Teaching Video NeuroImages: Pulsatile proptosis and wall-eyed bilateral internuclear ophthalmoplegia
Eleni Papageorgiou, Evangelia E. Tsironi, Sofia Androudi and Petros Koltsidopoulos
Neurology. April 24, 2018; 90 (17) RESIDENT & FELLOW SECTION

ARTICLE
A 65-year-old man with a history of hypertension presented with double vision. Examination revealed wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) (figure 1) and nonsymptomatic, pulse-synchronous, pulsatile proptosis of the left eye (video, links.lww.com/WNL/A389). According to the patient, there was a history of blunt head trauma in childhood and the pulsatile eye was present since then. CT revealed a meningocele into the left orbit due to a bony defect in the orbital roof (figure 2A). CT angiography ruled out a carotid-cavernous fistula. MRI showed an acute infarction at the midline of the midbrain tegmentum, which involved the medial longitudinal fasciculus bilaterally and caused the WEBINO (figure 2B).1 The pulsatile proptosis was attributed to the childhood head injury and due to the orbital roof fracture and associated meningocele pulsation of the brain vessels passed onto the CSF.2

Figure 1 Extraocular movements in 9 cardinal gaze positions
Extraocular eye movements demonstrate exotropia of both eyes in primary positions and bilateral internuclear ophthalmoplegia with impaired adduction on attempted lateral gaze. Upgaze is also mildly affected.

Figure 2 Coronal brain CT and axial brain MRI
(A) Coronal brain CT shows fracture of the left orbital roof with an associated meningocele.
(B) T2-weighted axial brain MRI demonstrates an acute infarction at the midline of the midbrain tegmentum, which involves the medial longitudinal fasciculus bilaterally.

Author contributions E.P.: study concept and design, acquisition of data, analysis and interpretation, writing of the manuscript. E.E.T. and S.A.: study supervision, critical revision of the manuscript for important intellectual content. P.K.: acquisition of data, analysis and interpretation.

Study funding No targeted funding reported.

Disclosure The authors report no disclosures relevant to the manuscript.

References:
1. Kim JS, Jeong SH, Oh YM, Yang YS, Kim SY. Teaching NeuroImage: wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) from midbrain infarction. Neurology 2008;70:e35.
2. Chousterman B, Gualino V, Dohan A, Payen D. A mysterious post-traumatic pulsatile exophthalmos. Intens Care Med 2014;40:102–103.