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In our study, persistent isolated 4th nerve palsy had the most frequency, so the trauma is the most common cause of isolated, unilateral or bilateral acquired palsies of the 4th nerve when a cause can be determined[33]. Hara et al [17]pointed out the coincidence of trochlear nerve palsy with subarachnoied hematoma. This association was observedbyhigh frequency of subarachnoied hematoma and trochlear nerve palsy in our study.
In a study by Park et al [34]on 206 patients with acquired third, fourth, and sixth cranial nerve palsy, results showed that the sixth cranial nerve was affected most frequently (52.4%) and vascular disease (31.1%) was the most common etiology. In study of Tiffin et al [35]on 165 cases with acquired third, fourth and sixth cranial nerve palsy, 35% had unknown etiology and 32% had vascular etiology. The incidence of sinister pathology such as neoplasia (2%) and aneurysm (1%) was surprisingly low. The sixth nerve palsies accounted for the majority of patients (57%), with the 4th nerve palsies (21%) occurring more frequently than the 3rd nerve palsies (17%) and multiple palsies (5%).
In Berlit[36] study of 412 patients with isolated or combined ocular nerve palsies 165 ocular nerve palsies were due to vascular causes. Oculomotor nerve palsies (n=172) and the abducens nerve palsies (n=165) were more frequent than trochlear nerve (n=25). Combined ocular nerve palsies (n=50)were generally combination of the 3rd and 6th cranial nerves (n=21) or pareses of all three ocular nerves (n=17). Also Richards et al [37]reported the abducens nerve as the most commonly affected nerve from collected data of 4278 patients with ocular palsies.
Traffic accidents and assaults were the major causes of acquired oculomotor nerve palsy of 120 patients in study[25]. Relatively high frequency of abducens nerve palsy in our study can draw trauma as the principal cause.
Although the relationship between closed head injury (CHI) and the clinical and imaging features of cranial nerve 3, 4, and 6 palsies has not been strictly addressed in a large number of studies. Dhaliwal et al[8] reviewed 210 consecutive patients with CHI from 1987 to 2002. Those with cranial nerve 3 palsy had the most severe head injury; those with cranial nerve 4 palsy had an intermediate level of head injury; and those with cranial nerve 6 palsy had the lowest level of head injury. Palsy of 3rd cranial nerve was associated with relatively more severe CHI than was palsy of cranial nerves 4 or 6. In our study cranial nerve palsy 3 and combination of 3rd and 4th cranial nerves palsy had the lowest frequency（ 14.3%) and severe head injury was observed in 8 cases (2.7%).
In conclusion, in view of the occurrence of cranial nerve palsy in minor head trauma and high frequency of head traumatic patients with GCS 1315 (minor head trauma) who are mostly in emergency room, it is advised in the clinical examination of ocular motor nerves especially trochlear nerve to detect likely hidden damage in this group of patients.
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