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Ptosis Not Such an Uncommon Sign of Hemispheric Stroke

This study suggests that ptosis is a more common sign of acute hemispheric stroke than previously thought and is more complete with right-sided than with left-sided infarcts.

Eyelid dysfunction (ptosis, apraxia of eyelid opening, or blepharospasm) may occur in the context of cerebral hemisphere disease, but the incidence and the natural history of these abnormalities have not been studied extensively. These authors prospectively studied "cerebral ptosis" as it occurred in patients admitted for acute hemispheric stroke and compared these findings with those in 40 age-matched controls without neurologic disease. The investigators carefully defined ptosis (for example, as distinguished from eyelid opening apraxia) and excluded patients who had hemorrhagic stroke or TIA, were too drowsy to cooperate with the neuro-ophthalmologic examination, or had signs of brainstem disease, levator dehiscence, or dermatochalasis.

Of 64 stroke patients included, just over a third (24) had ptosis (compared with none of the controls). In 10 patients with symmetric ptosis, 8 had right-hemispheric infarcts; conversely, in 14 patients with asymmetric ptosis, 11 had left-hemispheric infarcts. All patients with ptosis had hemiparesis (typically contralateral to the more ptotic side), and about two thirds had upgaze limitation, in keeping with the synkinetic relation between the superior rectus and levator palpebrae muscles. Gaze deviation occurred in 71% of patients with ptosis and in 18% of those without ptosis. Ptosis occurred before other signs of herniation in all 5 patients who subsequently developed malignant infarction. Except in 2 patients who died, the ptosis improved after 2 to 3 days.

Comment: These findings support the concept that, like gaze deviation, ptosis is transient and common in patients with large, hemispheric strokes. Ptosis can occur with either right- or left-sided infarction, but it is more complete with right-sided infarcts. As the authors state, these findings suggest that the nondominant, right hemisphere is more involved with alertness or attention than the left hemisphere is. Ptosis is a measure of that function.

— Richard Kay, MD, FRCP

Dr. Kay is Professor, Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, People's Republic of China.

Published in Journal Watch Neurology April 26, 2002

Citation(s):

Averbuch-Heller L et al. Ptosis in patients with hemispheric strokes. Neurology 2002 Feb 26; 58:620-4.

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