Atormac
briv
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 5549  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (988 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

 
  In this Article
 »  Abstract
 »  References
 »  Article Figures
 »  Article Tables

 Article Access Statistics
    Viewed250    
    Printed2    
    Emailed0    
    PDF Downloaded9    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents    
BRIEF REPORT
Year : 2021  |  Volume : 69  |  Issue : 4  |  Page : 1002-1004

Wall-Eyed Monocular Internuclear Ophthalmoplegia Syndrome in Midbrain Infarction


Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China

Date of Submission25-Aug-2018
Date of Decision26-Apr-2020
Date of Acceptance19-Jul-2020
Date of Web Publication2-Sep-2021

Correspondence Address:
Xiang Han
Department of Neurology, Huashan Hospital, No. 12, Wulumuqi Road (M), Jing'an District, Shanghai - 200 040
China
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.325370

Rights and Permissions

 » Abstract 


Wall-eyed monocular internuclear ophthalmoplegia (WEMINO) is a rare variant of internuclear ophthalmoplegia (INO), consisting of unilateral INO and ipsilateral exotropia. This distinctive syndrome is probably associated with damage to the medial longitudinal fasciculus. However, WEMINO caused by a midbrain lesion has not been previously reported. We herein report a 50-year-old man presenting with WEMINO and vertical gaze dysfunction resulting from infarction of the midbrain tegmentum.


Keywords: Infarction, internuclear ophthalmoplegia, midbrain, WEMINO
Key Message: WEMINO, Internuclear ophthalmoplegia, Midbrain, Infarction.


How to cite this article:
Yang SL, Yang Q, Dong Q, Han X. Wall-Eyed Monocular Internuclear Ophthalmoplegia Syndrome in Midbrain Infarction. Neurol India 2021;69:1002-4

How to cite this URL:
Yang SL, Yang Q, Dong Q, Han X. Wall-Eyed Monocular Internuclear Ophthalmoplegia Syndrome in Midbrain Infarction. Neurol India [serial online] 2021 [cited 2021 Sep 25];69:1002-4. Available from: https://www.neurologyindia.com/text.asp?2021/69/4/1002/325370




Wall-eyed monocular internuclear ophthalmoplegia (WEMINO) is a rare variant of internuclear ophthalmoplegia (INO), consisting of unilateral INO and ipsilateral exotropia.[1] This distinctive syndrome is probably associated with damage to the medial longitudinal fasciculus (MLF).[1] However, WEMINO caused by a midbrain lesion has not been previously reported.

A 66-year-old man presented with sudden onset of diplopia, vertigo, and gait instability. Past medical history was remarkable for high blood pressure and diabetes mellitus. Neuro-ophthalmological examination showed exotropia of the left eye in the primary gaze, intermittent right exotropia on downward gaze, adduction paresis of the left eye, abducting nystagmus of the right eye, deficiency of convergence, and upgaze limitation with normal pupils [Figure 1]. Other examination was unremarkable except mild dysarthria and truncal ataxia. Brain MRI revealed a tegmental lesion at the midbrain level with the left side being more affected. The lesion showed T1 hypointense signal, T2 and FLAIR hyperintense signal, and restricted diffusion [Figure 2]. WEMINO caused by acute ischemic stroke was diagnosed. Dual antiplatelet therapy (aspirin and clopidogrel) and statin administration were initiated. Only a slight improvement of the ocular movement was observed within 1 month of onset.
Figure 1: Neuro-ophthalmological findings. The patient showed exotropia of the left eye in the primary gaze, intermittent right exotropia on downward gaze, adduction paresis of the left eye, abducting nystagmus of the right eye, deficiency of convergence and upgaze limitation with normal pupils

Click here to view
Figure 2: Brain MRI of the patient. Brain MRI revealed a tegmental lesion in the midbrain with the left side being more affected. The lesion showed T1 hypointense signal (d), T2 (a) and FLAIR (b) hyperintense signal and restricted diffusion (c)

Click here to view


Patients with classic INO have parallel visual axes in primary gaze. WEMINO is a rare variant of INO, consisting of unilateral INO and ipsilateral exotropia in primary gaze.[1] WEMINO was first described by J. L. Johnston in 1994 in a poster abstract that included four patients without detailed individual description.[1] Histological damage to the MLF confined to the pontine tegmentum was identified in one patient. There have been only four other WEMINO patients reported over the past 24 years[2],[3],[4],[5] [Table 1]. While INO, ipsilateral exotropia, and deficiency of ipsilateral convergence were the invariable components of WEMINO syndrome in the four patients, other ocular signs including skew deviation, ocular tilt reaction, and vertical nystagmus had been observed in some of them. The etiology was acute ischemic stroke in three patients, and neurocysticercosis in one patient. The responsible lesion was located exclusively in the pontine tegmentum affecting unilateral MLF. The ocular movement dysfunction all had resolved or improved within less than 1 month.
Table 1: WEMINO patients in publications and the presenting case

Click here to view


Our patient had an infarction located in the tegmentum of midbrain rather than pons [Figure 3]. The involvement of left MLF and medial rectus subnucleus of oculomotor nucleus could explain the development of WEMINO in our case [Figure 3]a. However, damage to the medial rectus subnucleus was not required as was shown in the previously reported cases. In addition, upgaze limitation in our case was probably caused by damage to the rostral interstitial nucleus of the MLF and the interstitial nucleus of Cajal (INC), two key structures in the control of the vertical gaze [Figure 3]b. The ocular movement outcome was not as good as the previous cases, which was probably associated with the involvement of the medial rectus subnucleus beyond MLF.
Figure 3: Illustration of the infarct and relevant key brainstem structures. Our patient had an infarction (gray area) located in the tegmentum of midbrain rather than pons. The involvement of left MLF and medial rectus subnucleus of oculomotor nucleus could explain the development of WEMINO in our case (a). Upgaze limitation in our case was probably caused by damage to the rostral interstitial nucleus of the MLF (riMLF) and the interstitial nucleus of Cajal (INC), two key structures in the control of the vertical gaze (b)

Click here to view


In conclusion, WEMINO is a rare variant of INO, defined as unilateral INO with ipsilateral exotropia. The exact mechanism of WEMINO remains unclear. This is the first case of WEMINO resulting from a midbrain lesion. Presentation of WEMINO with vertical gaze dysfunction suggests damage to the midbrain tegmentum.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Johnston JL, Sharpe JA. The WEMINO syndrome-wall-eyed monocular internuclear ophthalmoplegia: An oculographic and neuropathologic characterization [abstract]. Neurology 1994;44(Suppl 2):A311.  Back to cited text no. 1
    
2.
Chandran SR, Balakrishnan RK, Umakanthan K, Govindarajan K. Neurocysticercosis presenting as isolated wall-eyed monocular internuclear ophthalmoplegia with contraversive ocular tilt reaction. J Neurosci Rural Pract 2012;3:84-6.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Tsuda H, Kamata K, Tanaka K, Kishida S. WEMINO syndrome with skew deviation and facial palsy. Intern Med 2011;50:2435-6.  Back to cited text no. 3
    
4.
Jeon SB, Chung SJ, Ahn H, Lee JH, Jung JM, Lee MC. Wall-eyed monocular internuclear ophthalmoplegia (WEMINO) with contraversive ocular tilt reaction. J Clin Neurol 2005;1:101-3.  Back to cited text no. 4
    
5.
Ikeda Y, Okamoto K. Lesion responsible for WEMINO syndrome confirmed by magnetic resonance imaging. J Neurol Neurosurg Psychiatry 2002;73:204-5.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow