Introduction: Intracranial lipomas account for <0.1% of primary brain lesions. They are most often asymptomatic incidental imaging findings, however have been reported to cause elevated ICP and seizures. Description: We present a case report of a 71 year old male with worsening binocular oblique diplopia since onset 3 years prior, found to have a right trochlear nerve palsy, without preceding head trauma. Conclusions: We report the first described case of a trochlear nerve palsy secondary to a quadrigeminal plate cistern lipoma, as confirmed by MRI imaging.