Cerebellar ischemia manifesting as vertical diplopia: a case study on skew deviation

Skew deviation mimics superior oblique palsy. Associated findings can include ocular torsion, head tilt, headache, and neurologic symptoms that may help localize the responsible intracranial lesion. Accurate diagnosis is essential in determining and treating the underlying cause. Imaging options will be reviewed.

A 29-year-old white male presented to the emergency room with sudden onset vertical diplopia after self-neck manipulation. An ophthalmic evaluation led to the diagnosis of skew deviation. Diagnostic imaging revealed an infarct of the cerebellum likely secondary to a vertebral artery dissection. Besides neck manipulation, other possible contributing factors include smoking, elevated cholesterol, and elevated testosterone. Symptoms resolved within 24 hours and the patient was treated with aspirin and atorvastatin calcium.

Skew deviation must be a consideration in patients with vertical diplopia, and ruled out before a superior oblique palsy diagnosis. Vertebral artery dissections are uncommon in the general population but can account for up to 25% of ischemic strokes in the young and middle-aged. Smoking, high cholesterol, and high testosterone are known risk factors of stroke. Research is inconclusive on spinal manipulation's relation to stroke. This report presents an example of neck manipulation directly preceding skew deviation secondary to stroke.