After stroke, apraxia of eyelid opening is associated with high mortality and right hemispheric infarction

Introduction: Apraxia of eyelid opening (AEO) refers to impaired voluntary eyelid elevation of supranuclear origin. AEO is well-described in neurodegenerative disorders, but its frequency in stroke is unknown.

Methods: To investigate the frequency of AEO after stroke, we enrolled patients with an anterior circulation occlusion admitted for endovascular thrombectomy (EVT). Exclusion criteria were posterior circulation stroke, impaired consciousness and ophthalmological disorders. Forty-eight hours after EVT, patients were screened for AEO, conjugated gaze palsies and cortical ptosis. Neurological deficits were classified using the National Institute of Health Stroke Scale (NIHSS). A blinded neuroradiologist analyzed CT brain 24 h after EVT using the Alberta Stroke Program Early CT Score.

Results: Ninety-eight EVT patients were included in 9 months. Six patients had AEO (6%), 37 conjugated gaze palsy (38%) and 16% cortical ptosis (16%). AEO was associated with higher median NIHSS compared to no eye symptoms (18.5 vs. 3; p < 0.001) and gaze palsy or cortical ptosis (18.5 vs. 7; p = 0.003). The median modified Rankin Scale (mRS) after 3 months was 2 in patients without AEO, but 6 in patients with AEO (mRS in AEO patients nr. 1-6: 3, 4, 6, 6, 6, and 6; p = 0.015; no longer significant after adjustment for stroke severity), including 4 deaths (66%) in AEO patients. All patients with AEO had right hemisphere stroke (6/6 vs. 43/98 in total, p = 0.006).

Conclusion: AEO was observed in 6% of EVT patients who showed poor survival and outcome. AEO occurred exclusively in right hemispheric infarctions, suggesting that supranuclear eyelid control is under the influence of the right cerebral hemisphere.

Keywords: Endovascular thrombectomy; Eye opening apraxia; Gaze palsy; Infarction; Large vessel stroke; Outcome; Prognosis; Stroke.