A patient with acute vertigo undergoes the alternate cover (skew deviation) test. A vertical corrective movement of the uncovered eye is observed. This finding indicates involvement of which pathway?

• A Peripheral vestibular nerve
• B Vestibulo-ocular reflex arc
• C Semicircular canal cupula
• D Central vestibular pathways (brainstem/cerebellum) ✓

Explanation

Skew deviation (vertical misalignment of the eyes on alternate cover test) indicates a central lesion involving the otolith-ocular pathways in the brainstem or cerebellum. It is a hallmark of central vertigo and is part of the HINTS exam. Peripheral vestibular lesions do not produce skew deviation. This finding in acute vertigo suggests posterior circulation stroke until proven otherwise.

Reference: Cummings Otolaryngology, 7th ed.

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