONB. Endonasal biopsy is required to confirm the diagnosis of ONB. The case provides a basis for discussion of ONB and highlights the possibility of extension of this tumor. Case: A 45-year-old male presented with a generalized clonic seizure, conjugate eye deviation, and pre-seizure headache. Post-seizure, the patient was unconscious and incontinent, later appearing conscious but confused. The patient had a history of seizures at home and in the ER, along with occasional headaches over the past year. The patient described nasal congestion, decreased smell, and recurrent nosebleeds, having undergone ethmoidectomy in 2020 for papilloma. Discussion: The patient experienced symptoms of seizures, headache, and nasal disturbances. Olfactory neuroblastoma (ONB) tumor was detected after comprehensive examination. Treatment involves multimodal therapy, including surgery, chemotherapy, and radiotherapy, with prognosis depending on tumor stage and grade. Conclusion: Early diagnosis of ONB is necessary to prevent further tumor progression. Intracranial extension of the ONB should be carefully investigated. Imaging as well as histopathological and immunohistochemical examinations are very helpful in identifying the location, metastasis and degree of malignancy of the tumor.

Delayed emergence from anesthesia caused by an intraoperative cerebral embolism of a malignant peripheral nerve sheath tumor in a neurofibromatosis type 1 patient: a case report

BackgroundMalignant peripheral nerve sheath tumors (MPNSTs) are aggressive soft tissue sarcomas which commonly arise from neurofibromatosis type 1. Lung metastases of the tumors are well-known, but intraoperative cerebral tumor embolisms of MPNSTs have not been reported in literature.Case presentationA 52-year-old female patient with neurofibromatosis type 1 underwent a right lung partial resection for lung tumors. She was extubated after adequate recovery of spontaneous breathing; however, she could not respond to verbal commands. In the intensive care unit, her neurological examination revealed conjugate eye deviation, right hemiparalysis, and aphasia. Magnetic resonance imaging revealed acute cerebral ischemia, so she underwent an endovascular thrombectomy. The histopathological diagnosis of emboli was a MPNST, which was identical with that of the resected lung tumor.ConclusionWe report the first case of delayed emergence caused by a cerebral tumor embolism of MPNST during partial lung resection.

Cortical symptoms described in emergency calls for patients with suspected large vessel occlusion: a descriptive analysis of 157 emergency calls

BackgroundEmergency medical dispatchers typically use the dispatch code for suspected stroke when the caller brings up one or more symptoms from the face-arm-speech triad. Paramedics and emergency department physicians are trained to suspect large vessel occlusion stroke when the stroke patient presents with hemiparesis and cortical symptoms: neglect, aphasia, and conjugate eye deviation (CED). We hypothesized that these symptoms could be evident in the emergency call.In this study, we aimed to describe common symptoms mentioned in the emergency calls for paramedic-suspected thrombectomy candidates. Secondly, we wanted to explore how the question about CED arises in the Finnish suspected stroke dispatch protocol. Our third aim was to find out if the symptoms brought up in suspected stroke and non-stroke dispatches differed from each other.MethodsThis was a retrospective study with a descriptive analysis of emergency calls for patients with paramedic-suspected large vessel occlusion stroke. We listened to the emergency calls for 157 patients transported to Tampere University Hospital, a Finnish comprehensive stroke centre. Two researchers listened for symptoms brought up in these calls and filled out a pre-planned case report form.ResultsSpeech disturbance was the most common symptom brought up in 125 (80%) calls. This was typically described as an inability to speak any words (n = 65, 52% of calls with speech disturbance). Other common symptoms were falling down (n = 63, 40%) and facial asymmetry (n = 41, 26%). Suspicion of stroke was mentioned by 44 (28%) callers. When the caller mentioned unconsciousness the emergency dispatcher tended to use a non-stroke dispatch code. The dispatchers adhered poorly to the protocol and asked about CED in only 57% of suspected stroke dispatches. We found CED in 12 emergency calls and ten of these patients were diagnosed with large vessel occlusion.ConclusionIn cases where paramedics suspected large vessel occlusion stroke, typical stroke symptoms were described during the emergency call. Speech disturbance was typically described as inability to say anything. It is possible to further develop suspected stroke dispatch protocols to recognize thrombectomy candidates from ischemic cortical signs such as global aphasia and CED.

Tacrolimus-associated posterior reversible encephalopathy syndrome after kidney transplantation

Calcineurin inhibitors are essential immunosuppressive agents for kidney transplant patients. Posterior reversible leukoencephalopathy syndrome is a rare complication of treatment with calcineurin inhibitors. Herein, we report three cases of tacrolimus-associated posterior reversible leukoencephalopathy syndrome after kidney transplantation and their unique clinical courses. Patients in Cases 1 and 2 presented with headache and visual field disturbance on the fourth day after transplantation. Both patients were successfully treated with antihypertensive therapy and a change in medications from tacrolimus to cyclosporine and everolimus. Case 3 was a kidney transplant patient at 12 years post-transplant who developed fever and conjugate eye deviation to the right. The patient was initially treated with antihypertensive medication and a reduction in tacrolimus dose, but she experienced prolonged disturbance of consciousness, which eventually improved. These cases highlight the importance of considering the possibility of posterior reversible leukoencephalopathy syndrome in kidney transplant recipients taking calcineurin inhibitors who present with acute neurological dysfunction. They also demonstrate the need to perform appropriate imaging to confirm the diagnosis and initiate treatment, even if a significant amount of time has passed since transplantation. The introduction of an mTOR inhibitor may be practical when changing or discontinuing calcineurin inhibitors.

Isolated abducens nucleus syndrome due to pontine tegmentum infarction

Introduction: Abnormalities of horizontal gaze could be caused by damage of the abducens nucleus due to ischemic lesion. We report a patient with isolated horizontal gaze palsy as a result of a small ischemic lesion of the pontine tegmentum. Observation: A 61-year-old man, with medical history of diabetes mellitus, dyslipidemia and high blood pressure, was hospitalized after 12 hours of transient dizziness and diplopia. On examination, he had conjugate eye deviation to the right side with horizontal gaze paralysis toward controlateral side. Vertical eye movements, convergence and pupillary reflex were preserved with no peripheral facial palsy. Brain MRI revealed a small lesion in the left pontine tegmentum. Patient received aspirin with atorvastatin and the gaze palsy has been disappeared three weeks later. Discussion: Conjugate lateral eye movement paralysis is commonly attributed to lesions of the caudal pons involving the abducens nucleus. horizontal gaze palsy is often associated to an ipsilateral peripheral facial palsy. In our case, the left lateral gaze palsy was isolated. The pontine lesion should be strictly confined the abducens nucleus which is extremely rare. the outcome of eye movement deviation in brainstem lesions is favorable within few weeks. Conclusion: Our case provides evidence that small pontine lesions can damage the abducens nerve nucleus without causing ipsilateral peripheral facial palsy.

Ping-pong gaze in a refractory focal status epilepticus

An 83-year-old woman presented to emergency department with fever, low level of consciousness and right deviation in the conjugate gaze. Neurological examination revealed a spontaneous, slow, horizontal and continuous conjugate eye deviation alternating every 2 to 3 seconds. An electroencephalogram revealed periodic paroxysmal activity with a frequency of 2-3 Hz in left frontal hemispheric. Neuroimaging didn’t show pathological findings. Polymorphonuclear leukocytes were observed in CSF without evidence of microorganisms. Antiepileptic therapy was started without improvement. Finally, the patient died because of refractory focal status. Ping Pong Gaze (PPG) is a slow and rhythmical horizontal abnormal eye movement with a fixed frequency that is observed in comatose states and indicates diffuse structural brain lesions with preserved brainstem functions. PPG presence is an indicator of bad prognosis. We describe a PPG case with a synchronous eye movement with the electroencephalogram activity. Keywords: Ping-pong gaze; status epilepticus; electroencephalography; epilepsy; seizure.

Does radiological conjugate eye deviation sign play a role in acute stroke imaging? A meta-analysis

The diagnostic value of non-contrast CT (NCCT) in acute stroke imaging remains indispensable, especially under emergency conditions with limited resources. The radiological conjugate eye deviation (RCED) has been demonstrated as a NCCT sign to predict acute ischemic stroke (AIS) or AIS secondary to large vessel occlusion (LVO) in recent studies. We performed a meta-analysis to gain a better understanding into the predictive role of RCED for AISs and LVO-AISs. We conducted a systematic literature search using PubMed, Embase, and Cochrane. The search focused on studies published between January 2000 and August 2020 that reported the predictive value of RCED for the diagnosis of AIS or LVO-AIS. Principal measurements of the meta-analysis were the overall sensitivity, specificity, the positive likelihood ratio (PLR), and the negative likelihood ratio (NLR) of RCED in predicting AIS and LVO-AIS. We included 11 studies (n = 2304). For AIS, RCED had a sensitivity of 0.37 (95% CI 0.27-0.47), a specificity of 0.86 (95% CI 0.73-0.93), the area under the receiver operating characteristic curve (AUC) was 0.58 (95% CI 0.53-0.62), PLR was 2.5 (95% CI 1.5-4.4), and NLR was 0.74 (95% CI 0.65-0.84). For LVO-AIS, RCED had a sensitivity of 0.63 (95% CI 0.46-0.77), a specificity of 0.77 (95% CI 0.71-0.82), AUC was 0.63 (95% CI 0.46-0.77), PLR was 2.7 (95% CI 1.7-4.3), and NLR was 0.49 (95% CI 0.3-0.78). RCED can be used to predict LVO-AIS. It is expected that this method will be extensively used and validated in acute stroke imaging, especially under emergency conditions with limited resources.

Field Assessment of Critical Stroke by Emergency Services for Acute Delivery to a Comprehensive Stroke Center: FACE2AD.

Patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) should be triaged to an endovascular-capable hospital by the emergency medical service (EMS). We designed a prehospital LVO prediction scale based on EMS assessments. In the derivation cohort, 1157 patients transferred to our hospital by the EMS because of suspected stroke within 24 h of onset were retrospectively examined. Factors associated with AIS due to LVO were identified based on the EMS assessment, and a prehospital scale identifying LVO was developed. The accuracy of this scale was validated in 502 consecutive patients who were transferred to 4 stroke centers, and its accuracy was compared with those of 4 previously reported scales. AIS due to LVO was diagnosed in 149 of 1157 patients (13%) in the derivation cohort. One point each was assigned for facial palsy, arm weakness, consciousness impairment (cannot say his/her name), atrial fibrillation, and diastolic blood pressure ≤ 85 mmHg, with two points for conjugate eye deviation (FACE2AD scale). In the derivation cohort, with the optimal cut-point of FACE2AD ≥ 3 determined by the area under the curve (AUC; 0.88; 95% confidence interval 0.87-0.90), sensitivity, specificity, positive predictive value, and negative predictive value for FACE2AD to predict LVO were 0.85, 0.80, 0.39, and 0.97, respectively. In the validation cohort, the FACE2AD scale had higher accuracy, with an AUC value of 0.84 for predicting LVO compared with the other scales (all p < 0.01). The FACE2AD scale is a simple, reliable tool for identifying AIS due to LVO by the EMS.

Conjugate Eye Deviation in Unilateral Lateral Medullary Infarction.

Background and PurposeThe initial diagnosis of medullary infarction can be challenging since CT and even MRI results in the very acute phase are often negative.MethodsA 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).ResultsConjugate 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).ConclusionsAll 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°.

Epileptic ictal strabismus: a case report and review of the literature

Ictal strabismus, sometimes associated with epileptic nystagmus, is an extremely rare epileptic phenomenon, suggestive of cortical involvement in monocular eye movement control. We describe a patient with ictal disconjugate contraversive horizontal eye deviation of cortical origin as the main clinical feature of a focal seizure. A 17-year-old, previously healthy woman had a seizure characterized by initial rightward conjugate eye deviation, followed by convergent strabismus due to adduction of the right eye towards the nose without conjugate left eye abduction (esotropia), forced leftward head deviation with impaired awareness, and subsequent evolution into a bilateral tonic-clonic seizure. Postictal and interictal neurological status were unremarkable; more specifically, neuro-ophthalmological examination revealed no nystagmus or altered eye motility. Ictal EEG showed a rhythmic theta activity over the right posterior temporal region, involving fronto-central regions when strabismus appeared. MRI showed cortical dysplasia in the right temporal lobe. Due to the low spatial resolution of scalp EEG, we could not identify with precision the symptomatogenic zone underlying ictal strabismus. However, the concomitant appearance of rhythmic theta activity over the right fronto-central region and the leftward head version with MRI perfusion sequences, showing cerebral blood flow increase in the right frontal eye field area, suggest involvement of the right frontal lobe. [Published with video sequence on www.epilepticdisorders.com].

The Finnish Prehospital Stroke Scale Detects Thrombectomy and Thrombolysis Candidates—A Propensity Score-Matched Study

Prehospital stroke triage is challenged by endovascular treatment for large vessel occlusion (LVO) being available only in major stroke centers. Conjugate eye deviation (CED) is closely related to LVO, whereas common stroke signs (face-arm-leg-speech-visual) screen stroke. We hypothesized that combining CED with common stroke signs would yield a prehospital stroke scale for identifying both LVO and stroke in general. We retrospectively analyzed consecutive patients (n = 856) with prehospital Code Stroke (recanalization candidate). The National Institutes of Health Stroke Scale (NIHSS) and computed tomography were administered to patients on arrival. Computed tomography angiography was performed on patients with NIHSS score of 8 or greater and considered to benefit from endovascular treatment. With random forest analysis and deviance analysis of the general linear model we confirmed the superiority of the NIHSS "Best Gaze" over other NIHSS items in detecting LVO. Based on this and commonly used stroke signs we presented the Finnish Prehospital Stroke Scale (FPSS) including dichotomized face drooping, extremity weakness, speech difficulty, visual disturbance, and CED. FPSS detected LVO with a sensitivity of 54%, specificity of 91%, positive predictive value of 48%, negative predictive value of 93%, and likelihood ratio of 6.2. Based on CED and universally used stroke signs, FPSS recognizes stroke in general and additionally, LVO as a stroke subtype comparably to other scales intended to detect LVO only. As the FPSS items are dichotomized, it is likely to be easy for emergency medical services to implement.

Conjugate eye deviation in two patients with pontine infarction

Background: Conjugate eye deviation (CED) typically results from hemispheric stroke involving frontal eye field; however, the role of brainstem on CED has not been well understood.

Conjugate Eye Deviation on CT Associated With Worse Outcomes Despite IV Thrombolysis.

Rapid stroke management has significant implications in patient outcomes. Ipsilateral computed tomography conjugate eye deviation (CT-CED) has been associated with worse outcomes but has never been evaluated as predictive of vascular occlusion. To test the hypothesis that CT-CED is a marker for vascular occlusion, we evaluated patients treated with intravenous tissue plasminogen activator (IV tPA). We performed a retrospective analysis of patients with acute ischemic stroke treated with IV tPA at a large tertiary care hospital over an 18-month period. A waiver of informed consent was granted. Two examiners evaluated baseline brain CTs blinded to the location of infarct to assess the presence of CT-CED and follow-up imaging for the location of infarct and the presence of intracranial large vessel occlusion. Demographics, initial National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scales (mRSs), and hospital length of stay (LOS) were collected. Among 104 patients treated with IV tPA, 36 had CT-CED. Inter-rater reliability for CT-CED was excellent (κ = 0.97; 95% confidence interval: 0.98-1.0). The CT-CED group was older (69.8 vs 64 years; P = .038), had higher initial NIHSS (14.6 vs 11; P = .01), worse mRS (3.2 vs 2.4; P = .03), and longer LOS (8.4 vs 6.4; P = .05) compared with those without CT-CED. A vascular occlusion in the territory of the infarct was seen in 58% of patients with CT-CED versus 32% without CT-CED (P < .01). Atrial fibrillation (AF) was diagnosed in 61% patients with CT-CED versus 22% without (P < .01). The CT-CED is associated with higher initial NIHSS, large vessel occlusion, and AF. Prospective studies are needed to ascertain whether CT-CED may be utilized part of a screen for endovascular therapy.

Visual Determination of Conjugate Eye Deviation on Computed Tomography Scan Predicts Diagnosis of Stroke Code Patients

Head computed tomography (CT) is critical for stroke code evaluations and often happens prior to completion of the neurological exam. Eye deviation on neuroimaging (DeyeCOM sign) has utility for predicting stroke diagnosis and correlates with National Institutes of Health Stroke Scale (NIHSS) gaze score. We further assessed the utility of the DeyeCOM sign, without complex caliper-based eye deviation calculations, but simply with a visual determination method. Patients with initial head CT and final diagnosis from an institutional review board-approved consecutive prospective registry of stroke codes at the University of California, San Diego, were included. Five stroke specialists and 1 neuroradiologist reviewed each CT. DeyeCOM+ patients were compared to DeyeCOM- patients (baseline characteristics, diagnosis, and NIHSS gaze score). Kappa statistics compared stroke specialists to neuroradiologist reads, and visual determination to caliper measurement of DeyeCOM sign. Of 181 patients, 46 were DeyeCOM+. Ischemic stroke was more commonly diagnosed in DeyeCOM+ patients compared to other diagnoses (P = .039). DeyeCOM+ patients were more likely to have an NIHSS gaze score of 1 or higher (P = .006). The NIHSS score of DeyeCOM+ stroke versus DeyeCOM- stroke patients was 8.3 ± 6.0 versus 6.7 ± 8.0 (P = .065). Functional outcomes were similar (P = .59). Stroke specialists had excellent agreement with the neuroradiologist (Κ = .89). Visual inspection had excellent agreement with the caliper method (Κ = .88). Using a time-sensitive visual determination of gaze deviation on imaging was predictive of ischemic stroke diagnosis and presence of NIHSS gaze score, and was consistent with the more complex caliper method. This study furthers the clinical utility of the DeyeCOM sign for predicting ischemic strokes.

Conjugate eye deviation as predictor of acute cortical and subcortical ischemic brain lesions

ObjectivesNon-enhanced computed tomography (NECT) of the brain is used to exclude intracranial hemorrhage in patients who are considered for treatment with tissue plasminogen activator due to stroke symptoms. However, early infarct signs on NECT have low sensitivity for ischemic stroke. It was hypothesized that horizontal conjugate eye deviation (average ocular gaze deviation-OGD >14°) on NECT predicts ischemic brain injury on a second detailed examination. Patients and methodsPatients who underwent brain NECT within three hours after the onset of stroke symptoms and subsequently had brain CT scan with intravenous contrast or MRI were potential participants. OGD was measured from the cross-sectional image including both globes at their maximum diameter. Results73 subjects were studied (mean age 64.2±20.8 years) with a median interval (interquartile range) of 56h (22–109.3h) between NECT and the second examination. On NECT, 24 of 73 (32.9%) subjects had OGD >14°. Of 32 individuals with acute ischemic injury on the second examination, 19 (59.4%) had OGD >14° on NECT. OGD >14° was associated with increased risk of ischemic injury: OR=10.5 (95% confidence interval 3.33–33.9); P=0.002. OGD >14° had significantly higher sensitivity and negative predictive value than early infarct signs on NECT (59.4% vs. 21.9% and 73.5% vs. 59.7%, respectively; P<0.05), and similar specificity and positive predictive value (87.8% vs. 90.2% and 79.2% vs. 63.6%; P>0.05). ConclusionIn the presence of stroke symptoms, average OGD >14° on the initial brain NECT is early predictor of ischemic brain injury.

Association between eye position on brain scan and hospital mortality in acute intracerebral hemorrhage.

Conjugate eye deviation (CED) and horizontal skew deviation are often seen in patients with intracerebral hemorrhage (ICH), but its prognostic significance is unclear. In this study, the association between brain scan assessed eye position and hospital mortality in patients with supratentorial ICH was tested. A retrospective analysis was performed in 316 patients with supratentorial ICH. Eye position was measured on first brain computed tomography or magnetic resonance imaging. Patients with CED, horizontal skew deviation or no deviation were distinguished. The association between eye position and hospital mortality was assessed using logistic regression analysis. Conjugate eye deviation was present in 96 (30.4%), skew deviation in 44 (13.9%) and no deviation in 176 (55.7%) patients. In patients with CED, 81.3% had an eye position to the ipsilateral side of the hemorrhage. In univariable regression analysis, skew deviation was associated with mortality (odds ratio 3.10, 95% confidence interval 1.57-6.11; P = 0.001). In multivariable regression analysis, adjusting for age, ICH volume, intraventricular extension and Glasgow Coma Scale, eye position was not independently associated with mortality. Horizontal skew eyes were found to be an unfavorable prognostic factor. However, this was not independent of other important predictors of ICH mortality and is most probably explained by its association with worse initial clinical presentation.

A CASE OF ‘PING–PONG’ GAZE OF UNKNOWN CAUSE

A 66 year-old Indian gentleman with a background of type II diabetes, Crohn's disease and previously treated tuberculosis presented with double vision and unsteadiness.He was found to have a right-sided...

Abstract TP304: Conjugate Eye Deviation in Acute Intracerebral Hemorrhage: Stroke Acute Management With Urgent Risk-factor Assessment and Improvement (SAMURAI) -ICH Study

Background and Purpose: Conjugate eye deviation (CED) occurs frequently in patients with acute stroke. The purpose of this study was to elucidate the factors that correlate with CED, as well as the relationship between CED and outcomes, in patients with acute intracerebral hemorrhage (ICH). Methods: A total of 211 patients with acute supratentorial ICH were recruited in a multicenter, prospective study. Both on admission and 72 hours later, CED was assessed with an NIH Stroke Scale “best gaze” subscore of ≥1. Hematoma location and volume were assessed on CT within 2.5 hours of onset. Results: Ninety-six (45%) patients had CED on admission. On multivariable analysis, right-sided lesion (OR 2.36, 95% CI 1.18-4.93), hematoma volume (OR 1.07, 95% CI 1.04-1.10 per 1 mL), and baseline GCS score (OR 0.66, 95% CI 0.53-0.80 per 1 point) were independently associated with CED. After adjusting for sex, age, intraventricular extension of the hematoma, baseline GCS score, and hematoma volume, the presence of CED both on admission and 72 hours later was an independent predictor of death or dependency at 3 months post-stroke (OR 5.77, 95% CI 2.27-16.94). The optimal cutoff volume of hematoma related to CED was ≥13.5 mL for patients with putaminal hemorrhage (sensitivity, 76%; specificity, 72%) and ≥7.7 mL for patients with thalamic hemorrhage (sensitivity, 82%; specificity, 83%). Conclusions: The persistence of CED was a significant predictor of death or dependency after acute supratentorial ICH even after adjusting for initial severity and hematoma volume. CED can be evoked by a relatively smaller thalamic hematoma than a putaminal hematoma. Bedside assessment of CED appears to provide valuable information related to chronic outcomes of patients with ICH.

Conjugate Eye Deviation in Acute Intracerebral Hemorrhage

Conjugate eye deviation (CED) occurs frequently in patients with acute stroke. The purpose of this study was to elucidate the factors that correlate with CED as well as the relationship between CED and outcomes in patients with acute intracerebral hemorrhage. A total of 211 patients with acute supratentorial intracerebral hemorrhage were recruited in a multicenter, prospective study. CED was assessed with a National Institutes of Health Stroke Scale "best gaze" subscore of ≥1. Hematoma location and volume were assessed on CT. Forty-five percent of the patients had CED. On multivariable analysis, right-sided lesion (OR, 2.36; 95% CI, 1.18-4.93), hematoma volume (OR, 1.07; 95% CI, 1.04-1.10 per 1 mL), and baseline Glasgow Coma Scale score (OR, 0.66; 95% CI, 0.53-0.80 per 1 point) were independently associated with CED. After adjusting for sex, age, intraventricular extension of the hematoma, baseline Glasgow Coma Scale score, and hematoma volume, the presence of CED both on admission and 72 hours later was an independent predictor of death or dependency at 3 months poststroke (OR, 5.77; 95% CI, 2.27-16.94). The optimal cutoff volume of hematoma related to CED was ≥13.5 mL for patients with putaminal hemorrhage (sensitivity, 76%; specificity, 72%) and ≥7.7 mL for patients with thalamic hemorrhage (sensitivity, 82%; specificity, 83%). The persistence of CED was a significant predictor of death or dependency after acute supratentorial intracerebral hemorrhage even after adjusting for initial severity and hematoma volume. CED can be evoked by a relatively smaller thalamic hematoma than a putaminal hematoma.

Frequency of Eye Deviation in Stroke and Non-stroke Patients Undergoing Head CT

Although conjugate eye deviation (CED) on head CT has been described in patients with acute stroke, the incidence in other patient groups remains unknown. The aim of this study was to determine the frequency of eye deviation on head CT in non-stroke patients compared to patients with acute stroke symptoms. Three groups of patients were identified retrospectively: emergency department (ED)/inpatients undergoing head CT for non-stroke symptoms (group 1), stroke patients receiving intravenous tPA (group 2), and stroke patients undergoing intra-arterial therapy (group 3). The presence on head CT of CED, lone eye deviation (LED), and skew deviation (SD) and the angle of deviation were recorded. The NIHSS score was recorded for groups 2 and 3. CED was present in 17 (14%) of 120 Group 1 patients, 17 (36%) of 47 group 2 patients, and 28 (50%) of 56 Group 3 patients (p < 0.0001). Mean deviation of CED in groups 1, 2, and 3 was 19(o) (range 7-36(o)), 25(o) (range 6-67(o)), and 27(o) (range 11-56(o)), respectively (p = 0.024). LED was seen in 42 (35%) of group 1, 7 (15%) of Group 2, and 2 (4%) of group 3 patients (p < 0.0001). There was no significant difference in SD among groups (p = 0.37). CED was associated with a higher National Institutes of Health Stroke Scale (NIHSS) score among stroke patients (p = 0.0008). CED is common in patients with acute stroke. Such deviation may be seen in non-stroke patients, but less commonly and with lesser degrees of deviation.