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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 + 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 -...
3 3rd nerve palsy with preserved 4th nerve function80-yo-woman with a left vasculopathic 3rd nerve palsy (minimal pupil involvement of about 1 mm relative mydriasis OS - other etiologies ruled out and resolved as expected over months). Although the inferior rectus is paretic, intact superior oblique muscle function can be demonstrated by asking the ...Image/MovingImage
4 A Comparison of Nystagmus and Saccadic Intrusions/OscillationsNystagmus can be classified into pendular and jerk waveforms, where both are generated by a slow, pathologic phase. Corrective phase (the position reset mechanism) differs. In pendular nystagmus, the eyes move back and forth with about the same velocity and amplitude, similar to that of a pendulum...
5 Aberrant regeneration of the 3rd nerveAberrant regeneration in two patients: 1) a young woman with a right cavernous sinus meningioma with subsequent development of aberrant regeneration demonstrated by eyelid elevation OD in attempted downgaze (i.e., some fibers that were supposed to innervate the right IR were misrouted to the right l...Image/MovingImage
6 Abnormal Head Impulse Test in Vestibular Neuritis 1 Week After OnsetThis 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 a...
7 Abnormal visually-enhanced VOR in cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS)A 67 year old woman presented with 1 year of progressive numbness, gait instability, and oscillopsia when walking or with head movements. Examination showed excessive square-wave jerks, bilateral horizontal gaze-evoked nystagmus, impairment of the visually-enhanced vestibular ocular reflex (vVOR - s...Image/MovingImage
8 Acute Vestibular Syndrome with skew deviation and positive head impulse test due to a demyelinating lesionThis is a patient who initially presented with the acute vestibular syndrome (AVS, e.g., acute prolonged vertigo, spontaneous nystagmus). ; See https://collections.lib.utah.edu/details?id=187730 for additional history. ; Her HINTS (Head Impulse, Nystagmus, Test of Skew) testing indicated a central e...
9 Alternating hypertropias - bilateral 4th nerve palsies and alternating skew deviationSeen here are two patients with alternating hypertropias. The first is a 70-year-old woman with a diagnosis of cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS). In the video, both spontaneous downbeat nystagmus (DBN) and gaze-evoked nystagmus (GEN) are apparent, in addition to a...
10 Anterior Canal - BPPV: Deep head hangingRegardless or whether it is thought that the patient has right or left anterior canal (AC) involvement, the deep head hanging maneuver is performed in the same way. • First the patient is placed in the long-sitting position • Then the patient is moved into a supine position with the head in at l...Image/MovingImage
11 Anterior canal BPPVAlthough the anterior canal (AC) variant of benign paroxysmal positional vertigo (BPPV) is rare, mainly owing to its orientation relative to gravity (which makes otoconial debris much less likely to enter it), it can occur. Because of the relatively para-sagittal orientation of the AC (more so than ...
12 Anti-GAD associated cerebellopathy and bilateral vestibulopathyThis is a 70-year-old woman with the subacute onset of severe imbalance and dizziness. On her initial examination, she had prominent gaze-evoked nystagmus and bilateral vestibular loss. Smooth pursuit was saccadic, although her vestibulo-ocular reflex (VOR) suppression was much smoother. Usually pur...
13 Approach to the Ocular Motor and Vestibular History and ExaminationHistory and examination of ocular motor and vestibular.
14 Apraclonidine testing in Horner's syndromeThis patient experienced relatively abrupt ptosis and was seen and diagnosed with a Horner's syndrome within a few days of the onset. There were no other exam findings and history did not offer clues as to the etiology. Neuroimaging of the oculosympathetic tract was unrevealing. Apraclonidine testin...Image/MovingImage
15 Assessing for hyperventilation-induced nystagmusHyperventilation induced nystagmus is tested by asking the patient to take quick deep breaths (~1/s) for 40-60 seconds. This increases ICP and CSF pH. This can be helpful in diagnosing irritative conditions of the vestibular nerve, including an acoustic neuroma (see video, https://collections.lib....
16 Atypical ocular motor features (gaze-evoked nystagmus) in PSPThis is a 70-yo-woman who met clinical and radiologic diagnostic criteria for progressive supranuclear palsy (PSP). Typical ocular motor features of PSP include square wave jerks, hypometric saccades, choppy pursuit/VORS, impaired down>upgaze (supranuclear in origin) and impaired down>upward saccade...
17 AudiometryAudiometry is the measurement of the sensitivity and range of an individual's hearing. As many etiologies of imbalance, nystagmus, vertigo and/or dizziness can have an otologic origin the audiogram is an important piece of information in the evaluation of the dizzy patient. A basic audiogram (Fig. 1...
18 Bilateral 6th nerve palsies due to idiopathic intracranial hypertensionThis is a 25-year-old woman who presented with diplopia and blurry vision. On exam, she was found to have papilledema and bilateral 6th nerve palsies. Her opening pressure was >40 cm of water with a normal CSF analysis, and neuroimaging was unremarkable aside from subtle findings that have been asso...
19 Bilateral Horizontal Gaze Palsy and Oculopalatal Tremor Due to Pontine HemorrhageThis 70-yo-woman experienced headache and diplopia and was found to have a hemorrhage centrally within the dorsal pons. Months after the onset, the patient was seen in clinic and had no horizontal eye movements (pursuit, saccades, VOR) in either eye, suggestive of bilateral nuclear 6th nerve palsies...Image/MovingImage
20 Bilateral INOs and partial 3rd nerve palsiesThis is a 45-year-old man with progressive ptosis and ophthalmoparesis. 10 years prior to presentation, he experienced diplopia and had a hyperintense lesion involving the medial longitudinal fasciculus (MLF) per report. Over time, he developed bilateral adduction paresis, ptosis and upgaze paresis ...
21 Bilateral pseudo-abducens palsies due to midbrain strokeThis is a man who suffered right>left midbrain strokes due to endocarditis complaining of ptosis and inability to move his eyes as well as hallucinations (peduncular hallucinosis). There was a presumed nuclear 3rd nerve palsy on the right (i.e., responsible for his mydriatic pupil, absent supra- and...Image/MovingImage
22 Brainstem ocular motor machinerySeen here is a sagittal view of the brainstem. The medulla has a significant role in gaze-holding, and the nucleus prepositus hypoglossi (NPH, along with the medial vestibular nucleus ) is the horizontal neural integrator. The abducens (6th) nucleus is located in the dorsal pons, and sends off the 6...
23 Bruns nystagmus due to a cerebellopontine angle tumorThis is a 15-yo-girl who experienced headache and imbalance leading to an MRI which showed a left sided cerebellopontine angle (CPA) tumor. Because of involvement of the left brainstem/cerebellum (e.g., dysfunction of the neural integrator/gaze holding apparatus) by the CPA mass, there was left-beat...
24 Caloric testingCaloric testing is a peripheral vestibular test which takes advantage of the fact that the labyrinth is sensitive to temperature changes. Warm stimulation causes excitation of the semicircular canals while cold stimulation causes inhibition of the semicircular canals. Caloric testing is performed by...
25 Cavernous sinus mass causing right 3rd and 4th nerve palsies25-yo-man who complained of diplopia and was initially found to have right 4th and 6th nerve palsies in the setting of a right cavernous sinus mass (subsequently diagnosed as Ewing's sarcoma). When seen in follow-up (this video), there was a new right 3rd nerve palsy, still with a right 4th nerve pa...Image/MovingImage
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