Case 03 · clinician
Diplopia and head tilt after a small midbrain bleed
Vignette
A 58-year-old woman on warfarin presents with sudden-onset vertical diplopia and a persistent leftward head tilt. Examination shows skew deviation (right eye hypotropic), conjugate ocular counter-roll to the left, and a left head tilt. Saccades and pursuit are otherwise intact. Bucket SVV is −9° (tilted left). MRI shows a small haemorrhage in the right rostral midbrain.
SVV trace
Contraversive tilt — away from the right-sided lesion