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TitleDescriptionType
1 Vertical semicircular canal pathwaysAnterior Canal Pathway Afferents that originate in the anterior canals (AC) of the peripheral labyrinth first synapse in the ipsilateral vestibular nucleus. Three pathways exist: 1) medial longitudinal fasciculus (MLF) - right AC afferents to right medial vestibular nucleus (MVN), decussate and asc...
2 Lateral pontine stroke involving the superior vestibular nucleus causing spontaneous upbeat-torsional nystagmusA 65-year-old man presented to the emergency department with spontaneous vertigo and unsteadiness, and had was noted to have spontaneous upbeat nystagmus (UBN), also with a torsional component (top poles beating toward the right ear) that was most noticeable in right and up gaze. General neurologic ...Image/MovingImage
3 Head-Shaking-Induced Nystagmus Following Ramsay Hunt VestibulopathyThis is a 50-year-old man who experienced the abrupt onset of imbalance, dizziness and left-sided hearing loss 4 months prior to this examination. He was found to have herpetic vesicles in the left external auditory canal and diagnosed with Ramsay Hunt syndrome. On exam (4 months after the onset), t...
4 Vibration-induced nystagmus in a patient with vestibular neuritisThis is a 60-year-old man who experienced the sudden onset of vertigo, oscillopsia, imbalance, nausea and vomiting. He was seen in the emergency department within hours and had spontaneous right-beating (RBN) and torsional (top poles toward right ear) nystagmus that was unidirectional in all directi...
5 Downbeat (perverted) head shaking nystagmus in a patient with spontaneous torsional nystagmusThis is a 75-year-old woman with vascular risk factors who experienced abrupt onset imbalance and dizziness. Symptoms were maximal at onset, and she denied progression over 6 months. Clinically, it was felt that she had suffered a stroke, although an MRI one months later demonstrated an unremarkable...
6 Reversal of vertical nystagmus with convergence in anti-DPPX encephalitisThis is a man who initially presented with spontaneous upbeat and torsional nystagmus, which led to the diagnosis of anti-DPPX encephalitis (for further details on this patient's course and for a video of his nystagmus, see reference 1). Over 6-12 months, his spontaneous (mainly) upbeat nystagmus (U...
7 Hyperventilation-induced downbeat nystagmus in a cerebellar disorderThis is a 45-year-old woman with a chronic progressive cerebellopathy of unclear etiology (worsening over at least 10 years) characterized by gait and limb ataxia, gaze-evoked nystagmus, saccadic pursuit and vestibulo-ocular reflex suppression, an esotropia greater at distance, along with very mild ...
8 The most common vestibular conditions categorized by timing and triggers, with specific historical features that should be sought for each (adapted from Approach to the Ocular Motor and Vestibular History and Examination)BPPV = benign paroxysmal positional vertigo; SCDS = superior canal dehiscence syndrome; BVL = bilateral vestibular loss; PPPD = persistent postural perceptual dizziness; MDDS = Mal de debarquement syndrome
9 The most common audiovestibular laboratory tests, and the specific conditions in which they may assist in making or supporting the diagnosisVN = vestibular neuritis; VM = vestibular migraine; VP = vestibular paroxysmia; vHIT = video head impulse test; VNG = video-nystagmography; ENG = electronystagmography; VOG = video-oculography; VEMPs = vestibular evoked myogenic potentials; SCDS = superior canal dehiscence syndrome; BPPV = benign pa...
10 The most common vestibular conditions categorized by timing and triggers, with specific ocular motor and vestibular features that should be sought for eachHINTS+ = Head Impulse, Nystagmus, Test of Skew, ‘Plus' bedside assessment of auditory function; HIT = head impulse test; NP = nerve palsy; BPPV = benign paroxysmal positional vertigo; SCDS = superior canal dehiscence syndrome; BVL = bilateral vestibular loss; PPPD = persistent postural perceptual ...
11 Central positional vertigo and nystagmus in a posterior fossa tumorThis is a 30-year old woman who presented with positional vertigo and vomiting following a concussion related to a car accident 3 months prior. She was initially diagnosed with posterior canal (PC) benign paroxysmal positional vertigo (BPPV), although there was no improvement with Epley maneuvers. T...
12 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...
13 Vestibular neuritis with a peripheral skew deviationThis 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 normal brain MRI within the first 24 hours. The first portion of the video was rec...
14 Square wave jerks and macrosaccadic oscillations in a patient with a cerebellar tumorThis is a 40-year-old man who developed severe headaches, confusion, and gait imbalance which led to neuroimaging which demonstrated a midline cerebellar mass with compression of the fourth ventricle and obstructive hydrocephalus. He underwent a suboccipital craniectomy for resection of the mass, an...
15 Mesodiencephalic stroke causing unilateral riMLF and INC ocular motor syndromesThis is a 65-year-old man who experienced the sudden onset of diplopia (with horizontal and vertical components), dysarthria and imbalance. An MRI performed the following day showed a left mesodiencephalic stroke. The patient was seen in clinic 10 days later (when the video was taken), and by that t...
16 Paroxysmal Ocular Tilt ReactionThis 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 and about 6 months following the hemorrhage the patient began to experience many...
17 Semicircular pathwaysOnce the semicircular canal fibers leave the peripheral labyrinth, they synapse in the ipsilateral vestibular nucleus, and then ascend to the ocular motor nuclei. This enables the vestibulo-ocular reflex to respond to head movements in the plane of any canal or combination of canals.
18 Pseudo-spontaneous nystagmus and bow and lean test in horizontal canal BPPVThis is a 70-year-old woman presenting to the Emergency Department with positional vertigo that was determined to be due to the apogeotropic variant of right horizontal canal (HC) benign paroxysmal positional vertigo (BPPV). When her head is in a neutral position with the head in axis with the trunk...
19 Saccadic hypermetria and ipsipulsion (behind closed eyelids and with vertical saccades)This is a 40-year-old woman who experienced oscillopsia and vertical diplopia, due to spontaneous torsional nystagmus and a skew deviation (right hypotropia), respectively. The symptom onset was 7 months prior to these videos. MRI demonstrated ill-defined T2 and FLAIR hyperintensity signal changes i...
20 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...
21 Vertical vergence and fusional amplitudeEssential information on vertical fusional vergences.
22 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...
23 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...
24 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...
25 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) nystagm...
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