Wall-Eyed Bilateral Internuclear Ophthalmoplegia With Concomitant Facial Diplegia: A Case Report and Review of the...

Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) syndrome is a rare neuro-ophthalmological condition. Its association with facial diplegia is even more uncommon, making this combination one of the rarest brainstem syndromes, with only a few cases reported in the literature. We report the case of a 62-year-old woman with multiple cardiovascular risk factors and a history of stroke attributed to small vessel disease. She presented with the sudden onset of diplopia and bilateral facial palsy. Neurological examination revealed WEBINO syndrome associated with facial diplegia. Brain magnetic resonance imaging demonstrated two bilateral acute ischemic lesions within the dorsal pontine tegmentum. Magnetic resonance angiography revealed atherosclerosis of the basilar artery and the right vertebral artery. Cardiac investigations, including an electrocardiogram and transthoracic echocardiography, were normal. Laboratory investigations were within normal limits apart from an elevated HbA1c. The presence of two bilateral pontine tegmental infarcts, rather than the single midline lesion reported in previous cases, suggests possible involvement of two paramedian perforating arteries. We hypothesize that this pattern may reflect a vascular variant in which the paramedian perforating arteries share a common origin from the basilar artery. This case may help clinicians recognize this rare pontine tegmental syndrome and highlight a distinct radiological pattern in WEBINO syndrome with facial diplegia.