Ping-pong Gaze Research Articles

S4405 Ping-Pong Gaze as an Atypical Presentation of Hepatic Encephalopathy: A Case Report

S4405 Ping-Pong Gaze as an Atypical Presentation of Hepatic Encephalopathy: A Case Report

Expanding the Spectrum of Ocular Dipping With Ping-Pong Gaze

Expanding the Spectrum of Ocular Dipping With Ping-Pong Gaze

Ping-pong gaze with “staircase” saccades in coma: An oculographic analysis using EEG (P3-9.005)

<h3>Objective:</h3> We report two cases of comatose patients with saccadic ping-pong gaze and the oculographic analyses of these eye movements using EEG only. <h3>Background:</h3> Ping-pong gaze is a form of periodic alternating gaze deviation in coma with each cycle lasting for a few seconds. These eye movements are typically described as “smooth”. Saccadic ping-pong gaze has been rarely described. The underlying anatomy and physiology are poorly understood. <h3>Design/Methods:</h3> We analyzed the eye movement artifact in two comatose patients. The eye acts like an electrical dipole with the anterior being more positive than the posterior. This leads to a characteristic movement artifact on EEG, which can be used to study the type and direction of eye movements. In this study, we analyzed multiple pages of the eye movement artifact on EEG for both patients. We used a prolonged time constant (TC) of 10s to characterize eye position and direction. A prolonged TC gets as close as possible to DC oculographic analysis. <h3>Results:</h3> Both patients demonstrated ping-pong gaze on EEG analysis, alternating direction every 2–5 seconds. In the patient with anoxic brain injury, the eye movement was smooth and it acquired a saccadic character when patient was stimulated. In the patient with hyperammonemic encephalopathy, the transition between smooth and saccadic was spontaneous. When the saccadic phase was analyzed with TC=10s, the waveform appeared like a “staircase” of saccades, marching toward one extreme over 2–5 seconds and then immediately switching direction. <h3>Conclusions:</h3> We report a novel finding of ping-pong gaze with “staircase” saccades in coma. Staircase saccades have been elicited by prolonged electrical stimulation of superior colliculus. We suggest that the presence of such eye movements indicate a supra-collicular level of injury, whereas isolated smooth ping-pong gaze likely indicates an infra-collicular level of injury. This could reflect a “lighter” state of consciousness in coma. <b>Disclosure:</b> Dr. Fotedar has nothing to disclose.

Ping-pong gaze in a refractory focal status epilepticus

An 83-year-old woman presented to emergency department with fever, low level of consciousness and right deviation in the conjugate gaze. Neurological examination revealed a spontaneous, slow, horizontal and continuous conjugate eye deviation alternating every 2 to 3 seconds. An electroencephalogram revealed periodic paroxysmal activity with a frequency of 2-3 Hz in left frontal hemispheric. Neuroimaging didn’t show pathological findings. Polymorphonuclear leukocytes were observed in CSF without evidence of microorganisms. Antiepileptic therapy was started without improvement. Finally, the patient died because of refractory focal status. Ping Pong Gaze (PPG) is a slow and rhythmical horizontal abnormal eye movement with a fixed frequency that is observed in comatose states and indicates diffuse structural brain lesions with preserved brainstem functions. PPG presence is an indicator of bad prognosis. We describe a PPG case with a synchronous eye movement with the electroencephalogram activity. Keywords: Ping-pong gaze; status epilepticus; electroencephalography; epilepsy; seizure.

A case of surgically-associated anti GQ1b antibody syndrome accompanied by saccadic ping pong gaze

BackgroundPeriodic alternating ping-pong gaze (PPG) is a rare disease with few reports. To our knowledge, there was no report on anti GQ1b antibody syndrome accompanied by PPG. This paper reported a case of anti GQ1b antibody syndrome with Bickerstaff’s Encephalitis (BBE) overlapping classic Guillain-Barre Syndrome (GBS) after aortic valve replacement, accompanied by an excessive PPG in the course of diagnosis and treatment, this was indeed rarely.Case presentationA 55-year-old male patient was admitted to our hospital with intermittent chest tightness for 3 months, and his condition has worsened in the past 10 days. Aortic valve replacement was performed because of the existence of the moderate and severe stenosis of aortic valve. Horizontal movement of the eyeball was involuntarily slow. The eyeball hovered and returned from one side to the other horizontally for 3–4 s per cycle. In combination with the patient’s typical clinical and laboratory tests, the final diagnosis was anti GQ1b antibody syndrome BBE combined with GBS, accompanied by saccadic ping pong gaze. Intravenous immunoglobulin (0.4 g/kg) was given for immunomodulation, methylprednisolone (1000 mg) therapy and symptomatic treatment were performed in the patient.ConclusionsThe patients were discharged from hospital on the thirtieth day because of economic reasons. After 6 months of follow up, the patients left behind a lack of fluency in speech and limb mobility, but the basic life can be taken care of by himself.

A closer look at ping-pong gaze: an observational study and literature review.

Little is known about ping-pong gaze (PPG) outside of individual case reports. We aimed to describe PPG through an observational study and literature review. Consecutive patients with PPG at Shanghai General Hospital (SGH) from February 2016 to March 2018 were enrolled. A literature review through March 2018 was conducted. Of the 14 patients with PPG in SGH, the median age was 60years and 12 were males. The median Glasgow coma scale score was 7.5. The cycle of the PPG ranged from 1.5 to 6.5s. The leading three etiologies were acute ischemic stroke in five patients, post-seizure state in three patients, and hypoxic-ischemic encephalopathy in two patients. A total of 88.9% (8/9) of the patients with consistent whole-field PPG had similar bilateral hemispheric damage, whereas 80.0% (4/5) of the patients with PPG in the hemifield had unilateral or extremely asymmetric bilateral hemispheric damage. The hemifiled side was the same side as the sole/dominant hemispheric lesion. The final clinical outcomes were neurologic remission for seven patients, vegetative state for one patient, and death for six patients. PPG is a sign with localizing value that suggests hemispheric damage and asymmetric PPG might help to predict lateralization of the lesions. Acute ischemic stroke is the most common cause of PPG. Etiology and initial outcome are likely important prognostic factors of PPG.

Ping-pong gaze and ocular nodding in bacterial meningitis.

A 27-year-old man presented with fever, somnolence, seizure, and nuchal rigidity. CSF culture indicated Streptococcus pneumoniae , confirming the diagnosis of bacterial meningitis. Ping-pong gaze was observed initially, and then replaced by what we called ocular nodding after IV administration of diazepam (video at [Neurology.org][1]). The eyes went downward and returned to primary position slowly, smoothly, and periodically (with a cycle lasting 12–17 seconds and a pause between 2 cycles), resembling a nodding head. He became alert with free eye movement within 3 days of antibiotic treatment. Ping-pong gaze has been reported,1 but ocular nodding is a novel finding. [1]: http://neurology.org/lookup/doi/10.1212/WNL.0000000000004633

Ping-pong gaze in a patient with unilateral hemispheric ischemic stroke

Ping-pong gaze in a patient with unilateral hemispheric ischemic stroke

A CASE OF ‘PING–PONG’ GAZE OF UNKNOWN CAUSE

A 66 year-old Indian gentleman with a background of type II diabetes, Crohn's disease and previously treated tuberculosis presented with double vision and unsteadiness.He was found to have a right-sided...

Saccadic Ping Pong Gaze in Coma

In this report, we describe the peculiar eye movements of a young man who became comatose after a head injury. The eyes moved rhythmically from one side to another, without pausing in the lateral positions. This phenomenon has been described as "ping pong gaze" (PPG), referring to short-cycling periodic alternating gaze with smooth eye deviations. In the present patient, however, a saccadic type of PPG could be confirmed by oculography. Possible clinical and pathophysiological implications are discussed.

Ping-pong gaze in hemifield may indicate bilateral asymmetrical hemispheric lesions

A 65-year-old man was found unresponsive at home. Initially, he showed ping-pong gaze only in the right hemifield, which subsequently involved the whole field 2 …

Ocular dipping and ping-pong gaze in hypoxic encephalopathy

A 16-year-old girl with fever of unknown origin was found comatose in the morning. Examination disclosed periodic eye movements with an initial downward deviation followed by rapid upward correction (dipping), which lasted 10 to 15 seconds (figure, A; video E-1, on the Neurology Web site at www.neurology.org). Intermittently, these movements were followed by slow to-and-fro horizontal eye motion (ping-pong gaze) immediately or with a latency of several seconds (figure, A, arrow; video E-1). During the dipping and roving eye motion, EEG …

Ping-pong gaze in coma may not indicate persistent hemispheric damage

Periodic alternating ping-pong gaze (PPG) is a continuous eye movement characterized by conjugate movements laterally from side to side at a rate of 3 to 7 seconds per cycle. It is usually smooth, but a saccadic form has been described.1 Fisher first described this clinical feature in 1967 in a patient with bilateral hemispheric infarction.2 There are a few reports of PPG associated with intoxications, but this curious eye movement abnormality has been observed predominantly in comatose patients with severe diffuse hemispheric injury.3 Other localizations have included a vermian hemorrhage but with other clinical findings suggesting a more widespread neurologic involvement,4 bilateral crura cerebri,5 and mesencephalic tegmentum.6 We report a patient with a good outcome. A 52-year-old right-handed man was diagnosed with cutaneous lymphoma 8 months before hospitalization and treated with six cycles of CHOP (a regimen of cyclophosphamide, hydroxydaunomycin [doxorubicin], …

Saccadic Ping-Pong Gaze

Ping-pong gaze (PPG), or short-cycle periodic alternating gaze, consists of horizontal conjugate ocular deviations alternating every few seconds. This alternating gaze has been described as appearing to be smooth. However, our electrooculographic study of four consecutive unconscious patients with PPG showed smooth waveforms in one patient but saccadic cog-wheeling in three patients. In one of the three patients with saccadic PPG, a transition from smooth to saccadic waveforms was noted with clinical improvement. Whereas the patient with smooth PPG died immediately, the patients with saccadic PPG survived in a persistent vegetative state. These findings suggest that saccadic PPG is a clinical variant of PPG in patients in a lighter state of consciousness, possibly related to less extensive brain damage.