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1 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 elements...Image/MovingImage
2 Skew Deviation and the Triad of the Ocular Tilt Reaction (OTR)This is a patient who presented with vertical diplopia, who was found to have a complete ocular tilt reaction including the following features: (1) Skew deviation - right hypertropia that was about 30 prism diopters in all directions of gaze including right, left, up, down, as well as in right and ...Image/MovingImage
3 The Utriculo-Ocular Motor Pathways - Physiologic and Pathologic Ocular Tilt Reaction: Physiologic Ocular Tilt Reaction (OTR) (Figure 1)A skew deviation is a non-paralytic vertical ocular misalignment that is due to imbalance in the utriculo-ocular motor pathways. While vestibular jerk nystagmus is a consequence of static semicircular canal pathway imbalance (e.g., left-beating nystagmus due to acute right vestibular hypofunction fr...Image
4 The Utriculo-Ocular Motor Pathways - Physiologic and Pathologic Ocular Tilt Reaction: OTR Diagram Pathologic EOMs Labelled (Figure 3)A skew deviation is a non-paralytic vertical ocular misalignment that is due to imbalance in the utriculo-ocular motor pathways. While vestibular jerk nystagmus is a consequence of static semicircular canal pathway imbalance (e.g., left-beating nystagmus due to acute right vestibular hypofunction fr...Image
5 The Utriculo-Ocular Motor Pathways - Physiologic and Pathologic Ocular Tilt Reaction: Pathologic OTR (Figure 2)A skew deviation is a non-paralytic vertical ocular misalignment that is due to imbalance in the utriculo-ocular motor pathways. While vestibular jerk nystagmus is a consequence of static semicircular canal pathway imbalance (e.g., left-beating nystagmus due to acute right vestibular hypofunction fr...Image
6 Spontaneous Torsional Nystagmus and Ocular Tilt Reaction𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗗𝗲𝘀𝗰𝗿𝗶𝗽𝘁𝗶𝗼𝗻: This is a 70-year-old man who experienced "a delay in focusing" with "some twisting movement" that began about 18 months prior to this video with mild progression over days or weeks. For the same period of time, he experi...Image/MovingImage
7 Wallenberg Syndrome in MS𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗗𝗲𝘀𝗰𝗿𝗶𝗽𝘁𝗶𝗼𝗻: 30-yo-woman with MS presenting with acute vertigo and vertical diplopia. Examination demonstrated several aspects of the Wallenberg syndrome (her acute demyelinating lesion was in the left lateral medulla): ipsilesional (...Image/MovingImage
8 Paraflocculus (Tonsillar) Ocular Motor Syndrome and Dysmetria in a Chiari Malformation - Pre and Post-Operative Exams𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗗𝗲𝘀𝗰𝗿𝗶𝗽𝘁𝗶𝗼𝗻: This is a 25-year-old woman presenting with 6 months or progressive imbalance, binocular vertical diplopia, and occipital headaches, which were brought on or aggravated by coughing or sneezing. Examination demonstrated hy...Image/MovingImage
9 Vestibular Neuritis with a Peripheral Skew Deviation𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗗𝗲𝘀𝗰𝗿𝗶𝗽𝘁𝗶𝗼𝗻: This is a 55-year-old hypertensive man who developed acute onset continuous vertigo and presented to the Emergency Department (ED) after several hours of symptoms. He was noted to have spontaneous nystagmus and had a nor...Image/MovingImage
10 Alternating Hypertropias - Bilateral 4th Nerve Palsies and Alternating Skew Deviation𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗗𝗲𝘀𝗰𝗿𝗶𝗽𝘁𝗶𝗼𝗻: Seen 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...Image/MovingImage
11 + 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 - A...Image/MovingImage
12 Paroxysmal Ocular Tilt Reaction𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗗𝗲𝘀𝗰𝗿𝗶𝗽𝘁𝗶𝗼𝗻: This is a 60-year-old woman who 2 years prior experienced a left sided hypertensive hemorrhagic stroke, resulting in right hemiparesis, dysarthria and vertical diplopia. The initial vertical diplopia resolved completely a...Image/MovingImage
13 Skew Deviation and Spontaneous Nystagmus Due to Posterior Fossa LesionsThis is a 50-year-old woman who reported the abrupt onset of imbalance, right upper extremity incoordination and binocular vertical diplopia several months prior to her presentation to our clinic. On examination, she had a left hypertropia that was fairly comitant (measuring 5 prism diopters) assoc...Image/MovingImage
14 Impaired Smooth Pursuit and Other Characteristic Ocular Motor Findings in Middle Cerebellar Peduncle Stroke𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗗𝗲𝘀𝗰𝗿𝗶𝗽𝘁𝗶𝗼𝗻: This 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 demon...Image/MovingImage
15 Medial Longitudinal Fasciculus Syndrome with Prominent Spontaneous Nystagmus𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗗𝗲𝘀𝗰𝗿𝗶𝗽𝘁𝗶𝗼𝗻: This 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 l...Image/MovingImage
16 Test Your Knowledge - The Acute Vestibular Syndrome and PtosisWhat is the most likely localization in this patient presenting with vertical diplopia and acute onset prolonged vertigo? A. Right medial longitudinal fasciculus (MLF) B. Left medial longitudinal fasciculus C. Right medulla D. Left medulla E. Left midbrain A. Incorrect. A right MLF lesion (stroke, M...Image/MovingImage
17 Test Your Knowledge - Vertical-Torsional NystagmusQuestion #1: Watch the first portion of the video until you are told to stop. Is this vestibular nystagmus more likely to be peripheral or central? A. Peripheral B. Central Answer for #1: A. Incorrect. While the patient has upbeat-torsional (top poles beating toward the right ear) nystagmus which is...Image/MovingImage
18 HINTS Exam and Saccadic Dysmetria in Lateral Medullary Stroke𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗗𝗲𝘀𝗰𝗿𝗶𝗽𝘁𝗶𝗼𝗻: This is a 50-year-old who experienced the abrupt onset of prolonged vertigo following chiropractic therapy 2 months prior. Initial work-up included an MRI and MR angiogram - MR-diffusion weighted imaging showed an acute l...Image/MovingImage
19 The Acute Vestibular Syndrome with Skew Deviation, Gaze-evoked Nystagmus, and Bilaterally Abnormal Head Impulse Testing Due to AICA StrokeThis is a 60-year-old man with the acute onset of prolonged vertigo and nystagmus, consistent with the acute vestibular syndrome (AVS). HINTS (Head Impulse, Nystagmus, Test of Skew) exam demonstrated a central pattern: 1) Head impulse test (HIT) was abnormal to the right and to the left. An abnormal...Image/MovingImage
20 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 n...Image/MovingImage
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