Wall-Eyed Monocular Internuclear Ophthalmoplegia (WEMINO) and Millard-Gubler Syndromes in a Patient with Isolated Pontine Infarction: Topographic, Oculomotor, and Radiological Analysis of Two Very Uncommon Conditions

Abstract

The syndromes of wall-eyed monocular internuclear ophthalmoplegia and Millard-Gubler are very rare clinical complexes commonly caused by pontine infarction, hemorrhage, or tumors that compromise the paramedian tegmentum, medial longitudinal fascicle, and the basis pontis. We present the case of a 58-year-old female with an isolated pontine infarction characterized by acute vertigo, sudden horizontal diplopia due to ipsilateral internuclear ophthalmoplegia with exotropia, facial palsy and contralateral hemiparesis. This report analyzes, theorizes, and emphasizes the correlation between these atypical neurological findings, the pontine anatomy, and magnetic resonance imaging; encouraging the clinician to make expeditious diagnoses using the bedside skills and a high-quality oculomotor clinical examination. The phenotype and simultaneity of both syndromes makes this case a didactic exercise for the topo-diagnosis based on the neurology of eye movements, the intrinsic physiology of the pons, and the pathways that emerge or project towards it.

Millard-Gubler Syndrome Associated with Cerebellar Ataxia in a Patient with Isolated Paramedian Pontine Infarction – A Rarely Observed Combination with a Benign Prognosis: A Case Report

“…MGS is a clinical syndrome which occurs following lesions involving the ventral portion of the caudal pons, resulting in classic clinical features such as ipsilateral abducens and facial nerve palsy and contralateral hemiparesis [3, 5, 11, 12]. The present patient presented late to our clinic, and by the time of evaluation he had horizontal nystagmus and gaze palsy from abducens nerve affection, dysarthria from ipsilateral facial muscle weakness, and contralateral (right)-sided appendicular ataxia.…”

Wall-Eyed Bilateral Internuclear Ophthalmoplegia Caused by Unilateral Subpontine Infarction: A Case Report

“…Only two cases were retrieved: one did not address the cause of the WEBINO [22] , whereas the other implicated abnormal vestibular signals to the MRSN, with resultant muscle tone asymmetry and ocular abduction toward the injured side. [23] Both the latter case and the present case included vertigo, which was likely related to the presence of the vestibule. Hence, the neural pathways between the pons and midbrain need to be further studied.…”

A Case of Traumatic Medial Longitudinal Fasciculus Syndrome Whose Causal Lesion Was Detected by Thin-Section MRI with Susceptibility-Weighted Imaging

“…Dissociated nystagmus is usually resolved earlier than adduction disturbance and becomes undetectable after the acute phase; hence, some cases were diagnosed as MLF syndrome only with monocular adduction disturbance [5]. In addition, the present case showed mild exotropia at the first presentation which could fit into Wall-Eyed Monocular Inter-Nuclear Ophthalmoplegia, a rare variant of INO [8, 9]. A previous report described that the most frequent cause of MLF syndrome was brain infarction (38%) and the next was multiple sclerosis (34%).…”