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76 Eyelid retraction, pseudoabducens and upgaze palsy due to a mesodiencephalic hemorrhageThis is a 70-yo-man who suffered a right midline thalamic/rostral midbrain hemorrhagic stroke causing a pretectal (Parinaud's) syndrome. There was prominent eyelid retraction (Collier's sign), a left pseudo-abducens, and upgaze palsy with convergence retraction nystagmus. There was no light-near dis...Image/MovingImage
77 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...
78 Paraneoplastic downbeat nystagmus and cerebellar ataxia due to small cell lung carcinomaThis is a 61-year-old woman (non-smoker) who developed a gait disorder, dizziness and oscillopsia that was progressive over 2 months. Exam demonstrated spontaneous downbeat nystagmus with side pocket nystagmus in lateral gaze (a combination of horizontal gaze-evoked and downbeat nystagmus, giving an...
79 Test Your Knowledge - Acute prolonged vertigoThis is a 60-year old man with diabetes presenting with acute onset prolonged vertigo that was ongoing at the time of this examination. Which of the following statements are true with regard to the localization and/or etiology of this patient's symptoms? ; A.; Whether or not symptoms worsen with he...
80 Acute Vestibular Syndrome with skew deviation and positive head impulse test due to a demyelinating lesionThis is a patient who initially presented with the acute vestibular syndrome (AVS, e.g., acute prolonged vertigo, spontaneous nystagmus). ; See https://collections.lib.utah.edu/details?id=187730 for additional history. ; Her HINTS (Head Impulse, Nystagmus, Test of Skew) testing indicated a central e...
81 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
82 Bilateral 6th nerve palsies due to idiopathic intracranial hypertensionThis is a 25-year-old woman who presented with diplopia and blurry vision. On exam, she was found to have papilledema and bilateral 6th nerve palsies. Her opening pressure was >40 cm of water with a normal CSF analysis, and neuroimaging was unremarkable aside from subtle findings that have been asso...
83 Trigeminal neuropathy with loss of the corneal reflexThis is a woman who underwent radiofrequency ablation for left trigeminal neuralgia. Examination demonstrated loss of facial sensation on the left in addition to an absent corneal reflex on the left, consistent with involvement of the V1 (ophthalmic) branch of the trigeminal nerve. When the cornea i...
84 Trigeminal motor neuropathy with weakness and atrophy of the muscles of masticationThis is a man who was diagnosed with polio in childhood, which involved the motor (VIII) division of the right trigeminal nerve. The motor portion of the trigeminal nerve innervates the muscles of mastication (temporalis, masseter - both of which demonstrate wasting in this patient - as well as the ...
85 Multiple lower cranial neuropathies following carotid endarterectomyThis is a patient who underwent a right carotid endarterectomy (CEA). Following the surgery, multiple right sided lower cranial nerves were involved. In his case, there was trapezius and sternocleidomastoid weakness and atrophy on the right, indicative of right CN XI injury. There was an absent gag ...
86 Multiple cranial neuropathies due to glomus tumorThis is a woman who was diagnosed with a right sided glomus tumor, and subsequently underwent resection. Seen here are multiple cranial neuropathies related to the tumor itself as well as to the surgery. She cannot abduct the right eye due to a right CN VI palsy. She has a right lower motor neuron f...
87 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...
88 Neuro-ophthalmic features and pseudo-MG lid signs in Miller Fisher syndromeThis is a 51-year-old woman who presented with imbalance, acute onset dizziness and diplopia that developed over three days following two weeks of upper respiratory infection and bacterial conjunctivitis. When she was initially seen as an outpatient, nystagmus was noted to the right and left, and a ...
89 Neuro-ophthalmic features and pseudo-MG lid signs in Miller Fisher syndrome - Figure 1This is a 51-year-old woman who presented with imbalance, acute onset dizziness and diplopia that developed over three days following two weeks of upper respiratory infection and bacterial conjunctivitis. When she was initially seen as an outpatient, nystagmus was noted to the right and left, and a ...
90 Summary of the most common audio-vestibular testingChart describing common audio-vestibular testing.
91 Parinaud's syndrome in a man with GBM of the pineal glandThis is a 60-yo-man who presented with diplopia, headaches, and difficulty looking up, and was found to have a mass involving the pineal gland. Biopsy was diagnostic of a GBM. Major features of Parinaud's (dorsal midbrain) syndrome were present including: upgaze palsy, convergence retraction nystagm...Image/MovingImage
92 Apraclonidine testing in Horner's syndromeThis patient experienced relatively abrupt ptosis and was seen and diagnosed with a Horner's syndrome within a few days of the onset. There were no other exam findings and history did not offer clues as to the etiology. Neuroimaging of the oculosympathetic tract was unrevealing. Apraclonidine testin...Image/MovingImage
93 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...
94 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
95 Monocular horizontal pendular nystagmus in MSBoth of these patients have MS and monocular (OS) horizontal pendular nystagmus. The first patient seen in the video has normal afferent function and no evidence of optic nerve disease in either eye, while the second patient has severe OS>>OD optic nerve disease related to bouts of optic neuritis (t...Image/MovingImage
96 Post-infectious ocular flutter and myoclonus syndromeThis is a 35-yo-woman presenting with oscillopsia following a viral illness. She described being easily startled, with "shakiness" of the head/neck and body. She had myoclonus and ocular flutter, with the latter evident when she initiated saccades. Eye movement recordings showed that most of her sac...Image/MovingImage
97 Periodic alternating nystagmus and perverted head-shaking nystagmus in cerebellar degenerationThis is a 60-yo-woman with several years of worsening imbalance, diplopia (hers was actually unrelated to cerebellar pathology [although she did have an esotropia greater at distance that was cerebellar in origin] and due to thyroid eye disease) and blurry vision (due to her spontaneous nystagmus). ...Image/MovingImage
98 Voluntary Ocular FlutterThis is a 45-yo-man with intermittent complaints of horizontal oscillopsia for 1 year. On examination, all classes of eye movements were normal, and neurologic examination was normal. MRI of the brain had been performed previously and was normal. During the exam while viewing any target close to his...Image/MovingImage
99 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...
100 Superior Oblique Myokymia (SOM)This is a patient with transient monocular oscillopsia OD and vertical diplopia noted to have many episodes of SOM in the office. There was not only myokymia OD, but also a 4 prism diopter left hypertropia during episodes (suggestive of mild depression OD from SO activation). Ocular motor and alignm...Image/MovingImage
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