The most cases with orbital metastases have been reported in patients with a prior established diagnosis of cancer and widespread systemic involvement. However, ocular symptoms can be developed as an initial presentation of cancer in patients without cancer history. We report a case of rapid progression from trochlear nerve palsy to orbital apex syndrome as an initial presentation of advanced gastric cancer.
Diagnosis ; Diplopia ; Humans ; Neoplasm Metastasis ; Optic Nerve Diseases ; Orbit ; Stomach Neoplasms ; Trochlear Nerve Diseases ; Trochlear Nerve

Cranial nerve palsies are relatively common after trauma, but trochlear nerve palsy is relatively uncommon. Although traumatic trochlear nerve palsy is easy to diagnose clinically because of extraocular movement disturbances, radiologic evaluations of this condition are difficult to perform because of the nerve's small size. Here, we report the case of a patient with delayed traumatic trochlear nerve palsy associated with a traumatic subarachnoid hemorrhage (SAH) and the related radiological findings, as obtained with high-resolution three-dimensional (3D) magnetic resonance imaging (MRI). A 63-year-old woman was brought to the emergency room after a minor head trauma. Neurologic examinations did not reveal any focal neurologic deficits. Brain computed tomography showed a traumatic SAH at the left ambient cistern. The patient complained of vertical diplopia at 3 days post-trauma. Ophthalmologic evaluations revealed trochlear nerve palsy on the left side. High-resolution 3D MRI, performed 20 days post-trauma, revealed continuity of the trochlear nerve and its abutted course by the posterior cerebral artery branch at the brain stem. Chemical irritation due to the SAH and the abutting nerve course were considered causative factors. The trochlear nerve palsy completely resolved during follow-up. This case shows the usefulness of high-resolution 3D MRI for evaluating trochlear nerve palsy.
Brain ; Brain Stem ; Cranial Nerve Diseases ; Craniocerebral Trauma ; Diplopia ; Emergency Service, Hospital ; Female ; Follow-Up Studies ; Humans ; Imaging, Three-Dimensional ; Magnetic Resonance Imaging* ; Middle Aged ; Neurologic Examination ; Neurologic Manifestations ; Posterior Cerebral Artery ; Subarachnoid Hemorrhage, Traumatic* ; Trochlear Nerve Diseases* ; Trochlear Nerve*

PURPOSE: To report a case of trochlear nerve palsy caused by quadrigeminal cistern lipoma located in the dorsal midbrain. CASE SUMMARY: A 65-year-old male visited our clinic for intermittent vertical diplopia over 2-year period. Symptoms of diplopia had worsened over the past two weeks. He had no previous medical history except having had diabetes for 1 month. The best-corrected visual acuity was 20/25 in the right eye and 20/20 in the left eye. Pupillary examination was not remarkable. Extraocular examination showed 4 prism diopters (PD) left hypertropia at distant gaze and 4 PD exotropia at near gaze, with adduction elevation of the left eye. The Bielschowsky head tilt test revealed 6 PD left hypertropia on the left gaze and orthotropia on the right tilt. Fundus examination showed excyclotorsion of the right eye and incyclotorsion of the left eye. Brain magnetic resonance imaging revealed quadrigeminal cistern lipoma. Prism glasses were prescribed to alleviate diplopia, and we followed up the lesions without further treatment. CONCLUSIONS: Trochlear nerve palsy can be caused by quadrigeminal cistern lipoma; however, it is uncommon for this condition to be caused by a compressive lesion. Prompt neuroimaging can be helpful to rule out the causes of this condition in patients with atypical symptoms.
Aged ; Brain ; Diplopia ; Exotropia ; Eyeglasses ; Glass ; Head ; Humans ; Lipoma ; Magnetic Resonance Imaging ; Male ; Mesencephalon ; Neuroimaging ; Strabismus ; Trochlear Nerve Diseases ; Trochlear Nerve ; Visual Acuity

Superior oblique myokymia (SOM) is a rare disorder characterized by unilateral paroxysmal oscillopsia or diplopia. Recent studies revealed that SOM can be associated with neuro-vascular cross compression (NVCC) of the trunk of the trochlear nerve. Although it frequently occurs without any underlying systemic disease or concurrent neurologic sign, we need to consider this NVCC especially in cases with persistent disturbing symptoms. Hereby, we present two cases of SOM whose neuroimaging studies suggest NVCCs and, discuss recent update of the pathomechanism of SOM.
Diplopia ; Nerve Compression Syndromes ; Neuroimaging ; Neurologic Manifestations ; Trochlear Nerve ; Trochlear Nerve Diseases

Congenital cranial dysinnervation disorders are a group of diseases caused by abnormal development of cranial nerve nuclei or their axonal connections, resulting in aberrant innervation of the ocular and facial musculature. Its diagnosis could be facilitated by the development of high resolution thin-section magnetic resonance imaging. The purpose of this review is to describe the method to visualize cranial nerves III, IV, and VI and to present the imaging findings of congenital cranial dysinnervation disorders including congenital oculomotor nerve palsy, congenital trochlear nerve palsy, Duane retraction syndrome, Möbius syndrome, congenital fibrosis of the extraocular muscles, synergistic divergence, and synergistic convergence.
Axons ; Cranial Nerves* ; Diagnosis ; Duane Retraction Syndrome ; Fibrosis ; Magnetic Resonance Imaging ; Methods ; Muscles ; Oculomotor Nerve Diseases ; Trochlear Nerve Diseases

Paranasal sinus mucoceles are an uncommon cause of isolated palsies of cranial nerves III, IV, and VI. The trochlear nerve has been reported to be less frequently affected than the abducens and oculomotor nerves. Isolated sphenoid sinus diseases may cause serious complications by involving adjacent vital structures such as the optic nerve, cavernous sinus, internal carotid artery, and cranial nerves III–VI. We report a case of a 76-year-old woman who presented to our emergency department with a chief complaint of acute double vision and headache. Her diplopia was diagnosed as left trochlear nerve palsy. Brain CT and MRI revealed expanding cystic lesions in both sphenoid sinuses with bony erosion of the left sinus wall. The patient underwent an endoscopic intranasal sphenoidotomy and recovered completely from diplopia at postoperative 2 months. The relationship between the trochlear nerve palsy and its anatomy is also discussed.
Aged ; Brain ; Carotid Artery, Internal ; Cavernous Sinus ; Cranial Nerves ; Diplopia ; Emergency Service, Hospital ; Female ; Headache ; Humans ; Magnetic Resonance Imaging ; Mucocele* ; Oculomotor Nerve ; Optic Nerve ; Paralysis ; Sphenoid Sinus* ; Trochlear Nerve Diseases* ; Trochlear Nerve*

PURPOSE: Superior oblique myokymia is intermittent spontaneous contractions of the superior oblique muscle presenting as rapid and small-amplitude intorsions and depressions of the eye. The authors report a case of superior oblique myokymia that was objectively and quantitatively diagnosed with slit lamp examination and video-oculography and completely resolved with medical treatment. CASE SUMMARY: A 44-year-old woman presented with a seven-year history of intermittent oscillopsia which continued for few seconds. She had no history of head trauma or systemic ocular disease, and the anterior segment and fundus examination were unremarkable. Right eye intorsion lasting for a few seconds as detected by slit lamp examination. Eye movements were recorded using video-oculography, which showed a torsional nystagmus of 5 to 10 degrees with 2 to 5 vertical components in the right eye. Based on these findings, the patient was diagnosed with superior oblique myokymia. The patient was prescribed topical timolol ophthalmic solution, one drop twice per day, but the symptoms persisted. Timolol ophthalmic solution was stopped and replaced with carbamazepine, 200 mg twice a day, which resolved her symptoms. CONCLUSIONS: Slit lamp examination and video-oculography can be used as objective and quantitative diagnostic tools in order to confirmed a diagnosis and lead to proper treatment.
Adult ; Carbamazepine ; Craniocerebral Trauma ; Depression ; Diagnosis* ; Eye Movements ; Female ; Humans ; Slit Lamp ; Timolol ; Trochlear Nerve Diseases*

PURPOSE: To investigate the clinical features and risk factors of ischemic third, fourth, sixth cranial nerve palsy. METHODS: Retrospectively, we reviewed the medical records of 46 eyes of 46 patients who were diagnosed with ischemic third, fourth, sixth nerve palsy alone such as age of onset, risk factors, recovery rate and recovery time. RESULTS: The mean age of onset was 64.9 years. Of the 46 patients, 15 patients (32.6%) in third cranial nerve palsy group, 15 patients (32.6%) in fourth cranial nerve palsy group, 16 patients (34.8%) in sixth cranial nerve palsy group. The risk factor of hypertension in 30 patients (65.2%) was the most common than other risk factors such as diabetes, hyperlipidemia, elevated blood hematocrit, ischemic heart disease, left ventricular hypertrophy, smoking. The mean number of risk factors was 2.3 +/- 0.5 in third cranial nerve palsy group, 1.6 +/- 1.1 in sixth cranial nerve palsy group, 1.4 +/- 1.1 in fourth cranial nerve palsy group. Of the 46 patients, 42 patients (91.3%) were recovered. There was no significant difference in recovery rate by cranial nerve palsy. Recovery time of intracranial abnormalities group (10.5 +/- 2.9 weeks) in brain imaging study was late as compared with that of no intracranial abnormalities group (7.5 +/- 5.1 weeks). CONCLUSIONS: The overall recovery rate of isolated ischemic third, fourth, sixth cranial nerve was high. But if there are intracranial abnormalities in imaging study, it took a long time to recover. Also ischemic third cranial nerve palsy had multiple risk factors characteristically.
Abducens Nerve ; Abducens Nerve Diseases ; Age of Onset ; Cranial Nerve Diseases* ; Hematocrit ; Humans ; Hyperlipidemias ; Hypertension ; Hypertrophy, Left Ventricular ; Medical Records ; Myocardial Ischemia ; Neuroimaging ; Oculomotor Nerve ; Paralysis ; Prognosis* ; Retrospective Studies ; Risk Factors* ; Smoke ; Smoking ; Trochlear Nerve Diseases

PURPOSE: To investigate the clinical features and risk factors of ischemic third, fourth, sixth cranial nerve palsy. METHODS: Retrospectively, we reviewed the medical records of 46 eyes of 46 patients who were diagnosed with ischemic third, fourth, sixth nerve palsy alone such as age of onset, risk factors, recovery rate and recovery time. RESULTS: The mean age of onset was 64.9 years. Of the 46 patients, 15 patients (32.6%) in third cranial nerve palsy group, 15 patients (32.6%) in fourth cranial nerve palsy group, 16 patients (34.8%) in sixth cranial nerve palsy group. The risk factor of hypertension in 30 patients (65.2%) was the most common than other risk factors such as diabetes, hyperlipidemia, elevated blood hematocrit, ischemic heart disease, left ventricular hypertrophy, smoking. The mean number of risk factors was 2.3 +/- 0.5 in third cranial nerve palsy group, 1.6 +/- 1.1 in sixth cranial nerve palsy group, 1.4 +/- 1.1 in fourth cranial nerve palsy group. Of the 46 patients, 42 patients (91.3%) were recovered. There was no significant difference in recovery rate by cranial nerve palsy. Recovery time of intracranial abnormalities group (10.5 +/- 2.9 weeks) in brain imaging study was late as compared with that of no intracranial abnormalities group (7.5 +/- 5.1 weeks). CONCLUSIONS: The overall recovery rate of isolated ischemic third, fourth, sixth cranial nerve was high. But if there are intracranial abnormalities in imaging study, it took a long time to recover. Also ischemic third cranial nerve palsy had multiple risk factors characteristically.
Abducens Nerve ; Abducens Nerve Diseases ; Age of Onset ; Cranial Nerve Diseases* ; Hematocrit ; Humans ; Hyperlipidemias ; Hypertension ; Hypertrophy, Left Ventricular ; Medical Records ; Myocardial Ischemia ; Neuroimaging ; Oculomotor Nerve ; Paralysis ; Prognosis* ; Retrospective Studies ; Risk Factors* ; Smoke ; Smoking ; Trochlear Nerve Diseases

PURPOSE: To report a case of bilateral trochlear nerve palsy following cisternography. CASE SUMMARY: A 43-year-old male with intermittent watery rhinorrhea persisting for 3 months visited the neurosurgery department of our institute. His past medical history included removal of a pituitary adenoma 22 years prior to presentation. Cerebrospinal fluid leakage was suspected and cisternography was performed. The patient was referred to our ophthalmology department for diplopia 3 days after the cisternography. An alternate prism cover test showed 5 prism diopter (PD) right hypertrophia in the primary position, and underaction of bilateral superior oblique muscles and overaction of the left inferior oblique muscle. A positive Bielschowsky test with the head tilted to either side was observed and excyclotorsion was 9degrees on the double Maddox rod test. The patient was diagnosed with bilateral trochlear nerve palsy. After 2 years of follow-up, diplopia persisted and recession of the bilateral inferior oblique muscles was performed. After the surgery, diplopia disappeared, the fundus photography showed no excyclotorsion, and the double Maddox rod test indicated 3degrees of excyclotorsion. CONCLUSIONS: Cisternography should be carefully performed due to the possibility of bilateral trochlear nerve palsy, an extremely rare but possible occurrence following the procedure.
Adult ; Cerebrospinal Fluid ; Diplopia ; Follow-Up Studies ; Head ; Humans ; Male ; Muscles ; Neurosurgery ; Ophthalmology ; Photography ; Pituitary Neoplasms ; Spinal Puncture ; Trochlear Nerve Diseases* ; Trochlear Nerve*