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Restless Legs Syndrome with Obstructive Sleep Apnea

Video Author: Alon Y. Avidan, MD, MPH, FAASM
Published on: 04.08.2013
Associated with: CONTINUUM: Lifelong Learning in Neurology. 19(1, Sleep Disorders):170-184, February 2013

Video demonstrates restless legs syndrome (RLS) in a 72-year-old man. Note the severe kicking of the legs against one another. Polysomnography is not required for the diagnosis of RLS in adults but may be useful if other comorbidities are thought to exacerbate the condition. This patient presented with RLS symptoms and apneic spells and was subsequently diagnosed and treated for obstructive sleep apnea, which resulted in some improvement of his RLS symptoms. The patient’s RLS symptoms did not respond to traditional first-line agents (dopamine agonists and gabapentin enacarbil) but responded well to opioid therapy, which resulted in some improvement.

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Creator: Nikolaus R. McFarland, MD, PhD
Duration: 4:03
A 65-year-old man with hypophonic and dysarthric speech and masked facial expression. Vertical saccades are reduced and horizontal saccades slowed. He has moderate bradykinesia of hand movements, finger tapping, and rigidity in the limbs. Gait is stooped and slow, and his stance is narrowed and unstable. Pull test reveals minimal to no compensation.
Creator: Nikolaus R. McFarland, MD, PhD
Duration: 6:47
An 80-year-old man demonstrating progressive asymmetric limb dysfunction, rigidity, bradykinesia, dystonia, apraxia, and cortical sensory deficits consistent with probable corticobasal degeneration.
Creator: Nikolaus R. McFarland, MD, PhD
Duration: 3:59
A 66-year-old man demonstrating hypokinetic dysarthric speech, jaw-opening dystonia, atypical tremor, symmetric rigid bradykinesia, and early postural instability consistent with multiple system atrophy–parkinsonism.
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Duration: 2:18
Creator: Francis O. Walker, MD, FAAN
Duration: 1:28
Relative median nerve and tendon movement with wrist and finger flexion.
Creator: Francis O. Walker, MD, FAAN
Duration: 0:42
Axial (short axis) video of the biceps in a patient with amyotrophic lateral sclerosis.
Creator: Francis O. Walker, MD, FAAN
Duration: 0:48
Dynamic scan of transected posterior interosseus nerve (PIN)
Creator: Francis O. Walker, MD, FAAN
Duration: 1:09
The median nerve in cross section as the probe is moved from the wrist to the antecubital fossa in a patient with Charcot-Marie-Tooth disease type 1A.
Creator: Francis O. Walker, MD, FAAN
Duration: 2:00
Video and still image contrasting the median nerve in a healthy patient with the median nerve in a patient with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP).
Creator: Kerry H. Levin, MD, FAAN
Duration: 0:37
Neuromyotonia. EMG recording from a middle-aged man includes multiple repeating discharges, each composed of multiple muscle fiber potentials with varying interpotential intervals corresponding to a firing frequency of up to 200 Hz.
Creator: Steven L. Lewis, MD, FAAN
Duration: 0:41
Myokymia in a patient with Morvan syndrome. A 45-year-old woman with Morvan syndrome, with myokymia predominantly involving her platysma.
Creator: W. David Freeman, MD, FSNS, FAAN
Duration: 2:23
Mild, abnormal ICP waveform during external ventricular drain (EVD) clamp trial with clustering of P1 to P3 waves. Respiratory variations are noted as well as Valsalva maneuver. The patient has muscle resistance testing of his deltoid, which causes the patient to perform the Valsalva maneuver and transiently increase ICP. Inspiration causes a decrease in ICP, and Valsalva maneuver during segmental muscle strength testing increases it.
Creator: W. David Freeman, MD, FSNS, FAAN
Duration: 2:22
The ICP waveform shown demonstrates a value of greater than 20 mm Hg and is frankly triangular with a low compliance/high elastance appearance. CSF is drained from the external ventricular drain (EVD) system (line goes flat for a while) and is later reopened periodically. By draining CSF, this essentially changes the ICP waveform by moving down and left on the elastance curve. Later, the ICP waveform returns after the external ventricular drain is opened and some P wave components are seen. However, it is important to recognize that the ICP waveform still has an overall noncompliant morphology indicative of a persistent abnormal intracranial pressure-volume state.
Creator: Jon Stone, MB, ChB, FRCP, PhD
Duration: 0:34
This video shows a 74-year-old woman with recurrent episodes of left functional hemiparesis. She describes acute dissociation at the onset of the symptoms and demonstrates jaw deviation to the left and left platysma contraction as part of functional facial spasm.
Creator: Jon Stone, MB, ChB, FRCP, PhD
Duration: 0:37
This video shows the patient in Case 15-1 who has right platysma contraction induced during the examination with jaw deviation to the right, which gives a superficial appearance of weakness but is actually functional facial spasm/dystonia.



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Duration: 0:34
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Duration: 0:44
Creator: Nikolaus R. McFarland, MD, PhD
Duration: 4:03
A 65-year-old man with hypophonic and dysarthric speech and masked facial expression. Vertical saccades are reduced and horizontal saccades slowed. He has moderate bradykinesia of hand movements, finger tapping, and rigidity in the limbs. Gait is stooped and slow, and his stance is narrowed and unstable. Pull test reveals minimal to no compensation.
Creator: Nikolaus R. McFarland, MD, PhD
Duration: 6:47
An 80-year-old man demonstrating progressive asymmetric limb dysfunction, rigidity, bradykinesia, dystonia, apraxia, and cortical sensory deficits consistent with probable corticobasal degeneration.
Creator: Nikolaus R. McFarland, MD, PhD
Duration: 3:59
A 66-year-old man demonstrating hypokinetic dysarthric speech, jaw-opening dystonia, atypical tremor, symmetric rigid bradykinesia, and early postural instability consistent with multiple system atrophy–parkinsonism.
Creator:
Duration: 2:18
Creator: Francis O. Walker, MD, FAAN
Duration: 1:28
Relative median nerve and tendon movement with wrist and finger flexion.
Creator: Francis O. Walker, MD, FAAN
Duration: 2:00
Video and still image contrasting the median nerve in a healthy patient with the median nerve in a patient with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP).
Creator: Steven L. Lewis, MD, FAAN
Duration: 0:41
Myokymia in a patient with Morvan syndrome. A 45-year-old woman with Morvan syndrome, with myokymia predominantly involving her platysma.
Creator: W. David Freeman, MD, FSNS, FAAN
Duration: 2:23
Mild, abnormal ICP waveform during external ventricular drain (EVD) clamp trial with clustering of P1 to P3 waves. Respiratory variations are noted as well as Valsalva maneuver. The patient has muscle resistance testing of his deltoid, which causes the patient to perform the Valsalva maneuver and transiently increase ICP. Inspiration causes a decrease in ICP, and Valsalva maneuver during segmental muscle strength testing increases it.
Creator: Jon Stone, MB, ChB, FRCP, PhD
Duration: 0:34
This video shows a 74-year-old woman with recurrent episodes of left functional hemiparesis. She describes acute dissociation at the onset of the symptoms and demonstrates jaw deviation to the left and left platysma contraction as part of functional facial spasm.
Creator: Jon Stone, MB, ChB, FRCP, PhD
Duration: 0:37
This video shows the patient in Case 15-1 who has right platysma contraction induced during the examination with jaw deviation to the right, which gives a superficial appearance of weakness but is actually functional facial spasm/dystonia.
Creator: Jon Stone, MB, ChB, FRCP, PhD
Duration: 0:42
This video shows a positive right leg Hoover sign in the patient in Case 15-1 who developed acute right facial spasm and a right hemiparesis and was initially thought to have had a stroke.
Creator: Louise S. Roper
Duration: 1:04
This video shows a patient with bilateral arm tremor. When asked to do mental arithmetic, the patient exhibits little difference in tremor. When copying cued movements in one hand, the contralateral tremor initially ceases, then entrains. Ballistic movements lead to brief pauses.
Creator: Jon Stone, MB, ChB, FRCP, PhD
Duration: 1:42
This video shows a patient who presents acutely with falls and unsteadiness on standing. She describes dissociation during the falls and is unsteady when standing, but she becomes stable when testing eye movements.
Creator: Jon Stone, MB, ChB, FRCP, PhD
Duration: 1:46
This video shows a patient describing his limbs feeling alien and artificial. He has a typical dragging gait of functional hemiparesis with the hip internally rotated. With his eyes closed, the patient’s bent foot feels straight, in keeping with a distorted cerebral map.
Creator: Jon Stone, MB, ChB, FRCP, PhD
Duration: 0:34
This video shows a patient with long-standing bilateral functional dystonia of both legs with characteristic internal hip rotation and ankle inversion.
Creator: Donald B. Sanders, MD, FAAN
Duration: 1:26
An 84-year-old man who has had myasthenia gravis for 3 years. The disease began with neck weakness, followed by asymmetric, bilateral lid ptosis. Examination demonstrates mild, fatigable diplopia on lateral gaze to either side, unmasked by cover/uncover maneuver.
Creator: Donald B. Sanders, MD, FAAN
Duration: 0:39
An 84-year-old man who has had myasthenia gravis for 3 years. Examination demonstrates mild weakness of forced eyelid closure
Creator: Donald B. Sanders, MD, FAAN
Duration: 2:06
A 64-year-old man with acetylcholine receptor antibody positive myasthenia gravis. After withholding pyridostigmine for several days, the patient has moderate right lid ptosis and horizontal diplopia at rest. These resolved within 30 seconds after injection of 2 mg edrophonium (Tensilon) and recurred 60 seconds later.
Creator: Matthew J. Thurtell, MBBS, FRACP
Duration: 00:42
This video shows a 67-year-old woman with downbeat nystagmus caused by lithium toxicity. Note that the nystagmus is more prominent with downward and lateral gaze.
Creator: Matthew J. Thurtell, MBBS, FRACP
Duration: 00:45
This video shows a 48-year-old man with upbeat and gaze-evoked nystagmus caused by Wernicke encephalopathy following gastric bypass surgery. The upbeat nystagmus is atypical in that it is less prominent with upward gaze. Note the gaze-evoked nystagmus on lateral gaze.
Creator: Matthew J. Thurtell, MBBS, FRACP
Duration: 00:30
This video shows a 55-year-old woman with jerk torsional nystagmus following a medullary stroke. The nystagmus is best detected by careful observation of the conjunctival blood vessels or iris.
Creator: Matthew J. Thurtell, MBBS, FRACP
Duration: 00:20
This video shows a 44-year-old man with pendular seesaw nystagmus following head trauma. The patient had a dense bitemporal hemianopia and MRI showed an atrophic optic chiasm without evidence of a compressive lesion.
Creator: Matthew J. Thurtell, MBBS, FRACP
Duration: 00:34
This video shows a 44-year-old woman with multiple sclerosis and horizontal acquired pendular nystagmus. The patient also has vision loss in both eyes secondary to optic neuropathy. Note that the nystagmus is more prominent in the left eye, which is the eye with greater vision loss.
Creator: Matthew J. Thurtell, MBBS, FRACP
Duration: 00:24
This video shows an 18-year-old woman with oculopalatal tremor that developed several months after a pontine hemorrhage. Note that the nystagmus is very disconjugate, being predominantly horizontal in the right eye and vertical-torsional in the left eye. The patient also has synchronous palatal oscillations.
Creator: Matthew J. Thurtell, MBBS, FRACP
Duration: 00:25
This video shows a 63-year-old woman with macrosaccadic oscillations following resection of a breast cancer metastasis to the cerebellum. Note that the macrosaccadic oscillations are triggered by gaze refixations and that her horizontal saccades are hypermetric.
Creator: Matthew J. Thurtell, MBBS, FRACP
Duration: 00:36
This video shows a 55-year-old woman with opsoclonus secondary to paraneoplastic brainstem encephalitis. Note that the saccades are back-to-back, without an intersaccadic interval, and multidimensional.
Creator: Marc Dinkin, MD
Duration: 00:14
This video of the same patient as in Supplemental Digital Content 8-1 shows an exotropia (reflective of left medial rectus weakness) and a left hypotropia (reflective of left superior rectus and inferior oblique weakness). Notice how the movements of the right eye are greater than the left eye during the test, even though it is not the paretic eye; the left eye is unable to move because of paresis. The deviation of the right eye (there is both an exotropia and hypertropia) is an example of a secondary deviation and results from the Hering law of equal innervation, which states that an equal force is provided to each eye.
Creator: Marc Dinkin, MD
Duration: 00:25
Video shows enhanced ptosis in a patient with ocular myasthenia gravis.
Creator: Marc Dinkin, MD
Duration: 00:25
In adduction, the lid lifts, reflecting aberrant regeneration of the adduction fibers of the oculomotor nerve to the levator palpebrae muscle fibers. The presence of aberrant regeneration is consistent with chronic oculomotor palsy.
Creator: Richard J. Barohn, MD, FAAN
Duration: 0:27
Video demonstrates the characteristic waxing and waning motor unit amplitude and frequency seen with myotonia on EMG. This produces the distinctive dive-bomber or motorcycle revving sound when amplified.
Creator: Richard J. Barohn, MD, FAAN
Duration: 0:18
Video demonstrates the clinical evaluation of percussion myotonia over the extensor digitorum communis. A fast strike with the reflex hammer over the extensor digitorum communis produces the characteristic extension of the fingers and wrist, with subsequent myotonic catch and delay of muscle relaxation.
Creator: Richard J. Barohn, MD, FAAN
Duration: 0:46
Video demonstrates the characteristic reduction in myotonia, or warm-up, with repetitive hand grips seen in patients with myotonia congenita. The patient is instructed to squeeze his hand closed as tightly as he can and then open his hand quickly. This maneuver is repeated to evaluate for warm-up of myotonia or paradoxical worsening.
Creator: Richard J. Barohn, MD, FAAN
Duration: 0:26
Video demonstrates the characteristic paradoxical increase in myotonia with repetitive hand grips, or paramyotonia, seen in patients with paramyotonia congenita. The patient is instructed to squeeze her hand closed as tightly as she can and then open her hand quickly. This maneuver is repeated to evaluate forwarm-up of myotonia or paradoxical worsening.
Creator: Irene Litvan, MD
Duration: 1:31
A 52-year-old man with a clinical diagnosis of idiopathic Parkinson disease. The patient shows left-hand resting tremor with reemergence on posture and exacerbation during walking. Decrement of amplitude and speed can be seen during performance of rapid alternating movements.
Creator: Irene Litvan, MD
Duration: 1:45
A 59-year old man clinically diagnosed with progressive supranuclear palsy. The oculomotor examination shows preserved horizontal pursuit and vertical gaze pursuit. Convergence is absent, and he shows minimal square wave jerks when fixing his gaze on the camera. Optokinetic nystagmus is horizontally preserved and vertical optokinetic nystagmus is reduced, with observation of square wave jerks. He also shows poor blink rate.
Creator: David R. Williams, MBBS, PhD, FRACP
Duration: 1:47
A 58-year-old woman with an early clinical diagnosis of Parkinson disease who progressed to a progressive supranuclear palsy phenotype between 6 and 8 years after symptom onset (both time points shown in the video). Later development of oculomotor impairment and blepharospasm with apraxia of eyelid opening were clues regarding the revised diagnosis.
Creator: Irene Litvan, MD
Duration: 3:52
A 50-year-old man clinically diagnosed with multiple system atrophy, parkinsonian type. He is shown to have a tremorless parkinsonism with axial-greater-than-appendicular rigidity, distal-arm postural and stimulus-sensitive myoclonus, and slow, slightly wide-based gait with freezing and postural instability when turning.
Creator: Irene Litvan, MD
Duration: 3:33
A 75-year-old woman clinically diagnosed with corticobasal syndrome. Among other features, she illustrates an asymmetric parkinsonism with a markedly dystonic right arm, myoclonus, ideomotor apraxia, and cortical sensory loss.
Creator: David R. Williams, MBBS, PhD, FRACP
Duration: 1:37
Examination of a 74-year-old woman demonstrating left-sided dystonia, rigidity, apraxia, myoclonus, and cortical sensory loss. Pathologic diagnosis confirmed Creutzfeldt-Jakob disease.
Creator: Francesca Morgante, MD, PhD
Duration: 0:40
First segment demonstrates a 36-year-old woman with cervical dystonia. Second segment shows a 72-year-old man with a 30-year history of task-specific focal hand dystonia. Motor overflow is evident when the patient writes. Third segment demonstrates lower limb dystonia in a patient with advanced Parkinson disease in the off-medication phase.
Creator: Francesca Morgante, MD, PhD
Duration: 0:23
A 78-year-old woman with a 25-year history of craniocervical dystonia. Blepharospasm occurred when the patient was 53 years old, and dystonia spread to her oromandibular (at 55 years old) and cervical areas (at 60 years old).
Creator: Francesca Morgante, MD, PhD
Duration: 0:23
A 5-year-old child with generalized dystonia caused by perinatal brain injury. The first symptoms appeared in the patient’s lower limbs, affecting gait, and subsequently spreading to the trunk and upper limbs.
Creator: Francesca Morgante, MD, PhD
Duration: 0:26
A 56-year-old woman with hemidystonia occurring as part of multiple system atrophy. Dystonic movements affecting the right side of her body presented 1 hour after taking 150 mg of levodopa/carbidopa.
Creator: Francesca Morgante, MD, PhD
Duration: 0:28
Cervical dystonia in a 72-year-old woman chronically exposed to antipsychotic drugs.
Creator: Christine Klein, MD
Duration: 0:33
Writer’s cramp in a 22-year-old woman, which developed at 6 years of age in her right hand. After switching to her left hand for writing, dystonia spread to the left arm. Over several years, the dystonia became present with other tasks and was accompanied by dystonic tremor; however, it remained bibrachial with no spread to any other body region and no further worsening.
Creator: Ruth H. Walker, MB, ChB, PhD, FAAN
Duration: 0:37
A man with marked cognitive impairment and disinhibition. He displays chorea of his trunk and arms, dystonic posturing of both hands, and dystonic jaw protrusion.
Creator: Ruth H. Walker, MB, ChB, PhD, FAAN
Duration: 2:25
A 31-year-old man with mild-to-moderate generalized chorea, dysarthria, dysdiadochokinesia (more pronounced on the left), and ataxia of gait.
Creator: Ruth H. Walker, MB, ChB, PhD, FAAN
Duration: 0:56
A 45-year-old man showing mild generalized chorea, truncal rocking, and a wide-based, lurching gait. Occasional tongue protrusions, but no feeding dystonia occur.
Creator: Steven Frucht, MD
Duration: 0:32
A 79-year-old woman with left-sided hemichorea affecting face and limbs.
Creator: Ruth H. Walker, MB, ChB, PhD, FAAN
Duration: 0:48
A 59-year-old man with moderate chorea of his trunk, neck, and limbs, and dystonic facial movements, but no limb ataxia.
Creator: Alberto J. Espay, MD, MSc, FAAN
Duration: 1:43
A 23-year-old woman with lupus who has experienced finger shakes since the age of 16. These difficult-to-characterize, tremulous movements (of lower amplitude than, and not as fast as, myoclonus), were ultimately categorized as neuromyotonia or electric myokymia, a peripheral nerve hyperexcitability disorder.
Creator: Alberto J. Espay, MD, MSc, FAAN
Duration: 1:13
An 82-year-old woman with rest and postural hand myoclonus. Once standing, she reported weakness and unsteadiness, which worsened the longer she remained erect. Electrophysiology revealed abnormal movements in her legs, which were myoclonic, and almost impossible to see, with the naked eye.
Creator: Cindy Zadikoff, MD
Duration: 1:53
A 6-year-old boy displaying classic axial-predominant (neck, upper arms) myoclonus with mild associated cervical dystonia. As is typical, myoclonic movements were exacerbated during handwriting.
Creator: Alberto J. Espay, MD, MSc, FAAN
Duration: 0:55
A 32-year-old cardiorespiratory arrest survivor with action-stimulus myoclonus, magnified by the intent to move. The myoclonic jerks prevent the performance of most movements and preclude the patient’s ability to ambulate.
Creator: Alberto J. Espay, MD, MSc, FAAN
Duration: 0:59
A 32-year-old cardiorespiratory arrest survivor with action-stimulus myoclonus. This video was taken after treatment with a combination of clonazepam and levetiracetam, added sequentially to optimize outcome.
Creator: Alberto J. Espay, MD, MSc, FAAN
Duration: 1:49
A 74-year-old man with Parkinson disease who is severely disabled exhibiting spontaneous resting and postural myoclonic movements in the hands and neck, intermittent right-hand tremor, and marked postural and gait impairments.
Creator: Francesca Morgante, MD, PhD
Duration: 1:18
A 17-year-old girl with EPM1 gene mutation, with prominent resting and action myoclonus in the upper and lower limbs causing marked impairment in ambulation.
Creator: Steven Wu, MD
Duration: 0:42
A 10-year-old boy with multiple simple motor tics including eye rolling, eye squinting, facial grimace, raising eyebrows, neck protrusion, and shoulder shrugging. He complains of eye discomfort due to frequent tics. Toward the end of the video, he makes several simple phonic tics (expiratory “huh” sound).
Creator: Alberto J. Espay, MD, MSc, FAAN
Duration: 0:46
A 17-year-old boy with a history of vocalizations and arm flailing, which started at 6 years of age, followed by multiple tics, including wrist flexion, feet cracking, throat clearing, shoulder popping, and neck jerking. After a fluctuating course with an almost quiescent 2-year period, neck jerking resurfaced. The movements caused degenerative disc disease and pain. Treatment with aripiprazole helped, but the movements still caused disruption at school and made driving less safe.
Creator: Steven Wu, MD
Duration: 0:15
A 16-year-old boy with frequent socially impairing coprolalia and copropraxia.
Creator: Massimo Pandolfo, MD; Mario Manto, MD, PhD
Duration: 0:52
A 25-year-old man with Friedreich ataxia since childhood, who has been in wheelchair for 3 years. Note the evident proximal weakness of the upper limbs, slowness of movement, and lack of an obvious kinetic tremor. The video also shows the characteristic eye movement abnormality of Friedreich ataxia and fixation instability with square-wave jerks. Note the absence of nystagmus.
Creator: Alfonso Fasano, MD, PhD; Bastiaan R. Bloem, MD, PhD
Duration: 0:21
Ataxic gait in a patient with alcoholic ataxia. Note the wide base of support and feet dysmetria during stepping.
Creator: Alfonso Fasano, MD, PhD; Bastiaan R. Bloem, MD, PhD
Duration: 0:25
Difficulty Performing Tandem Gait in a Patient With Severe Essential Tremor
Creator: Alfonso Fasano, MD, PhD; Bastiaan R. Bloem, MD, PhD
Duration: 0:20
Quadriceps Gait in a Patient With Cervical Myelopathy
Creator: Alfonso Fasano, MD, PhD; Bastiaan R. Bloem, MD, PhD
Duration: 0:26
Hemiparetic gait in a patient with left-hemisphere stroke. Note lower limb circumduction.
Creator: Alfonso Fasano, MD, PhD; Bastiaan R. Bloem, MD, PhD
Duration: 0:14
Scissoring gait in a patient with secondary dystonia because of juvenile cerebral palsy.
Creator: Alfonso Fasano, MD, PhD; Bastiaan R. Bloem, MD, PhD
Duration: 0:19
Dyskinetic gait in a patient with lower limb dystonia because of a mitochondrial disorder. Note the left foot inversion.
Creator: Alfonso Fasano, MD, PhD; Bastiaan R. Bloem, MD, PhD
Duration: 0:15
Dyskinetic and stiff gait in a patient with Parkinson disease experiencing disabling levodopa-induced dyskinesia. Note the dystonic features of the left lower limb.
Creator: Alfonso Fasano, MD, PhD; Bastiaan R. Bloem, MD, PhD
Duration: 0:32
Small-stepped gait, tight-quarters hesitation, and freezing of gait in a patient with long-standing Parkinson disease.
Creator: Alfonso Fasano, MD, PhD; Bastiaan R. Bloem, MD, PhD
Duration: 0:21
Stiff gait due to spastic paraparesis and freezing of gait during turning in a patient with primary lateral sclerosis.
Creator: Alfonso Fasano, MD, PhD; Bastiaan R. Bloem, MD, PhD
Duration: 0:20
Note the inconsistency and variability of the disorder over time.
Creator: Mark J. Edwards, MBBS
Duration: 2:12
A 45-year old woman with sudden-onset right hand tremor. Tremor was present at rest, with variable posturing of right hand, and during finger movements. Tremor was disrupted and its frequency changed during finger tapping with the unaffected left hand at different rates. Tremor was temporarily suppressed when engaged in the finger-nose task with the unaffected hand.
Creator: Alberto J. Espay, MD, MSc, FAAN
Duration: 0:59
A 62-year-old woman with sudden-onset left foot posturing after a minor motor vehicle accident 7 years ago. Fixed foot flexion and inversion are present, with excessive pain and associated abnormalities of skin coloration and sweating. She was diagnosed with complex regional pain syndrome type 1.
Creator: Francesca Morgante, MD, PhD
Duration: 0:59
A 51-year-old man exhibiting gait impairment, right hand action tremor, and left leg resting tremor. Examination showed brief motor arrests during gait initiation and turning, steppage of the left foot, and fixed posture of both hands. While sitting, fixed hand posturing disappeared during distraction maneuvers. Leg tremor was present when the foot was resting on the anterior sole but not when resting on the heel or when unsupported. Deliberate slowness in both upper limbs was demonstrated during finger-to-nose movements and repetitive arm movements, although spontaneous movements were normal, as was writing.
Creator: Geert Mayer, MD, PhD
Duration: 0:24
Video demonstrates cataplexy elicited by the strong emotional stimulus of conducting an orchestra. The patient becomes excited, has loss of muscle tone with unbuckling of the knees, and falls to the ground. Consciousness is preserved completely, and he never loses awareness. He recovers quickly, regaining his muscle strength and standing up as if he never experienced the episode.
Creator: Nancy Foldvary-Schaefer, DO, MS, FAASM
Duration: 0:49
Video demonstrates a bilateral, asymmetric, tonic seizure with semiology characteristic of frontal lobe (mesial) activation in a 32-year-old man with a normal MRI, no interictal discharges on scalp EEG, and a nonlocalizable scalp ictal EEG pattern. An ictal SPECT shows hyperperfusion in the left medial frontal lobe, so a stereo EEG evaluation is planned. The patient is medically intractable, with repetitive seizures at sleep-wake transition at bedtime most nights that have not responded to medication. The seizures routinely wake him up, but he typically can recall what happens during the seizure and responds immediately thereafter.
Creator: Geert Mayer, MD, PhD
Duration: 0:20
Video demonstrates head rolling in an adult man. The stereotyped and repetitive movement artifact is depicted at the frequency of 1 Hz to 2 Hz.
Creator: Marcel Hungs, MD, PhD
Duration: 0:24
Video shows a 56-year-old woman with psychogenic movement of both hands at bedtime. She is alert and has no urge to move her hands. The movements interfere with her sleep onset, disappear in sleep, and reoccur upon awakening. The movements are at times also seen during the day in wakefulness.
Creator: Soňa Nevšímalová, MD, DSc
Duration: 0:44
Video demonstrates confusional arousal in an adult man. The patient has an arousal, appears confused, and gets out of bed, demonstrating automatic behavior. This is an example of a hybrid attack in which the patient begins the episode with a confusional arousal and proceeds for exhibit somnambulistic behavior.
Creator: Rama Maganti, MD
Duration: 1:54
Video demonstrates confusional arousal in an adult man, demarcated by sudden arousal, confusion, searching behavior, and rapid return to baseline with amnesia for the event when conversing with the technologist.
Creator: Hrayr Attarian, MD, FAASM, FCCP
Duration: 0:50
Video demonstrates sleepwalking in a 34-year-old woman on zolpidem for chronic severe insomnia. The patient was seen by a community sleep doctor for episodes of sleepwalking and sleep smoking. She had let herself out of her house a few times, so safety was a concern. After a normal polysomnogram, the patient was started on clonazepam, which made her symptoms worse, and she was referred to a sleep center for a consultation. Video EEG showed normal N2 sleep during the entire 30-minute episode of sleepwalking (edited here for brevity).
Creator: Rama Maganti, MD
Duration: 0:56
Video demonstrates sleep terror in an adult woman. She screams suddenly, beginning from slow-wave non-REM sleep. The video segment after the event illustrates conversation with the technologist in which the patient recalls being awakened, but has little recollection for the event, and returns to baseline fairly quickly.
Creator: Soňa Nevšímalová, MD, DSc
Duration: 1:30
Video demonstrates an episode of sleep terror in a child that consists of sudden arousal, increase in sympathetic tone, confusion, aggressive behavior, inconsolability, and increased aggression.
Creator: Geert Mayer, MD, PhD
Duration: 0:37
Video demonstrates REM sleep behavior disorder in an adult man. Note the purposeful body movements correlating with dream enactment against electrographic augmentation of EMG tone.
Creator: Geert Mayer, MD, PhD
Duration: 1:54
Video demonstrates aggressive behavior in patients with REM sleep behavior disorder necessitating prompt safety modifications and pharmacologic interventions
Creator: Carlos Schenk, MD
Duration: 0:38
Video montage of REM sleep behavior disorder demonstrating vigorous, aggressive, and violent behaviors during REM sleep in an older adult male patient. Note violent and aggressive dream enactment correlating with dream sequence, placing both the patient and the bed partner at risk for injury.
Creator: Soňa Nevšímalová, MD, DSc
Duration: 0:34
Video demonstrates the often-stereotyped rhythmic movement of body rocking in a child. Body rocking tends to have a frequency of 1 Hz to 3 Hz and creates noise that sometimes awakens family members or bed partners.
Creator: Soňa Nevšímalová, MD, DSc
Duration: 0:35
Video demonstrates head banging in an adult.
Creator: Hrayr Attarian, MD, FAASM, FCCP
Duration: 0:30
Video demonstrates head rocking movements in a 55-year-old woman with severe pulmonary sarcoidosis who was also diagnosed with obstructive sleep apnea and referred for a continuous positive airway pressure titration. During the study she was discovered to have these head rocking movements that arose out of N1 sleep. The results of her neurologic workup were normal. On subsequent history she mentioned that she has always rocked herself to sleep.
Creator: Reproduced with permission from Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.
Duration: 0:53
Video demonstrates the Lempert (barbecue) roll maneuver for right geotropic horizontal canal benign paroxysmal positional vertigo (BPPV). The mirror image maneuver can be done for left geotropic horizontal canal BPPV.
Creator: Reproduced with permission from Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.
Duration: 0:46
Video demonstrates canalith repositioning treatment for right posterior canal benign paroxysmal positional vertigo (BPPV). The mirror image maneuver can be done for left posterior canal BPPV.
Creator: Reproduced with permission from Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.
Duration: 0:17
Video demonstrates the Dix-Hallpike maneuver to the right. This maneuver should evoke paroxysmal positional nystagmus for right-sided benign paroxysmal positional vertigo related to the posterior semicircular canal. The mirror image of this maneuver constitutes a left-sided Dix-Hallpike maneuver.
Creator: Kevin A. Kerber, MD, MS
Duration: 0:10
The cross-cover test is performed with the patient focusing on an object in the distance. No vertical misalignment is observed, so the test is negative for skew.
Creator: Kevin A. Kerber, MD, MS
Duration: 0:34
Spontaneous nystagmus and gaze testing in a patient who presented with acute vestibular syndrome and findings that localize to the right vestibular nerve. The patient has spontaneous left-beat nystagmus. The velocity of the nystagmus increases when he looks to the left and decreases when he looks to the right. When he looks to the right, the nystagmus does not change direction. When he looks up, the nystagmus remains left-beat. Thus, the patient has a unidirectional horizontal nystagmus.
Creator: Kevin A. Kerber, MD, MS
Duration: 0:21
Patient’s head is quickly moved to one side, then to the other. On movements to the patient’s left, the eyes stay focused on the target in front of him. With head movements to the patient’s right, the eyes move off the target. He then makes a voluntary corrective saccade to bring the eyes back to the target. This is considered a positive head-impulse test to the right. The corrective saccade is more obvious after some of the tests than others, likely due to variation in the speed of the movement and the patient’s ability to predict it.
Creator: Reproduced with permission from Weber KP, Aw ST, Todd MJ, et al. Head impulse tests in unilateral vestibular loss: vestibulo-ocular reflex and catch-saccades. Neurology 2008;70(6): 454Y463.
Duration: 1:24
Video demonstrates overt versus covert corrective saccades. In some patients, corrective saccades are easily visualized by the examiner (ie, overt saccades) whereas in other patients they may be difficult to observe or may even be imperceptible to the examiner (ie, covert saccades). This video shows examples of overt and covert corrective saccades after the head-impulse test in two patients with unilateral vestibular loss.



Creator: Geert Mayer, MD, PhD
Duration: 1:54
Video demonstrates aggressive behavior in patients with REM sleep behavior disorder necessitating prompt safety modifications and pharmacologic interventions