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201 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...Medulla; Cerebellar; Jerk nystagmus; Rotary nystagmus
202 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...Jerk Nystagmus, Rotary Nystagmus, OMS Medulla
203 Traumatic 3rd nerve palsy with aberrant regenerationThis is a 20-yo-woman who experienced severe head trauma and diplopia upon awakening from a coma several weeks after the injury. She had a partial left 3rd nerve palsy (adduction spared), and when she looked to the right and down, her mildly ptotic lid elevated. Aberrant regeneration of CN 3 occurs ...Third Nerve Palsy, , Third Subnuclear Palsy, Aberrant Regeneration
204 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 ...Pendular Nystagmus; Oculopalatal Tremor
205 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 ...Trigeminal Nerve
206 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...Trigeminal Nerve
207 Trigeminal, Facial (with Aberrant Regeneration), and Vestibulocochlear Nerve Palsies Following Tumor ResectionThis is a 30-yo-woman who underwent resection of a right trigeminal schwannoma. Post-operatively, she was vertiginous with a clearly + head impulse test to the right (and spontaneous left-beating nystagmus), had lost hearing in the right ear, had no facial sensation on the right, and had a right low...Vestibulo-ocular reflex and head impulse testing abnormal; Facial nerve
208 Two patients with Parinaud's syndrome with slow upward saccades and normal upward range of movementsPresented here are two patients with Parinaud's syndrome: Patient 1) suffered a hemorrhage of the dorsal midbrain causing slow upward saccades (with convergence retraction nystagmus, but normal vertical range of eye movements), and light-near dissociation, and Patient 2) had a germinoma of the dorsa...Abnormal Saccades, Dorsal Midbrain, Jerk Nystagmus, Gaze Evoked Nystagmus
209 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...Abnormal Range, Duane Syndrome, Sixth Nerve Palsy
210 Typical lid signs (Cogan's lid twitch, lid hopping, enhanced ptosis) in myasthenia gravisThis is a 60-yo-woman with MG who displays typical eyelid signs including Cogan's lid twitch, lid hopping (appreciated during horizontal smooth pursuit in this patient), and enhanced ptosis in accordance with Hering's law of equal innervation to the two levator muscles.Myasthenia Gravis
211 Unidirectional nystagmus in lateral medullary syndromeThis is a 70-yo-man who presented with acute vertigo. Examination demonstrated very mild spontaneous torsional nystagmus (towards the right ear) in primary (not seen well in this video), with robust downbeat-torsional (towards right ear) nystagmus in right gaze and (less robust) almost pure torsiona...Medula, Rotary Nystagmus, Jerk Nystagmus, Acute Vestibula, Vestibular Nystagmus, Abnormal Saccades
212 Unidirectional vestibular nystagmus60-yo-man with recurrent vertigo attacks - this video was taken during one of his typical attacks, and shows left-beating nystagmus that stayed left-beating in all directions of gaze, more in left gaze (in accordance with Alexander's Law), and less in right gaze. This pattern is more commonly seen w...Jerk nystagmus; Vestibular nystagmus; Vestibulo-ocular reflex; Head impulse testing; Benign recurrent vertigo; Migraine variant
213 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...Abnormal Range, Third Nerve Palsy, Aberrant Regeneration, Fourth Nerve Palsy, Sixth Nerve Palsy, Jerk Nystagmus, Downbeat Nystagmus, Gaze Evoked Nystagmus, Abnormal Saccades
214 Upbeat and downbeat nystagmus due to anti-VGCC antibodiesSeen here are two patients who presented with imbalance and vertical oscillopsia, the first with upbeat nystagmus, and the second with downbeat nystagmus. Both patients were found to have voltage-gated calcium channel antibodies in serum without evidence of systemic malignancy. The UBN patient had m...Jerk Nystagmus, Upbeat Nystagmus, Gaze Evoked Nystagmus, Downbeat Nystagmus
215 Upbeating and gaze-evoked nystagmus, V-pattern esotropia from bilateral 4th nerve palsiesUpbeat Nystagmus, Gaze Evoked Nystagmus, Fourth Nerve Palsy
216 Using video head impulse testing to unmask covert saccades in compensated vestibular neuritisThis is a 30-year-old woman who experienced the acute vestibular syndrome (prolonged vertigo for >24 hours, nausea, unsteadiness, spontaneous nystagmus, head motion intolerance) and was diagnosed with vestibular neuritis. This diagnosis was based on a positive head impulse test to the left (see Figu...VOR normal; VOR abnormal
217 Using video head impulse testing to unmask covert saccades in compensated vestibular neuritis - Figures 1 and 2This is a 30-year-old woman who experienced the acute vestibular syndrome (prolonged vertigo for >24 hours, nausea, unsteadiness, spontaneous nystagmus, head motion intolerance) and was diagnosed with vestibular neuritis. This diagnosis was based on a positive head impulse test to the left (see Figu...VOR normal; VOR abnormal
218 VOR (Slow and Fast)Slow vestibulo-ocular reflex (VOR): Since smooth pursuit and VOR systems are both active, if eye movements are choppy with this maneuver this implies deficits in both pursuit and the vestibular system as in CANVAS; Fast (HIT): Since smooth pursuit fails at high frequencies and high speeds, the VOR i...Vestibulo-ocular reflex (VOR), exam
219 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...vestibulo-ocular reflex (VOR) supression, exam
220 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...OMS Mesencephalon, Square Wave Jerks, Upgaze Palsy, Downgaze Palsy, Abnormal Range, Skew, Vertical Gaze Palsy
221 Vertical semicircular canal pathwaysAnterior Canal Pathway; Afferents that originate in the anterior canals (AC) of the peripheral labyrinth first synapse in the ipsilateral vestibular nucleus. Three pathways exist: ; 1) medial longitudinal fasciculus (MLF) - right AC afferents to right medial vestibular nucleus (MVN), decussate and a...Anterior Canal Pathway; Posterior Canal Pathway
222 Vertical vergence and fusional amplitudeEssential information on vertical fusional vergences.Normal Alignment, Abnormal Alignment, Fourth Nerve Palsy, Vergence, Fusional Amplitudes
223 Vertical-Torsional Pendular Nystagmus and Convergence Spasm Due to Anti-MaTa EncephalitisThis is a 50-yo-woman with debilitating oscillopsia due to a high frequency (6 Hz) vertical-torsional pendular (quantitative eye movement recordings were performed) nystagmus. She also had intermittent double vision due to (organic) convergence spasm. Her nystagmus and spasm were thought to be relat...Mesencephalon; Pendular nystagmus; Convergence spasm
224 Vestibular evoked myogenic potentials (VEMPs)Vestibular-evoked myogenic potentials (VEMP) are electromyographic potential reflex tests that reflect the function of the saccule in cervical VEMP and the utricle in ocular VEMP.1 In the cervical VEMP an inhibitory reflex is evoked from the saccule to the sternocleidomastoid ipsilateral to the stim...Vestibular lab testing, Vestibular Evoked Myogenic Potentials (VEMPs)
225 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...Jerk Nystagmus, Acute Vestibular, Vestibular Nystagmus
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