The "eye sign" due to hemispatial neglect: A case report

Porto, Fábio Henrique de Gobbi; Machado, Gislaine Cristina Lopes; Silva, Mari-Nilva Maia da; Freitas, Gabriel Rodriguez de

doi:10.1590/S1980-57642009DN30300013

Abstract

Conjugate eye deviation is characterized by a sustained shift in horizontal gaze, usually toward the affected brain hemisphere. When detected on neuroimaging, it is called the "eye sign". It is classically associated with lesions involving the frontal eye fields, ipsilateral to the side of the deviation. Neglect may be conceptualized as a spatially addressed bias of the sensory events in explicit behaviors and in the absence of perceptual and motor deficits. Hemispatial neglect is a common disabling condition that occurs following acute unilateral brain damage, usually to the right side. We report a case of a patient presenting with the "eye sign" on tomography, following an acute subinsular stroke, in the absence of conjugated eyes deviation. Our hypothesis was that the sign may have been due to hemispatial neglect in this patient. The aim of this article was to discuss the mechanisms involved in the attention network and its neuroanatomic correlates.

Key words:
hemispatial neglect; insular stroke; conjugate eye deviation; "eye sign".

Resumo

Desvio conjugado do olhar é caracterizado por um desvio sustentado horizontal da mirada, normalmente para o lado do hemisfério afetado. Quando visto por métodos de imagem, é chamado "sinal do olhar". O sinal é normalmente associado a lesões envolvendo o "campo frontal do olho" ipsilateral ao lado do desvio. Negligência pode ser conceitualizada como um viés espacial dos eventos sensoriais no comportamento explícito, na ausência de alterações da percepção e motoras. Negligência hemiespacial é uma condição comum e incapacitante que ocorre após lesão cerebral aguda, principalmente à direita. Nós relatamos um caso de um paciente que apresenta o "sinal do olhar" na tomografia, após um infarto subinsular, na ausência de desvio conjugado do olhar. Nossa hipótese é que, neste paciente, o sinal pode ser devido à negligência hemiespacial. O objetivo deste artigo é discutir os mecanismos envolvidos na rede da atenção e seus correlatos anatômicos.

Palavras-chave:
negligência hemiespacial; infarto insular; desvio conjugado do olhar; "sinal do olhar".

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References

¹
Simon JE, Morgan SC, Pexman JHW, Hill MD, Buchan AM. CT assessment of conjugate eye deviation in acute stroke. Neurology 2003;60:135-137.
²
Friedman Y, Pettersen JA, Aviv RI, Murray BJ. The "eye sign" in acute stroke: not necessarily poor outcome. J Neurol Neurosurg Psychiatry 2009;80:291.
³
Fruhmann B, Prob RD, Ilg UJ, Karnath HO. Deviation of eyes and head in acute cerebral stroke. BMC Neurology 2006;6:23.
⁴
Ringman JM, Saver J L, Woolson RF, Adams HP. Hemispheric asymmetry of gaze deviation and relationship to neglect in acute stroke. Neurology 2005;65:1661-1662.
⁵
Tijssen CC, Schulte BPM, Leyten ACM. Prognostic significance of conjugate eye deviation in stroke patients. Stroke 1991;22:200-202.
⁶
DeRenzi E, Colombo A, Faglioni P, Gibertoni M. Conjugate gaze paresis in stroke patients with unilateral damage. An unexpected instance of hemispheric asymmetry. Arch Neurol 1982;39:482-486.
⁷
Mesulam MM. Attentional Networks, Confusional States and Neglect Syndromes. In: Mesulam MM, editor. Principles of Behavioral and Cognitive neurology. 2nd ed. New York: Oxford Press; 2000:174-256.
⁸
Bowen A, McKenna K, Tallis RC. Reasons for Variability in the Reported Rate of Occurrence of Unilateral Spatial Neglect After Stroke. Stroke 1999;30:1196-1202.
⁹
Lyden P, Brott T, Tilley B, et al. Improved reliability of the NIH Stroke Scale using video training. NINDS TPA Stroke Study Group. Stroke 1994;25:2220-2226.
¹⁰
Manes F, Paradiso S, Springer JA, Lamberty G, Robinson RG. Neglect After Right Insular Cortex Infarction. Stroke 1999;30:946-948.
¹¹
Kumral E, Özdemirkiran T, Alper Y. Strokes in the subinsular territory: Clinical, topographical, and etiological patterns. Neurology 2004;63:2429-2432.
¹²
Augustine J. Circuitry and functional aspects of the insular lobe in primates including humans. Brain Res Rev 1996;22: 229-244.
¹³
Karnath HO, Fruhmann Berger M, Küker W, Rorden C. The anatomy of spatial neglect based on voxelwise statistical analysis: a study of 140 patients. Cereb Cortex 2004;14:1164-1172.
¹⁴
Karnath HO, Dieterich M. Spatial neglect - a vestibular disorder? Brain 2006;129:293-305.
¹⁵
Hornak J. Ocular exploration in the dark by patients with visual neglect. Neuropsychologia 1999;30:547-552.
¹⁶
Parton A, Malhotra P, Husain M. Hemispatial neglect. J Neurol Neurosurg. Psychiatry 2004;75:13-21.
¹⁷
Thomas RH, Hughes TAT. Dot-to-dot. Pract Neurol 2008;8: 325-329.
¹⁸
Hillis AE, Barker PB, Ulatowski J, Beauchamp NJ, Wityk RJ. A simple test of hemispatial neglect reflects change in tissue perfusion with intervention in acute nondominant hemisphere stroke. Stroke 2003;34:252.
¹⁹
Wilson BA, Cockburn J, Halligan PW. Behavioural inattention test. Titchfield, Hants, England: Thames Valley Test Company Ltd.; 1987.
²⁰
Lopes MA, Ferreira HP, Carvalho JC, Cardoso L, André C. Screening tests are not enough to detect hemineglect. Arq Neuropsiquiatr 2007;65:1192-1195.
²¹
Fink JN, Selim MH, Kumar S, et al. Is the association of National Institutes of Health Stroke Scale scores and acute magnetic resonance imaging stroke volume equal for patients with right- and left-hemisphere ischemic stroke? Stroke 2002;33: 954-958.

Publication Dates

Publication in this collection
Jul-Sep 2009

History

Received
25 May 2009
Accepted
14 Aug 2009

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] ¹
Simon JE, Morgan SC, Pexman JHW, Hill MD, Buchan AM. CT assessment of conjugate eye deviation in acute stroke. Neurology 2003;60:135-137.

[2] ²
Friedman Y, Pettersen JA, Aviv RI, Murray BJ. The "eye sign" in acute stroke: not necessarily poor outcome. J Neurol Neurosurg Psychiatry 2009;80:291.

[3] ³
Fruhmann B, Prob RD, Ilg UJ, Karnath HO. Deviation of eyes and head in acute cerebral stroke. BMC Neurology 2006;6:23.

[4] ⁴
Ringman JM, Saver J L, Woolson RF, Adams HP. Hemispheric asymmetry of gaze deviation and relationship to neglect in acute stroke. Neurology 2005;65:1661-1662.

[5] ⁵
Tijssen CC, Schulte BPM, Leyten ACM. Prognostic significance of conjugate eye deviation in stroke patients. Stroke 1991;22:200-202.

[6] ⁶
DeRenzi E, Colombo A, Faglioni P, Gibertoni M. Conjugate gaze paresis in stroke patients with unilateral damage. An unexpected instance of hemispheric asymmetry. Arch Neurol 1982;39:482-486.

[7] ⁷
Mesulam MM. Attentional Networks, Confusional States and Neglect Syndromes. In: Mesulam MM, editor. Principles of Behavioral and Cognitive neurology. 2nd ed. New York: Oxford Press; 2000:174-256.

[8] ⁸
Bowen A, McKenna K, Tallis RC. Reasons for Variability in the Reported Rate of Occurrence of Unilateral Spatial Neglect After Stroke. Stroke 1999;30:1196-1202.

[9] ⁹
Lyden P, Brott T, Tilley B, et al. Improved reliability of the NIH Stroke Scale using video training. NINDS TPA Stroke Study Group. Stroke 1994;25:2220-2226.

[10] ¹⁰
Manes F, Paradiso S, Springer JA, Lamberty G, Robinson RG. Neglect After Right Insular Cortex Infarction. Stroke 1999;30:946-948.

[11] ¹¹
Kumral E, Özdemirkiran T, Alper Y. Strokes in the subinsular territory: Clinical, topographical, and etiological patterns. Neurology 2004;63:2429-2432.

[12] ¹²
Augustine J. Circuitry and functional aspects of the insular lobe in primates including humans. Brain Res Rev 1996;22: 229-244.

[13] ¹³
Karnath HO, Fruhmann Berger M, Küker W, Rorden C. The anatomy of spatial neglect based on voxelwise statistical analysis: a study of 140 patients. Cereb Cortex 2004;14:1164-1172.

[14] ¹⁴
Karnath HO, Dieterich M. Spatial neglect - a vestibular disorder? Brain 2006;129:293-305.

[15] ¹⁵
Hornak J. Ocular exploration in the dark by patients with visual neglect. Neuropsychologia 1999;30:547-552.

[16] ¹⁶
Parton A, Malhotra P, Husain M. Hemispatial neglect. J Neurol Neurosurg. Psychiatry 2004;75:13-21.

[17] ¹⁷
Thomas RH, Hughes TAT. Dot-to-dot. Pract Neurol 2008;8: 325-329.

[18] ¹⁸
Hillis AE, Barker PB, Ulatowski J, Beauchamp NJ, Wityk RJ. A simple test of hemispatial neglect reflects change in tissue perfusion with intervention in acute nondominant hemisphere stroke. Stroke 2003;34:252.

[19] ¹⁹
Wilson BA, Cockburn J, Halligan PW. Behavioural inattention test. Titchfield, Hants, England: Thames Valley Test Company Ltd.; 1987.

[20] ²⁰
Lopes MA, Ferreira HP, Carvalho JC, Cardoso L, André C. Screening tests are not enough to detect hemineglect. Arq Neuropsiquiatr 2007;65:1192-1195.

[21] ²¹
Fink JN, Selim MH, Kumar S, et al. Is the association of National Institutes of Health Stroke Scale scores and acute magnetic resonance imaging stroke volume equal for patients with right- and left-hemisphere ischemic stroke? Stroke 2002;33: 954-958.

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