Vertical Gaze Palsy in Midbrain Infarction

Clinical Presentation and Diagnosis

Skew deviation with contralateral hypotropia and head tilt can occur when rostral pons/midbrain structures are involved, as noted by the American Academy of Ophthalmology 1
High-resolution T2-weighted images of the brainstem are essential to confirm midbrain lesions causing vertical gaze abnormalities, according to the American College of Radiology 3
The examination must assess both vertical saccades and smooth pursuit, vestibular eye movements, and horizontal gaze to distinguish supranuclear from nuclear causes, with testing for skew deviation and head tilt helping identify associated posterior fossa involvement, as recommended by the American Academy of Ophthalmology 1

Patients with vertical gaze palsy following stroke require urgent neurological evaluation and neuroimaging to identify the extent of midbrain involvement and guide acute stroke management, as advised by the American Heart Association 2
Prism correction for diplopia management may be necessary for patients with persistent vertical gaze palsy, as suggested by the American Academy of Ophthalmology 1