Trochlear nerve palsy with contralateral Horner's syndrome: A rare presentation post trauma

Abstract

We describe a case of posttraumatic vertical diplopia and Horner's syndrome (HS). The patient presented 2 weeks post road traffic accident with acute onset double vision more in left gaze and right tilt. The left eye had mild ptosis. The apparent elevation deficit in the left eye in levoelevation was misinterpreted as left eye superior rectus paresis instead of right eye inferior oblique overaction and thus mimicked superior division third nerve palsy in the left eye. Anisocoria was more in the dark. Computerized tomography of the brain and orbit was normal. Magnetic resonance imaging of the cervical spine showed left C6–C7 nerve root avulsion. A diagnosis of right fourth nerve palsy with left eye HS secondary to brachial plexus injury was made. We could not find a previous description of fourth nerve palsy with contralateral HS following trauma in the literature.

Keywords

• brachial plexus injury
• horner's syndrome
• trochlear nerve palsy