Trochlear Nerve Palsy Caused by Quadrigeminal Cistern Lipoma

Nam Hyeon Choi; Won Jae Kim; Myung-Mi Kim

doi:10.3341/jkos.2018.59.11.1087

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Choi, Kim, and Kim: Trochlear Nerve Palsy Caused by Quadrigeminal Cistern Lipoma

Case Report

Journal of the Korean Ophthalmological Society 2018; 59(11): 1087-1090.

Published online: 16 November 2018

DOI: https://doi.org/10.3341/jkos.2018.59.11.1087

Trochlear Nerve Palsy Caused by Quadrigeminal Cistern Lipoma

Nam Hyeon Choi, MD, Won Jae Kim, MD, Myung-Mi Kim, MD, PhD

Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea.

Address reprint requests to Myung-Mi Kim, MD, PhD. Department of Ophthalmology, Yeungnam University Hospital, #170 Hyeonchung-ro, Nam-gu, Daegu 42415, Korea. Tel: 82-53-620-3441, Fax: 82-53-626-5936, mmk@med.yu.ac.kr

Received 5 July 2018 Revised 20 August 2018 Accepted 18 October 2018

The Korean Ophthalmological Society

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

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.

Keywords: Diplopia, Lipoma, Quadrigeminal cistern, Trochlear nerve palsy

Figures and Tables

Figure 1

Image of the patient in nine diagnostic position and both side tilting. The patient showed left hypertropia at primary position with elevation in adduction of the left eye. The hypertropia of the left eye increased in left side tilting position.

Figure 2

T1-weighted magnetic resonance imaging (MRI) of brain. (A) Sagittal T1-weighted magnetic resonance imaging (MRI) of brain showed a well-defined hyperintensity suggesting lipoma in median region of quadrigeminal cistern adjacent to the anterior medullary vellum (arrow). (B) Axial T1-weighted MRI image demonstrated lipoma located adjacent to the emerging site of trochlear nerve fiber (arrowhead).

Notes

^{Conflicts of Interest} The authors have no conflicts to disclose.

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