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Nuclear Fourth Nerve Palsy

      A 71-year-old woman reported vertical diplopia immediately following cardiac catheterization. On examination, she had a right hypertropia that increased on left gaze and right head tilt, with 8 degrees of excyclotorsion of the right eye in primary gaze. She had no other neurologic findings. Postcontrast axial computed tomography (Fig A) and sagittal T1 magnetic resonance imaging (Fig B) demonstrate enhancement of the left fourth nerve nucleus (arrows). Companion anatomic illustrations show the location of the fourth nerve nucleus in the caudal midbrain and its decussation to innervate the contralateral superior oblique muscle. The patient experienced a presumed embolic stroke of the left fourth nerve nucleus (Magnified version of Fig A-B is available online at www.aaojournal.org).
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