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Fracica E, Hale D, Gold DR. Diagnosing and localizing the acute vestibular syndrome - Beyond the HINTS exam. J Neurol Sci 2022; 442:120451. [PMID: 36270149 DOI: 10.1016/j.jns.2022.120451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/11/2022] [Accepted: 10/02/2022] [Indexed: 10/31/2022]
Abstract
When assessing the acutely dizzy patient, the HINTS 'Plus' (Head Impulse, Nystagmus, Test of Skew, 'Plus' a bedside assessment of auditory function) exam is a crucial component of the bedside exam. However, there are additional ocular motor findings that can help the clinician distinguish peripheral from central etiologies and enable accurate localization, especially when the patient has acute dizziness, vertigo and/or imbalance but without spontaneous nystagmus. We will review the literature on these findings which are 'beyond HINTS' and include saccades/ocular lateropulsion, smooth pursuit, and provocative maneuvers including head-shaking and positional testing (not part of the HINTS exam). Additionally, we will expound on the localizing value of nystagmus, ocular alignment and the ocular tilt reaction (parts of the HINTS exam). The paper has been organized neuroanatomically, based on brainstem and cerebellar structures that have been reported to cause the acute vestibular syndrome.
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Affiliation(s)
- Elizabeth Fracica
- The Johns Hopkins Hospital, Department of Neurology, United States of America.
| | - David Hale
- The Johns Hopkins Hospital, Department of Neurology, United States of America
| | - Daniel R Gold
- The Johns Hopkins Hospital, Department of Neurology, United States of America; The Johns Hopkins Hospital, Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, United States of America
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Zhang Q, Li J. Seesaw nystagmus with internuclear ophthalmoplegia from bilateral dorsomedial pons and left thalamus infarction: a case report. J Med Case Rep 2019; 13:352. [PMID: 31779712 PMCID: PMC6883617 DOI: 10.1186/s13256-019-2269-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 09/22/2019] [Indexed: 11/30/2022] Open
Abstract
Background We describe for the first time the clinical features and mechanisms of a bilateral dorsomedial pons and left thalamus infarction with seesaw nystagmus and internuclear ophthalmoplegia. Case presentation A 62-year-old Chinese man was hospitalized for sudden-onset dizziness, diplopia, and gait disturbance. A neurological examination revealed seesaw nystagmus and internuclear ophthalmoplegia. Magnetic resonance imaging disclosed an acute infarction confined to the bilateral dorsomedial pons and left thalamus. Subsequently, 2 weeks of antithrombotic therapy led to an improvement in his symptoms. Conclusions This case illustrates that the acute onset of seesaw nystagmus and internuclear ophthalmoplegia accompanied by risk factors for cerebrovascular diseases are highly suggestive of brainstem infarction.
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Affiliation(s)
- Qian Zhang
- Department of Neurology, the First Affiliated Hospital of Jinzhou Medical University, No. 2, Section 5, People Street, Jinzhou, 121000, Liaoning, China
| | - Jian Li
- Department of Neurology, the First Affiliated Hospital of Jinzhou Medical University, No. 2, Section 5, People Street, Jinzhou, 121000, Liaoning, China.
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Eggers SD, Bisdorff A, von Brevern M, Zee DS, Kim JS, Perez-Fernandez N, Welgampola MS, Della Santina CC, Newman-Toker DE. Classification of vestibular signs and examination techniques: Nystagmus and nystagmus-like movements. J Vestib Res 2019; 29:57-87. [PMID: 31256095 PMCID: PMC9249296 DOI: 10.3233/ves-190658] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This paper presents a classification and definitions for types of nystagmus and other oscillatory eye movements relevant to evaluation of patients with vestibular and neurological disorders, formulated by the Classification Committee of the Bárány Society, to facilitate identification and communication for research and clinical care. Terminology surrounding the numerous attributes and influencing factors necessary to characterize nystagmus are outlined and defined. The classification first organizes the complex nomenclature of nystagmus around phenomenology, while also considering knowledge of anatomy, pathophysiology, and etiology. Nystagmus is distinguished from various other nystagmus-like movements including saccadic intrusions and oscillations. View accompanying videos at http://www.jvr-web.org/ICVD.html
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Affiliation(s)
| | - Alexandre Bisdorff
- Department of Neurology, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg
| | - Michael von Brevern
- Private Practice of Neurology and Department of Neurology, Charité, Berlin, Germany
| | - David S. Zee
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | | | - Miriam S. Welgampola
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Central Clinical School, University of Sydney, Sydney, Australia
| | - Charles C. Della Santina
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David E. Newman-Toker
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
BACKGROUND AND PURPOSE Physical therapists caring for patients with neurologic or vestibular disorders must routinely examine and characterize nystagmus and other oscillatory eye movements. Often, the diagnosis hinges on proper interpretation of the nystagmus pattern. This requires understanding the terminology surrounding the numerous attributes and influencing factors of nystagmus, a systematic approach to the examination, and a classification structure that guides practitioners to the specific nystagmus type and subsequent evaluation and management. SUMMARY OF KEY POINTS Nystagmus is an involuntary, rapid, rhythmic, oscillatory eye movement with at least 1 slow phase. Jerk nystagmus has a slow phase and a fast phase. Pendular nystagmus has only slow phases. Nystagmus is distinguished from other types of oscillatory eye movements, such as saccadic intrusions or oscillations. Characterizing nystagmus requires clearly describing its trajectory. This includes choosing a reference frame to describe the axes or planes and direction of eye movements. Several attributes are used to describe nystagmus: binocularity, conjugacy, velocity, waveform, frequency, amplitude, intensity, temporal profile, and age at first appearance. Several factors may influence nystagmus, including gaze position, visual fixation, vergence, and a variety of provocative maneuvers. Classification of nystagmus may be organized by physiologic or pathologic nystagmus versus other nystagmus-like movements. Pathologic nystagmus may be spontaneous, gaze-evoked, or triggered by provocative maneuvers. The combination of attributes allows differentiation between the many peripheral and central forms. RECOMMENDATIONS FOR CLINICAL PRACTICE Therapists should carefully examine and characterize the trajectory and other attributes and influencing factors of nystagmus to accurately classify it and arrive at the correct diagnosis.
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Choi SY, Kim HJ, Kim JS. Impaired vestibular responses in internuclear ophthalmoplegia. Neurology 2017; 89:2476-2480. [DOI: 10.1212/wnl.0000000000004745] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/14/2017] [Indexed: 11/15/2022] Open
Abstract
Objective:To determine the role of the medial longitudinal fasciculus (MLF) in conveying vestibular signals.Methods:In 10 patients with isolated acute unilateral internuclear ophthalmoplegia (INO) due to an acute stroke, we performed comprehensive vestibular evaluation using video-oculography, head impulse tests with a magnetic search coil technique, bithermal caloric tests, tests for the ocular tilt reaction, and measurements of subjective visual vertical and cervical and ocular vestibular evoked myogenic potentials (VEMPs).Results:The head impulse gain of the vestibulo-ocular reflex (VOR) was decreased invariably for the contralesional posterior canal (PC) (n = 9; 90%) and usually for the ipsilesional horizontal canal (n = 5; 50%). At least one component of contraversive ocular tilt reaction (n = 9) or contraversive tilt of the subjective visual vertical (n = 7) were common along with ipsitorsional nystagmus (n = 5). Cervical or ocular VEMPs were abnormal in 5 patients.Conclusions:The MLF serves as the main passage for the high-acceleration VOR from the contralateral PC. The associations and dissociations of the vestibular dysfunction in our patients indicate variable combinations of damage to the vestibular fibers ascending or descending in the MLF even in strokes causing isolated unilateral INO.
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Abstract
Dizziness/vertigo and imbalance are the most common symptoms of vertebrobasilar ischemia. Even though dizziness/vertigo usually accompanies other neurologic symptoms and signs in cerebrovascular disorders, a diagnosis of isolated vascular vertigo is increasing markedly by virtue of recent developments in clinical neurotology and neuroimaging. It is important to differentiate isolated vertigo of a vascular cause from more benign disorders involving the inner ear, since therapeutic strategies and prognosis differ between these two conditions. Over the last decade, we have achieved a marked development in the understanding and diagnosis of vascular dizziness/vertigo. Introduction of diffusion-weighted magnetic resonance imaging (MRI) has greatly enhanced detection of infarctions in patients with vascular dizziness/vertigo, especially in the posterior-circulation territories. However, well-organized bedside neurotologic evaluation is even more sensitive than MRI in detecting acute infarction as a cause of spontaneous prolonged vertigo. Furthermore, detailed evaluation of strategic infarctions has elucidated the function of various vestibular structures of the brainstem and cerebellum. In contrast, diagnosis of isolated labyrinthine infarction still remains a challenge. This diagnostic difficulty also applies to isolated transient dizziness/vertigo of vascular origin. Regarding the common nonlacunar mechanisms in the acute vestibular syndrome from small infarctions, individual strategies may be indicated to prevent recurrences of stroke in patients with vascular vertigo.
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Affiliation(s)
- K-D Choi
- Department of Neurology, College of Medicine, Pusan National University Hospital, Busan, Korea
| | - H Lee
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - J-S Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Korea.
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Cakir A, Duzgun E, Demir S, Aydin A. Jerky seesaw nystagmus with internuclear ophthalmoplegia as the presenting finding in systemic lupus erythematosus. J Fr Ophtalmol 2014; 37:e157-9. [DOI: 10.1016/j.jfo.2014.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 04/09/2014] [Accepted: 04/14/2014] [Indexed: 11/29/2022]
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Kah TA, Jeng TC, Premsenthil M. Jerk Seesaw Nystagmus After Posterior Cranial Fossa Decompression with Cerebellar Tonsillectomy for Chiari I Malformation. Neuroophthalmology 2012. [DOI: 10.3109/01658107.2012.710922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Jeong SH, Kim EK, Lee J, Choi KD, Kim JS. Patterns of dissociate torsional-vertical nystagmus in internuclear ophthalmoplegia. Ann N Y Acad Sci 2011; 1233:271-8. [DOI: 10.1111/j.1749-6632.2011.06155.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Choi SY, Kim DH, Lee JH, Kim J. Jerky hemi-seesaw nystagmus and head tilt reaction combined with internuclear ophthalmoplegia from a pontine infarction. J Clin Neurosci 2009; 16:456-8. [DOI: 10.1016/j.jocn.2008.03.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Revised: 02/11/2008] [Accepted: 03/02/2008] [Indexed: 11/16/2022]
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Kim JS, Yoon B, Choi KD, Oh SY, Park SH, Kim BK. Upbeat nystagmus: clinicoanatomical correlations in 15 patients. J Clin Neurol 2006; 2:58-65. [PMID: 20396486 PMCID: PMC2854944 DOI: 10.3988/jcn.2006.2.1.58] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2005] [Accepted: 02/14/2006] [Indexed: 11/23/2022] Open
Abstract
Background and Purpose The mechanism of upbeat nystagmus is unknown and clinicoanatomical correlative studies in series of patients with upbeat nystagmus are limited. Methods Fifteen patients with upbeat nystagmus received full neuro-ophthalmological evaluation by the senior author. Nystagmus was observed using video Frenzel goggles and recorded with video-oculography. Brain lesions were documented with MRI. Results Lesions responsible for nystagmus were found throughout the brainstem, mainly in the paramedian area: in the medulla (n=8), pons (n=3), pons and midbrain with or without cerebellar lesions (n=3), and midbrain and thalamus (n=1). Underlying diseases comprised cerebral infarction (n=10), multiple sclerosis (n=2), cerebral hemorrhage (n=1), Wernicke encephalopathy (n=1), and hydrocephalus (n=1). Upbeat nystagmus was mostly transient and showed occasional evolution during the acute phase. In one patient with a bilateral medial medullary infarction, the upbeat nystagmus changed into a hemiseesaw pattern with near complete resolution of the unilateral lesion. Gaze and positional changes usually affected both the intensity and direction of the nystagmus. A patient with a cervicomedullary lesion showed a reversal of upbeat into downbeat nystagmus by straight-head hanging and leftward head turning while in the supine position. Gaze-evoked nystagmus (n=7), ocular tilt reaction (n=7), and internuclear ophthalmoplegia (n=4) were also commonly associated with upbeat nystagmus. Conclusions In view of the responsible lesions and associated neuro-ophthalmological findings, upbeat nystagmus may be ascribed to damage to the pathways mediating the upward vestibulo-ocular reflex or the neural integrators involved in vertical gaze holding.
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Affiliation(s)
- Ji Soo Kim
- Department of Neurology, College of Medicine, Seoul National University, Seongnam, Korea
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