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151 Slow volitional saccades and poor fast phases to an optokinetic stimulus, with preserved head impulse testingThis is a 67-year-old woman presenting with imbalance and binocular horizontal diplopia at near. On examination there were frequent square wave jerks, limited supraduction OU and convergence insufficiency, which explained her diplopia. Pursuit and suppression of the vestibulo-ocular reflex were sa...video/mp4
152 Vestibular neuritis with + head impulse test and unidirectional nystagmus-Figure 1Vestibular neuritis is the most common cause of the acute vestibular syndrome, which is characterized by continuous vertigo and spontaneous nystagmus lasting days. It may be mimicked by central causes, including stroke, but in the hands of subspecialists, the HINTS+ (Head Impulse, Nystagmus, Test of...image/jpeg
153 Vestibular neuritis with + head impulse test and unidirectional nystagmusVestibular neuritis is the most common cause of the acute vestibular syndrome, which is characterized by continuous vertigo and spontaneous nystagmus lasting days. It may be mimicked by central causes, including stroke, but in the hands of subspecialists, the HINTS+ (Head Impulse, Nystagmus, Test o...video/mp4
154 Oculopalatal tremor and internuclear ophthalmoplegia due to hemorrhagic pontine cavernomaThis is a 60-year-old woman who experienced 2 episodes of vertigo, nausea and vomiting, which was felt to be related to recurrent hemorrhage of a pontine cavernoma that was adjacent to the fourth ventricle. The cavernoma was resected, and diplopia and left facial palsy were noted after the surgery. ...video/mp4
155 Pendular, gaze-evoked and abducting nystagmus in MSThis is a 40-year-old woman with a history of multiple sclerosis who presented for oscillopsia. On examination, she had bilateral internuclear ophthalmoplegia (INO-adduction lag OU and abducting nystagmus OU), with a corresponding exotropia that increased in right and left gaze. She also had horiz...video/mp4
156 Slow saccades due to unilateral paramedian pontine reticular formation (PPRF) injury with preserved movements using the vestibulo-ocular reflexThis is a 60-year-old man who presented for imbalance and oscillopsia 10 months after surgery and 8 months after radiation for Merkel cell carcinoma of the neck. He developed imbalance after surgery and diplopia and oscillopsia 6 months prior to our evaluation. MRI showed enhancement of both 6th n...video/mp4
157 Oculopalatal tremor and one-and-a-half syndrome due to pontine hemorrhageThis is a 65-year-old man who was put on a blood thinner, and shortly thereafter experienced a midline pontine hemorrhage, which was more dense on the left side. Immediately afterwards, right hemiparesis and hemi-anesthesia, left lower motor neuron (LMN) facial palsy and ophthalmoparesis were noted....video/mp4
158 Test your knowledge - Bilateral 4th nerve palsiesWatch the video until instructed to stop. Which of the following features is likely to be present given her exam findings? ; a.; Gaze-evoked nystagmus and impaired smooth pursuit; b.; History of traumatic brain injury; c.; History of blepharoplasty or brow lift surgery and prominence of superior su...video/mp4
159 Test your knowledge: The acute vestibular syndrome with gaze-evoked nystagmus and bilaterally abnormal head impulse testing due to middle cerebellar peduncle and flocculus hemorrhageThis is a 70-year-old woman with a history of atrial fibrillation on warfarin presenting with acute prolonged vertigo and imbalance. In addition to the findings demonstrated in the first part of the video, what else should be seen to reassure the examiner that the etiology of her vertigo is benign? ...video/mp4
160 Range of Eye Movements and Evaluation for NystagmusRange: Assesses for motility deficit due to an ocular motor palsy, particularly if a posterior fossa localization is being considered; Nystagmus: Spontaneous nystagmus may or may not be noted and gaze-evoked nystagmus is common with posterior fossa lesions; nystagmus that is unidirectional in all di...video/mp4
161 Test Your Knowledge - OscillopsiaThis 65-year-old man with multiple sclerosis described that objects in front of him appear to spontaneously jump or move horizontally for the last few months. He reported that his symptoms occur independent of head movements and head impulse testing was normal. After viewing the video, what is the m...video/mp4
162 VOR (Suppression)Deficits in pursuit and vestibulo-ocular reflex (VOR)S usually go together, except when the VOR is absent or markedly diminished in which case there is no VOR to suppress, so that VORS seems better than pursuit. This is an important clue that the VOR is diminished. Instructional ocular motor examina...video/mp4
163 Test Your Knowledge - Vertical-torsional nystagmusQuestion #1:; Watch the first portion of the video until you are told to stop. Is this vestibular nystagmus more likely to be peripheral or central? ; A.; Peripheral ; B.; Central ; Answer for #1:; A.; Incorrect. While the patient has upbeat-torsional (top poles beating toward the right ear) nystagm...video/mp4
164 Abnormal visually-enhanced VOR in cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS)A 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...video/mp4
165 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...video/mp4
166 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...video/mp4
167 One-and-a-half syndrome due to pontine hemorrhageThis is a 50-year-old woman who, while exercising in the gym, suddenly experienced vertigo, nausea, vomiting, tingling in the left arm, and diplopia. MRI demonstrated a brainstem hemorrhage that involved the right greater than left pons. Examination demonstrated a right horizontal gaze palsy due to ...video/mp4
168 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...video/mp4
169 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...video/mp4
170 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...video/mp4
171 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...video/mp4
172 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...video/mp4
173 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...video/mp4
174 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...video/mp4
175 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 ...video/mp4
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