Alternating skew on lateral gaze. Neuroanatomic pathway and relationship to superior oblique overaction

Abstract

Background: Previous studies of patients with heterogeneous, often diffuse neurologic disorders concluded that the neurologic substrate for alternating skew on lateral gaze may be localized at the level of the brain stem tegmentum or the cervico-medullary junction, or both. The localized nature of brain tumors offers an opportunity to further investigate the anatomic localization for this as well as other conditions.

Methods: To test the hypothesis that cervico-medullary and cerebellar lesions are responsible for alternating skew on lateral gaze, the authors investigated a series of 50 children with brain tumors, 39 of whom showed neuro-ophthalmologic abnormalities on clinical testing. Seven children had alternating skew on lateral gaze.

Results: All seven children with alternating skew on lateral gaze showed neoplastic involvement at the level of the cervico-medullary junction and/or the cerebellum on critical analysis of neuro-imaging studies.

Conclusion: The authors conclude that the neuroanatomic substrate for alternating skew on lateral gaze is localized at the level of the cervico-medullary junction and/or the cerebellum. Knowing that (1) alternating skew on lateral gaze closely mimics superior oblique overaction clinically, (2) superior oblique overaction is frequently found in patients with myelomeningocele, and (3) myelomeningocele is uniformly associated with Arnold-Chiari type II which includes cerebellar and cervico-medullary region abnormalities, the authors propose that alternating skew on lateral gaze and superior oblique overaction associated with myelomeningocele have similar neuroanatomic pathways.