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TitleDescriptionType
26 Brainstem ocular motor machinerySeen here is a sagittal view of the brainstem. The medulla has a significant role in gaze-holding, and the nucleus prepositus hypoglossi (NPH, along with the medial vestibular nucleus ) is the horizontal neural integrator. The abducens (6th) nucleus is located in the dorsal pons, and sends off the 6...
27 Bruns nystagmus due to a cerebellopontine angle tumorThis is a 15-yo-girl who experienced headache and imbalance leading to an MRI which showed a left sided cerebellopontine angle (CPA) tumor. Because of involvement of the left brainstem/cerebellum (e.g., dysfunction of the neural integrator/gaze holding apparatus) by the CPA mass, there was left-beat...
28 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...
29 Cavernous sinus mass causing right 3rd and 4th nerve palsies25-yo-man who complained of diplopia and was initially found to have right 4th and 6th nerve palsies in the setting of a right cavernous sinus mass (subsequently diagnosed as Ewing's sarcoma). When seen in follow-up (this video), there was a new right 3rd nerve palsy, still with a right 4th nerve pa...Image/MovingImage
30 Central (Nuclear) 3rd Nerve PalsiesShown here are two patients with left sided midbrain pathology (hemorrhage and ischemia) which caused damage to the 3rd nucleus. Both of the patients have ipsilateral mydriasis, adduction, supra- and infraduction paresis. Ipsilateral>contralateral ptosis is also present, and localizes to the central...Image/MovingImage
31 Central 4th nerve palsy with contralateral Horner's syndromeThis is a 60-yo-woman who presented with a complaint of diplopia. Examination demonstrated a left hypertropia that worsened in right and down gaze as well as in left head tilt, and a left 4th nerve palsy was diagnosed. There was also evidence of a mild motility deficit in down/medial gaze OS, consis...Image/MovingImage
32 Central Acute Vestibular Syndrome due to posterior fossa hemorrhageThis is a patient presenting with the acute vestibular syndrome (AVS, e.g., acute prolonged vertigo, spontaneous nystagmus) whose HINTS (Head Impulse, Nystagmus, Test of Skew) testing indicated a central etiology based on negative (normal) head impulse testing (HIT). Nystagmus was unidirectional and...
33 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...
34 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...
35 Central HINTS (with an abnormal head impulse sign) in the acute vestibular syndrome due to lateral pontine/middle cerebellar peduncle demyelinationThis is a 30-year-old man presenting with vertigo, diplopia and mild left facial weakness (not seen in the video). On exam, there was right-beating nystagmus (RBN) in primary gaze that increased in right gaze (in accordance with Alexander's law), and the RBN stayed unidirectional, but lessened, in l...
36 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...
37 Cerebellar Ataxia, Neuropathy, & Vestibular Areflexia Syndrome (CANVAS): Impaired visually-enhanced VOR and abnormal head impulse testingA 67 year old woman presented with 1 year of progressive numbness, gait instability, and oscillopsia when walking or with head movements. Examination showed excessive square-wave jerks, bilateral horizontal gaze-evoked nystagmus, impairment of the visually-enhanced vestibular ocular reflex (vVOR - s...
38 Cerebellar degeneration with downbeat nystagmus provoked by convergenceDescription: This is a 70-yo-woman with a progressive gait disorder, diagnosed with cerebellar ataxia. She displayed typical cerebellar ocular motor signs including gaze-evoked nystagmus, choppy pursuit and VOR suppression, and there was very subtle spontaneous downbeat nystagmus, best appreciated w...Image/MovingImage
39 Cerebellar eye signs in SCA8This is a 30-yo-man with a diagnosis of SCA 8 who had appendicular and gait ataxia in addition to choppy smooth pursuit and VORS, downbeat nystagmus, saccadic hypermetria, and gaze-evoked nystagmus with rebound nystagmus. He also had an esotropia worse at distance, which is commonly found with cereb...Image/MovingImage
40 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 ...
41 Chronic progressive external ophthalmoplegia (CPEO) and cerebellar signsThis is a 60-yo-woman who initially presented with imbalance and ophthalmoparesis. Initially, there was mild horizontal gaze limitation with mild gaze-evoked nystagmus and slow saccades, and over the years, gait ataxia and dysarthria (mainly a scanning quality to her speech) developed, and her ophth...Image/MovingImage
42 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...
43 Complete peripheral vestibulopathy & ipsilateral facial palsy60-yo-man who suffered the fairly abrupt onset (over hours) of right lower motor neuron facial nerve palsy (7th cranial nerve), vertigo and deafness in the right ear (8th cranial nerve). Vesicles were noted on otoscopy, and herpes zoster infection (Ramsay Hunt) was diagnosed. Whereas many cases of "...Image/MovingImage
44 Congenital nystagmusPresented here are two patients with congenital nystagmus demonstrating characteristic features including: mixed pendular and jerk nystagmus (usually gaze-evoked) waveforms, stays horizontal even in vertical gaze, suppression with convergence, strabismus and a latent component (common but not always...Image/MovingImage
45 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 procedures.Image/MovingImage
46 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...
47 Coronal section of the brainstem showing ocular motor nuclei and anatomy of the vestibular nucleus (with SCC inputs)(A) Seen here is a coronal view of the brainstem showing the locations of the ocular motor nuclei (IIIrd, IVth, VIth) as well as the nuclei of VII and VIII (vestibular and cochlear). The vestibular nucleus (VN) is divided into the inferior, lateral, medial, and superior subnuclei, and the medial ves...
48 Demonstration of HINTS examination in a normal subjectIn the acute vestibular syndrome - consisting of acute prolonged vertigo, spontaneous nystagmus, imbalance, nausea/vomiting, head motion intolerance which is typically due to vestibular neuritis or posterior fossa stroke - a 3 step test of ocular motor and vestibular function known as HINTS, has hig...Image/MovingImage
49 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
50 Dix-Hallpike maneuver in posterior BPPV with reversal of nystagmus on sitting upThis is a patient with typical posterior canal (PC) benign paroxysmal positional vertigo (BPPV), which is provoked by the Dix-Hallpike maneuver. When the patient is moved into the right Dix-Hallpike maneuver, after a brief latency, upbeat-torsional (towards the lowermost or affected [right] ear) nys...
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