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176 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 ...
177 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...
178 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...
179 The acute vestibular syndrome with dysarthria, dysphagia, dysphonia, hemi-ataxia, and saccadic dysmetria due to the lateral medullary (Wallenberg) syndromeThis is a 50-year-old woman with the acute onset of vertigo, dysarthria, dysphagia and dysphonia/hoarseness (nucleus ambiguus), ptosis and imbalance. Her examination localized to a left lateral medullary (Wallenberg) syndrome - there was decreased sensation on the left side of the face (spinal trige...
180 Ocular bobbing due to hepatic encephalopathyThis is a 55-year-old man presented with hepatic encephalopathy, and found to have ocular bobbing. Head CT did not show any acute changes. Ocular bobbing almost always localizes to the pons, although cerebellar pathology has also (rarely) been identified as a cause. Typical bobbing consists of rhyth...Image/MovingImage
181 Oculogyric crisisThis is a patient with neuroleptic-induced oculogyric crisis.
182 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 ...
183 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 ...
184 Summary of the most common audio-vestibular testingChart describing common audio-vestibular testing.
185 "Pseudonystagmus" due to bilateral vestibular loss and head tremorThis is a 65-yo-woman with complaints of imbalance, dizziness, and horizontal oscillopsia. On exam, she had a high frequency, low amplitude (mainly horizontal) head tremor, and with ophthalmoscopy, the optic nerve was clearly oscillating back and forth at the same frequency as her head tremor, which...
186 Pseudo-spontaneous nystagmus and bow and lean test in horizontal canal BPPVThis is a 70-year-old woman presenting to the Emergency Department with positional vertigo that was determined to be due to the apogeotropic variant of right horizontal canal (HC) benign paroxysmal positional vertigo (BPPV). When her head is in a neutral position with the head in axis with the trunk...
187 Vertical vergence and fusional amplitudeEssential information on vertical fusional vergences.
188 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...
189 The utriculo-ocular motor pathways - physiologic and pathologic ocular tilt reaction: Physiologic ocular tilt reaction (OTR) (Figure 1)A skew deviation is a non-paralytic vertical ocular misalignment that is due to imbalance in the utriculo-ocular motor pathways. While vestibular jerk nystagmus is a consequence of static semicircular canal pathway imbalance (e.g., left-beating nystagmus due to acute right vestibular hypofunction fr...
190 Saccadic hypermetria and ipsipulsion (behind closed eyelids and with vertical saccades)This is a 40-year-old woman who experienced oscillopsia and vertical diplopia, due to spontaneous torsional nystagmus and a skew deviation (right hypotropia), respectively. The symptom onset was 7 months prior to these videos. MRI demonstrated ill-defined T2 and FLAIR hyperintensity signal changes i...
191 Paroxysmal Ocular Tilt ReactionThis is a 60-year-old woman who 2 years prior experienced a left sided hypertensive hemorrhagic stroke, resulting in right hemiparesis, dysarthria and vertical diplopia. The initial vertical diplopia resolved completely and about 6 months following the hemorrhage the patient began to experience many...
192 The utriculo-ocular motor pathways - physiologic and pathologic ocular tilt reaction: OTR Diagram Pathologic EOMs Labelled (Figure 3)A skew deviation is a non-paralytic vertical ocular misalignment that is due to imbalance in the utriculo-ocular motor pathways. While vestibular jerk nystagmus is a consequence of static semicircular canal pathway imbalance (e.g., left-beating nystagmus due to acute right vestibular hypofunction fr...
193 The utriculo-ocular motor pathways - physiologic and pathologic ocular tilt reaction: Pathologic OTR (Figure 2)A skew deviation is a non-paralytic vertical ocular misalignment that is due to imbalance in the utriculo-ocular motor pathways. While vestibular jerk nystagmus is a consequence of static semicircular canal pathway imbalance (e.g., left-beating nystagmus due to acute right vestibular hypofunction fr...
194 Alternating hypertropias - bilateral 4th nerve palsies and alternating skew deviationSeen here are two patients with alternating hypertropias. The first is a 70-year-old woman with a diagnosis of cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS). In the video, both spontaneous downbeat nystagmus (DBN) and gaze-evoked nystagmus (GEN) are apparent, in addition to a...
195 The most common audiovestibular laboratory tests, and the specific conditions in which they may assist in making or supporting the diagnosisVN = vestibular neuritis; VM = vestibular migraine; VP = vestibular paroxysmia; vHIT = video head impulse test; VNG = video-nystagmography; ENG = electronystagmography; VOG = video-oculography; VEMPs = vestibular evoked myogenic potentials; SCDS = superior canal dehiscence syndrome; BPPV = benign pa...
196 The most common vestibular conditions categorized by timing and triggers, with specific ocular motor and vestibular features that should be sought for eachHINTS+ = Head Impulse, Nystagmus, Test of Skew, ‘Plus' bedside assessment of auditory function; HIT = head impulse test; NP = nerve palsy; BPPV = benign paroxysmal positional vertigo; SCDS = superior canal dehiscence syndrome; BVL = bilateral vestibular loss; PPPD = persistent postural perceptual ...
197 The most common vestibular conditions categorized by timing and triggers, with specific historical features that should be sought for each (adapted from Approach to the Ocular Motor and Vestibular History and Examination)BPPV = benign paroxysmal positional vertigo; SCDS = superior canal dehiscence syndrome; BVL = bilateral vestibular loss; PPPD = persistent postural perceptual dizziness; MDDS = Mal de debarquement syndrome
198 Vestibular neuritis with a peripheral skew deviationThis is a 55-year-old hypertensive man who developed acute onset continuous vertigo and presented to the Emergency Department (ED) after several hours of symptoms. He was noted to have spontaneous nystagmus and had a normal brain MRI within the first 24 hours. The first portion of the video was rec...
199 Maddox Rod and Red Glass TestingStrabismus basics
200 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
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