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TitleDescriptionType
151 Downbeat nystagmus and cerebellar atrophyThis 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...
152 Upbeating and gaze-evoked nystagmus, V-pattern esotropia from bilateral 4th nerve palsiesImage/MovingImage
153 Oscillopsia: a common symptom of bilateral vestibular lossThis video is an example of what a patient with bilateral vestibular loss experiences while walking. Without a VOR, there is no mechanism to ensure retinal stability of the world with each head movement, and oscillopsia (illusion of movement of the stationary environment) is the result. Jumpy vision...Image/MovingImage
154 Saccadic intrusions with an intersaccadic intervalSeen here are patients with saccadic intrusions that have preserved intersaccadic intervals. Although square wave jerks (SWJ) are present in everyone to some degree at times, when prominent or when they interfere with vision, neurodegenerative conditions should be considered, mainly those involving ...Image/MovingImage
155 Typical features of Duane syndrome type 1This is a patient seen for vestibular complaints, who on exam, was found to have (unrelated to her vestibular symptoms) impaired abduction OS. In adduction, there was narrowing of the palpebral fissure OS, a result of globe retraction due to co-contraction of the medial and lateral rectus muscles. T...Image/MovingImage
156 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
157 Medullary structures relevant to upbeat nystagmusThis is an axial section of the medulla, slightly more caudal as compared to (please refer to figure "medullary structures relevant to the ocular motor and vestibular consequences of the lateral medullary (Wallenberg) syndrome). Again seen are the inferior cerebellar peduncle (ICP) and caudal aspect...
158 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...
159 Eyelid anatomySeen here are the major muscles of eyelid opening and closure. The levator palpebrae, which is innervated by the oculomotor nerve, inserts on the tarsus via the levator aponeurosis and directly on the skin of the upper eyelid. The superior tarsal muscle (also known as Muller's muscle, which is inner...
160 Unilateral 3rd, 4th, and 6th nerve palsies due to cavernous sinus meningiomaThis is a 50-year-old woman presenting with a partial 3rd nerve palsy (mild pupil involvement), partial 6th nerve palsy, and no clear incyclotorsion with downgaze, suggestive of additional 4th nerve palsy, all on the left. With compressive lesions involving the 3rd nerve, often aberrant regeneration...Image/MovingImage
161 Positional downbeat nystagmus mimicking anterior canal BPPVAlthough positional downbeat nystagmus (pDBN) can indicate the rare anterior canal variant of benign paroxysmal positional vertigo, central mimics are common causes of pDBN. pDBN may be seen in multiple system atrophy (MSA), or seen with posterior fossa lesions, with a common example being a stroke ...Image/MovingImage
162 Maddox Rod and Red Glass TestingStrabismus basics
163 Saccadic pathways in the brainstem and cerebellum & mechanism for saccadic dysmetria in Wallenberg syndrome - Abnormal function of the brainstem/cerebellar saccadic pathways with a left Wallenberg syndromeThe end result of a lesion involving the climbing fibers within the left lateral medulla is deficient rightward saccades (contralesional hypometric saccades), and over-active leftward saccades (ipsilesional hypermetric saccades), and ipsilesional ocular lateropulsion given this baseline imbalance. M...
164 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...
165 Eye closure and oculopalatal tremorThis patient suffered a traumatic brain injury with brainstem injury resulting in damage to Mollaret's triangle and palatal tremor. Inferior olivary hypertrophy was noted on her MRI, although no vertical and/or torsional pendular nystagmus was present even when observing closely with the ophthalmosc...Image/MovingImage
166 Triangle of Guillain-MollaretSeen here is a schematic representation of the Gullain-Mollaret triangle (Figure 1), also referred to as the dentato-olivary pathway, reflecting the 3 points of this imaginary triangle - 1) dentate nucleus, 2) red nucleus, and 3) inferior olivary nucleus. The olive sends decussating climbing fibers ...
167 Subtle torsional pendular nystagmus in oculopalatal tremor (OPT)This is a 50-year-old woman who presented with imbalance, and MRI demonstrated a right cerebellar cavernous malformation. She underwent surgery to resect the malformation, and post-operatively experienced right hemiparesis and ataxia. Six months after the surgery, balance worsened and vision became ...
168 Subtle torsional pendular nystagmus in oculopalatal tremor (OPT) - Figure 1This is a 50-year-old woman who presented with imbalance, and MRI demonstrated a right cerebellar cavernous malformation. She underwent surgery to resect the malformation, and post-operatively experienced right hemiparesis and ataxia. Six months after the surgery, balance worsened and vision became ...
169 Vibration and hyperventilation-induced nystagmus from vestibular schwannomaThis is a 50-yo-woman with imbalance, and with fixation removed on her examination (with Frenzel goggles), there was no spontaneous nystagmus. Using a handheld vibrator to vibrate the mastoids and vertex, there was a rightward slow phase and corrective leftward fast phase (left-beating nystagmus). V...Image/MovingImage
170 Rotary Chair TestingRotary chair testing includes rotation around a vertical axis, and evaluates the horizontal semicircular canal vestibulo-ocular reflex (VOR). The patient sits in a mechanized chair with the head secured in a neutral position or in 30 degree forward flexion (to better isolate the horizontal canals)....
171 Vertical vergence and fusional amplitudeEssential information on vertical fusional vergences.
172 Provocative maneuvers (removal of fixation, vibration, head-shaking) to accentuate peripheral vestibular nystagmus)With an acute destructive process like vestibular neuritis that causes significant unilateral vestibular loss, spontaneous nystagmus is always present. However, over days to months, spontaneous nystagmus should resolve completely. In a patient with vestibular neuritis involving the right side, left-...
173 Horizontal Canal - BPPV: Gufoni for right apogeotropicTo treat the right apogeotropic (beating towards the sky with right ear down and with left ear down - e.g., left beating nystagmus with right supine roll test or with right ear down; right beating nystagmus with left supine roll test or with left ear down) horizontal canal (HC) variant: • The pati...Image/MovingImage
174 Horizontal Canal - BPPV: BBQ Roll to treat the right sideTo treat right horizontal canal (HC)-BPPV (each position maintained for at least 30 seconds or until nystagmus and/or vertigo cease): • First the patient is placed in the long-sitting position • Then in a supine position with the head elevated 30 degrees • Then the patient's head (or whole bod...Image/MovingImage
175 Anterior Canal - BPPV: Deep head hangingRegardless or whether it is thought that the patient has right or left anterior canal (AC) involvement, the deep head hanging maneuver is performed in the same way. • First the patient is placed in the long-sitting position • Then the patient is moved into a supine position with the head in at l...Image/MovingImage
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