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1 "Pseudonystagmus" due to bilateral vestibular loss and head tremorThis is a 65-yo-woman with complaints of imbalance, dizziness, and horizontal oscillopsia. On exam, she had a high frequency, low amplitude (mainly horizontal) head tremor, and with ophthalmoscopy, the optic nerve was clearly oscillating back and forth at the same frequency as her head tremor, which...
2 Oscillopsia and bilateral vestibular loss with gentamicin ototoxicityPatients with bilateral vestibular loss commonly experience oscillopsia with head movements, or an inability to stabilize retinal images with subsequent bouncing or jumping of the environment due to loss of vestibular function. This causes significant blurring of vision and disorientation, dizziness...Image/MovingImage
3 Monocular downbeat nystagmus due to a posterior fossa cystThis is a 40-yo-man who experienced months of imbalance and was found to have an epidermoid cyst (immediately posterior to the 4th ventricle), which was resected. Months after surgery, he experienced monocular vertical oscillopsia. On examination, there was subtle downbeat nystagmus (DBN) in the rig...Image/MovingImage
4 Leukemic leptomeningeal carcinomatosis causing 4th and 6th nerve palsiesThis is a 55-yo-man with CML that recurred as AML. Diagonal diplopia developed, and on examination he was found to have a partial right 6th nerve palsy, in addition to a left hypertropia that increased in right gaze, down gaze, and in left head tilt consistent with a left 4th nerve palsy. There was ...Image/MovingImage
5 Chiari malformation causing downbeat nystagmus in lateral gazeThis is a 20-yo-man who presented with oscillopsia in lateral gaze from downbeat nystagmus (DBN). In primary gaze, very subtle DBN was only noted with ophthalmoscopy, but in lateral gaze, prominent DBN was present. Other central ocular motor signs included gaze-evoked nystagmus (GEN) vertically, in ...
6 Divergence insufficiency in cerebellar ataxiaThis is a 65-yo woman with complaints of imbalance (progressive over years) and horizontal diplopia at distance. On her exam, there was a small symptomatic esotropia at distance, but only a small esophoria at near. There were no obvious abduction deficits, and the 6 prism diopter ET at distance was...Image/MovingImage
7 Examples of patients with saccadic intrusions (square wave jerks)Seen here are patients with saccadic intrusions that do have an intersaccadic interval. Square wave jerks are commonly seen in degenerative conditions, mainly involving the posterior fossa (e.g., cerebellar degeneration) and basal ganglia (e.g., progressive supranuclear palsy).Image/MovingImage
8 + HIT, + Skew, Unidirectional Nystagmus: Central acute vestibular syndrome due to Wallenberg syndromeThis is a 45-year-old woman who presented to the ED with acute prolonged vertigo and vertical diplopia. She was seen as an outpatient 1 month after her ED visit, and double vision and balance were improving by that time. Her HINTS testing showed the following (seen in the video):; 1); Head Impulse -...
9 The episodic vestibular syndromeThis is a 55-year-old man with 6 months of episodic vertigo without clear triggers/provocative factors, with each of his 3 previous episodes lasting less than 5 minutes. While in the clinic, he had one of his typical vertigo attacks. There was initially 30 seconds of right-beating-torsional nystagmu...
10 Nystagmus due to paraneoplastic (anti-Yo) brainstem and cerebellar degenerationThis is a 40-yo-woman with anti-Yo antibody associated with ovarian cancer. Initial symptoms 2.5 years prior (to this video) included imbalance and dysarthria. She complained of oscillopsia which was due to her upbeat nystagmus (presumably the result of brainstem involvement), and diplopia (she had ...Image/MovingImage
11 Mild 6th nerve palsy due to pontine strokeThis is a 70-year-old woman with HTN and diabetes who presented with horizontal diplopia for several weeks, worse in right gaze. There was a very subtle abduction paresis OD with full motility elsewhere. With cover-uncover testing, there was a small esotropia in right gaze (esodeviation seen with al...
12 Convergence insufficiency and square wave jerks in PSPThis is a 70-yo-woman with progressive supranuclear palsy with complaints of difficulty reading. Her husband noticed that she would frequently close one eye when attempting to read, and words were not clear on the page, and this would in fact improve by covering one eye. On her exam, she had a 1 pri...
13 Using video head impulse testing to unmask covert saccades in compensated vestibular neuritisThis is a 30-year-old woman who experienced the acute vestibular syndrome (prolonged vertigo for >24 hours, nausea, unsteadiness, spontaneous nystagmus, head motion intolerance) and was diagnosed with vestibular neuritis. This diagnosis was based on a positive head impulse test to the left (see Figu...
14 Complete microvascular 6th nerve palsy with slow abducting saccadeThis is a 90-year-man with HTN, HLD, DM who woke up with horizontal diplopia. Two years prior, he was diagnosed with a microvascular right 6th nerve palsy that resolved over several months. There was little concern for giant cell arteritis, myasthenia gravis, or a mass lesion in the absence of typic...
15 Downbeat nystagmusThis is a 40-year-old man with 2 years of progressive ataxia and oscillopsia. On examination, he had downbeat nystagmus (DBN), an ocular motor finding that is usually (but not always) associated with flocculus/paraflocculus dysfunction, which causes overaction of the anterior canal (upward or anti-g...
16 Opsoclonus provoked by convergenceThis is a 40-yo-man with post-infectious opsoclonus-myoclonus syndrome. Opsoclonus was intermittently evident in primary position, but was consistently provoked (and intensified) by convergence. Occasionally, opsoclonus (back-to-back saccades in horizontal, vertical, torsional planes without an inte...Image/MovingImage
17 Torsional nystagmus due to medullary pilocytic astrocytomaThis is a 30-year-old woman who experienced headaches which led to an MRI and the diagnosis of a right medullary pilocytic astrocytoma, confirmed pathologically. Examination was performed a year after the initial diagnosis, and several months prior to this exam oscillopsia was experienced for the fi...
18 Medial longitudinal fasciculus syndrome with prominent spontaneous nystagmusThis is a 60-year-old man who experienced the abrupt onset of diplopia and imbalance. He had typical features of a left medial longitudinal fasciculus (MLF) syndrome including left internuclear ophthalmoplegia (INO) and left hypertropia from skew deviation, but he also had very prominent upbeat-tors...
19 Impaired smooth pursuit and other characteristic ocular motor findings in middle cerebellar peduncle strokeThis is a 50-year-old woman who underwent resection of a left-sided acoustic neuroma, and post-operatively, she had vertigo, binocular diplopia, left hemi-ataxia and severe gait ataxia. MR diffusion weighted imaging demonstrated an acute stroke involving the left middle cerebellar peduncle (MCP) and...
20 Ocular motor signs in SCA 6This is a 45-yo-man who was recently diagnosed with SCA 6. There was no clear spontaneous downbeat nystagmus (DBN) in primary gaze, although DBN could clearly be provoked by convergence. Other ocular motor features included choppy pursuit and VOR suppression horizontally and vertically, in addition ...
21 Pendular nystagmus and ocular motor signs in MSThis is a 30-year-old man with a 15 year history of multiple sclerosis. For the last 12 months, he experienced horizontal oscillopsia. On examination, there were ocular motor abnormalities including gaze-evoked nystagmus, saccadic smooth pursuit, and hypermetric saccades which were attributable to h...
22 Pendular nystagmus and vision lossThree patients are presented here, each with poor vision (counting fingers or worse) related to retinitis pigmentosa in one patient (Usher's syndrome) and optic neuropathy in two patients, each of whom developed pendular nystagmus after vision loss developed. Visually mediated movements normally pre...Image/MovingImage
23 Periodic alternating nystagmus due to nodulus strokeThis is a 70-year-old woman who experienced the acute onset of vertigo and imbalance. MRI demonstrated a diffusion-weighted imaging hyperintensity involving the nodulus (with corresponding ADC hypointensity) consistent with an acute stroke. On examination several weeks after the stroke, periodic alt...
24 Pontine hemorrhage causing oculopalatal tremor and multiple cranial neuropathiesThis is a 45-yo-woman who had a dorsal pontine cavernoma that bled 2 years prior to this video. Symptoms included diplopia and oscillopsia. On examination, she had left>right facial palsies (upper and lower face from involvement of the nucleus/fascicle - i.e., lower motor neuron palsies) and sixth n...Image/MovingImage
25 Head-shaking nystagmus - a "central" patternEvaluating for nystagmus provoked by head-shaking, so-called head-shaking nystagmus (HSN), should be performed in all patients with complaints of dizziness or vertigo, regardless of the chronicity. The maneuver is performed by passively moving the head horizontally (can also be performed vertically)...
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