A 32-year-old female presents with a 3-day history of vertigo, oscillopsia, and unsteadiness. Why?

Neuro Coach #6 - Fig. 1
Figure 1. Frenzel goggles
Neuro Coach #6 - Fig. 2
Figure 2. Frenzel goggles


Our patient's neurologic exam was unremarkable, except for questionable right-sided tongue fasciculations (twitching) and unsteady gait. Examination of extraocular movements with Frenzel goggles revealed torsional nystagmus that is bilateral and symmetric, with the rapid component beating towards her left (Figures 1 and 2). Neuroimaging showed a cyst at the level of the fourth ventricle that was impinging on her medulla (Figure 3 below).

This patient was diagnosed with acute vestibular syndrome, which is a central cause of nystagmus. Acute vestibular syndrome can be diagnosed using the HiNTS exam, comprised of assessment of nystagmus, skew, and head impulse test. Positive findings on one or more components of the HiNTS exam suggests a central (potentially dangerous) cause of nystagmus that warrants neuroimaging.

In this 11-minute video featuring Dr. Paul Freund, Assistant Professor at Dalhousie University in Halifax, you will learn:

  • How to distinguish between central and peripheral causes of nystagmus
  • How to use the HiNTS clinical exam to triage patients with nystagmus
  • The importance of a thorough history and neurologic exam in triaging nystagmus
Neuro Coach #6 Analysis
Figure 3.

Neuro Coach Tip

The HiNTS exam can distinguish between central and peripheral etiologies of nystagmus; central causes warrant further investigation, whereas peripheral causes may be observed.

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