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1 Brainstem Ocular Motor MachinerySeen here is a sagittal view of the brainstem. The medulla has a significant role in gaze-holding, and the nucleus prepositus hypoglossi (NPH, along with the medial vestibular nucleus ) is the horizontal neural integrator. The abducens (6th) nucleus is located in the dorsal pons, and sends off the 6...Medulla OMS; Pons OMS; Mesencephalon OMS; Dorsal Midbrain OMS
2 Coronal Section of the Brainstem Showing Ocular Motor Nuclei and Anatomy of the Vestibular Nucleus (with SCC Inputs)(A) Seen here is a coronal view of the brainstem showing the locations of the ocular motor nuclei (IIIrd, IVth, VIth) as well as the nuclei of VII and VIII (vestibular and cochlear). The vestibular nucleus (VN) is divided into the inferior, lateral, medial, and superior subnuclei, and the medial ves...Pons; Medullar OMS; Mesencephalon OMS; Figures
3 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...Abnormal Saccades, Acute Vestibular Syndrome, Jerk Nystagmus, Vestibular Nystagmus, Normal VOR, Skew Deviation, OMS Medulla
4 Medial medullary syndromesThis is a video of two patients who suffered small strokes involving the right medial medulla, and who presented with acute vertigo and oscillopsia. The first patient in the video had pure upbeat nystagmus, while the second patient had upbeat-torsional (towards the right ear) nystagmus in addition t...Medulla; Jerk Nystagmus; Upbeat Nystagmus; Gaze Evoked Nystagmus; Vestibular Nystagmus; Acute Vestibular
5 Medullary Structures Relevant to Upbeat NystagmusThis is an axial section of the medulla, slightly more caudal as compared to (please refer to figure "medullary structures relevant to the ocular motor and vestibular consequences of the lateral medullary (Wallenberg) syndrome). Again seen are the inferior cerebellar peduncle (ICP) and caudal aspect...Medulla OMS; Figures
6 Medullary Structures Relevant to the Ocular Motor and Vestibular Consequences of Lateral Medullary (Wallenberg) SyndromeThis is an axial section of the medulla showing the structures that, when damaged, are responsible for the vestibular and ocular motor features of the lateral medullary or Wallenberg syndrome. The nucleus prepositus hypoglossi (NPH) and medial vestibular nucleus (MVN) complex is important for horizo...Medulla OMS; Figures
7 Ocular Motor Signs in Brainstem Demyelinating Disease - Spontaneous Upbeat, Vertical Gaze-Evoked Nystagmus, Slow Saccades, Bilateral Vestibular Loss, INOsThis is a 25-year-old woman who presented with painful vision loss bilaterally two years prior to this video recording, which was diagnosed as optic neuritis. Months later, she experienced oscillopsia and binocular horizontal diplopia and was subsequently diagnosed with multiple sclerosis. No record...Abnormal Saccades; Abnormal VOR-HIT; Abnormal Range; INO; Upbeat Nystagmus; Abducting Nystagmus; Gaze-Evoked Nystagmus
8 Paraflocculus (Tonsillar) Ocular Motor Syndrome and Dysmetria in a Chiari Malformation - Pre and Post-Operative ExamsThis is a 25-year-old woman presenting with 6 months or progressive imbalance, binocular vertical diplopia, and occipital headaches, which were brought on or aggravated by coughing or sneezing. Examination demonstrated hyperreflexia in the arms and legs with sustained clonus at the ankles and Babins...Saccades; Skew Diviation; VOR Supression; Pursuit; Medulla
9 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...Jerk Nystagmus; Torsional Nystagmus; Saccades; Lateropulsion; Medulla
10 Saccadic Pathways in the Brainstem and Cerebellum & Mechanism for Saccadic Dysmetria in Wallenberg Syndrome - Abnormal Function of the Brainstem/Cerebellar Saccadic Pathways with a Left Wallenberg SyndromeThe end result of a lesion involving the climbing fibers within the left lateral medulla is deficient rightward saccades (contralesional hypometric saccades), and over-active leftward saccades (ipsilesional hypermetric saccades), and ipsilesional ocular lateropulsion given this baseline imbalance. M...Medulla OMS; Normal Saccades; Abnormal Saccades; Figures
11 Saccadic Pathways in the Brainstem and Cerebellum & Mechanism for Saccadic Dysmetria in Wallenberg Syndrome - Normal Function of the Brainstem/Cerebellar Saccadic PathwaysThe inferior cerebellar peduncle (ICP) carries climbing fibers to the dorsal vermis, and these fibers have an inhibitory influence over the Purkinje cells. These Purkinje cells normally inhibit the ipsilateral fastigial nucleus, and the fastigial nucleus projects to the contralateral inhibitory burs...Medulla OMS; Normal Saccades; Abnormal Saccades; Figures
12 Saccadic dysmetria and ocular lateropulsion in lateral medullary strokeThis is a 30-yo-man who suffered a right lateral medullary stroke. Examination showed saccadic hypermetria to the right (ipsilesional), hypometria to the left (contralesional)and rightward ocular lateropulsion (ipsilesional), common ocular motor features of the lateral medullary syndrome. Saccadic h...Lateral medullary syndrome, Wallenberg Syndrome, Saccadic dysmetria, Ocular lateropulsion, Saccades
13 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...Upbeat Nystagmus; Jerk Nystagmus; Medullar OMS
14 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...Jerk Nystagmus; Acute Vestibular Syndrome; Vestibular Nystagmus; Skew Deviation; Upbeat Nystagmus; Torsional Nystagmus; Rotary Nystagmus; Horner Syndrome
15 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...Acute Vestibular Syndrome, Ninth Nerve, OMS Medulla, Abnormal Saccades, Tenth Nerve, Lateropulsion, Horner Syndrome
16 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
17 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
18 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
19 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
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