{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T14:45:18Z","timestamp":1790779518532,"version":"4.1.0"},"reference-count":65,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2023,9,18]],"date-time":"2023-09-18T00:00:00Z","timestamp":1694995200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Stroke"],"abstract":"<jats:p>The head impulse-nystagmus-test of skew (+ hearing) or HINTS+ exam is a well-established clinical bedside test used in evaluating whether patients with the acute vestibular syndrome have features concerning for a central etiology (e.g., stroke). There are other components of the ocular motor exam that are helpful in the acute setting, including smooth pursuit and saccades. We discuss the anatomy and physiology of the saccade and smooth pursuit pathways from the cortex to the infratentorial region in the context of anterior and posterior circulation strokes in general but with a particular emphasis on distinct vestibular stroke syndromes. For each stroke localization, we review the vascular supply and the expected findings on the HINTS+ exam and correlate this with the expected findings on the smooth pursuit and saccade exams to aid in bedside diagnosis.<\/jats:p>","DOI":"10.3389\/fstro.2023.1247326","type":"journal-article","created":{"date-parts":[[2023,9,19]],"date-time":"2023-09-19T06:46:50Z","timestamp":1695106010000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":14,"title":["A review of pursuit and saccadic eye movements and their utility in stroke"],"prefix":"10.3389","volume":"2","author":[{"given":"Elizabeth","family":"Fracica","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David E.","family":"Hale","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel R.","family":"Gold","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2023,9,18]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"600","DOI":"10.1111\/j.1749-6632.1981.tb30904.x","article-title":"Eye movements in patients with wallenberg's syndrome","volume":"374","author":"Baloh","year":"1981","journal-title":"Ann. N Y. Acad. Sci"},{"key":"B2","doi-asserted-by":"publisher","first-page":"882","DOI":"10.1212\/WNL.48.4.882","article-title":"Medial medullary stroke: Report of seven patients and review of the literature","volume":"48","author":"Bassetti","year":"1997","journal-title":"Neurology"},{"key":"B3","doi-asserted-by":"publisher","first-page":"541","DOI":"10.1016\/j.ncl.2015.04.010","article-title":"Overview of the international classification of vestibular disorders","volume":"33","author":"Bisdorff","year":"2015","journal-title":"Neurol. Clin."},{"key":"B4","doi-asserted-by":"publisher","first-page":"528","DOI":"10.1002\/ana.410330518","article-title":"Skew deviation with ocular torsion: A vestibular brainstem sign of topographic diagnostic value","volume":"33","author":"Brandt","year":"1993","journal-title":"Ann. Neurol."},{"key":"B5","doi-asserted-by":"publisher","first-page":"1359","DOI":"10.1093\/brain\/115.5.1359","article-title":"Saccadic reaction times in patients with frontal and parietal lesions","volume":"115","author":"Braun","year":"1992","journal-title":"Brain."},{"key":"B6","first-page":"621","volume-title":"Stroke Syndromes.","author":"Caplan","year":"2012"},{"key":"B7","doi-asserted-by":"publisher","first-page":"125","DOI":"10.3389\/fneur.2016.00125","article-title":"The diagnostic accuracy of truncal ataxia and HINTS as cardinal signs for acute vestibular syndrome","volume":"7","author":"Carmona","year":"2016","journal-title":"Front. Neurol"},{"key":"B8","doi-asserted-by":"publisher","first-page":"e94","DOI":"10.1097\/WNO.0000000000000928","article-title":"Upbeat nystagmus in dorsolateral pontine infarction","volume":"41","author":"Chang","year":"2021","journal-title":"J. Neuroophthalmol."},{"key":"B9","doi-asserted-by":"publisher","first-page":"e1053","DOI":"10.1212\/WNL.0000000000006167","article-title":"Persistent geotropic positional nystagmus in unilateral cerebellar lesions","volume":"91","author":"Choi","year":"2018","journal-title":"Neurology."},{"key":"B10","doi-asserted-by":"publisher","first-page":"396","DOI":"10.1097\/WNP.0000000000000593","article-title":"Ocular motor and vestibular disorders in brainstem disease","volume":"36","author":"Choi","year":"2019","journal-title":"J. Clin. Neurophysiol."},{"key":"B11","doi-asserted-by":"publisher","first-page":"817a","DOI":"10.1136\/jnnp.64.6.817a","article-title":"Sudden bilateral deafness: lateral inferior pontine infarction","volume":"64","author":"Deplanque","year":"1998","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"B12","doi-asserted-by":"publisher","first-page":"323","DOI":"10.1097\/00005072-196107000-00001","article-title":"Lateral medullary infarction\u2014the pattern of vascular occlusion","volume":"20","author":"Fisher","year":"1961","journal-title":"J. Neuropath. Exp. Neurol."},{"key":"B13","doi-asserted-by":"publisher","first-page":"79","DOI":"10.1097\/00041327-199606000-00001","article-title":"Torsional nystagmus during vertical pursuit","volume":"16","author":"FitzGibbon","year":"1996","journal-title":"J. Neuro-Ophthalmol."},{"key":"B14","doi-asserted-by":"publisher","first-page":"799","DOI":"10.1136\/jnnp.56.7.799","article-title":"Smooth pursuit eye movement deficits after pontine nuclei lesions in humans","volume":"56","author":"Gaymard","year":"1993","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"B15","unstructured":"GoldD. R.\n          Saccadic dysmetria and ocular lateropulsion in lateral medullary stroke. Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E SLC, UT 84112-58902016"},{"key":"B16","unstructured":"GoldD. R.\n          Saccadic Pathways in the Brainstem and Cerebellum and Mechanism for Saccadic Dysmetria in Wallenberg Syndrome - Abnormal Function of the Brainstem\/Cerebellar Saccadic Pathways with a Left Wallenberg Syndrome. Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E SLC, UT 84112-58902017"},{"key":"B17","unstructured":"GoldD. R.\n          Impaired Smooth Pursuit and Other Characteristic Ocular Motor Findings in Middle Cerebellar Peduncle Stroke. Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E SLC, UT 84112-58902018"},{"key":"B18","doi-asserted-by":"crossref","DOI":"10.1007\/978-3-030-76875-1","volume-title":"Neuro-Ophthalmology and Neuro-Otology: A Case-Based Guide for Clinicians and Scientists.","author":"Gold","year":"2021"},{"key":"B19","doi-asserted-by":"publisher","first-page":"1951","DOI":"10.1093\/brain\/119.6.1951","article-title":"Deficits of smooth pursuit eye movements after frontal and parietal lesions","volume":"119","author":"Heide","year":"1996","journal-title":"Brain"},{"key":"B20","doi-asserted-by":"publisher","first-page":"694","DOI":"10.1161\/01.STR.0000117570.41153.35","article-title":"Lateral and medial medullary infarction: a comparative analysis of 214 patients","volume":"35","author":"Kameda","year":"2004","journal-title":"Stroke."},{"key":"B21","doi-asserted-by":"publisher","first-page":"224","DOI":"10.1097\/WNO.0b013e3182606bcd","article-title":"Up-down asymmetry of saccadic contrapulsion in lateral medullary syndrome","volume":"32","author":"Kaski","year":"2012","journal-title":"J. Neuroophthalmol."},{"key":"B22","doi-asserted-by":"publisher","first-page":"260","DOI":"10.3109\/00016489109131396","article-title":"EOG findings in patients with lesions in cerebellar peduncles","volume":"111","author":"Kato","year":"1991","journal-title":"Acta Otolaryngol."},{"key":"B23","doi-asserted-by":"publisher","first-page":"3763","DOI":"10.1007\/s00415-020-10100-5","article-title":"Ocular lateral deviation with brief removal of visual fixation differentiates central from peripheral vestibular syndrome","volume":"267","author":"Kattah","year":"2020","journal-title":"J. Neurol."},{"key":"B24","doi-asserted-by":"publisher","first-page":"120374","DOI":"10.1016\/j.jns.2022.120374","article-title":"Role of incubitus truncal ataxia, and equivalent standing grade 3 ataxia in the diagnosis of central acute vestibular syndrome","volume":"441","author":"Kattah","year":"2022","journal-title":"J. Neurol. Sci."},{"key":"B25","doi-asserted-by":"publisher","first-page":"3504","DOI":"10.1161\/STROKEAHA.109.551234","article-title":"HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early mri diffusion-weighted imaging","volume":"40","author":"Kattah","year":"2009","journal-title":"Stroke."},{"key":"B26","doi-asserted-by":"publisher","first-page":"2484","DOI":"10.1161\/01.STR.0000240329.48263.0d","article-title":"Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study","volume":"37","author":"Kerber","year":"2006","journal-title":"Stroke."},{"key":"B27","doi-asserted-by":"publisher","first-page":"1558","DOI":"10.1161\/STROKEAHA.110.582783","article-title":"Isolated vestibular nucleus infarction mimicking acute peripheral vestibulopathy","volume":"41","author":"Kim","year":"2010","journal-title":"Stroke."},{"key":"B28","doi-asserted-by":"publisher","first-page":"1864","DOI":"10.1093\/brain\/awg169","article-title":"Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive patients","volume":"126","author":"Kim","year":"2003","journal-title":"Brain"},{"key":"B29","doi-asserted-by":"publisher","first-page":"1325","DOI":"10.1212\/01.WNL.0000140704.83719.B9","article-title":"Ocular contrapulsion in rostral medial medullary infarction","volume":"63","author":"Kim","year":"2004","journal-title":"Neurology."},{"key":"B30","doi-asserted-by":"publisher","first-page":"845707","DOI":"10.3389\/fneur.2022.845707","article-title":"Significance of vertigo, imbalance, and other minor symptoms in hyperacute treatment of posterior circulation stroke","volume":"13","author":"Kim","year":"2022","journal-title":"Front. Neurol."},{"key":"B31","doi-asserted-by":"publisher","first-page":"63","DOI":"10.1007\/s00415-017-8455-6","article-title":"Isolated vestibular syndromes due to brainstem and cerebellar lesions","volume":"264","author":"Kim","year":"2017","journal-title":"J. Neurol."},{"key":"B32","doi-asserted-by":"publisher","first-page":"37","DOI":"10.1007\/s13760-017-0860-1","article-title":"Eye movement abnormalities in middle cerebellar peduncle strokes","volume":"119","author":"Kim","year":"2019","journal-title":"Acta Neurol. Belg."},{"key":"B33","doi-asserted-by":"publisher","first-page":"117442","DOI":"10.1016\/j.jns.2021.117442","article-title":"Bedside video-oculographic evaluation of eye movements in acute supratentorial stroke patients: A potential biomarker for hemispatial neglect","volume":"425","author":"Kudo","year":"2021","journal-title":"J. Neurol. Sci."},{"key":"B34","doi-asserted-by":"publisher","first-page":"3533","DOI":"10.1007\/s10072-022-05967-3","article-title":"Update on the medial longitudinal fasciculus syndrome","volume":"43","author":"Lee","year":"2022","journal-title":"Neurol. Sci."},{"key":"B35","doi-asserted-by":"publisher","first-page":"429","DOI":"10.1002\/ana.24094","article-title":"Isolated unilateral infarction of the cerebellar tonsil: Ocular motor findings: Tonsillar Infarction","volume":"75","author":"Lee","year":"2014","journal-title":"Ann. Neurol."},{"key":"B36","doi-asserted-by":"publisher","first-page":"251","DOI":"10.1016\/j.jns.2015.01.006","article-title":"Ipsilesional limb ataxia and truncal ipsipulsion in isolated infarction of the superior cerebellar peduncle","volume":"349","author":"Lee","year":"2015","journal-title":"J. Neurol. Sci."},{"key":"B37","unstructured":"LeighR. J.\n            ZeeD. S.\n          The Neurology of Eye Movements2015"},{"key":"B38","doi-asserted-by":"publisher","first-page":"473","DOI":"10.1093\/brain\/119.2.473","article-title":"Cerebral control of eye movements: I. The relationship between cerebral lesion sites and smooth pursuit deficits","volume":"119","author":"Lekwuwa","year":"1996","journal-title":"Brain."},{"key":"B39","doi-asserted-by":"publisher","first-page":"249","DOI":"10.1007\/s00415-020-10134-9","article-title":"What guides decision-making on intravenous thrombolysis in acute vestibular syndrome and suspected ischemic stroke in the posterior circulation?","volume":"268","author":"Machner","year":"2021","journal-title":"J. Neurol."},{"key":"B40","doi-asserted-by":"publisher","first-page":"g3175","DOI":"10.1136\/bmj.g3175","article-title":"Posterior circulation ischaemic stroke","volume":"348","author":"Merwick","year":"2014","journal-title":"BMJ."},{"key":"B41","doi-asserted-by":"publisher","first-page":"284","DOI":"10.1212\/WNL.40.2.284","article-title":"Cerebral hemispheric localization of smooth pursuit asymmetry","volume":"40","author":"Morrow","year":"1990","journal-title":"Neurology"},{"key":"B42","doi-asserted-by":"publisher","first-page":"27","DOI":"10.1002\/ana.24532","article-title":"Missed stroke in acute vertigo and dizziness: It is time for action, not debate: Missed Stroke in Acute Vertigo","volume":"79","author":"Newman-Toker","year":"2016","journal-title":"Ann. Neurol."},{"key":"B43","doi-asserted-by":"publisher","first-page":"765","DOI":"10.4065\/83.7.765","article-title":"Spectrum of dizziness visits to us emergency departments: cross-sectional analysis from a nationally representative sample","volume":"83","author":"Newman-Toker","year":"2008","journal-title":"Mayo. Clin. Proc"},{"key":"B44","unstructured":"Newman-TokerD. E.\n            PetersonS. M.\n            BadihianS.\n            HassoonA.\n            NasseryN.\n            ParizadehD.\n          25905148Diagnostic errors in the emergency department: a systematic review. agency for healthcare research. and quality (AHRQ)2022"},{"key":"B45","doi-asserted-by":"publisher","first-page":"244","DOI":"10.1212\/WNL.41.2_Part_1.244","article-title":"Lateral medullary infarction: Prognosis in an unselected series","volume":"41","author":"Norrving","year":"1991","journal-title":"Neurology"},{"key":"B46","doi-asserted-by":"publisher","first-page":"2919","DOI":"10.1016\/j.jstrokecerebrovasdis.2018.05.040","article-title":"Clinical study on 3 patients with infarction of the vermis\/tonsil in the cerebellum","volume":"27","author":"Ogawa","year":"2018","journal-title":"J. Stroke Cerebrovasc. Dis."},{"key":"B47","doi-asserted-by":"publisher","first-page":"887","DOI":"10.1111\/acem.13960","article-title":"Can emergency physicians accurately rule out a central cause of vertigo using the HINTS examination? A systematic review and meta-analysis","volume":"27","author":"Ohle","year":"2020","journal-title":"Acad. Emerg. Med."},{"key":"B48","doi-asserted-by":"publisher","first-page":"1576","DOI":"10.1007\/s00415-013-6837-y","article-title":"Isolated floccular infarction: impaired vestibular responses to horizontal head impulse","volume":"260","author":"Park","year":"2013","journal-title":"J. Neurol."},{"key":"B49","doi-asserted-by":"publisher","first-page":"2174","DOI":"10.1007\/s00415-023-11566-9","article-title":"Incidence, characteristics, and neuroanatomical substrates of vestibular symptoms in supratentorial stroke","volume":"270","author":"Park","year":"2023","journal-title":"J. Neurol."},{"key":"B50","doi-asserted-by":"publisher","first-page":"65","DOI":"10.1016\/S1474-4422(12)70299-5","article-title":"Transient isolated brainstem symptoms preceding posterior circulation stroke: a population-based study","volume":"12","author":"Paul","year":"2013","journal-title":"Lancet Neurol."},{"key":"B51","doi-asserted-by":"publisher","first-page":"1473","DOI":"10.1093\/brain\/114.3.1473","article-title":"Cortical control of reflexive visually-guided saccades","volume":"114","author":"Pierrot-Deseilligny","year":"1991","journal-title":"Brain"},{"key":"B52","doi-asserted-by":"publisher","first-page":"232443","DOI":"10.1007\/BF00232443","article-title":"Eye movement disorders after frontal eye field lesions in humans","volume":"102","author":"Rivaud","year":"1994","journal-title":"Exp. Brain Res"},{"key":"B53","doi-asserted-by":"publisher","first-page":"609","DOI":"10.1001\/archneur.1993.00540060049016","article-title":"Wallenberg's lateral medullary syndrome: clinical-magnetic resonance imaging correlations","volume":"50","author":"Sacco","year":"1993","journal-title":"Arch. Neurol"},{"key":"B54","unstructured":"\u201cClinical applications of control systems models: The neural integrators for eye movements,\u201d\n            SadeghpourS.\n            ZeeD. S.\n            LeighR. J.\n          10.1016\/bs.pbr.2018.12.00131239124Progress in Brain Research2019"},{"key":"B55","doi-asserted-by":"publisher","first-page":"346","DOI":"10.1001\/archneurol.2011.2083","article-title":"Symptoms and signs of posterior circulation ischemia in the new england medical center posterior circulation registry","volume":"69","author":"Searls","year":"2012","journal-title":"Arch. Neurol"},{"key":"B56","doi-asserted-by":"publisher","first-page":"241","DOI":"10.1016\/j.bandc.2008.08.015","article-title":"Neurophysiology and neuroanatomy of smooth pursuit: Lesion studies","volume":"68","author":"Sharpe","year":"2008","journal-title":"Brain Cogn."},{"key":"B57","doi-asserted-by":"publisher","first-page":"81","DOI":"10.3109\/01658109108997300","article-title":"Cerebral hemispheric smooth pursuit disorders","volume":"91","author":"Sharpe","year":"1991","journal-title":"Acta Neurol Belg."},{"key":"B58","doi-asserted-by":"publisher","first-page":"405","DOI":"10.1097\/WNP.0000000000000579","article-title":"Eye movement disorders and the cerebellum","volume":"36","author":"Shemesh","year":"2019","journal-title":"J. Clin. Neurophysiol."},{"key":"B59","doi-asserted-by":"publisher","first-page":"327","DOI":"10.3233\/VES-1994-4502","article-title":"Saccadic dysmetria is similar in patients with a lateral medullary lesion and in monkeys with a lesion of the deep cerebellar nucleus","volume":"4","author":"Straube","year":"1994","journal-title":"J. Vestib. Res. Equilib. Orientat."},{"key":"B60","doi-asserted-by":"publisher","first-page":"542","DOI":"10.1007\/s00415-014-7385-9","article-title":"Central ocular motor disorders, including gaze palsy and nystagmus","volume":"261","author":"Strupp","year":"2014","journal-title":"J. Neurol."},{"key":"B61","doi-asserted-by":"publisher","first-page":"1468","DOI":"10.1212\/WNL.0000000000003814","article-title":"ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis","volume":"88","author":"Tarnutzer","year":"2017","journal-title":"Neurology."},{"key":"B62","doi-asserted-by":"publisher","first-page":"443","DOI":"10.1002\/ana.410290419","article-title":"Selective impairment of smooth-pursuit eye movements due to an ischemic lesion of the basal pons","volume":"29","author":"Thier","year":"1991","journal-title":"Ann. Neurol."},{"key":"B63","unstructured":"TourkevichR.\n            GoldD. R.\n          Ocular Motor Signs in Early Progressive Supranuclear Palsy2017"},{"key":"B64","doi-asserted-by":"publisher","first-page":"112","DOI":"10.1161\/CIR.0000000000001123","article-title":"Heart Disease and Stroke Statistics-\u22122023 Update: A Report From the American Heart Association","volume":"147","author":"Tsao","year":"2023","journal-title":"Circulation."},{"key":"B65","doi-asserted-by":"publisher","first-page":"122","DOI":"10.1007\/s12311-017-0878-1","article-title":"The floccular syndrome: dynamic changes in eye movements and vestibulo-ocular reflex in isolated infarction of the cerebellar flocculus","volume":"17","author":"Yacovino","year":"2018","journal-title":"Cerebellum."}],"container-title":["Frontiers in Stroke"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fstro.2023.1247326\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,9,19]],"date-time":"2023-09-19T06:46:54Z","timestamp":1695106014000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fstro.2023.1247326\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,9,18]]},"references-count":65,"alternative-id":["10.3389\/fstro.2023.1247326"],"URL":"https:\/\/doi.org\/10.3389\/fstro.2023.1247326","relation":{},"ISSN":["2813-3056"],"issn-type":[{"value":"2813-3056","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,9,18]]},"article-number":"1247326"}}