COVID-19 provoked internuclear ophthalmoplegia in a child with arrested hydrocephalus

Internuclear ophthalmoplegia (INO) is a neuro-ophthalmic disorder caused by damage in the medial longitudinal fasciculus between the third and sixth cranial nerve nuclei. We present a 4-year-old female diagnosed with INO triggered by coronavirus disease 2019 (COVID-19) infection. The patient had history of neonatal meningitis with hydrocephalus without history of surgical intervention. To the best of our knowledge, this is the first case with combined COVID-19 and chronic hydrocephalus as an etiology for INO in a child. COVID-19 may trigger neurological manifestations as INO in susceptible cases.

Oftalmoplejía internuclear bilateral (WEBINO) en un paciente pediátrico con Lupus Eritematoso Sistémico / Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) in a pediatric patient with Systemic Lupus Erythematosus

Resumen El síndrome de WEBINO (wall-eyed bilateral internuclear ophthalmoplegia), se presenta por una lesión del tegmento pontino (incluye área pontina paramediana, fascículo longitudinal medial y núcleo del abducens). Presenta limitación bilateral en la aducción y exotropía en la posición de la mirada primaria, nistagmo del ojo que abduce e incapacidad para la convergencia. Reporte de caso: Presentamos el caso de una paciente de 14 años con antecedente de Lupus Eritematoso Sistémico que debutó con diplopía horizontal de inicio súbito. El diagnóstico de WEBINO fue clínico y asociado con hallazgos de lesión isquémico pontomesencefálica en Resonancia Nuclear Magnética y angioresonancia cerebral. Se administró tratamiento con Metilprednisolona y presentó resolución gradual de los síntomas, sin embargo una semana después falleció por criptococosis sistémica. Conclusiones: Hacer el diagnostico de WEBINO se hace desafiante por su rareza y por la precisión de su localización neuroanatómica. Se debe realizar una exploración detallada para definir la causa probable y establecer el tratamiento oportuno que favorezca el pronóstico neurológico.

Background: Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) is presented by a lesion of the pontine tegment (includes paramedian pontine area, medial longitudinal fascicle and nuclei of the abducens). It presents bilateral limitation in adduction and exotropia in the position of the primary gaze, abducting eye nystagmus and inability to converge. Case report: We present the case of a 14-year-old patient with a history of Systemic Lupus Erythematosus who debuted with sudden onset horizontal diplopia. WEBINO's diagnosis was clinical and associated with findings of ponto-mesencephalic ischemic injury in magnetic resonance imaging and magnetic resonance angiography. Treatment with Methylprednisolone was administered and she presented gradual resolution of the symptoms, however, one week later she died of systemic cryptococcosis. Conclusions: Making the WEBINO diagnosis is challenging due to its rarity and the precision of its neuroanatomical location. A detailed examination should be performed to define the probable cause and establish the appropriate treatment that favors the neurological prognosis.

Clinical features and imaging study of brainstem infarction dominantly presented as internuclear ophthalmoplegia / 重庆医学

Objective To describe the clinical features and magnetic resonance imaging (MRl) findings of brainstem infarction producing internuclear ophthalmoplegia (INO) as an predominant clinical manifestation.Methods The clinical data of 9 patients diagnosed with brainstem infarction presenting with INO by angiography and MRI diagnosis in our hospital were collected from January 2010 to October 2016.The clinical features and imaging findings of these patients were analysed,and the pathogenesis mechanisms was analysed by literature research.Results The median age of the 9 patients was 56 years old,and there were 5 young and middle aged cases (under 60 years old),accounted for 55.6％.Among them,8 cases (88.9％) with INO typically presenting with horizontal diplopia,the most common accompanied symptom was dizzness (accounted for 55.6％),and most of them (accounted for 77.8％) were unilateral.A total of 6 cases were anterior INO,3 cases were both anterior and posterior INO.Five cases (55.6％) retained converging movement.The MRI showed that paramedian ventral infarcts located in the the cerebral aqueduct were responsible for INO in 1 case,and paramedian dorsal infarcts located in the pons were responsible for INO in 8 cases.The magnetic resonance angiography (MRA) indicated that vascular occlusion or stenosis was found in posterior circulation in 6 patients,there were 5 cases with stenosis of the posterior cerebral artery which was the most common.The ocular symptoms,including diplopia and blurred vision,of 6 cases (66.7％) disappeared during their hospital stay (range:13-23 d,median:14 d).During following up,ocular symptoms of 1 case finally disappeared within 3 months.Conclusion Brainstem infarction presenting with INO is mainly caused by paramedian dorsal infarcts located in the pons,and most of the patients complicated with posterior circulation atherosclerotic lesions.The pathogenesis varies,and the patients have a good clinical prognosis.For the young and middle-aged patients presenting with diplopia as an initial symptom,it should pay more attention to differential diagnosis.

Migrainous infarction: a rare and often overlooked diagnosis

Migraine is a neurological entity and a well-known independent risk factor for cerebral infarction, which mostly afflicts the young female population. Researching focal neurological signs in this subset of the population with the diagnosis of a neurological ischemic event should always take into account the migraine as the etiology or as an associated factor. The etiology of central nervous system (CNS) ischemia is considerable. Migraine, although rare, also may be included in this vast etiological range, which is called migrainous infarction. In this setting, the diagnostic criteria required for this diagnosis is extensive. Herein, we present the case of a female adolescent who submitted to the emergency facility complaining of diplopia, dysarthria, and imbalance, which started concomitantly with a migrainous crisis with aura­a challenging clinical case that required extensive research to address all possible differential diagnoses.

A Case of Traumatic Unilateral Internuclear Ophthalmoplegia: Clinical Significance of Susceptibility-Weighted Imaging / 대한신경손상학회지

A 43-year-old man was admitted for head trauma after falling backward. The patient complained of diplopia. Unilateral internuclear ophthalmoplegia (INO) was diagnosed during the neurologic examination. Initially, no specific finding was shown on T2-weighted, T1-weighted, and fluid attenuated inversion recovery brain magnetic resonance image (MRI) or brain computed tomography (CT). However, susceptibility-weighted imaging (SWI) definitively demonstrated a tiny hemorrhage at the midline of the pontomesencephalic junction. The patient's symptom improved after 12 weeks. We discuss the clinical significance of SWI when traumatic INO due to a tiny hemorrhage is suspected.

Myasthenia Gravis Presenting With Bilateral Pseudo-Internuclear Ophthalmoplegia

No abstract available.

Bilateral Internuclear Ophthalmoplegia Following Spontaneous Subarachnoid Hemorrhage

A 44-year-old woman presented with horizontal diplopia 2 days after spontaneous subarachnoid hemorrhage. Neurological examination disclosed bilateral internuclear ophthalmoplegia and neck stiffness. Neurovascular imagings documented subarachnoid and intraventriclar hemorrhage with an aneurysm arising from the left superior cerebellar artery, and vasogenic edema in the bilateral pontomesencephalic junction. Parenchymal vasogenic edema due to microvascular damage may give rise to bilateral internuclear ophthalmoplegia during the acute stage of spontaneous subarachnoid hemorrhage.

A Catastrophic-Onset Longitudinal Myelitis Accompanied by Bilateral Internuclear Ophthalmoplegia in a Patient with Systemic Lupus Erythematosus

Transverse myelitis (TM) extending from midbrain to the entire spinal cord accompanied by internuclear ophthalmoplegia is extremely rare but cause serious central nervous system complications in patients with systemic lupus erythematosus. We report a case of a 28-yr-old woman with TM extending from the midbrain to the conus medullaris longitudinally and internuclear ophthalmoplegia associated with systemic lupus erythematosus. Her neurological symptoms had an abrupt catastrophic onset and rapidly progressed to respiratory failure within 24 hr. Bilateral internuclear ophthalmoplegia was also followed by TM. Brain MR images showed definite brainstem lesions, which were deeply associated with internuclear ophthalmoplegia, and diffuse signal changes in the whole spinal cord, medulla, pons and midbrain. Clinical improvement of her ophthalmoplegia and of neurological dysfunction of the upper extremities was noted after prompt and aggressive treatment with intravenous pulsed methylprednisolone and cyclophosphamide. However, the neurological dysfunction of the lower limbs and bladder and colon paralysis were almost unchanged until six months passed.

Jerky Seesaw Nystagmus in Isolated Internuclear Ophthalmoplegia

The authors report jerky seesaw nystagmus, extorsional downbeating in the right eye and intorsional upbeating in the left eye, in a patient with right internuclear ophthalmoplegia (INO). This pattern of nystagmus may occur by disrupting pathways from contralateral posterior and anterior semicircular canals by a lesion in the medial longitudinal fasciculus. Depending on damage to the pathways from contralateral vertical canals, various patterns of dissociated torsional-vertical nystagmus may accompany INO.

Wall-Eyed Monocular Internuclear Ophthalmoplegia (WEMINO) with Contraversive Ocular Tilt Reaction

Wall-eyed monocular internuclear ophthalmoplegia (WEMINO) with contraversive ocular tilt reaction has not been previously reported. A 71-year-old woman suddenly developed blurred vision. Examination revealed left internuclear ophthalmoplegia, left exotropia, right hypotropia, and rightward head tilt. Magnetic resonance imaging showed a tiny infarction at the area of the left medial longitudinal fasciculus in the upper pons. WEMINO with contraversive ocular tilt reaction may be caused by a paramedian pontine tegmental infarction that selectively involves the medial longitudinal fasciculus.

A Case of Cryptococcal Meningitis with Bilateral Internuclear Ophthalmoplegia and Ptosis

A 73-year-old woman with long-term steroid medication for arthralgia, suffered a sudden decrement of mental status, bilateral internuclear ophthalmoplegia and ptosis. T2-weighted MR images revealed high signals in the midbrain and both thalami. In cerebrospinal fluid studies, a test for cryptococcal antigen was positive and Cryptococcus neoformans was cultured. Bilateral internuclear ophthalmoplegia and ptosis may develop in cryptococcal meningitis from ischemic complications.

Possible Mechanism of Seesaw Nystagmus in Internuclear Ophthalmoplegia

The authors report jerky seesaw nystagmus, extorsional downbeating in the ipsilesional eye and intorsional upbeating in the contralesional eye, in a patient with internuclear ophthalmoplegia (INO) from focal pontine lesion. This pattern of nystagmus may occur by disrupting pathways from contralateral posterior and anterior semicircular canals by a lesion in the medial longitudinal fasciculus. Depending on the pathways involved, various patterns of dissociated torsional-vertical nystagmus may accompany INO.

A Case of Adjustable Surgery in Wall-eyed Bilateral Internuclear Ophthalmoplegia after Head Trauma

PURPOSE: Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) is a variation of bilateral internuclear ophthalmoplegia (Bilateral INO) that has profound exotropia in primary position. Head trauma is a rare cause in WEBINO. We report a case of WEBINO after head trauma which was not improved for 9 months and underwent extraocular muscle surgery with adjustable suture. METHODS: A 39-year-old man was referred to the department of ophthalmology for diplopia after head trauma from the department of neurosurgery. He was profoundly exotropic in the primary position and hads bilateral marked limitation of adduction with contralateral abducting nystagmus. There was no improvement even 9 months after the injury, so he underwent extraocular muscle surgery with adjustable suture. RESULTS: At postoperative 6 months, the patient showed orthophoria in the primary position and ocular motility was increased in adduction. There was no diplopia with a large area of binocular single vision in the primary position. CONCLUSIONS: Because of the disruption of normal ocular motor control in WEBINO, the effect of standard muscle surgery is unpredictable. Adjustable surgery is considerable as a useful technique because it is important in making accurate postoperative alignment, especially for diplopia.

A Case of Bilateral Internuclear Ophthalmoplegia with No Brain Stem Lesion

PURPOSE: Bilateral internuclear ophthalmoplegia (INO) has been reported mostly in bilateral medial longitudinal fasciculus (MLF) lesion. To report a case who presented with typical bilateral internuclear ophthalmoplegia (INO) with no brainstem lesion on brain MRI. METHODS: Case presentation. RESULTS: Seventy two year-old woman presented with bilateral marked adduction limitation and diplopia. Bilateral marked adduction limitation did not cross midline. Nystagmus occured in abducting eye. Elevation and depression were normal in duction. Transcranial doppler revealed moderated stenosis of right internal carotid artery and severe stenosis of left intracranial internal carotid artery. Brain MRI revealed focal old infarction of right corona radiata and circumscribed acute infarction at more upper level of corona radiata, however, no pathologic finding was identified in brainstem. Initial severe exotropia was improved to 30 PD exotropia in primary position. Adduction limitation was markedly improved 2 months later but bilateral horizontal nystagmus in abducting eye persisted

Isolated Unilateral Internuclear Ophthalmoplegia After Head Trauma

No abstract available.

A Case of Bilateral Internuclear Ophthalmoplegia

Internuclear ophthalmoplegia(INO) is a disorder of medial longitudinal fasciculus(MLF) that interconnects the ocular motor nuclei in the pons and midbrain. An intact MLF is essential for the production of all conjugate eye movements and an injury to the MLF results in ipsilateral adduction limitation and characteristic dissociated nystagmus of contralateral abducting eye. We experienced one case of bilateral internuclear ophthalmoplegia in a 70 years old ma, who had multiple lacunar infarctions in preaquductal gray matter, brain stem and basal ganglia.

Traumatic Unilateral Tegmental Hematoma Representing Internuclear Ophthalmoplegia and Hornor's Syndrome: A Case Report

Traumatic intracerebral hemorrhage associated with internuclear ophthalmoplegia is uncommon and usually presents itself in combination with diffuse axonal injury or cerebral contusion. On a review of the literatures, there hav been 23 cases of post-traumatic internuclear ophthalmoplegia reported. The authors are reporting a case of pure traumatic unilateral internuclear ophthalmoplegia with Hornor's syndrome caused by traumatic unilateral tegmental hemorrhage without diffusse axonal injury or cerebral contusion. The lesion was diagnosed by magnetic resonance image(MRI) and computed tomography(CT). The clinical feature, mechanism, and prognosis are discussed together with a review of the literatures.

Two Cases of True and Pseudo-internuclear Ophthalmoplegia with Bilateral Exodeviation

Internuclear ophthalmoplegia(INO) is characterized by the adduction deficit on lateral gaze associated with dissociated nystagmus of an abducting eye and caused by the lesion in the medial longitudinal fasciculus(MLF). It occurs unilaterally or bilaterally in infarction of brain stem and multiple sclerosis. Ocular myasthenia is a localized form of myasthenia involving extraocular, levator palpebrae perioris, and/or orbicularis oculi muscles. It is frequently confused with a variety of ocular mortility disorders including INO. We experienced 2 patients who had bilateral wall-eyes and diplopia. One was a true bilateral INO due to hypertensive brain stem infarction(Wall-eyed bilateral INO) and the other was a myasthenic bilateral pseudo-INO. Diagnosis was made by Tensilon test, repetitive nerve stimulation test of orbicularis oculi muscles, and serum antibody assay in latter case.

MR imaging of internuclear ophthalmoplegia due to cerebrovascular diseases / 영남의대학술지

Internuclear ophthalmoplegia is a conjugated gaze disorder characterized by impaired adduction on the side of a lesion involving the medial longitudinal fasciculus with dissociated nystagmus of the other abducting eye. Six patients with INO (who had clinical cerebrovascular diseases) underwent MR imaging and the results were as follows: 1. The MLF lesions were identified by MR imaging in 5 cases 2. The ratio of unilateral INO to bilateral INO was 5:1 3. The nature of lesions was infarction in 4 cases and hemorrhage in 1 case 4. The sites of MLE lesion were in the midbrain in 4 cases and in the pons in 1 case 5. All 5 cases of INO identified by MR imaging had other lesion sites in addition to MLE lesion.

A Case of Bilateral Internuclear Ophthalmoplegia

Internuclear ophthalmoplegia(INO)is a horiwntal ocular motor disturbance caused by a lesion of the medial longitudinal fasciculus. We have experienced a case of bilateral internuclear ophthalmoplegia associated with exotropia, which revealed the symptom of bilateral impairment of adduction and dissociated nystagmus of the abducting eye on horizontal gaze in either direction. No bilateral internuclear ophthalmoplegia caused by trauma has yet been reported in this country. Here we report the case of the trauma-related medial longitudinal fasciculus lesion and its pathophysiology along with a literatural review.