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Volume 15
Issue 23
10.3390/diagnostics15233082
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Systematic Review

Trochlear Nerve Palsy: A Systematic Review of Etiologies and Diagnostic Insights

by
Areti Alexandrou
1,†,
Nicholas Georgiou
1,†,
George G. Botis
1,2,
Ioannis Vezakis
2,
George Triantafyllou
1,3,
Eirini Christodoulaki
1,
Harris Pishiaras
1,
Alexandros Samolis
1,
Nikiforos Christakos
1,
Theodosis Kalamatianos
4,5,
Ioannis Lamprianidis
1,
Ioannis Kakkos
2,
George K. Matsopoulos
2,
George Tsakotos
1,
Ourania Tzortzi
1 and
Maria Piagkou
1,3,*
1
Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, 11527 Athens, Greece
2
Biomedical Engineering Laboratory, School of Electrical and Computer Engineering, National Technical University of Athens, 15772 Athens, Greece
3
“VARIANTIS” Research Laboratory, Department of Clinical Anatomy, Masovian Academy in Plock, 09402 Plock, Poland
4
Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, 10676 Athens, Greece
5
Department of Biomedical Engineering, University of West Attica, 12243 Athens, Greece
*
Author to whom correspondence should be addressed.
†
These authors contributed equally to this work.
Diagnostics 2025, 15(23), 3082; https://doi.org/10.3390/diagnostics15233082
Submission received: 19 September 2025 / Revised: 16 November 2025 / Accepted: 30 November 2025 / Published: 3 December 2025
(This article belongs to the Special Issue Imaging and Diagnosis in Neurosurgery)
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Abstract

Background/Objectives: Trochlear nerve palsy (TNP) is a clinically significant neuro-ophthalmic disorder with a broad and heterogeneous etiologic spectrum. Due to the trochlear nerve (TN)’s long intracranial course and its proximity to key neurosurgical corridors, it is particularly susceptible to injury. This systematic review aimed to synthesize contemporary evidence on TNP etiologies and highlight diagnostic considerations. Methods: Following PRISMA 2020 guidelines (PROSPERO registration: CRD420251150614), we systematically searched PubMed through July 2025 for studies reporting TNP etiologies. Given substantial heterogeneity in study populations and methodologies, a qualitative synthesis was performed examining study characteristics, patient demographics, etiological distribution, and clinical outcomes. Results: Thirty-three studies (n = 5785) met the inclusion criteria. Reported etiologies clustered into seven categories: congenital, vascular/ischemic, infectious/inflammatory, structural, traumatic, iatrogenic, and idiopathic. Congenital cases frequently demonstrated absence of the TN or superior oblique hypoplasia. Microvascular ischemia predominated in older adults with vascular risk factors and typically exhibited spontaneous recovery. Structural lesions (e.g., tumors, aneurysms) and trauma were major acquired causes, often associated with more persistent deficits. Iatrogenic palsy predominantly followed skull base and petroclival procedures; most cases resolved, although lasting dysfunction occurred after complex or radiosurgical interventions. A proportion of cases remained idiopathic, and many resolved spontaneously. Conclusions: TNP displays a broad etiologic spectrum with distinct clinical profiles and prognostic trajectories. Accurate etiologic classifications supported by targeted neuroimaging and focused clinical evaluation are essential for optimizing management and informing neurosurgical decision-making.
Keywords: trochlear nerve; fourth nerve; cranial nerve IV; superior oblique; diplopia; ocular motor cranial neuropathy; ischemic neuropathy; skull base surgery; iatrogenic injury trochlear nerve; fourth nerve; cranial nerve IV; superior oblique; diplopia; ocular motor cranial neuropathy; ischemic neuropathy; skull base surgery; iatrogenic injury

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MDPI and ACS Style

Alexandrou, A.; Georgiou, N.; Botis, G.G.; Vezakis, I.; Triantafyllou, G.; Christodoulaki, E.; Pishiaras, H.; Samolis, A.; Christakos, N.; Kalamatianos, T.; et al. Trochlear Nerve Palsy: A Systematic Review of Etiologies and Diagnostic Insights. Diagnostics 2025, 15, 3082. https://doi.org/10.3390/diagnostics15233082

AMA Style

Alexandrou A, Georgiou N, Botis GG, Vezakis I, Triantafyllou G, Christodoulaki E, Pishiaras H, Samolis A, Christakos N, Kalamatianos T, et al. Trochlear Nerve Palsy: A Systematic Review of Etiologies and Diagnostic Insights. Diagnostics. 2025; 15(23):3082. https://doi.org/10.3390/diagnostics15233082

Chicago/Turabian Style

Alexandrou, Areti, Nicholas Georgiou, George G. Botis, Ioannis Vezakis, George Triantafyllou, Eirini Christodoulaki, Harris Pishiaras, Alexandros Samolis, Nikiforos Christakos, Theodosis Kalamatianos, and et al. 2025. "Trochlear Nerve Palsy: A Systematic Review of Etiologies and Diagnostic Insights" Diagnostics 15, no. 23: 3082. https://doi.org/10.3390/diagnostics15233082

APA Style

Alexandrou, A., Georgiou, N., Botis, G. G., Vezakis, I., Triantafyllou, G., Christodoulaki, E., Pishiaras, H., Samolis, A., Christakos, N., Kalamatianos, T., Lamprianidis, I., Kakkos, I., Matsopoulos, G. K., Tsakotos, G., Tzortzi, O., & Piagkou, M. (2025). Trochlear Nerve Palsy: A Systematic Review of Etiologies and Diagnostic Insights. Diagnostics, 15(23), 3082. https://doi.org/10.3390/diagnostics15233082

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