Selected Topics: Neurological Emergencies|Articles in Press

Ocular lateral deviation as a vestibular sign to improve detection of posterior circulation strokes: A review of the literature

  • Deema Fattal
    Corresponding author.
    University of Iowa Health Care, 200 Hawkins Drive, Neurology Department, Iowa City, IA 52242 USA

    Iowa City VA Medical Center, 601 Highway 6 West, Iowa City, IA 52246 USA
    Search for articles by this author
  • Author Footnotes
    4 University of South Florida, Neurology Department, 17 David Blvd Suite 308, Tampa, FL, 33606
    Nicole Platti
    4 University of South Florida, Neurology Department, 17 David Blvd Suite 308, Tampa, FL, 33606
    University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242 USA
    Search for articles by this author
  • Author Footnotes
    4 University of South Florida, Neurology Department, 17 David Blvd Suite 308, Tampa, FL, 33606


      • Ocular Lateral Deviation, OLD, is a vestibular finding that can be seen in strokes
      • OLD refers to eye deviation that is made worse after brief eye closure
      • OLD is different from gaze palsy in that the eye movements are otherwise full
      • OLD is seen in posterior fossa strokes, most commonly in dorsolateral medulla



      Posterior circulation stroke can present with dizziness/vertigo without other general neurological symptoms or signs, making it difficult to detect, and missed stroke can deteriorate. Therefore, a sign that can be easily identified during an exam would be helpful to improve the detection of this type of stroke.

      Objective of the Review

      The objective of this review is to highlight an ocular sign that is seen in posterior circulation strokes called ocular lateral deviation (OLD). OLD is mostly seen in dorsolateral medullary strokes, and it is also seen in pontine and cerebellar strokes. OLD is detected by asking a patient to look straight ahead and then briefly close their eyes. Upon re-opening their eyes, the examiner will see that the eyes have deviated to one side; the patient's eyes will then make corrective saccade(s) to return to looking straight ahead. Complete eye deviation is a central sign of posterior circulation stroke.


      OLD is an under-recognized vestibular ocular sign of central vestibulopathies including posterior circulation stroke. Most common location is in dorsolateral medulla where one third of such strokes have complete OLD. Eye deviation can also be appreciated on CT or MRI imaging. OLD can be detected up to 6 months after a posterior circulation stroke.


      Checking for the sign of complete eye deviation in patients with dizziness/vertigo could be a simple, quick method for detecting posterior circulation stroke, and a means to improving the patients’ outcome.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kerber KA
        • Brown DL
        • Lisabeth LD
        • et al.
        Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study.
        Stroke. 2006 Oct; 37 (Epub 2006 Aug 31. PMID: 16946161 PMCID: PMC1779945): 2484-2487
        • Newman-Toker DE
        • Kerber KA
        • Hsieh YH
        • et al.
        HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness.
        Acad Emerg Med. 2013 Oct; 20: 986-996
        • Kattah JC
        • Talkad AV
        • Wang DZ
        • et al.
        HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging.
        Stroke. 2009; 40: 3504-3510
        • Kattah Jorge C
        Update on HINTS Plus, With Discussion of Pitfalls and Pearls.
        Journal of Neurologic Physical Therapy:. April 2019; 43 (Issue) (last accessed 7/3/22 11;53 AM CT): S42-S45
        • Dumitrascu OM
        • Torbati S
        • Tighiouart M
        • et al.
        Pitfalls and Rewards for Implementing Ocular Motor Testing in Acute Vestibular Syndrome: A Pilot Project.
        Neurologist. 2017; 22: 44-47
        • Shaban A
        • Zafar A
        • Borte B
        • et al.
        The Bucket Test Improves Detection of Stroke in Patients With Acute Dizziness.
        J Emerg Med. 2021 Apr; 60 (Epub 2020 Dec 8): 485-494
        • Saber Tehrani AS
        • Kattah JC
        • Mantokoudis G
        • et al.
        Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms.
        Neurology. 2014 Jul 8; 83 (Epub 2014 Jun 11. PMID: 24920847): 169-173
        • Kattah JC
        • Badihian S
        • Pula JH
        • et al.
        Ocular lateral deviation with brief removal of visual fixation differentiates central from peripheral vestibular syndrome.
        J Neurol. 2020 Dec; 267 (Epub 2020 Jul 28. PMID: 32719976): 3763-3772
        • Choi WY
        • Gold DR.
        Ocular Motor and Vestibular Disorders in Brainstem Disease.
        J Clin Neurophysiol. 2019 Nov; 36 (PMID: 31688322 Review): 396-404
        • Waespe W
        • Wichmann W.
        Oculomotor disturbances during visual-vestibular interaction in Wallenberg's lateral medullary syndrome.
        Brain. 1990 Jun; 113 (PMID: 2364271): 821-846
        • Ranalli PJ
        • Sharpe JA
        Syndrome of the superior cerebellar artery: Contralateral saccadic lateropulsion and ipsilateral limb ataxia.
        Can J Neurol Sci. 1985; 12: 209
        • Britton Z
        • Scott G.
        Ocular Ipsipulsion Caused by Posterior Inferior Cerebellar Artery Stroke.
        Stroke. 2022 Mar; 53 (Epub 2022 Feb 9): e122-e125
        • Kim JS
        • Moon SY
        • Kim KY
        • et al.
        Ocular contrapulsion in rostral medial medullary infarction.
        Neurology. 2004 Oct 12; 63 (PMID: 15477568 No abstract available): 1325-1327
        • Hornsten G.
        Wallenberg's syndrome. Part 11. Oculomotor and oculostatic disturbances.
        Acta Neurol Scand. 1974; 50: 447-468
        • Kattah JC
        • Pula J
        • Newman-Toker DE.
        Ocular lateropulsion as a central oculomotor sign in acute vestibular syndrome is not posturally dependent.
        Ann N Y Acad Sci. 2011 Sep; 1233: 249-255
        • Meyer KT
        • Baloh RW
        • Krohel GB
        • et al.
        Ocular lateropulsion. A sign of lateral medullary disease.
        Arch Ophthalmol. 1980 Sep; 98 (PMID: 7425924): 1614-1616
        • Kommerell G
        • Hoyt WF.
        Lateropulsion of saccadic eye movements. Electro-oculographic studies in a patient with Wallenberg's syndrome.
        Arch Neurol. 1973 May; 28: 313-318
        • Frisen L
        Lateropulsion of the eyes a localizing brainstem sign.
        J Neurol. 1978; 218: 171-177
        • Crevits L
        • vander Eecken H.
        Ocular lateropulsion in Wallenberg's syndrome: a prospective clinical study.
        Acta Neurol Scand. 1982 Mar; 65 (PMID: 7080807): 219-222
        • Hata T
        • Nohira O
        • Kanda T
        • et al.
        [A case of superior cerebellar artery syndrome with ocular lateropulsion contralateral to the cerebellar lesion].
        Rinsho Shinkeigaku. 1988 Nov; 28 (PMID: 3233825 Japanese. No abstract available): 1255-1261
        • Platti N
        • Fakih R
        • Maley J
        • et al.
        Ocular lateral deviation as a clinical sign of medial Posterior Inferior Cerebellar Artery Strokes: A Case Report.
        Stroke and Cerebrovascular Diseases. August 1 2022; 31 (CASE REPORT|ISSUEPublished:July 01, 2022)106618
        • Nishimura K
        • Ohara T
        • Nagatsuka K
        • et al.
        Radiographic conjugate horizontal eye deviation in patients with acute cerebellar infarction.
        J Neurol Sci. 2015 Aug 15; 355 (Epub 2015 May 21. PMID: 26026945): 68-71
        • Yang YJ
        • Choi JE
        • Kim MT
        • et al.
        Measurement of horizontal ocular deviation on magnetic resonance imaging in various disease with acute vertigo.
        PLoS One. 2019 Oct 31; 14 (PMID: 31671145; PMCID: PMC6822736)e0224605
        • Pierrot-Deseilligny C
        • Amarenco P
        • Roullet E
        • et al.
        Vermal infarct with pursuit eye movement disorders.
        J Neurol Neurosurg Psychiatry. 1990 Jun; 53 (PMID: 2380734; PMCID: PMC1014215): 519-521
        • Benjamin EE
        • Zimmerman CF
        • Troost BT.
        Lateropulsion and upbeat nystagmus are manifestations of central vestibular dysfunction.
        Arch Neurol. 1986 Sep; 43 (PMID: 3488729): 962-964
        • Brazis PW.
        Ocular motor abnormalities in Wallenberg's lateral medullary syndrome.
        Mayo Clin Proc. 1992 Apr; 67 (PMID: 1548952): 365-368
        • Paul NL
        • Simoni M
        • Rothwell PM
        Transient isolated brainstem symptoms preceding posterior circulation stroke: a population-based study.
        Lancet Neurol. 2013; 12: 65-71
        • Gerlier C
        • Hoarau M
        • Fels A
        • et al.
        Differentiating central from peripheral causes of acute vertigo in an emergency setting with the HINTS, STANDING, and ABCD2 tests: A diagnostic cohort study.
        Acad Emerg Med. 2021 Dec; 28 (Epub 2021 Jul 20): 1368-1378
        • Lee H
        • Sohn S-I
        • Cho Y-W
        • et al.
        Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns.
        Neurology. 2006 Oct 10; 67: 1178-1183
        • Tarnutzer AA
        • Lee SH
        • Robinson KA
        • et al.
        ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis.
        Neurology. 2017; 88: 1468-1477
        • Choi KD
        • Kim JS.
        Vascular vertigo: updates.
        J Neurol. 2019 Aug; 266 (Epub 2018 Sep 5): 1835-1843
        • Blum CA
        • Kasner SE.
        Transient ischemic attacks presenting with dizziness or vertigo.
        Neurol Clin. 2015; 33 (ix): 629-642
        • Sylaja PN
        • Coutts SB
        • Krol A
        • et al.
        VISION Study Group. When to expect negative diffusion-weighted images in stroke and transient ischemic attack.
        Stroke. 2008; 39: 1898-1900
        • Oppenheim C
        • Stanescu R
        • Dormont D
        • et al.
        False-negative diffusion-weighted MR findings in acute ischemic stroke.
        AJNR Am J Neuroradiol. 2000; 21: 1434-1440
        • Choi JH
        • Park MG
        • Choi SY
        • et al.
        Acute Transient Vestibular Syndrome: Prevalence of Stroke and Efficacy of Bedside Evaluation.
        Stroke. 2017; 48: 556-562
        • Newman-Toker DE
        • Kattah JC
        • Alvernia JE
        • et al.
        Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis.
        Neurology. 2008 Jun 10; 70 (PMID: 18541870): 2378-2385
      1. Fattal D, Platti N, Kiel S, et al. Detecting Posterior Circulation Stroke in the Dizzy patient in the Emergency Department: Detecting Posterior Circulation Stroke in the Dizzy patient: Bucket of HINTS and ABCD2 Scores- article in preparation.

        • Carmona S
        • Martínez C
        • Zalazar G
        • et al.
        The Diagnostic Accuracy of Truncal Ataxia and HINTS as Cardinal Signs for Acute Vestibular Syndrome.
        Front Neurol. 2016 Aug 8; 7 (eCollection 2016): 125
        • Kerber K
        • Meurer W
        • Brown D
        • et al.
        Stroke risk stratification in acute dizziness presentations: A prospective imaging-based study.
        Neurology. 2015 Nov 24; 85 (PMCID: PMC4662702. PMID: 26511453): 1869-1878
        • Kommerell G.
        • Hoyt W.F.
        Systematisch abgelenkte Blickzielbewegungen – ein neues Symptom des unteren Hirnstammes.
        Deutsche Ophthalmol Ges. 1975; 73: 642-646
        • Teufel J
        • Strupp M
        • Linn J
        • et al.
        Conjugate eye deviation in unilateral lateral medullary infarction.
        J Clin Neurol. 2019; 15: 228-234
        • Dieterich M
        • Brandt T.
        Perception of Verticality and Vestibular Disorders of Balance and Falls.
        Front Neurol. 2019 Apr 3; 10 (eCollection 2019): 172
        • Solomon D
        • Galetta SL
        • Liu GT.
        Possible mechanisms for horizontal gaze deviation and lateropulsion in the lateral medullary syndrome.
        J Neuroophthalmol. 1995 Mar; 15 (PMID: 7780568): 26-30