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TitleDescriptionType
201 Peripheral (vestibular) and central (gaze-evoked) patterns of nystagmus in a single patientA 55-year-old man experienced episodic vertigo and was diagnosed with Meniere's disease affecting the left ear (based on audiograms and his clinical course) about 1 year prior to presentation. About 6 months prior to presentation, intratympanic (IT) gentamicin was injected into the left ear, at whic...
202 Oculopalatal tremor with prominent nystagmus, bilateral horizontal gaze palsy, and bilateral facial palsies Figure 1Figure 1, MRI T2 sequence demonstrating hyperintensities involving bilateral inferior olives of the medulla. This is a 50-year-old woman who experienced the acute onset of right sixth and seventh nerve palsies and left hemiparesis. Two cavernomas within the right pons (one in the region of the facia...
203 Demonstration of HINTS examination in a normal subjectIn the acute vestibular syndrome - consisting of acute prolonged vertigo, spontaneous nystagmus, imbalance, nausea/vomiting, head motion intolerance which is typically due to vestibular neuritis or posterior fossa stroke - a 3 step test of ocular motor and vestibular function known as HINTS, has hig...Image/MovingImage
204 Ocular motor signs in early progressive supranuclear palsyThis is a 64-year old man who experienced imbalance and falls (usually backwards) for the last 6 months. He experienced difficulty navigating stairs and had become a messy eater (thought to be in large part due to his vertical gaze palsy), and had developed hypophonia. Exam demonstrated square wave ...
205 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...
206 Optokinetic nystagmusDuring the bedside evaluation of optokinetic nystagmus (OKN), the patient is instructed to look at each red (or white) square as it moves past. Because this is not a full-field visual stimuli, using an optokinetic flag mainly allows the examiner to quickly evaluate for right/left and up/down symmet...
207 Central HINTS (with an abnormal head impulse sign) in the acute vestibular syndrome due to lateral pontine/middle cerebellar peduncle demyelinationThis is a 30-year-old man presenting with vertigo, diplopia and mild left facial weakness (not seen in the video). On exam, there was right-beating nystagmus (RBN) in primary gaze that increased in right gaze (in accordance with Alexander's law), and the RBN stayed unidirectional, but lessened, in l...
208 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 ...
209 Lateral pontine stroke involving the superior vestibular nucleus causing spontaneous upbeat-torsional nystagmusA 65-year-old man presented to the emergency department with spontaneous vertigo and unsteadiness, and had was noted to have spontaneous upbeat nystagmus (UBN), also with a torsional component (top poles beating toward the right ear) that was most noticeable in right and up gaze. General neurologic ...Image/MovingImage
210 Dix-Hallpike maneuver in posterior BPPV with reversal of nystagmus on sitting upThis is a patient with typical posterior canal (PC) benign paroxysmal positional vertigo (BPPV), which is provoked by the Dix-Hallpike maneuver. When the patient is moved into the right Dix-Hallpike maneuver, after a brief latency, upbeat-torsional (towards the lowermost or affected [right] ear) nys...
211 ConvergenceCan bring out or change the direction of vertical nystagmus in Wernicke's, or cerebellar disease; may be impaired in Parkinson's disease, head trauma, elderly patients; may overcome an adduction deficit with an INO. Instructional ocular motor examination procedures.Image/MovingImage
212 ENG, VNG, & VOGElectronystagmography (ENG), and videonystagmography (VNG) or videooculography (VOG) are a collection of tests of eye movements that are performed either using surface electrodes around the eye (ENG) or with video goggles (VNG, VOG) (Figure 1). For all clinical intents and purposes, VNG and VOG ar...
213 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 head ...
214 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...Image/MovingImage
215 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...
216 HINTS exam and saccadic dysmetria in lateral medullary strokeThis is a 50-year-old who experienced the abrupt onset of prolonged vertigo following chiropractic therapy 2 months prior. Initial work-up included an MRI and MR angiogram - MR-diffusion weighted imaging showed an acute left lateral medullary stroke and left vertebral artery occlusion, which was tho...
217 Posterior canal BPPV pre- and post-Epley maneuverThis is a patient with typical right posterior canal benign paroxysmal positional vertigo (BPPV), which was provoked by the Dix-Hallpike maneuver. When the patient was moved into the right Dix-Hallpike maneuver, after a brief latency, upbeat-torsional (towards the lowermost or affected [right] ear) ...
218 Central Acute Vestibular Syndrome due to posterior fossa hemorrhageThis is a patient presenting with the acute vestibular syndrome (AVS, e.g., acute prolonged vertigo, spontaneous nystagmus) whose HINTS (Head Impulse, Nystagmus, Test of Skew) testing indicated a central etiology based on negative (normal) head impulse testing (HIT). Nystagmus was unidirectional and...
219 Duane's syndrome type 3This is a 40-yo-woman seen in neurology clinic for a complaint unrelated to her eyes. On exam, there was impaired adduction and abduction OS. In adduction, there was narrowing of the palpebral fissure OS, a result of her globe retraction due to co-contraction of the medial and lateral rectus muscles...Image/MovingImage
220 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 lesion (stroke, M...
221 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...
222 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 and had experienced ...
223 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 distribution stroke A...
224 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 agraphia E. Le...
225 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...
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