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26 Ocular motor signs in SCA 6This is a 45-yo-man who was recently diagnosed with SCA 6. There was no clear spontaneous downbeat nystagmus (DBN) in primary gaze, although DBN could clearly be provoked by convergence. Other ocular motor features included choppy pursuit and VOR suppression horizontally and vertically, in addition ...
27 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...
28 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...
29 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 ...
30 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
31 Periodic alternating nystagmus due to nodulus stroke - Figure 1This is a 70-year-old woman who experienced the acute onset of vertigo and imbalance. MRI demonstrated a diffusion-weighted imaging hyperintensity involving the nodulus (with corresponding ADC hypointensity) consistent with an acute stroke. On examination several weeks after the stroke, periodic alt...
32 Periodic alternating nystagmus due to nodulus strokeThis is a 70-year-old woman who experienced the acute onset of vertigo and imbalance. MRI demonstrated a diffusion-weighted imaging hyperintensity involving the nodulus (with corresponding ADC hypointensity) consistent with an acute stroke. On examination several weeks after the stroke, periodic alt...
33 Pontine hemorrhage causing oculopalatal tremor and multiple cranial neuropathiesThis is a 45-yo-woman who had a dorsal pontine cavernoma that bled 2 years prior to this video. Symptoms included diplopia and oscillopsia. On examination, she had left>right facial palsies (upper and lower face from involvement of the nucleus/fascicle - i.e., lower motor neuron palsies) and sixth n...Image/MovingImage
34 Saccadic pathways in the brainstem and cerebellum & mechanism for saccadic dysmetria in Wallenberg syndrome - Normal function of the brainstem/cerebellar saccadic pathwaysThe inferior cerebellar peduncle (ICP) carries climbing fibers to the dorsal vermis, and these fibers have an inhibitory influence over the Purkinje cells. These Purkinje cells normally inhibit the ipsilateral fastigial nucleus, and the fastigial nucleus projects to the contralateral inhibitory burs...
35 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...
36 Vestibular evoked myogenic potentials (VEMPs)Vestibular-evoked myogenic potentials (VEMP) are electromyographic potential reflex tests that reflect the function of the saccule in cervical VEMP and the utricle in ocular VEMP.1 In the cervical VEMP an inhibitory reflex is evoked from the saccule to the sternocleidomastoid ipsilateral to the stim...
37 Head-shaking nystagmus - a "central" patternEvaluating for nystagmus provoked by head-shaking, so-called head-shaking nystagmus (HSN), should be performed in all patients with complaints of dizziness or vertigo, regardless of the chronicity. The maneuver is performed by passively moving the head horizontally (can also be performed vertically)...
38 Isolated central 4th nerve palsyThis is a 40-year-old man with a right hypertropia that worsened in left and down gaze in addition to right head tilt, and improved in left head tilt. There was subjective excyclotorsion OD with double Maddox rod testing. This was consistent with a right 4th nerve palsy. He had a known left midbrain...
39 Test Your Knowledge - Central and peripheral vestibular and ocular motor signs due to a large vestibular schwannomaWhich of the following is least likely to be the correct localization or etiology given the findings seen in the video? ; 1); Acute right 8th cranial neuropathy ; 2); Right-sided vestibular schwannoma; 3); Right vestibular nucleus infarction ; 4); Right anterior inferior cerebellar artery distributi...
40 Video head impulse testingThe video head impulse test (vHIT) is a clinical assessment technique used to assess the function of the semicircular canals-the angular acceleration detectors-which initiate the vestibulo-ocular reflex (VOR). The HIT and vHIT are performed similarly (see assessment of VOR using HIT video LINK), alt...
41 Test Your Knowledge - Optokinetic nystagmus with a parietal lesionGiven the finding seen in the first part of the video, which of the following associated features are most likely? (more than one answer may be correct); A.; Left homonymous visual field defect; B.; Right homonymous visual field defect; C.; Visual neglect and/or extinction; D.; Alexia without agraph...
42 Spontaneous upbeat nystagmus in acute Wernicke's encephalopathyThis is a 40-year-old woman presenting with imbalance, confusion and oscillopsia. Exam demonstrated upbeat nystagmus (UBN) in primary gaze that remained UB in all directions of gaze, with a slight torsional component (top poles beating toward right ear) in certain directions of gaze. Her nystagmus f...
43 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...
44 ENG, VNG, & VOGElectronystagmography (ENG), and videonystagmography (VNG) or videooculography (VOG) are a collection of tests of eye movements that are performed either using surface electrodes around the eye (ENG) or with video goggles (VNG, VOG) (Figure 1). For all clinical intents and purposes, VNG and VOG ar...
45 Test Your Knowledge - Vertical saccadic palsy due to bilateral riMLF infarctionsThis is a 30-year-old who was found minimally responsive on the lounge floor of an ice skating rink. He was brought to the ED, where he had a GCS score of 8 (where 15 is normal) for poor responsiveness. His ocular motor exam is shown in the video.; ; Regarding Finding #1, which of the following is f...
46 Ocular motor & vestibular features of the MLF syndrome - Figures 1, 2, and 3This 61-year-old woman with HTN and DM presented for evaluation of acute onset diagonal diplopia. Adduction OS was about 60% of normal while medialization OS improved with convergence. In right gaze, dissociated abducting nystagmus was present OD, and there was a clear adduction lag when asking he...
47 Ocular motor & vestibular features of the MLF syndromeThis 61-year-old woman with HTN and DM presented for evaluation of acute onset diagonal diplopia. Adduction OS was about 60% of normal while medialization OS improved with convergence. In right gaze, dissociated abducting nystagmus was present OD, and there was a clear adduction lag when asking he...
48 Oculopalatal tremor with prominent nystagmus, bilateral horizontal gaze palsy, and bilateral facial palsies Figure 1Figure 1, MRI T2 sequence demonstrating hyperintensities involving bilateral inferior olives of the medulla. This is a 50-year-old woman who experienced the acute onset of right sixth and seventh nerve palsies and left hemiparesis. Two cavernomas within the right pons (one in the region of the facia...
49 Oculopalatal tremor with prominent nystagmus, bilateral horizontal gaze palsy, and bilateral facial palsiesThis is a 50-year-old woman who experienced the acute onset of right sixth and seventh nerve palsies and left hemiparesis. Two cavernomas within the right pons (one in the region of the facial colliculus) were demonstrated by MRI. Five years after her initial presentation she developed recurrent r...
50 Testing for adduction lag in partial INO using an optokinetic stimulusIn this patient we demonstrate the use of an optokinetic stimulus to elicit an internuclear ophthalmoplegia (INO). Occasionally adduction appears to be normal with an INO, and an adduction lag with horizontal saccades should be sought as a confirmatory sign. Optokinetic tape is an easy way to assess...
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