1

KonradP.Weber

Interdisciplinary Centerfor Vertigo andNeurologicalVisualDisorders

UniversityHospitalZürich

EANSpringSchool2018

Stare Splavy,12May2018

Ocularmotorandvestibularbedsidetesting

A. Bradshaw

VestibularBedsideTesting

1. SpontaneousNystagmus2. HeadImpulseTest3. SkewDeviation4. RombergTestonFoam5. DynamicVisualAcuity6. Polyneuropathy7. Reposition,Reposition,Reposition!

HINTS

Cerebellum

Labyrinth

Vision

Proprioception

Help,my vision is jiggling!

Oszillopsia

DownbeatNystagmus Bilateralvestibularloss

Atrest Withheadmovement

CourtesyM.Strupp

1.SpontaneousNystagmus

Chronic Downbeat Nystagmus

2

Cerebellar Atrophy Acute Upbeat Nystagmus

Courtesy Alexander Tarnutzer, M.D.

Pontomesencephalic stroke HeadShakingNystagmus

NystagmusWaveforms

Constantvelocityslowphase(e.g.vestibularnystagmus)

Decreasingvelocityslowphase(e.g.gaze-evokednystagmus)

Increasingvelocityslowphase(e.g.congenitalnystagmus)

Pendular Nystagmus(e.g.congenital/acquired)

VideoOculography

Investigation is Key

Gaze-evoked nystagmusdetectad atage 14.

Eye Doctor

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2.HeadImpulseTest

Weberetal.Neurology 2008

EyeVelocity

VestibularNeuritis OvertSaccades

Vestibulo-OcularReflex

NormalSubject Vestibulo-OcularReflex

EyeVelocity

False Positive False Negative

Acute Vestibular Syndrome• Vertigo• Nausea• Vomiting

PeripheralVestibular Syndrome

• Vestibular Neuritis

Central Vestibular Syndrome

• Cerebellar or Brainstem Stroke

Head Impulse Test

Unnecessary MRIStroke missed!

9% False Positives (Newman-Toker et al. Neurology 2008)

+ _

HINTS?HI Head Impulse testN NystagmusTS Test of Skew

INFARCT!IN Impulse NormalFA Fast phase Alternating nystagmusRCT Refixation on Cover Test

• 100% Sensitivity, 96% Specificity• More sensitive than early MRI (72%)• Skew predicts brainstem stroke in

false positive head impulse test Kattah et al, Stroke 2009

Nystagmus Test of Skew

Romberg*Test

visual

proprioceptive

vestibular cerebellum

*Moritz Heinrich Romberg 1795-1873

Fromberg*Test

*RombergTestonFoam

4

FrombergTest

Gentamicin Vestibulotoxicity!

Polyneuropathy HepatitisC-associatedPolyneuropathy

Encouragewalkingsticks&goodfootwear Dynamicvisual acuity DVA

• Headshaking atleast2Hertz

• Lossof3or more linesis indicative ofbilateralvestibular loss

5

DynamicVisualAcuity Test

VitalD2010Arch Otolaryngol Bockisch etal.2014Curing a96-year-oldpatient afflicted with benign paroxysmalpositional vertigo onamotorized turntable..

96-yearoldlady

• Short-lastingvertigowhenstooping

• Hospitalizedafterafall

• Fractureofherpubicbone

• RightposteriorBPPV

• Referralforrepositioningonourmotorizedturntable

BPPVEpidemiologyintheElderly

• 10%cumulativeincidenceat80y

• Upto9%unrecognizedBPPVingeriatricoutpatientclinics

• Fallslead,directlyorindirectly,to12%ofalldeathsinelderly

Cum

ulat

ive

inci

denc

e of

BPP

V

0.10

0.08

0.06

0.04

0.02

0.00

0 10 20 30 40 50 60 70 80Age (years)

CumulativeBPPVincidence

Baraff LJAnnEmerg Med 1997.VonBevern Metal.JNeurol Neurosurg Psychiatry 2007.Oghalai JSetal.Otolaryngol HeadNeckSurg 2000.

TheFosterManeuver

www.halfsomersaultmaneuver.com

Summary

Diagnosis• Vestibular• Visualinput• Proprioception• Cerebellum

ExaminationSteps1. SpontaneousNystagmus2. HeadImpulseTest3. SkewDeviation4. RombergTestonFoam5. DynamicVisualAcuity6. Polyneuropathy7. Reposition,Reposition,

Reposition!

HINTS

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VideoHeadImpulseTest VideoHead-Impulse-Test

Acute vestibular neuritisAffected sideHealthy side

Ocular MotorBedside Testing

Here's looking atyou,kid!

6Classes of EyeMovements

• Stabilizing gaze onthe retina (non-volitional)• Fixation->while stationary• Vestibulo-ocular reflex ->during self-motion• Optokinetic nystagmus ->moving environment

• Directinggazetoatarget(volitional)• Smoothpursuit->following amoving target• Saccades->fastgazeshift• Vergence ->binocularcontrol

Alternate CoverTest HeadImpulseTest

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Optokineticnystagmus

Impairedsmoothpursuiteyemovements

stimulus

eye

catch-upsaccades

Impairedsmoothpursuiteyemovements

LeighandZee.Neurologyofeyemovements,4thed.OxfordUniversityPress2006

Cerebellar Atrophy

Saccadic eye movements

• Fasteye movements for shifting gaze

• Triggered by brainstem nuclei andunder cerebellar control

• Disorders of• Velocity (slow)• Metrics (hypo/hypermetric)• Latency (increased)

Slowsaccadesspino-cerebellar ataxia type2

Leighand Zee.Neurology ofeye movements,4thed.OxfordUniversityPress2006

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Convergencespasm Discourageprogressivelenses

6ClassesofEyeMovements

• Stabilizing gaze onthe retina (non-volitional)• Fixation->while stationary• Vestibulo-ocular reflex ->during self-motion• Optokinetic nystagmus ->moving environment

• Directinggazetoatarget(volitional)• Smoothpursuit->following amoving target• Saccades->fastgazeshift• Vergence ->binocularcontrol

Questions?