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Isolated Fourth Nerve Palsy in Nontraumatic Tentorial Hemorrhage

Walter, Eyal, MD; Trobe, Jonathan D., MD

Section Editor(s): Ko, Melissa W. MD; Cestari, Dean M. MD

Journal of Neuro-Ophthalmology: March 2019 - Volume 39 - Issue 1 - p 122–124
doi: 10.1097/WNO.0000000000000708
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Abstract: A 46-year-old woman being treated with warfarin for antiphospholipid antibody syndrome experienced a rise in international normalized ratio (INR) to 5.4 and developed sudden headache and diplopia. Neuro-ophthalmologic examination disclosed a right fourth nerve palsy. Noncontrast computed tomography revealed a subdural hematoma layered along the right tentorium cerebelli, directly in the path of the nerve. With normalization of the INR, the palsy markedly improved over subsequent weeks. This is a unique case of a nontraumatic subdural hematoma causing a fourth nerve palsy.

Department of Ophthalmology and Visual Sciences (EW, JDT), Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan; and Department of Neurology (JDT), University of Michigan, Ann Arbor, Michigan.

Address correspondence to Jonathan D. Trobe, MD, University of Michigan, Ann Arbor, MI 48105; E-mail:

The authors report no conflicts of interest.

© 2019 by North American Neuro-Ophthalmology Society