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176 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...
177 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...
178 Smooth PursuitA pursuit deficit in one direction suggests an ipsilesional localization, but beware of a superimposed spontaneous nystagmus; a pursuit deficit in all directions is commonly seen with cerebellar lesionsImage/MovingImage
179 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...
180 Square wave jerks and macrosaccadic oscillations in a patient with a cerebellar tumorThis is a 40-year-old man who developed severe headaches, confusion, and gait imbalance which led to neuroimaging which demonstrated a midline cerebellar mass with compression of the fourth ventricle and obstructive hydrocephalus. He underwent a suboccipital craniectomy for resection of the mass, an...
181 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 ...
182 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 ...
183 Summary of the most common audio-vestibular testingChart describing common audio-vestibular testing.
184 Superior Canal DehiscenceThis is a 60-yo-man who complained of autophony (eg, hearing his own heartbeat, noting that his own voice sounded too loud) and dizziness triggered with loud noises and straining at times. With pinched-nose Valsalva maneuver, there was downbeat-torsional (towards the right ear) nystagmus, suggestive...Image/MovingImage
185 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
186 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...
187 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...
188 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...
189 Test Your Knowledge - Monocular OscillopsiaWhich of the following associated signs is most likely to be seen in this patient presenting with oscillopsia? ; A.; Optic nerve pallor ; B.; Palatal tremor; C.; Severe unilateral cataract ; D.; Head bobbing; E.; Neurovascular contact on MR CISS/FIESTA imaging; ; A.; Correct. This patient has MS an...
190 Test Your Knowledge - Ocular tilt reaction and subjective visual verticalLesions of which of the following neuro-anatomic structures could result in the clinical findings shown? A. Right medulla B. Right interstitial nucleus of Cajal C. Right medial longitudinal fasciculus D. Left trochlear nerve E. Right caudal midbrain A. Correct. This patient presents with elements...
191 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...
192 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...
193 Test your knowledge - Parinaud's syndrome in neurosarcoidosisWatch the first segment of the video up to "Stop! What would you expect with vertical gaze?" and select the best response below. The patient also has mild right-beating nystagmus which can be ignored for the purposes of this question. ; A.; The patient has pupillary findings consistent with bilatera...
194 Test Your Knowledge - The acute vestibular syndrome and ptosisWhat is the most likely localization in this patient presenting with vertical diplopia and acute onset prolonged vertigo? ; A.; Right medial longitudinal fasciculus (MLF); B.; Left medial longitudinal fasciculus ; C.; Right medulla; D.; Left medulla; E.; Left midbrain; ; A.; Incorrect. A right MLF l...
195 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...
196 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...
197 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? ...
198 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...
199 Torsional Jerk NystagmusPresented here are 3 patients with torsional jerk nystagmus. The first patient presented with vertigo and experienced oscillopsia due to her torsional nystagmus. Pure or predominantly torsional nystagmus is highly suggestive of a central process. Her nystagmus was unidirectional and followed Alexand...Image/MovingImage
200 Torsional nystagmus due to medullary pilocytic astrocytomaThis is a 30-year-old woman who experienced headaches which led to an MRI and the diagnosis of a right medullary pilocytic astrocytoma, confirmed pathologically. Examination was performed a year after the initial diagnosis, and several months prior to this exam oscillopsia was experienced for the fi...
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