Abnormal Head Impulse Test in Vestibular Neuritis 1 Week After Onset

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Identifier Abnormal_head_impulse_test_in_vestibular_neuritis_1_week_after_onset
Title Abnormal Head Impulse Test in Vestibular Neuritis 1 Week After Onset
Subject Abnormal VOR; Vestibulocochlear Nerve; Acute Vestibular Sydrome
Creator Daniel R. Gold, DO, Departments of Neurology, Ophthalmology, Neurosurgery, Otolaryngology - Head & Neck Surgery, Emergency Medicine, and Medicine, The Johns Hopkins School of Medicine
Description This is a 25-year-old woman who experienced the acute vestibular syndrome due to right-sided vestibular neuritis 1 week prior to this video. Left-beating nystagmus (LBN) was only noted in left gaze, but with fixation-removed, there was clear LBN in primary position that increased with head-shaking and vibration. The head impulse test (HIT) was abnormal to the right: when her head was moved quickly to the right (while being asked to fixate on the examiner's nose), due to a deficient vestibulo-ocular reflex on the right, the eyes initially moved to the right with the head. Since the visual target (examiner's nose) moves off the fovea, a refixation or catch-up saccade is necessary to bring the eyes back to the desired target. In this case, since the eyes have moved with the head to the right, the catch-up saccade is directed leftward back to center. This is referred to as an overt saccade, and is usually fairly obvious in the acute setting, occurring after the head movement. However, as compensation occurs over time, it may be more and more difficult to identify an abnormal HIT months or years later. Many patients develop compensatory covert saccades, which occur during the head movement, and these may only be seen with video HIT. Since covert saccades take some time to develop, they are generally not present (or not prominent) in the acute setting, and the bedside HIT is enough to differentiate vestibular neuritis from posterior fossa stroke. An abnormal HIT is a reassuring physical exam sign in that it is suggestive of a peripheral (benign) etiology such as vestibular neuritis. However, ischemia involving the labyrinth (‘peripheral', but dangerous), vestibular nucleus, fascicle of the 8th cranial nerve and other regions may cause an abnormal HIT. However, when paired with the pattern of nystagmus (unidirectional or gaze-evoked?) and test of skew (skew deviation present or absent?), the HINTS exam (Head Impulse, Nystagmus, Test of Skew) outperforms even MR-diffusion weighted imaging in the first 24-48 hours.
Publisher Spencer S. Eccles Health Sciences Library, University of Utah
Date 2019
Type Image/MovingImage
Format video/mp4
Relation is Part of NOVEL: Neuro-ophthalmology Virtual Education Library Examination Collection
Rights Management Copyright 2019. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright
Holding Institution Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E, SLC, UT 84112-5890
Collection Neuro-ophthalmology Virtual Education Library: NOVEL http://NOVEL.utah.edu
Language eng
ARK ark:/87278/s6x398q2
Setname ehsl_novel_gold
Date Created 2019-01-31
Date Modified 2021-05-06
ID 1398545
Reference URL https://collections.lib.utah.edu/ark:/87278/s6x398q2