Periodic Alternating Gaze Deviation

Photo and Video Essay Section Editors: Melissa W. Ko, Dean M. Cestari, Peter Quiros, Kimberly M. Winges, MD MD MD MD Periodic Alternating Gaze Deviation Daniel Talmasov, MD, Rajan Jain, MD, Steven L. Galetta, MD, Janet C. Rucker, MD A 69-year-old woman with COVID-19 and postcardiac arrest coma developed periodic alternating gaze deviation (PAGD) (1,2), a rare eye movement related to periodic alternating nystagmus (PAN). PAN, a form of jerk nystagmus changing direction every 1–2 minutes, signifies cerebellar nodulus/uvula injury. PAGD, characterized by periodic gaze deviations without quick phases, is attributed to injury of the cerebellar nodulus/uvula, with additional pontine saccadic burst neuron injury obliterating quick phases. A central neurogenic hyperventilation respiratory pattern also suggested pontine injury in our patient. Our patient’s MRI showed no brainstem/cerebellar injury, but widespread injury from hypoxia was likely. PAGD is also reported with bilateral occipital lobe injury (2), as seen in our patient. PAGD can mimic fixed gaze deviation from seizure or stroke, but on continued observation, can be distinguished by its rhythmic directional alternation (See Supplemental Digital Content, Video, http://links.lww.com/WNO/A571). STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: D. Talmasov and J. Rucker; b. Acquisition of data: D. Talmasov; c. Analysis and interpretation of data: D. Talmasov, J. Rucker, R. Jain, and S. Galetta. Category 2: a. Drafting the manuscript: D. Talmasov and J. Rucker; b. Revising it for intellectual content: R. Jain and S. Galetta. Category 3: a. Final approval of the completed manuscript: D. Talmasov, R. Jain, S. Galetta, and R. Jain. REFERENCES 1. Averbuch-Heller L, Meiner Z. Reversible periodic alternating gaze deviation in hepatic encephalopathy. Neurology. 1995;45:191–192. 2. Mackay DD, Zepeda Garcia R, Galetta SL, Prasad S. Periodic alternating gaze deviation and nystagmus in posterior reversible encephalopathy syndrome. Neurol Clin Pract. 2014;4:482–485. Department of Neurology (DT, SLG, JCR), New York University School of Medicine, New York, NY; and Department of Radiology (RJ), New York University School of Medicine, New York, NY. The authors report no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the full text and PDF versions of this article on the journal’s Web site (www. jneuro-ophthalmology.com). D. Talmasov: Drafting/revision of the manuscript for content, including medical writing for content; Major role in the acquisition of data; Analysis or interpretation of data; R. Jain: Drafting/revision of the manuscript for content, including medical writing for content; Analysis or interpretation of data. S. L. Galetta: Drafting/revision of the manuscript for content, including medical writing for content; Analysis or interpretation of data; J. C. Rucker: Drafting/revision of the manuscript for content, including medical writing for content; Major role in the acquisition of data; Analysis or interpretation of data. Address correspondence to Janet C. Rucker, MD, Department of Neurology, New York University School of Medicine, 222 E 41st Street, NY 10017; E-mail: [e-mail] e554 Talmasov et al: J Neuro-Ophthalmol 2022; 42: e554 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.