00:01
Let's start by understanding
the head impulse test.
00:04
This is a rapid and passive
horizontal head rotation
from the center
to the lateral position
when the patient is fixated
at a central target.
00:14
So typically,
I'll ask the patient to look at me,
or look at my nose, or
look at something on the midline.
00:20
With both hands on each side
of the patient's face,
I will induce a rapid head turn.
00:27
This is a passive head turn
with the patient being
as relaxed as possible.
00:31
And we'll start in the middle
and go to the right,
or start in the middle
and go to the patient's left.
00:36
A normal head impulse test
is where the patient remains
fixated on the examiner.
00:42
So the patient's eyes
remain fixated on me.
00:45
As the head move left,
the vestibular apparatus
recognizes that
the brain recognizes
that the head is moving left
and compensatory
moves the eyes right,
so the patient is able
to stay fixated on me.
01:00
When we go
from straight to right,
when we move
the patient's head to the right,
again, the vestibular apparatus
should recognize that,
and the brain should activate
eye movement back to the left.
01:11
And so the eye should
remain fixed on the target.
01:14
That's a normal head impulse test.
01:17
What about an abnormal
head impulse test?
This is where the patient
again is instructed
to remain fixated
on the examiner at all times.
01:25
And when the head is moved,
the eyes move with the head.
01:30
So when I start in the midline and
move the patient's head to the left,
the eyes initially
move out to the left.
01:35
And then we see
a corrective saccade,
where the patient recognizes
that they need to be
looking at the examiner
and induced that goal
directed eye movement
back to the examiner.
01:46
That would be a left sided abnormal
head impulse test.
01:49
If we move the patient's head
to the right,
again, we may see the eyes
remain fixed out to the right
as the head moves,
and then a corrective saccade.
01:57
It's that corrective saccade
that we're looking for,
that indicates an abnormal
head impulse test.
02:03
This is the first of the
three critical exam maneuvers
that we're going to do for patients
with the acute vestibular syndrome.
02:13
A normal head impulse test,
a little bit paradoxically
suggests that this
could be a central cause
of the acute vestibular syndrome.
02:21
So this is one of those tests
in neurology,
where a normal test
is not reassuring.
02:27
And a normal head impulse test
could indicate
a signs of a brainstem,
or cerebellar stroke,
or multiple sclerosis,
or one of those central causes.
02:36
Here, an abnormal head impulse
test is a reassuring finding.
02:41
That reassures the examiner
that the cause of
this patient's vertigo
and acute vestibular syndrome
is likely to be
of a peripheral origin.
02:50
Vestibular neuritis
or labyrinthitis.
02:54
The second exam technique
is to look for nystagmus.
02:58
And I can find nystagmus to be
very difficult to understand,
categorize,
and evaluate in patients.
03:05
Let's start with a definition.
03:06
It's repetitive
uncontrolled movements,
where they're shaking
or jerking of the eyes.
03:11
And we see many
different descriptions
Pendular nystagmus,
optokinetic nystagmus,
Jerk nystagmus,
gaze-evoked nystagmus,
there's a lot written about
and that can be seen in patients.
03:24
When we're evaluating
the acute vestibular syndrome,
I would break nystagmus down
into two options.
03:31
Unidirectional or bidirectional.
03:34
Into the trained eye,
or even the untrained eye.
03:37
We should be able to
categorize and evaluate
the patient's nystagmus
in one of these two ways.
03:43
So let's start with
unidirectional nystagmus.
03:46
What is it?
Well as you see here,
whether the eyes are in
primary gaze or primary position,
or looking to the left
or looking to the right,
the fast phase of the nystagmus
the jerk is always
in the same direction.
04:00
So at primary position,
we see jerking,
the fast phase of jerking
in one direction.
04:05
When the patient
looks to the left,
we ask the patient
to follow our finger
and look to the left.
04:10
Again we see that
the fast phase of the nystagmus
the jerk
is to the same side.
04:15
And when we asked the patient
to look to the right,
again, we see the fast phase
of the nystagmus
in the same direction.
04:23
The nystagmus made jerk
to the left,
it made jerk to the right.
04:26
But with unidirectional nystagmus
it's always in the same direction.
04:31
And this indicates
peripheral pathology.
04:34
This is a reassuring finding.
04:35
Something that reassures us that
this is likely not of central origin
and more likely
of peripheral origin.
04:42
Importantly, we often see
that unidirectional nystagmus,
nystagmus that is evoked
by a peripheral source
often follows Alexander's law.
04:52
Where the intensity and severity
of the nystagmus is worse
on the side of the lesion.
04:59
So when the nystagmus
is worse on the right,
we worry about a right sided
peripheral vestibular pathology,
when the status is worse
on the left
and a little bit better when the
patient's looking to the right,
we worry about a left sided
peripheral vestibular pathology.
05:14
and that's Alexander's law
helps us to localize the side of
the peripheral vestibular syndrome.
05:22
That's different from
direction changing nystagmus.
05:25
And this is the second type
nystagmus we'll look for
in these patients.
05:30
Direction-changing nystagmus
indicates central pathology
and it is exactly as it sounds.
05:36
It's nystagmus that
changes directions.
05:39
We may see nystagmus
in one direction
at primary position, and
another direction at right gaze.
05:44
In one direction with left gaze and
another direction with right gaze.
05:48
It's nystagmus that changes
position.
05:52
The third technique we'll look for
is the test of skew.
05:55
And here we're looking for a
vertical misalignment of the eye.
05:59
This is a
subtle dis-conjugation
of vertical dis-conjugation
of the eyes.
06:05
In some patients,
it can induce diplopia.
06:07
Patients may see double.
06:09
In others,
it's so subtle,
that the patient
will only see one image.
06:14
We can see some patients
compensate with a head tilt,
and in others it requires
provocative maneuvers
to find that
this vertical misalignment,
and to test for a skew deviation.
06:25
There's two ways we do that
on physical exam.
06:28
The first is to shine our light
into the patient's eyes.
06:32
And as you can see here,
we see a reflection.
06:35
And that's that small white ellipse
that you see
in this patient's two eyes.
06:40
Patients with a skewed deviation
with a vertical misalignment,
we'll see that reflection
hit in different spots,
different points of the eye.
06:48
Here you can see
in the patient's right eye,
the reflection is
at a normal level
where you would expect it.
06:55
On the patient's left eye, that
reflection is lower down in the eye,
indicating that there's
a vertical misalignment.
07:02
And this is the
first tip off on exam
that we may be dealing
with an abnormal test of skew.
07:09
The second test is to perform
an alternate cover test.
07:13
Where we cover one eye
and then cover the other
asking the patient
to fixate on the examiner.
07:19
When one is covered
the eye that's uncovered
we'll look at the examiner.
07:24
And when we alternate,
we see that that
vertical misalignment
is accentuated
and we can see that on exam.
07:32
Again, a normal finding
is no skew deviation.
07:36
A normal test of skew,
no vertical misalignment.
07:40
And this is reassuring and
suggests a peripheral cause.
07:43
An abnormal test is the
presence of a skewed deviation.
07:47
A positive test of skew,
a finding that indicates
that there's a
vertical misalignment.
07:52
And this suggests a central cause.
07:54
Of the three exam techniques
we talked about,
head impulse test,
nystagmus, and test of skew,
this is the most specific.
08:02
Where if it's positive, this
strongly points to a central source.
08:07
Let's look a little bit closer
at that alternate cover test.
08:10
Here you can see the two eyes.
08:12
And we're covering
the patient's right eye.
08:15
Will alternate back and
forth to cover each eye
in rapid succession.
08:20
And we're looking for the eyes
to bob up and down.
08:23
This alternate cover
test accentuates
the vertical misalignment
in this test of skew.