Periodic nonalternating ocular skew deviation accompanied by head tilt and pathologic lid retraction

A 60-year-old black male with a 13-year history of adult onset diabetes mellitus and hypertension with a previous lacunar stroke suddenly developed a periodic head and eye movement disorder characterized by nonalternating skew deviation, rotatory nystagmus, head tilt, and lid retraction. On CT scan, the patient had a lacunar infarct in the right midbrain in the region of the interstitial nucleus of Cajal, an anatomical area involved with head tilt, torsional eye movement, and skew deviation.