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Case Reports
. 2021 Sep 14;14(9):e244830.
doi: 10.1136/bcr-2021-244830.

Wall eyed bilateral internuclear ophthalmoplegia (WEBINO) syndrome as a false localising sign in intracranial haemorrhage due to snake bite

Shruti Sinha  1 , Bhaimangesh Bhanudas Naik  2 , Jaishree Ghanekar  2
Affiliations
Case Reports

Wall eyed bilateral internuclear ophthalmoplegia (WEBINO) syndrome as a false localising sign in intracranial haemorrhage due to snake bite

Shruti Sinha et al. BMJ Case Rep. .

Abstract

A 48-year-old woman presented with sudden-onset altered sensorium 2 days after a snake bite (unidentified species) and was found to have a large right frontal intracerebral haemorrhage (ICH) with transtentorial herniation (TTH) causing brain stem compression. A day later, neurological examination revealed internuclear ophthalmoplegia (INO) fitting the clinical description of wall eyed bilateral INO syndrome. INO is a rare ocular motor sign, the most common causes being brain stem infarction, haemorrhage or demyelinating disease. It rarely acts as a false localising sign, such as in this case, and in an even rarer cause for ICH, that is, haemotoxic snake bite without initial evidence of coagulopathy. An emphasis needs to be laid on detailed physical examination, often considered a lost art nowadays, to help detect subtle clinical signs which could herald ominous complications of conditions like TTH and help in early diagnosis and treatment of the same.

Keywords: brain stem / cerebellum; cranial nerves; emergency medicine; neurology.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Fang marks (of an unidentified species of snake) with a linear abrasion, visible near the nail bed of the right fourth finger.
Figure 2
Figure 2
Extraocular movements depicting bilateral exotropia (Right > Left) on primary gaze and adduction palsy of contralateral eye on horizontal gaze bilaterally, suggestive of wall eyed bilateral internuclear ophthalmoplegia.
Figure 3
Figure 3
Loss of convergence (as depicted in this case) may be a feature of WEBINO syndrome. WEBINO, wall eyed bilateral internuclear ophthalmoplegia.
Figure 4
Figure 4
Non-contrast CT of the brain depicting a large acute intracranial haematoma with surrounding intracerebral oedema in the right frontoparietal cortex with midline shift to left and effacement of basal cisterns suggestive of transtentorial herniation, at admission (left) and 10 days later, at discharge (right), showing reduction of oedema with more clearly defined midline structures.
See this image and copyright information in PMC

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