Internuclear ophthalmoplegia following radial artery cardiac catheterization approach: An unusual presentation

Internuclear ophthalmoplegia (INO) may happen following percutaneous coronary intervention and angiography. However, no reports of INO during radial artery angioplasty were reported yet. We report a rare case in a 47-year-old man presenting with diplopia after radial artery angioplasty. Although the symptoms were resolved after 60 days, diagnosing this obstacle is necessary to reduce the patient and physician's anxiety.

One-and-a-Half Syndrome in a Case of Brainstem Bleed

One-and-a-half syndrome (OHS) is a horizontal gaze palsy in one direction with internuclear ophthalmoplegia (INO) in the other. The only eye movement possible is the abduction of the contralateral eye with nystagmus. The usual structures affected are the medial longitudinal fasciculus and paramedian pontine reticular formation or the abducens nucleus. Most commonly, the OHS is caused by ischemia and demyelinating lesions. The other causes include infectious, neoplastic, and rarely traumatic. We report a case of a 42-year-old non-compliant hypertensive female who presented with giddiness, projectile vomiting, and right-sided hemiparesis and was found to have OHS on cranial nerve examination in the emergency department (ED). In the ED, the presence of complete horizontal gaze palsy in one direction with INO in the other direction should raise suspicion of a brainstem pathology.

Pure Isolated Internuclear Ophthalmoplegia as Presentation of Midbrain Ischemic Stroke: A Case Report

Internuclear ophthalmoplegia (INO) is a condition characterized by impaired ocular movement, leading to an inability to perform coordinated lateral gaze, resulting in ophthalmoplegia. This impairment results from damage to the medial longitudinal fasciculus (MLF), which can occur because of various types of lesions localized in the pons or midbrain. In this case, we report on a 67-year-old man with multiple comorbidities who arrived at the emergency department with complaints of sudden dizziness and an unsteady gait. During the examination, he exhibited left INO, which was characterized by limited left eye adduction and multidirectional nystagmus of the right eye when performing right lateral gaze.

Case report: A disconjugate pattern in video head impulse testing hints toward a central cause of acute vertigo

When acute vertigo occurs, the challenge for the medical practitioner lies in the focused assessment to find the cause of its symptoms. Especially in the case of central pathology, a fast diagnosis is essential for therapy. The head impulse, nystagmus, test of skew (HINTS) protocol and the additional video head impulse test (VHIT) can distinguish between central and peripheral vestibular causes in the acute setting and thus help to set the right path for further evaluation and treatment. In this case, a patient with acute onset of vertigo presented with an unusual pattern in the VHIT. Binocular eye tracking showed a disconjugate horizontal vestibulo-ocular reflex (VOR) with severe loss or gain for the adducting eye yet with a lack of corrective saccades. The abducting eye produced a pattern of mild VOR gain loss yet with pronounced corrective saccades. Together with clinical findings that were compatible with internuclear ophthalmoplegia, a probable central lesion in the medial longitudinal fasciculus (MLF) region was suspected. The patient was sent to a tertiary hospital, where the initial MRI was negative, but due to additional neurological symptoms occurring later, multiple lesions in the cervical spine and cerebellum were detected. The hypothesis of an inflammatory demyelinating disease of the central nervous system (CNS) was made. A further workup led to the final diagnosis of neurosarcoidosis. In a retrospective neuroradiologic assessment, an alteration compatible with a non-active demyelinating lesion in the MLF was detected on secondary imaging as a probable cause of the initial pathophysiologic finding. In this report, we aimed to highlight the unusual case of a disconjugate VOR as a distinctive VHIT pattern hinting toward a central cause of acute vertigo that clinicians should be aware of.

Isolated Internuclear Ophthalmoplegia as an Embolic Complication of Transcatheter Aortic Valve Implantation

An 83-year-old male developed horizontal diplopia immediately following elective transfemoral transcatheter aortic valve implantation (TAVI). On right gaze, left eye adduction was impaired while there was horizontal nystagmus of the abducting right eye, representative of internuclear ophthalmoplegia (INO). The remainder of the neurological examination was normal. Computer tomography (CT) imaging of the brain and CT angiogram of the head and neck were normal. Magnetic resonance imaging (MRI) of the brain showed five small foci of restricted diffusion affecting both the anterior and posterior circulation bilaterally. One such tiny infarct was seen in the left parasagittal upper pontine tegmentum and was attributed to his presentation. While all symptoms rapidly improved, minimal residual signs of INO were still detectable at the six-month follow-up. Isolated intra-nuclear ophthalmoplegia is a rare stroke syndrome and an unusual cardio-embolic complication of minimally invasive cardiac procedures. TAVI is an increasingly popular technique, although has been associated with a higher incidence of micro-embolic cerebrovascular events evident on MRI than surgical repairs. While the use of embolic protection devices has high-quality evidence in reducing the burden of these usually silent cerebrovascular events, their role in preventing long-term neurocognitive sequala has not been demonstrated.

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.

[A case of cardioembloic stroke with wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) syndrome]

Here, we report a case of an 85-year-old man who presented sudden onset of diplopia, dysarthria, and gait disturbance. On admission, he exhibited bilateral adduction palsy, convergence palsy, and binocular exotropia in the forward gaze showing wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) syndrome. He had a history of chronic nonvalvular atrial fibrillation. DWI-MRI revealed acute ischemic lesions in the paramedian pontine tegmentum, lower midbrain, both cerebellar hemispheres, and left frontal cortex. He was thus diagnosed with an acute phase of cardioembolic stroke. Subsequently, the right eye adduction palsy in the forward gaze was slightly improved, but other eye movement disorders persisted during discharge from the hospital. The pathology was suspected to involve bilateral damages to both medial longitudinal fasciculus and the paramedian pontine reticular formation. WEBINO syndrome was not only ascribed to lacunar infarction and large artery atherosclerosis but also cardioembolic stroke. The presence of other non-eye symptoms and multiple ischemic lesions could be the characteristics of WEBINO syndrome following cardioembolic stroke.

Strabismus surgery outcomes for internuclear ophthalmoplegia with exotropia

Exotropia (XT) in internuclear ophthalmoplegia (INO) is a difficult problem to treat. The purpose of this study is to describe surgical approaches in treating INO and glean insight into various pre-operative factors that may affect outcomes for XT in INO. We conducted a retrospective review from 1 January 1995 - 5 January 2021 and identified seven patients with INO who underwent strabismus surgery for XT. Patient age, sex, etiology of INO, pre-operative alignment and sensorimotor exam, presence of diplopia, surgery performed, subsequent surgeries, use of adjustable sutures, post-operative alignment, presence of post-operative diplopia, presence of post-operative diplopia with use of prism correction, and length of follow-up were all collected. Initial surgeries undertaken included unilateral medial rectus (MR) plication and lateral rectus (LR) recession, bilateral medial rectus (MR) plications or resections, or bilateral MR plications combined with either unilateral or bilateral LR recessions. Chart review yielded ten charts, however two were excluded due to manifest esotropia (ET), and one was excluded due to incomplete records. Seven total patients were used in final analysis. The cohort age range was from 29 to 79 years. Pre-operative horizontal distance alignment ranged from 35 to 95 XT with an average exodeviation of 67.8 ± 22.6 prism diopters (PD). Horizontal adduction deficit ranged from -1 to -4 and was present bilaterally in all patients. A variety of initial surgical approaches were undertaken. After two muscle surgeries, distance deviation had an average change of 57.3 PD. After three muscle surgeries, distance deviation had an average change of 75 PD. After four muscle surgeries, distance deviation had an average change of 60 PD. Three patients required additional surgery for XT. Time to follow-up ranged from 1 to 58 months. Horizontal distance alignment in primary gaze at latest follow-up ranged from 30 ET to 30 XT with an average of 0 (orthotropia) ± 16.0 PD. One patient had a consecutive esotropia of 30 PD, one had a persistent exotropia of 30 PD, and five patients were orthotropic at distance. All patients reported relief of diplopia in primary gaze at near and distance either with or without use of prism. Horizontal ductions improved to some degree in all patients. Horizontal rectus surgery can treat many cases of XT in INO. Surgeons should consider INO etiology and concomitant vertical deviations when considering surgery. The degree of pre-operative adduction limitation is another important factor, though did not always dictate final motor and sensory outcomes.

Wall-Eyed Monocular Internuclear Ophthalmoplegia Syndrome in Midbrain Infarction

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.

MRI topography of lesions related to internuclear ophthalmoplegia in patients with multiple sclerosis or ischemic stroke

BACKGROUND AND PURPOSE

Internuclear ophthalmoplegia is a dysfunction of conjugate eye movements, caused by lesions affecting the medial longitudinal fasciculus (MLF). Multiple sclerosis (MS) and ischemic stroke represent the most common pathophysiologies. While magnetic resonance imaging (MRI) allows for localizing lesions affecting the MLF, comprehensive comparative studies exploring potential different spatial characteristics of lesions affecting the MLF are missing until now.

METHODS

We retrospectively investigated MRI examinations of 82 patients (40 patients with MS and 42 patients with ischemic stroke). For lesion localization, the brainstem was segmented into (1) ponto-medullary junction, (2) mid pons, (3) upper pons, and (4) mesencephalon.

RESULTS

Corresponding lesions affecting the MLF were observed in 29/40 (72.5%) MS and 38/42 (90.5%) stroke patients. Compared to stroke patients, MS patients had significantly more lesions in multiple locations (P < .001). Stroke patients showed more lesions at the level of the mesencephalon (P < .001), while lesions at the level of the ponto-medullary junction, mid, and upper pons did not statistically differ between the groups.

CONCLUSION

Our results demonstrate that multiple lesions affecting the MLF make inflammatory-demyelination due to MS more likely, while lesion localization at the level of the mesencephalon favors ischemia.

Isolated Third Nerve Palsy as a Rare and Solo Presentation of Internal Carotid Artery Dissection in a Young Female - a Surprising Finding in the Angiogram

Internal carotid artery dissection (ICAD) is a known but uncommon cause of ischemic stroke among young and middle-aged patients. A common presentation includes ipsilateral headache, unilateral oculosympathetic palsy (partial Horner syndrome), or ischemic stroke but some reported cases present with less common manifestations, such as lower cranial nerve syndrome (IX, X, XI, XII). However, third cranial nerve palsy is an extremely rare presentation of ICAD. We present a case of ICAD with pseudoaneurysm presenting with third nerve palsy, with ptosis, outward deviation, and binocular diplopia, emphasizing the importance of considering ICAD as a differential diagnosis in patients with third nerve palsy due to the anatomical proximity of ICA to third nerve within the cavernous sinus.

Non-Paralytic Pontine Exotropia as a Predominant Sign of Brainstem Infarction - A Case Report

The association of internuclear ophthalmoplegia (INO) with exotropia in the contralateral eye is a rare finding, known as non-paralytic pontine exotropia (NPPE). We report a case of an 80-year-old woman with acute onset of diplopia on admission who presented with left eye exotropia with left-beating nystagmus whilst fixating with the right eye and inability to adduct the right eye on left gaze. Brain magnetic resonance imaging showed two small areas of vertebrobasilar territory ischaemic stroke, one beneath the inferior portion of the aqueduct and another in the right occipital lobe. Our case highlights an interesting clinical manifestation of brainstem infarction that, along with ocular motility examination, allowed us to review its pathophysiology, including the influence of the contralateral paramedian pontine reticular formation stimulation in the mechanism of contralateral exotropia in NPPE. The fast clinical resolution of these cases can explain the scarcity of NPPE reports.

[A case of bilateral medial medullary and left tegmentum of pontine infarction in whom DSA-MR fusion imaging identified infarct-relevant arteries]

We herein reported a patient with acute ischemic stroke in the bilateral medial medullary and the left tegmentum of the pons who presented with various neurological symptoms. Fusing digital subtraction angiography (DSA) and MRI (DSA-MR fusion imaging) could reveal the infarct-relevant arteries. A 41-year-old male presented with headache, bilateral arm's dysesthesia, quadriplegia, left Horner's syndrome, upbeat nystagmus, internuclear ophthalmoplegia and left peripheral facial paralysis. Diffusion weighted MRI (DWI) revealed the high intensity lesion in the bilateral medial medullary and the left tegmentum of the pons. MRA showed right vertebral artery (VA) occlusion. A high intensity on T₁ weighted imaging was shown on the right VA vessel wall. DSA-MR fusion imaging revealed the anterior spinal artery (ASA) occlusion proximal to the infarction. The stenosis was located at the origin of the right VA perforating branch distributing into the infarct lesion. The steno-occlusive lesion of ASA and VA perforating branch due to VA dissection resulted in infarction in the pontomedullary junction and caused various neurological symptoms. DSA-MR fusion imaging would prove the radiological anatomy of infarct-relevant arteries and clarify the etiology of ischemic stroke.

Wernekink commissure syndrome secondary to a rare 'V'-shaped pure midbrain infarction: a case report and review of the literature

Purpose: Wernekink commissure syndrome is a typical but extremely rare mesencephalic syndrome, and generally presents with bilateral cerebellar dysfunction, diverse oculomotor disorders and occasionally delayed-onset palatal myoclonus or tremor. However, it has been reported infrequently.Methods: We report a case of a 55-year-old man who suffered an acute paramedian midbrain infarction presenting with bilateral cerebellar ataxia, bilateral anterior internuclear ophthalmoplegia and unilateral pseudoabducens palsy, which is confirmed as Wernekink commissure syndrome by magnetic resonance imaging (MRI). We summarized the clinical data of this entity and performed a literature review of 20 previous reports of patients with this syndrome.Results: In combination with previous reports, we found that the most common symptom was bilateral cerebellar ataxia (100%) and other frequent symptoms were oculomotor disorders (81%), delayed palatal myoclonus or tremor (33%) and consciousness dysfunction (33%). Lesions on brain MRI of all patients affected the area of caudal paramedian midbrain (CPM).Conclusion: Bilateral cerebellar ataxia and lesions involved in the area of CPM on MRI are the major features of Wernekink commissure syndrome and should be the necessary conditions of diagnostic criteria. The simultaneous occurrence of bilateral cerebellar ataxia and oculomotor disorders is significant for localization diagnosis. Consciousness dysfunction is also a relatively frequent symptom of this syndrome. Moreover, pseudoabducens palsy might be attributed to a midbrain lesion. Clinicians should be familiar with and early to recognize this unique syndrome to avoid misdiagnosis.

Treatment of internuclear ophthalmoparesis in multiple sclerosis with fampridine: A randomized double-blind, placebo-controlled cross-over trial

Aim

To examine whether the velocity of saccadic eye movements in internuclear ophthalmoparesis (INO) improves with fampridine treatment in patients with multiple sclerosis (MS).

Methods

Randomized, double‐blind, placebo‐controlled, cross‐over trial with fampridine in patients with MS and INO. Horizontal saccades were recorded at baseline and at multiple time points post‐dose. Main outcome measures were the change of peak velocity versional dysconjugacy index (PV‐VDI) and first‐pass amplitude VDI (FPA‐VDI). Both parameters were compared between fampridine and placebo using a mixed model analysis of variance taking patients as their own control. Pharmacokinetics was determined by serial blood sampling.

Results

Thirteen patients had a bilateral and 10 had a unilateral INO. One patient had an INO of abduction (posterior INO of Lutz) and was excluded. Fampridine significantly reduced both PV‐VDI (−17.4%, 95% CI: −22.4%, −12.1%; P < 0.0001) and FPA‐VDI (−12.5%, 95% CI: −18.9%, −5.5%; P < 0.01). Pharmacokinetics demonstrated that testing coincided with the average t_max at 2.08 hours (SD 45 minutes). The main adverse event reported after administration of fampridine was dizziness (61%).

Conclusion

Fampridine improves saccadic eye movements due to INO in MS. Treatment response to fampridine may gauge patient selection for inclusion to remyelination strategies in MS using saccadic eye movements as primary outcome measure.

Nine Syndrome: Case Report and Review of Clinical Signs in Internuclear Ophthalmoplegia

The pathologic involvement of brainstem and midbrain nuclei and white matter tracts in various combinations may result in a spectrum of arithmetically derived syndromes. They include ‘one and a half syndrome’, ‘eight and a half syndrome’ and ‘fifteen and a half syndrome’. We report a case of ‘nine syndrome’, which has been reported more recently, caused by caused by acute pontine infarcts and characterised clinically by a combination of internuclear ophthalmolplegia, ipsilateral horizontal gaze palsy, lower motor neuron type of facial palsy, contralateral hemiparesis and hemianesthesia. We highlight the genesis of this combination of clinical signs, revisit the different variants of INO and review the literature on ‘Nine syndrome’.

Eye Movement Abnormalities in Multiple Sclerosis: Pathogenesis, Modeling, and Treatment

Multiple sclerosis (MS) commonly causes eye movement abnormalities that may have a significant impact on patients’ disability. Inflammatory demyelinating lesions, especially occurring in the posterior fossa, result in a wide range of disorders, spanning from acquired pendular nystagmus (APN) to internuclear ophthalmoplegia (INO), among the most common. As the control of eye movements is well understood in terms of anatomical substrate and underlying physiological network, studying ocular motor abnormalities in MS provides a unique opportunity to gain insights into mechanisms of disease. Quantitative measurement and modeling of eye movement disorders, such as INO, may lead to a better understanding of common symptoms encountered in MS, such as Uhthoff’s phenomenon and fatigue. In turn, the pathophysiology of a range of eye movement abnormalities, such as APN, has been clarified based on correlation of experimental model with lesion localization by neuroimaging in MS. Eye movement disorders have the potential of being utilized as structural and functional biomarkers of early cognitive deficit, and possibly help in assessing disease status and progression, and to serve as platform and functional outcome to test novel therapeutic agents for MS. Knowledge of neuropharmacology applied to eye movement dysfunction has guided testing and use of a number of pharmacological agents to treat some eye movement disorders found in MS, such as APN and other forms of central nystagmus.

Preferential Impairment of the Contralesional Posterior Semicircular Canal in Internuclear Ophthalmoplegia

BACKGROUND

The vertical vestibulo-ocular reflex (VOR) may be impaired in internuclear ophthalmoplegia (INO) as the medial longitudinal fasciculus (MLF) conveys VOR-signals from the vertical semicircular canals. It has been proposed that signals from the contralesional posterior semicircular canal (PSC) are exclusively transmitted through the MLF, while for the contralesional anterior canal other pathways exist.

OBJECTIVE

Here, we aimed to characterize dysfunction in individual canals in INO-patients using the video-head-impulse test (vHIT) and to test the hypothesis of dissociated vertical canal impairment in INO.

METHODS

Video-head-impulse testing and magnetic resonance imaging were obtained in 21 consecutive patients with unilateral (n = 16) or bilateral (n = 5) INO and 42 controls. VOR-gains and compensatory catch-up saccades were analyzed and the overall function (normal vs. impaired) of each semicircular canal was rated.

RESULTS

In unilateral INO, largest VOR-gain reductions were noted in the contralesional PSC (0.55 ± 0.11 vs. 0.89 ± 0.08, p < 0.001), while in bilateral INO both posterior (0.43 ± 0.11 vs. 0.89 ± 0.08, p < 0.001) and anterior (0.58 ± 0.19 vs. 0.88 ± 0.09, p < 0.001) canals showed marked drops. Small, but significant VOR-gain reductions were also found in the other canals in unilateral and bilateral INO-patients. Impairment of overall canal function was restricted to the contralesional posterior canal in 60% of unilateral INO-patients, while isolated involvement of the posterior canal was rare in bilateral INO-patients (20%). Reviewers correctly identified the INO-pattern in 15/21 (71%) patients and in all controls (sensitivity = 84.2% [95%-CI = 0.59.5-95.8]; specificity = 95.5% [95%-CI = 83.3-99.2]).

CONCLUSION

Using a vHIT based overall rating of canal function, the correct INO-pattern could be identified with high accuracy. The predominant and often selective impairment of the contralesional posterior canal in unilateral INO further supports the role of the MLF in transmitting posterior canal signals. In patients with acute dizziness and abnormal vHIT-results, central pathologies such as INO should be considered as well, especially when the posterior canal is involved.

Isolated medial longitudinal fasciculus syndrome: Review of imaging, anatomy, pathophysiology and differential diagnosis

Isolated medial longitudinal fasciculus (MLF) syndrome due to infarction limited only to the midbrain is a rare occurrence. The MLF are a group of fiber tracts located in the paramedian area of the midbrain and pons. They control horizontal eye movements by interconnecting oculomotor and abducens nuclei in the brain stem. Such small infarcts can easily be overlooked by young neuroradiologists and trainees. In this review, we discuss the clinical and imaging characteristics, comprehensive review of the anatomy, pathophysiology, and differential diagnosis.

Bilateral Internuclear Ophthalmoplegia as a Presenting Manifestation of Primary Sjögren's Syndrome

Bilateral internuclear ophthalmoplegia has been linked with various pathological conditions of the central nervous system (CNS), such as multiple sclerosis, stroke, tumours, and brainstem inflammatory processes. Herein the authors report a case of a 45-year-old female patient who presented with diplopia due to bilateral internuclear ophthalmoplegia, with no evidence of brainstem lesion in brain magnetic resonance imaging (MRI) and was diagnosed with primary Sjögren's syndrome.

Is there a role for optokinetic nystagmus testing in contemporary orthoptic practice? Old tricks and new perspectives

Optokinetic nystagmus is a physiological oscillation of the eyes that requires intact development of motion perception, pursuit function, and saccadic function to be smoothly executed. Neuro-ophthalmological disorders often produce distinct perturbations in optokinetic responses that can be used to unmask the clinical diagnosis. With the advent of modern neuroimaging, optokinetic testing has slowly become a lost art in clinical examination. The purpose of this paper is to review the conditions wherein optokinetic testing provides a critical neurodiagnostic role, and to revitalize interest in this simple and valuable clinical tool.

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.