---

VNG Diagnostic Report - Gulab Devi

---

EXECUTIVE SUMMARY

---

SECTION 1: OCULOMOTOR TESTING

1.1 Saccades (0.3 Hz)

• Saccade velocities are within the broad acceptable range for a 75-year-old.
• Latencies are significantly prolonged bilaterally (horizontal: 440 ms and 409 ms; vertical: 380 ms bilaterally). Normal saccadic latency is 150-250 ms. Prolonged latency is commonly seen with age-related slowing (physiological) but, when bilateral and marked, may also indicate mild cerebellar or frontal-lobe processing delays.
• Left-eye horizontal precision (128.02) is mildly hypermetric, while right-eye horizontal precision (83.87) is mildly hypometric, suggesting asymmetric saccadic accuracy.
• Clinical significance: These findings are mostly consistent with age-related oculomotor changes (presbystasis) but should prompt consideration of a central origin if accompanied by other central signs (none clearly evident here).

1.2 Smooth Pursuit (0.2 Hz)

• Horizontal smooth pursuit is mildly reduced bilaterally, particularly leftward and for the left eye (0.59). Normal gain for a 75-year-old at 0.2 Hz should be ≥0.80.
• Vertical upward pursuit gain (0.48/0.46) is notably reduced. Upward pursuit gain below 0.60 is abnormal at any age. Reduced vertical pursuit, particularly upward, can reflect:
  • Age-related physiological decline (common in >70 years)
  • Early cerebellar vermis or dorsal midbrain dysfunction
• Downward gain is acceptable (0.73/0.62).
• Overall: Bilateral, symmetric smooth pursuit reduction is consistent with age-related central smooth pursuit degradation, common in the elderly. The asymmetric left-sided reduction adds mild concern but is not overtly pathological in isolation.

1.3 Optokinetic (OPK) Test

• OPK gains are symmetric and within normal range (0.80-1.20 typically expected), though the left eye shows supra-normal gain in horizontal directions (1.57-1.73). This likely represents a measurement artefact or fixation variation rather than true pathology.
• Fast phase direction is absent ("-"), indicating no pathological nystagmus during OPK stimulation.
• Conclusion: OPK is normal. No OPK asymmetry suggesting unilateral cortical or brainstem lesion.

---

SECTION 2: NYSTAGMUS TESTING

2.1 Spontaneous Nystagmus (Light and Dark)

• No spontaneous nystagmus in light or dark. This is a normal, reassuring finding.
• Absence of spontaneous nystagmus in darkness rules out an active, uncompensated peripheral vestibular lesion (e.g., acute vestibular neuritis) or central spontaneous nystagmus.

2.2 Head Shake Nystagmus (High Frequency)

• No measurable slow phase velocity, amplitude, frequency, or fast phase direction recorded.
• Result: Negative head shake test. No post-head-shake nystagmus, suggesting symmetric horizontal semicircular canal function and adequate vestibular compensation if a prior lesion existed.

2.3 Gaze Test (With Fixation - Center, Left, Right, Up, Down)

• All gaze positions: SPV = "-", Amplitude = "-", Frequency = "-".
• Result: No gaze-evoked nystagmus with fixation. This rules out gaze-evoked nystagmus due to cerebellar lesion, drug toxicity, or brainstem pathology.

---

SECTION 3: GAZE TEST WITHOUT FIXATION (Critical Findings)

3.1 Center Gaze - Without Fixation

• A downbeating nystagmus (negative vertical SPV = downbeating) is present in the right eye at center gaze in darkness. SPV of -5.69 °/s is just above the threshold for clinical significance (normal <4-5 °/s).
• Downbeating nystagmus at center gaze, even if subtle, has central significance (cervicomedullary junction, cerebellar flocculus/paraflocculus). However, in isolation at borderline velocity in an elderly patient, this may also represent otolithic positional contamination.
• This finding warrants monitoring and MRI consideration if persistent.

3.2 Left Gaze - Without Fixation

• Mild rightward horizontal nystagmus on left gaze without fixation (SPV 2.23 °/s). This is of low amplitude and borderline significance.
• The same frequency (1.14 Hz) as the center gaze finding suggests a single nystagmus generator.

---

SECTION 4: POSITIONAL TESTING (Dix-Hallpike) - KEY FINDINGS

4.1 Dix-Hallpike Right

4.1.1 Supine Head Extended & Right

• POSITIVE Dix-Hallpike Right. This is the most significant finding in the entire report.
• Strong vertical nystagmus bilaterally in the supine head-extended right position. SPV of 9.42 °/s (right) and 6.48 °/s (left) are clearly above the 5 °/s threshold for clinical significance.
• The nystagmus is vertical (posterior canal component). The absence of a fast phase direction data leaves the torsional component unclear from text extraction; however, the SPV magnitude and bilateral presence indicate a genuine posterior canal response.
• Consistent with RIGHT POSTERIOR CANAL BPPV (Canalithiasis).

4.1.2 Return to Sit (Post Hallpike Right)

• No significant nystagmus on returning to sit. This is typical for posterior canal BPPV (nystagmus is transient and reversal on sitting is often low amplitude).

4.2 Dix-Hallpike Left

4.2.1 Supine Head Extended & Left

• Borderline positive Dix-Hallpike Left. SPV values of 5.69 °/s and 5.81 °/s are at the threshold of clinical significance (5 °/s).
• Bilateral vertical nystagmus, slightly weaker than the right-side response.
• This finding can represent either bilateral posterior canal BPPV (less common) or a central direction-changing positional nystagmus. Given the overall pattern, left posterior canal involvement (lighter debris load) is plausible, making this a possible bilateral posterior canal BPPV, though this is less common.

4.2.2 Return to Sit Post-Left DH (Second recording)

• Residual mild nystagmus in right eye on returning to sit after left DH - borderline.

---

SECTION 5: POSITIONAL TESTING (McClure-Pagnini / Supine Roll Test) - KEY FINDINGS

5.1 Right Lateral Position

• POSITIVE right lateral roll test. Strong horizontal nystagmus with SPV 8.75 °/s (right) and 5.44 °/s (left).
• Fast phase direction of 340.88° (near-rightward, ~northward in standard convention = rightward horizontal with slight torsional component) on right lateral positioning.
• In the right lateral (head-right) position, nystagmus beats toward the right (geotropic) - this is the classic "geotropic" pattern of Horizontal Canal BPPV - Canalithiasis variant.
• In geotropic HC-BPPV, the stronger nystagmus on the side of the affected ear identifies the affected canal: stronger response on right = RIGHT horizontal canal BPPV.

5.2 Supine Head Neutral (First Recording)

• Mild horizontal nystagmus in supine neutral position (right eye only, SPV 0.97 °/s - low magnitude, borderline clinical significance).

5.3 Left Lateral Position

• Significant horizontal nystagmus also on LEFT lateral position (SPV 7.44 °/s). In the geotropic pattern of HC-BPPV, nystagmus on the contralateral (non-affected) side is expected to be weaker.
• The nystagmus is present in BOTH lateral positions, with right being slightly stronger (8.75 vs 7.44 °/s). The dominant side (right) indicates right horizontal canal as the affected ear.

5.4 Supine Head Neutral (Second Recording)

• Leftward horizontal nystagmus in supine neutral on second recording (left eye, SPV -7.23 °/s). The direction change between recordings (right neutral vs left neutral) over time may reflect nystagmus reversal typical of cupulolithiasis or debris migration.

---

SECTION 6: POSITIONAL TESTING (Head Position Series)

6.1 Yaw Right

• Strong leftward horizontal nystagmus (SPV -12.55 °/s in left eye) on Yaw Right position.
• SPV of -12.55 °/s is substantially above normal threshold. This is clinically significant positional nystagmus.

6.2 Yaw Left

• No nystagmus recorded. This asymmetry (Yaw Right positive, Yaw Left negative) supports right-sided horizontal canal involvement (in Yaw Right, the left eye shows stronger nystagmus away from the affected ear - consistent with apogeotropic contribution from cupulolithiasis element).

6.3 Pitch Backward

• STRONGEST positional response in the entire test. Downbeating vertical nystagmus bilaterally (SPV -14.80 °/s and -8.92 °/s) in the Pitch Backward (head extended supine) position.
• This is the "Head Back" position which stimulates the posterior canals and anterior canals.
• Bilateral downbeating nystagmus in the pitch-back position at this magnitude is consistent with:
  1. Bilateral posterior canal BPPV (most likely given overall context)
  2. Anterior canal BPPV component (anterior canal BPPV produces downbeating nystagmus)
  3. Central positional nystagmus (less likely given peripheral overall pattern)
• Given the strong responses on both DH right and DH left positional tests, bilateral posterior/anterior canal involvement is the favored interpretation.

6.4 Roll Right

• Leftward horizontal nystagmus with torsional component (fast phase 100.89°) in right roll position.
• Confirms persistent geotropic/torsional nystagmus during roll testing, consistent with canalithiasis of right horizontal canal.

6.5 Roll Left

• Rightward horizontal nystagmus + upward/torsional nystagmus in left eye (fast phase 324.97° - upward/torsional direction) in left roll position.
• The vertical-torsional component (8.28 °/s, fast phase 324.97°) during left roll suggests posterior canal activation, adding evidence for posterior canal BPPV component.

---

SECTION 7: SUBJECTIVE VISUAL VERTICAL (SVV)

• SVV during optoflow (clockwise and anti-clockwise) is within normal limits (0° and +2°).
• SVV on blank background = -5° (leftward tilt) is abnormal (exceeds ±2.5° threshold).
• Leftward SVV tilt suggests right utricular dysfunction (the utricle on the right side normally pulls the perceived vertical to the right; right utricle dysfunction causes leftward perception bias).
• This is consistent with right-sided vestibular pathology seen throughout the positional tests.
• The discrepancy between optoflow SVV (normal) and blank background SVV (abnormal) suggests the patient can use visual cues to compensate, but the intrinsic otolithic reference is skewed.

---

SECTION 8: INTEGRATED DIAGNOSIS

Primary Diagnosis

1. Positive McClure-Pagnini right lateral test (SPV 8.75 °/s) with geotropic horizontal nystagmus
2. Bilateral response in roll test (right > left), with right being dominant
3. Fast phase direction 340.88° (rightward/geotropic) on right lateral position
4. Roll Right position producing leftward horizontal nystagmus (away from affected ear during cupular displacement)
5. Yaw Right producing strong leftward nystagmus (-12.55 °/s) affecting both eyes
6. Abnormal SVV (-5°) indicating right otolithic/utricular dysfunction

Secondary / Co-existing Diagnosis

1. Positive Dix-Hallpike Right (SPV 9.42 °/s vertical - strongest response)
2. Borderline positive Dix-Hallpike Left (SPV 5.69-5.81 °/s vertical) - possible bilateral involvement
3. Strong bilateral downbeating nystagmus in Pitch Backward position (SPV -14.80 °/s / -8.92 °/s)
4. Vertical-torsional nystagmus in Roll Left (fast phase 324.97°)
5. Multi-canal positional responses are well-documented in the elderly and after head trauma

Tertiary Finding (Monitoring Recommended)

1. Prolonged saccadic latency bilaterally (380-440 ms vs normal 150-250 ms)
2. Reduced smooth pursuit gain, especially vertical upward (0.48/0.46)
3. Borderline downbeating nystagmus at center gaze in dark (SPV -5.69 °/s, right eye)
4. These findings collectively suggest age-related vestibulocerebellar degeneration, which is expected in a 75-year-old

---

SECTION 9: DIFFERENTIAL DIAGNOSES CONSIDERED

---

SECTION 10: RECOMMENDED MANAGEMENT

Immediate Treatment

1. Epley Canalith Repositioning Maneuver (RIGHT side) - for right posterior canal BPPV (if torsional-upbeat component confirmed on clinical exam)
2. BBQ Roll (Lempert Maneuver) or Gufoni Maneuver - for right horizontal canal BPPV canalithiasis. The BBQ roll involves sequential 90° rolls from right lateral → supine → left lateral → prone → upright, moving debris from horizontal canal to utricle.
3. Treat the side with the strongest response first (right side).

If Bilateral BPPV Confirmed

• Perform Epley maneuver bilaterally in separate sessions (right first, reassess in 48-72 hours, then treat left if persistent).

Further Investigations

1. MRI Brain with posterior fossa protocol - to rule out central cause of:
   • Borderline downbeating nystagmus at center gaze
   • Bilateral positional responses
   • Reduced vertical smooth pursuit
2. Audiometry / Pure Tone Audiogram - baseline hearing assessment (not included in this report)
3. Caloric testing / Video Head Impulse Test (vHIT) - if available, to quantify individual canal gain and assess peripheral vestibular symmetry
4. Neurological examination - assess for cerebellar signs, given central oculomotor findings

Patient Counseling

• BPPV is benign and highly treatable with repositioning maneuvers
• At age 75, recurrence rate is higher; falls risk assessment and home safety review are important
• Vestibular rehabilitation exercises (Brandt-Daroff) may help between formal treatments
• Avoid anti-vertigo medications (betahistine, antihistamines) as first-line - they can slow central compensation

---

SECTION 11: SUMMARY TABLE

---

FINAL IMPRESSION

---