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A 67-year-old man was found comatose after subarachnoid hemorrhage from rerupture of a previously clipped anterior communicating artery aneurysm. He had no motor response and no eye opening in response to pain. Corneal, cough, and pupil reflexes were intact. Initially he had forced downward gaze with small reactive pupils that evolved in a matter of hours to an extreme exotropia of both eyes that persisted for days (Figure 1). Oculovestibular responses to cold caloric stimulation were absent.
A, Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) after subarachnoid hemorrhage. B-D, Resolution of WEBINO after ventriculostomy and improvement in intraventricular hemorrhage was seen 20 days after presentation.
Noncontrast head computed tomography showing subarachnoid hemorrhage, cerebral edema, and marked intraventricular blood with hydrocephalus. Note the enlarged fourth ventricle (E) and aqueduct filled with blood (D). Angiogram images are before (C) and after (F) endovascular coiling.
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