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HOME > J Korean Bal Soc > Volume 2(1); 2003 > Article
Practical Review Reversal of Skew Deviation by Lateral Head Tilt

Department of Neurology, College of Medicine, Seoul National University
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and Objectives: Alternating sSkew deviation (SD) refers to vertical dissociation of the eyes from supranuclear lesions. Alternating SD, in which the side of the higher lower eye changes depending upon whether gaze is directed to the left or to the rightthe direction of gaze, is a frequent signoccurs in patients with posterior fossa lesions. However, there have not been reports forreversal of SD by lateral head tilt skew deviation alternated by lateral head tiltinghas not been described.
s: One patient with left Wallenberg syndrome had SD with hypotropic left eye in the primary position. He showed an increase of SD on right head tilting and reversal of SD on left head tilting. Patient 1 (M/45) complained vertigo, vomiting, diplopia, numbness in right leg and gait disturbance. Neurological examination revealed left-sided Horner syndrome, left horizontal nystagmus at upward and leftward gaze, impaired smooth pursuit to the left with intact saccade, hypethesia to the pain stimuli in right face and body and veering tendency in tandem gait. He showed right hypertropia in primary position, which increased in head tilting to the right and reversed to the left hypertropia in head tilting to the left. Head tilt, ocular torsion and body lateropulsion were not observed. Brain MRI showed left lateral medullary and cerebellar vermian infarction with cerebellar hemorrhagehemorrhagic transformation. Another patient developed vertigo, diplopia, and Patient 2 (M/23) complained vertigo, diplopia, and gait disturbance. Neurological eExamination showed veering to the right in tandem gait. He revealedSD with hypotropic leftright hypertropia eye in the primary position. The SD, which increased in on head tilting to the left and reversed in direction on to the right hypertropia in head tilting to the right. Head tilt, ocular torsion and body lateropulsion were not observed. Brain MRI revealed a small infarct in the medial side of left inferior cerebellum. left cerebellar infarction in brain MRI.
Skew deviationSD can be interpreted as a disordered static otolith-ocular reflex in which the primary utriculo-ocular connections predominate. Primary otolith-ocular pathways do not pass through the cerebellum, but vestibulocerebellum receives both direct and indirect otolith projections. As the cerebellum governs the semicircular canal-ocular reflex, it also influences the otolith-ocular reflexes.The reversal of SD by lateral head tilt in our patients with inferior cerebellar lesions suggests a role of this area in the modulation of head tilt reaction.

Res Vestib Sci : Research in Vestibular Science