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26 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
27 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 ...
28 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...
29 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
30 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
31 + 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 -...
32 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...
33 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
34 Central anatomy of the IIIrd nerveSeen here is an axial section of the midbrain at the level of the superior colliculus. The paired nuclei are located ventral to the periaqueductal grey, and the midline central caudal nucleus (CCN) is located between the right and left nuclei. The CCN sends projections to bilateral levator palpebrae...
35 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...
36 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...
37 Sagittal section of the brainstem showing structures related to normal eyelid functionSeen here is a sagittal view of the brainstem, with the structures relevant to normal eyelid function highlighted. The M-group, which can be found medial to the riMLF (coordinates eye and lid movements), has (weak) projections to the facial nucleus for frontalis muscle contraction, and (strong) proj...
38 Sagittal section of the midbrain showing structures related to normal eyelid functionDuring a vertical saccade, the rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF) is activated, which excites the superior rectus (SR) and inferior oblique (IO) (IIIrd nerve) subnuclei. Additionally, the riMLF activates the nearby M-group. The M-group's primary excitatory out...
39 Using video head impulse testing to unmask covert saccades in compensated vestibular neuritis - Figures 1 and 2This 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...
40 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...
41 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...
42 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...
43 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
44 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...
45 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...
46 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...
47 Pons: 6th, 7th, 8th, and middle cerebellar peduncle anatomyFrom this cross-section of the pons, the proximity of the 7th and 8th fascicles can be appreciated, and a lateral inferior pontine syndrome (anterior inferior cerebellar artery territory), which could involve both of these fascicles, could cause acute prolonged vertigo accompanied by a + ipsilateral...
48 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...
49 Pons: 6th and 7th nerve anatomy and the central tegmental tractFrom this cross-section of the pons, the proximity of the 6th nucleus to the 7th nerve fascicles is apparent. This is the basis of the so-called facial colliculus syndrome, where an ipsilesional horizontal gaze palsy from a nuclear 6th lesion (usually related to stroke or demyelination) can be seen ...
50 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
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