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Images in Neurology |

Ping-Pong Gaze Sherrington Would Not Have Done It Better

Marcello Moccia, MD1; Roberto Allocca, MD1; Roberto Erro, MD2,3; Paolo Barone, MD, PhD4; Carmine Vitale, MD, PhD5
[+] Author Affiliations
1Department of Neurosciences, University Federico II, Naples, Italy
2Sobell Department of Motor Neuroscience and Movement Disorders, University College London (UCL) Institute of Neurology, London, England
3Dipartimento di Scienze Neurologiche e del Movimento, Università di Verona, Policlinico Borgo Roma, Verona, Italy
4Center for Neurodegenerative Diseases (CEMAND), Neuroscience Section, Department of Medicine, University of Salerno, Salerno, Italy
5Department of Motor Sciences, University Parthenope, Naples, Italy
JAMA Neurol. 2014;71(11):1450. doi:10.1001/jamaneurol.2014.1072.
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An 84-year-old man with an acute and progressive disorder of consciousness presented with ping-pong gaze1 (Video and Figure, A-C) and Cheyne-Stokes breathing, suggestive of metabolic or toxic cause. However, a midrange pupil not responsive to light indicated a lesion involving the brainstem. Metabolic or toxic causes were excluded by blood tests. At 6 hours from symptom onset, a computed tomographic scan showed a hypodense lesion in the midbrain tectum at the collicular level, suggestive of ischemic stroke (Figure, D). The patient died a few hours later, after the onset of decerebrate rigidity, according to Sherrington’s original description of cats with the brainstem’s collicular section.2

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Figure.
Sequence of Ping-Pong Gaze and Computed Tomographic Scan Findings

Eyes deviated conjugately to the right (A), then in orthotropic primary position (B), and deviated conjugately to the left 2 to 3 seconds later (C). D, At 6 hours from symptom onset, a computed tomographic scan showed a hypodense lesion in the midbrain tectum, over the collicular level, suggestive of ischemic stroke; no additional discharges were found.

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Ping-Pong Gaze

Periodic alternating gaze (ping-pong gaze), with conjugate roving of the eyes from one extreme of horizontal gaze to the other, holding the extreme position for 2 to 3 seconds. Cheyne-Stokes breathing with a pattern of escalating hyperventilation followed by decremental hypoventilation; midrange pupils not responsive to light.

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