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Images in Neurology
March 2012

Rapid Reversal of Wall-Eyed Bilateral Internuclear Ophthalmoplegia

Author Affiliations

Author Affiliations: Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Arch Neurol. 2012;69(3):405. doi:10.1001/archneurol.2011.995

A 41-year-old man with cryptococcal meningitis was treated with intravenous antifungal agents and lumbar punctures. Four weeks later, the patient developed confusion and somnolence. Examination demonstrated wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) as well as upbeat and downbeat nystagmus (Figure, A and B; video). A computed tomographic scan revealed hydrocephalus (Figure, C), and an extraventricular drain was placed. Three days later, the patient had improved mental status and resolution of internuclear ophthalmoplegia (Figure, D and E) with residual gaze-holding nystagmus (video). A repeated computed tomographic scan showed reduced hydrocephalus (Figure, F).

Figure. On presentation, the patient had limited adduction with rightward (A) and leftward (B) lateral gaze and a computed tomographic image showed enlargement of the temporal horns of the lateral ventricles and the fourth ventricle (C). Three days after an extraventricular drain was placed, bilateral ophthalmoplegia resolved with rightward (D) and leftward (E) gaze and a repeated computed tomographic scan showed decreased enlargement of all ventricles (F).

Figure. On presentation, the patient had limited adduction with rightward (A) and leftward (B) lateral gaze and a computed tomographic image showed enlargement of the temporal horns of the lateral ventricles and the fourth ventricle (C). Three days after an extraventricular drain was placed, bilateral ophthalmoplegia resolved with rightward (D) and leftward (E) gaze and a repeated computed tomographic scan showed decreased enlargement of all ventricles (F).

Comment

The WEBINO syndrome is caused by injury to the bilateral medial longitudinal fasciculi, often due to demyelination or ischemic stroke. Rare causes include brainstem tumors, trauma, and hydrocephalus, and the pattern of eye movements may be mimicked by myasthenia gravis.1 The mechanism of WEBINO in hydrocephalus is poorly understood but likely related to mass effect from an enlarged fourth ventricle at the pons-midbrain junction, causing impaired transmission through the ascending medial longitudinal fasciculi.2 The rapid reversibility of the deficits suggests that the pathophysiology relates to hydrostatic disruption of these tracts without permanent axonal injury.

The neuro-ophthalmic findings in hydrocephalus typically include sixth-nerve palsies or limitations in upward gaze. This case illustrates that WEBINO should also be recognized as an important manifestation of acute hydrocephalus.

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Article Information

Correspondence: Dr Jadhav, Kaufmann Medical Bldg, Ste 811, 3471 Fifth Ave, Pittsburgh, PA 15213 (ashu@post.harvard.edu).

Author Contributions:Study concept and design: Jadhav and Prasad. Acquisition of data: Jadhav and Prasad. Analysis and interpretation of data: Jadhav and Prasad. Drafting of the manuscript: Jadhav and Prasad. Critical revision of the manuscript for important intellectual content: Jadhav and Prasad. Administrative, technical, and material support: Jadhav. Study supervision: Prasad.

Financial Disclosure: None reported.

References
1.
Nishizaki T, Tamaki N, Nishida Y, Matsumoto S. Bilateral internuclear ophthalmoplegia due to hydrocephalus: a case report.  Neurosurgery. 1985;17(5):822-8254069338PubMedGoogle ScholarCrossref
2.
Jacob JT, Burns JA, Dupont SA, Lanzino G, Wijdicks  EF. Wall-eyed bilateral internuclear ophthalmoplegia after ruptured aneurysm.  Arch Neurol. 2010;67(5):636-63720457967PubMedGoogle ScholarCrossref
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