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TitleDescriptionSubject
1 "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...Abnormal VOR HIT
2 + HIT, + Skew, Unidirectional Nystagmus: Central acute vestibular syndrome due to Wallenberg syndromeThis is a 45-year-old woman who presented to the ED with acute prolonged vertigo and vertical diplopia. She was seen as an outpatient 1 month after her ED visit, and double vision and balance were improving by that time. Her HINTS testing showed the following (seen in the video):; 1); Head Impulse -...VOR HIT Abnormal, Abnormal Alignment, Skew, Jerk Nystagmus, Vestibular Nystagmus, Acute Vestibular Nystagmus
3 Abnormal Head Impulse Test in Vestibular Neuritis 1 Week After OnsetThis is a 25-year-old woman who experienced the acute vestibular syndrome due to right-sided vestibular neuritis 1 week prior to this video. Left-beating nystagmus (LBN) was only noted in left gaze, but with fixation-removed, there was clear LBN in primary position that increased with head-shaking a...Abnormal VOR, Vestibulocochlear Nerve, Acute Vestibular Sydrome
4 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...Abnormal Pursuit, Abnormal VOR, Abnormal HIT, Cerebellar, Jerk Nystagmus, Gaze Evoked Nystagmus,
5 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...VOR HIT, Alignment, Acute Vestibular
6 Anti-GAD associated cerebellopathy and bilateral vestibulopathyThis is a 70-year-old woman with the subacute onset of severe imbalance and dizziness. On her initial examination, she had prominent gaze-evoked nystagmus and bilateral vestibular loss. Smooth pursuit was saccadic, although her vestibulo-ocular reflex (VOR) suppression was much smoother. Usually pur...Abnormal Pursuit, Normal VORS, VOR Abnormal, HIT Abnormal, Jerk Nystagmus, Gaze Evoked Nystagmus
7 Bilateral Horizontal Gaze Palsy and Oculopalatal Tremor Due to Pontine HemorrhageThis 70-yo-woman experienced headache and diplopia and was found to have a hemorrhage centrally within the dorsal pons. Months after the onset, the patient was seen in clinic and had no horizontal eye movements (pursuit, saccades, VOR) in either eye, suggestive of bilateral nuclear 6th nerve palsies...VOR HIT Abnormal, Horizontal Gaze Palsy, OMS PONS, Pendular Nystagmus, Oculopalatal
8 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...VOR HIT, Alignment, Jerk Nystagmus, Vestibular Nystagmus, Acute Vestibular
9 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...Abnormal Alignment, Vestibulocochlear, OMS Pons, Rotary Nystagmus, Vestibular Nystagmus, Acute Vestibular Nystagmus, Jerk Nystagmus, VOR HIT Abnormal
10 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...VOR Abnormal, HIT Abnormal, Jerk Nystagmus, Gaze Evoked Nystagmus, Square Wave Jerks
11 Complete peripheral vestibulopathy & ipsilateral facial palsy60-yo-man who suffered the fairly abrupt onset (over hours) of right lower motor neuron facial nerve palsy (7th cranial nerve), vertigo and deafness in the right ear (8th cranial nerve). Vesicles were noted on otoscopy, and herpes zoster infection (Ramsay Hunt) was diagnosed. Whereas many cases of "...Ramsay Hunt; Facial nerve palsy; Vestibulocochlear nerve palsy; Vestibulo-ocular reflex (VOR)
12 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...Acute Vestibular; Normal VOR; Vertigo; HINTS examination
13 Impaired smooth pursuit and other characteristic ocular motor findings in middle cerebellar peduncle strokeThis is a 50-year-old woman who underwent resection of a left-sided acoustic neuroma, and post-operatively, she had vertigo, binocular diplopia, left hemi-ataxia and severe gait ataxia. MR diffusion weighted imaging demonstrated an acute stroke involving the left middle cerebellar peduncle (MCP) and...Abnormal Pursuit, VOR-HIT Abnormal, Abnormal Alignment, Vestibulocochlear Nerve, OMS Pons, Jerk Nystagmus, Gaze-Evoked Nystagmus, Bruns Nystagmus, Vestibular Nystagmus, Acute Vestibular Syndrome
14 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 ...Abnormal Saccades, Sixth Nerve Palsy, INO, One and a Half Syndrome, Jerk Nystagmus, Gaze Evoked Nystagmus
15 Oscillopsia and bilateral vestibular loss with gentamicin ototoxicityPatients with bilateral vestibular loss commonly experience oscillopsia with head movements, or an inability to stabilize retinal images with subsequent bouncing or jumping of the environment due to loss of vestibular function. This causes significant blurring of vision and disorientation, dizziness...Abnormal VOR, Abnormal HIT
16 Oscillopsia: a common symptom of bilateral vestibular lossThis video is an example of what a patient with bilateral vestibular loss experiences while walking. Without a VOR, there is no mechanism to ensure retinal stability of the world with each head movement, and oscillopsia (illusion of movement of the stationary environment) is the result. Jumpy vision...VOR Abnormal, HIT Abnormal
17 Parinaud's syndrome with impaired upward saccades and otherwise normal vertical eye movementsThis is a 50-yo-man who suffered a dorsal midbrain stroke. Exam demonstrated normal vertical range of eye movements, normal vertical VOR and smooth pursuit, but inability to perform upward saccades. Another feature of Parinaud's syndrome seen on his exam was light-near dissociation (not shown in thi...abnormal saccades, range of eye movements, abnormal range of eye movements, smooth pursuit, normal VOR, Dorsal midbrain syndrome
18 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...Jerk Nystagmus, Vestibular Nystagmus, Bruns, Gaze Evoked Nystagmus, VOR HIT Abnormal
19 Semicircular pathwaysOnce the semicircular canal fibers leave the peripheral labyrinth, they synapse in the ipsilateral vestibular nucleus, and then ascend to the ocular motor nuclei. This enables the vestibulo-ocular reflex to respond to head movements in the plane of any canal or combination of canals.Vestibulo-ocular reflex
20 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...Abnormal Saccades, VOR HIT Normal
21 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? ...Abnormal VOR, Jerk Nystagmus, Acute Vestibular Syndrome, Cerebellar OMS, Gaze Evoked Nystagmus,
22 The acute vestibular syndrome in MS due to middle cerebellar peduncle/root entry zone lesionThis is a 13 year-old girl with relatively abrupt onset vertigo and oscillopsia. On exam, there was primarily right-beating nystagmus in primary gaze with a slight upward (upbeat) component, giving the nystagmus an oblique appearance. The upward component and lack of a clear torsional component acut...Jerk nystagmus; Vestibular nystagmus; Vestibulo-ocular reflex; Head impulse testing; Gaze-evoked nystagmus
23 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...Abnormal VOR-HIT, Abnormal Alignment, Skew, Jerk Nystagmus, Gaze Evoked Nystagmus, Acute Vestibular Syndrome, Seventh Nerve, OMS Pons, OMS Cerebellar
24 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
25 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
26 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
27 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
28 Wallenberg syndrome in MS30-yo-woman with MS presenting with acute vertigo and vertical diplopia. Examination demonstrated several aspects of the Wallenberg syndrome (her acute demyelinating lesion was in the left lateral medulla): ipsilesional (left) ocular lateropulsion (hypermetric saccades to the left, hypo to the right...Vestibulo-ocular reflex; Head impulse testing; Abnormal alignment; Lateropulsion; Wallenberg syndrome; Medulla; Vestibular nystagmus; Skew Deviation
29 riMLF Syndrome from Artery of Percheron StrokeThis is a 65-yo-man who suffered the abrupt onset of loss of consciousness followed by difficulty looking down. MRI showed bilateral rostral midbrain strokes in the distribution of the artery of Percheron. He could not initiate downward saccades and had fair upward saccades. However, downward vestib...Saccades abnormal; Vestibulo-ocular reflex and head impulse testing normal; Pursuit normal; Vertical gaze palsy; Downgaze palsy; Mesencephalon
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