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1 Parinaud's syndrome in a man with GBM of the pineal glandThis is a 60-yo-man who presented with diplopia, headaches, and difficulty looking up, and was found to have a mass involving the pineal gland. Biopsy was diagnostic of a GBM. Major features of Parinaud's (dorsal midbrain) syndrome were present including: upgaze palsy, convergence retraction
2 Test Your Knowledge - Ocular tilt reaction and subjective visual verticalLesions of which of the following neuro-anatomic structures could result in the clinical findings shown? A. Right medulla B. Right interstitial nucleus of Cajal C. Right medial longitudinal fasciculus D. Left trochlear nerve E. Right caudal midbrain A. Correct. This patient presents with
3 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
4 Central anatomy of the IVth nerveThe IVth or trochlear nucleus is located ventral to the central periaqueductal grey matter, dorsal to the medial longitudinal fasciculus (MLF) and medial to the oculosympathetic tract at the level of the inferior colliculus. The fascicles of the IVth nerve travel dorsally and caudally around the cen...image/jpeg
5 Idiopathic downbeat nystagmus exacerbated with positional maneuvers - Part 2: patient is now on 4-aminopyridineThis is a 45-yo-woman presented in "Idiopathic downbeat nystagmus exacerbated with positional maneuvers". This video was taken after the patient had been on 4-aminopyridine for 3 months. There was marked improvement in subjective oscillopsia and objective downbeat nystagmus. The strong positional
6 Sequelae of cerebellar hemorrhage - gaze-evoked nystagmus, alternating skew deviation and palatal tremorThis is a 75-yo-woman presenting with a gait disorder. Two years prior, she suffered a cerebellar hemorrhage. On examination, there were typical cerebellar ocular motor signs including gaze-evoked nystagmus, choppy smooth pursuit and VOR suppression, and saccadic dysmetria. There was also an
7 Rebound nystagmusThis is a 50-yo-man who presented for dizziness and imbalance. His exam demonstrated choppy smooth pursuit and VOR suppression as well as mild gait ataxia. There was mild right-beating nystagmus in right gaze and left-beating nystagmus in left gaze without vertical gaze-evoked nystagmus.
8 Eye signs in infantile esotropia - latent nystagmus and inferior oblique overactionThis is a 25-yo-man with a history of amblyopia and intermittent eye crossing. On exam, he had a comitant 25 prism diopter esotropia, and other features of infantile (or congenital) esotropia including: latent nystagmus (right-beating nystagmus with occlusion of the left eye and left-beating
9 Horner's syndrome with anhidrosisThis is a patient with the onset of ptosis OD years prior, with clear evidence of a Horner's syndrome. Imaging of the oculosympathetic tract was unrevealing. The patient also mentioned that with exercise, the left side of her face will sweat and turn red while the right side wouldn't. She took a
10 INO in multiple sclerosisDescription: This video includes 3 patients each with a known history of MS found to have unilateral or bilateral INOs on their exam. In the first 2 patients, the INOs are relatively subtle with normal adduction. However, with rapid horizontal saccades, an adduction lag is apparent which is
11 INOs in strokeThis video shows 3 patients with vascular risk factors who suffered strokes of the MLF resulting in unilateral INO in each case. In the second case, INO was diagnosed status post cardiac catherization and MRI was found to be normal. In the third case, the patient had a clear left medial rectus
12 Parinaud's syndrome with impaired upward saccades and otherwise normal vertical eye movementsThis is a 50-yo-man who suffered a dorsal midbrain stroke. Exam demonstrated normal vertical range of eye movements, normal vertical VOR and smooth pursuit, but inability to perform upward saccades. Another feature of Parinaud's syndrome seen on his exam was light-near dissociation (not shown in
13 Medullary structures relevant to the ocular motor and vestibular consequences of lateral medullary (Wallenberg) syndromeThis is an axial section of the medulla showing the structures that, when damaged, are responsible for the vestibular and ocular motor features of the lateral medullary or Wallenberg syndrome. The nucleus prepositus hypoglossi (NPH) and medial vestibular nucleus (MVN) complex is important for horizo...image/jpeg
14 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
15 ConvergenceCan bring out or change the direction of vertical nystagmus in Wernicke's, or cerebellar disease; may be impaired in Parkinson's disease, head trauma, elderly patients; may overcome an adduction deficit with an INO. Instructional ocular motor examination
16 Ocular AlignmentThese tests allow for detection of eso-, exo- or hyperdeviations (phorias (one eye viewing) or tropias (both eyes viewing) that can be seen with ocular motor palsy, skew deviation, or with cerebellar disease (commonly esodeviation greater at distance) Instructional ocular motor examination
17 SaccadesThe examiner should note: conjugacy (a lag of the adducting eye may be seen with an INO); accuracy (posterior fossa lesions commonly produce dysmetria (overshooting or undershooting); velocity (if slow, may suggest a lesion of the burst neurons in the pons [PPRF - horizontally] or midbrain [riMLF -
18 Smooth PursuitA pursuit deficit in one direction suggests an ipsilesional localization, but beware of a superimposed spontaneous nystagmus; a pursuit deficit in all directions is commonly seen with cerebellar lesionsvideo/mp4
19 VOR (Slow and Fast)Slow vestibulo-ocular reflex (VOR): Since smooth pursuit and VOR systems are both active, if eye movements are choppy with this maneuver this implies deficits in both pursuit and the vestibular system as in CANVAS; Fast (HIT): Since smooth pursuit fails at high frequencies and high speeds, the VOR
20 Range of Eye Movements and Evaluation for NystagmusRange: Assesses for motility deficit due to an ocular motor palsy, particularly if a posterior fossa localization is being considered; Nystagmus: Spontaneous nystagmus may or may not be noted and gaze-evoked nystagmus is common with posterior fossa lesions; nystagmus that is unidirectional in all
21 VOR (Suppression)Deficits in pursuit and vestibulo-ocular reflex (VOR)S usually go together, except when the VOR is absent or markedly diminished in which case there is no VOR to suppress, so that VORS seems better than pursuit. This is an important clue that the VOR is diminished. Instructional ocular motor
22 Eyelid retraction, pseudoabducens and upgaze palsy due to a mesodiencephalic hemorrhageThis is a 70-yo-man who suffered a right midline thalamic/rostral midbrain hemorrhagic stroke causing a pretectal (Parinaud's) syndrome. There was prominent eyelid retraction (Collier's sign), a left pseudo-abducens, and upgaze palsy with convergence retraction nystagmus. There was no light-near
23 Vertical gaze palsy and saccadic intrusions due to anti-Ri from head and neck carcinomaA 55-yo- woman was admitted for imbalance and double vision. Three weeks prior to presentation she first noticed swelling on the right side of her face and neck. CT of the head and neck showed right-sided cervical adenopathy and enlarged left retropharyngeal node. Ultrasound- guided biopsy of the
24 Horizontal Canal - BPPV: Gufoni for right apogeotropicTo treat the right apogeotropic (beating towards the sky with right ear down and with left ear down - e.g., left beating nystagmus with right supine roll test or with right ear down; right beating nystagmus with left supine roll test or with left ear down) horizontal canal (HC) variant: • The
25 Horizontal Canal - BPPV: BBQ Roll to treat the right sideTo treat right horizontal canal (HC)-BPPV (each position maintained for at least 30 seconds or until nystagmus and/or vertigo cease): • First the patient is placed in the long-sitting position • Then in a supine position with the head elevated 30 degrees • Then the patient's head (or whole
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