Can a cerebellar (Cerebrovascular Accident) CVA cause double vision?

Cerebellar CVA Can Cause Double Vision

Yes, a cerebellar cerebrovascular accident (CVA) can cause double vision (diplopia). 1 Cerebellar strokes can lead to ocular motility abnormalities that result in diplopia, particularly when they affect areas involved in eye movement control.

Mechanisms of Diplopia in Cerebellar Stroke

Cerebellar strokes can cause diplopia through several mechanisms:

1. Disruption of ocular motor control pathways:

   • The cerebellum plays a critical role in coordinating eye movements
   • Damage can lead to incoordination of eye muscles and misalignment

2. Specific presentations:

   • Skew deviation (vertical misalignment of the eyes)
   • Nystagmus (involuntary rhythmic eye movements)
   • Impaired vestibulo-ocular reflexes 2

Clinical Presentation and Associated Symptoms

When a cerebellar stroke causes diplopia, it typically presents with additional neurological symptoms:

• Progressive impairment of consciousness
• Nausea and vomiting
• Headaches
• Progressive ataxia (incoordination)
• Other cranial nerve palsies 1

Signs of impending brainstem compression may develop and include:

• Hypertension
• Bradycardia
• Decreased consciousness
• In severe cases, respiratory arrest 1

Risk Factors for Space-Occupying Cerebellar Infarction

Patients with the following features are at higher risk for developing significant edema after cerebellar infarction:

• Impairment of consciousness
• Hypodensity in >2/3 of the cerebellar hemisphere on imaging
• Compression/displacement of the 4th ventricle
• Obstructive hydrocephalus
• Displacement of the brainstem
• Compression of the basal cisternae
• Hemorrhagic transformation 1

Diagnostic Approach

When a patient presents with acute diplopia, a thorough evaluation is necessary to determine if it's due to a cerebellar stroke:

• Careful assessment of ocular motility
• Evaluation for nystagmus, especially downbeat nystagmus
• Assessment for other neurological signs (ataxia, dysarthria)
• Brain imaging (MRI with DWI is preferred) 3

It's important to note that diplopia can be the presenting symptom of a brainstem stroke, even in the absence of other neurological symptoms, as documented in case reports of patients who presented with "wake-up diplopia" as their only initial symptom 4.

Management Considerations

For patients with diplopia due to cerebellar stroke:

1. Acute management:

   • Immediate neurological consultation
   • Monitoring for signs of increased intracranial pressure
   • In cases of significant edema, surgical decompression may be necessary

2. Diplopia management:

   • Initial treatment with prisms may help manage diplopia while waiting for possible recovery
   • Botulinum toxin injections may be considered for persistent diplopia
   • Strabismus surgery may be needed for cases that don't resolve 1

Prognosis

The prognosis for diplopia following cerebellar stroke varies:

• Some patients experience spontaneous resolution as the brain adapts
• Others may have persistent diplopia requiring long-term management
• The outcome depends on the size and location of the infarct, as well as the timeliness of intervention

Clinical Pearls and Pitfalls

• Important pitfall: Diplopia may be the only initial presenting symptom of a cerebellar stroke, leading to potential misdiagnosis or delayed diagnosis 5, 4
• Key consideration: Cerebellar strokes can rapidly deteriorate due to edema and brainstem compression, making prompt recognition crucial
• Clinical pearl: Patients with isolated diplopia but normal funduscopic examination should be evaluated for possible posterior circulation stroke, including cerebellar infarction

In summary, cerebellar strokes should be considered in the differential diagnosis of acute-onset diplopia, especially when accompanied by other cerebellar signs or symptoms of increased intracranial pressure.