THE CRANIAL NERVES

General considerations: -Are equivalent to the peripheral nerves: -Do not cross (with few exceptions) -Motor branches are axons of alpha motor neurons from the motor nuclei of the brainstem -Sensory branches have a sensory ganglion attache ! synapse with the secon sensory neuron in the sensory nuclei (equivalent to the secon sensory neuron in the posterior horns of the spinal cor )

"# $he olfactory nerve

%euroepithelium locate in the superior part of the nasal cavities &eceptors ' cilia of the bipolar cells Axons of receptor cells pass through the cribriform plate( run as olfactory nerve to the olfactory bulb (secon sensory neuron ) mitral cells)# Axons of mitral cells run in the olfactory tract along the olfactory groove an pro*ect to the limbic cortex (prepiriform cortex( periamyg aloi cortex( nucleus of the amyg ala)

$he olfactory nerve

$he olfactory pathways

Disturbances of olfaction
+# $ransport olfactory loss ,# Sensory olfactory loss -# %eural olfactory loss

.ualitative abnormalities: - Dysosmia - /lfactory hallucinations

""# $he optic nerve

&eceptors ' ro s an cones (photopigment) +0 layers of the retina Sensory information converges on the ganglion cells( whose axons exit the eye at the optic isc an form the optic nerve 1 optic chiasm 1 optic tract ' lateral geniculate nucleus of the thalamus 1 optic ra iations ' occipital cortex

$he optic nerve

$he optic nerve-pupillary reflex pathways

$esting of visual acuity

Snellen chart 2egal blin ness ) best correcte visual acuity 3430 or less in the better eye 5A less than 34,60 ' test the perception of light( ability to count fingers( etc

5isual fiel
$he visual fiel refers to the total area in which ob*ects can be seen in the si e (peripheral) vision while you focus your eyes on a central point# $he visual field is the 7spatial array of visual sensations available to observation in introspectionist psychological experiments $he normal human visual fiel exten s to approximately 30 egrees nasally (towar the nose( or inwar ) from the vertical meri ian in each eye( to +00 egrees temporally (away from the nose( or outwar s) from the vertical meri ian( an approximately 30 egrees above an 89 below the hori:ontal meri ian

;aris as seen with full visual fiel s

/ptic fun us examination

Papilledema (or papilloedema) is optic isc swelling that is cause by increase intracranial pressure# /ther forms of optic isc swelling shoul be calle optic isc e ema

;apille ema

%ormal optic fun us photograph

;upil si:e
Myosis My riasis Anisocoria $este for light an near response <orner syn rome

;apillitis an retrobulbar neuropathy

/ptic neuritis ) inflammation of the optic nerve = swollen optic isc ) papillitis = normal optic isc ) retrobulbar optic neuritis Acute impairment of vision uni4bilateral M&" shows $, bright signal areas of enhancement an optic nerve enlargement $reatment ' methylpre nisolone - ays( followe by a ,-wee> course of oral pre nisone

$he thir nerve

$hir nerve palsy-clinical picture

?tiology of thir nerve palsy

+# 2esions in the mi brain:

- %othnagel syn rome: """ = cl cerebellar ataxia - @ene i>tAsy: """ = cl chorea( tremor( athetosis - Beber sy: """ ' cl hemiplegia ,# Subarachnoi space: aneurysm( meningitis( tumor( infarction( compression -# Cavernous sinus: fistula( thrombosis( tumor 6# Cerebral herniation: compression between tentorium an uncus of the temporal lobe

$rochlear nerve

?tiology of trochlear nerve palsy

Same as for """r nerve palsy ?DC?;$ aneurysm /E$?% ' hea trauma: e ge of the tentorium may impinge upon the nerve uring a concussive blow

$he ab ucens nerve

Ab ucens nerve palsy-clinical picture

?tiology of ab ucens nerve palsy

+# "n the pons (co-involvement of the ;;&E) ' 5" =

,# -# 6# 9# 3#

lateral ga:e palsy to the si e of lesion with eviation of eyes cl = 5"" = cl hemiplegia (EovilleAs syn rome) 5entral pontine in*ury ' 5" = cl hemiplegia (Millar ' Fubler sy) Fra enigoAs sy (petrous apex): 5"""( 5"( 5 Subarachnoi space: meningitis( SA<( aneurysm( trauma Cavernous sinus EA2S? 2/CA2"G"%F S"F% in ""C;

Supranuclear ga:e palsies

Erontal area H ' turns the eyes to the opposite si e! estruction ' eviation of the eyes to the ipsilateral si e (patients loo>s to his lesion) Descen ing pathways run through posterior limb of the internal capsule( basis pe unculi( cross in the rostral pons( terminate in the parame ian pontine reticular formation (;;&E)

Supranuclear an internuclear pathways of ga:e

"nternuclear ga:e palsies

;;&E pro*ects to the ipsilateral sixth nerve nucleus an ( via contralateral me ial longitu inal fasciculus (M2E) to the me ial rectus neurons of the oculomotor nucleus

"nternuclear ophtalmoplegia

5# $rigeminal nerve
Sensory branches ' ggl Fasser ' nucleus of the spinal tract Motor branches ' emerge from the pontine motor nucleus to supply the masseter an pterygoi masticatory muscles

Trigeminal nerve palsy - YouTube.mp4

$rigeminal nerve

$rigeminal neuralgia
- brief( lancinating( excruciating paroxysms

of pain in the lips( gums( chee>( or chin an ( very rarely( in the istribution of the ophthalmic ivision of the fifth nerve# - paroxysms recur frequently( both ay an night( for several wee>s at a time - $rigger :ones

$rigeminal neuralgia - treatment

Me ical treatment: a# carbama:epine 300-+,00 mg4 ay b# oxcarba:epine I00-+H00 mg4 ay c# phenytoin ,00-600 mg4 ay # baclofen 6x,0 mg4 ay e# gabapentin I00-+,00 mg4 ay( pregabalin 600300 mg4 ay ,# Surgical treatment: ra iofrequency selective thermal rhi:otomy( glycerol in*ections into the Mec>el cave( microvascular ecompression( stereotactic ra iosurgery (gamma >nife)
+#

5""# Eacial nerve

Motor nucleus ' pons (ant an lateral to the ab ucens nucleus) ' supplies muscles of facial expression Sensory component (nervus interme ius Brisberg) conveys taste from anterior ,4- of tongue Autonomic fibers ' to the submaxillary an sphenopalatine ganglia ' innervate the salivary an lacrimal glan s# Course ' through pons( cerebellopontine angle( enters the int au itory meatus( through the facial canal( exits the s>ull via stylomastoi foramen

$he facial nerve

Eacial nerve palsy ' clinical picture

Bells Palsy Onset- Day 2 - YouTube

$opographic iagnosis
+# At the stylomastoi foramen ' paralysis of ,#

-# 6# 9#

muscles of facial expression "n the mi le ear: = loss of taste over ant ,4- of tongue =4- hyperacusis (interruption of the branch to the stape ius muscle) "nternal au itory meatus: 5"" = 5""" "ntrapontine: 5"" = 5" = cl hemiplegia =4- cl sensory loss Supranuclear ' only lower half of the face involve = hemiparesis

@ellAs palsy
"nci ence: ,-4+00(000 annually 5iral inflammation of the nerveJ Differential iagnosis: &amsay <unt syn rome( accoustic neuroma( lyme isease( polyra iculoneuritis $reatment: ;re nisone( =4- antiviral agents( protection of the eye( massage of the wea>ene musc>es( splinting to prevent rooping of the face

5"""# $he vestibulo-cochlear nerve

Tinnitus is an au itory sensation that arises within the hea an is perceive as a continuous( intermittent( or pulsatile soun in one or both ears or insi e the hea # <earing loss ' con uctive an sensorineural Verti o is a hallucination of self- or environmental movement( most commonly a feeling of spinning( usually ue to a isturbance in the vestibular system#

5estibular nerve
&eceptors ' in the semicircular canals an the otholitic apparatus# %eural output ' conveye to the vestibular nuclei in the brainstem ' pro*ect to nuclei of cranial nerves """( "5( 5"( spinal cor ( cerebellum( cerebral cortex 5estibuloocular reflex maintains visual stability uring hea movements ' epen s on pro*ections from vestibular nc to ;;&E an 5" nc as well as """ nc (via M2E)# $hese connections for thr nystagmus#

5ertigo
P!"siolo ic verti o occurs when (+) the brain is confronte with a mismatch among the three stabili:ing sensory systems (vestibular( visual( somatosensory)! (,) the vestibular system is sub*ecte to unfamiliar hea movements to which it has never a apte ( such as in seasic>ness! or (-) unusual hea 4nec> positions( such as the extreme extension when painting a ceiling# Pat!olo ic verti o results from lesions of the visual( somatosensory( or vestibular systems# 5isual vertigo is cause by new or incorrect spectacles or by the su en onset of an extraocular muscle paresis with iplopia! somatosensory vertigo( rare in isolation( is usually ue to a peripheral neuropathy that re uces the sensory input necessary for central compensation when there is ysfunction of the vestibular or visual systems# $he most common cause of pathologic vertigo is vestibular ysfunction#

5ertiginous syn romes

Acute labyrinthine ysfunction ' unilateral or bilateral Schwannomas MeniereAs isease ;ositional vertigo ' @;;5 ;sychogenic vertigo

Acute labyrinthine ysfunction

Severe rotational vertigo = nausea( vomiting( autonomic signs &omberg laterali:ing towar s lesion = slow con*ugate eviation of arms towar lesion = nystagmus beats away from the si e of lesion ?tiology: infection( trauma( ischemia( $reatment: be rest = vestibular suppressants = antiemetics = early ambulation to in uce compensatory mechanisms#

MeniereAs isease
&ecurrent unilateral labyrinthine ysfunction = signs an symptoms of cochlear isease 9th eca e Attac>s of vertigo lasting minutes ' hours( sensorineural hearing loss between attac>s <istopathology ' en olymphatic hy rops (cochlear uct( utricle( saccule) $reatment: be rest = vestibular suppresants in attac> Se ative rugs( between attac>s =4- surgery

/ther vertiginous syn romes

Schwannomas of eighth nerve Acute bilateral labyrinthine ysfunction @;;5

"D# Flossopharyngeal nerve

$he ninth nerve contains both motor fibers (from me ullary nucleus ambiguus) which supply the stylopharyngeus muscle an the constrictors of the pharynx( an sensory fibers which carry general sensation from the upper part of the pharynx an the sensation of taste from the posterior two thir s of the tongue# Attache ' ganglia of An ersch an ?hrenritter 2esion: taste is lost on the posterior thir of the tongue an the gag reflex is absent on the si e of the lesion# 2esions ' usually together with lesions of nerves D an D" ' *ugular foramen syn rome Flossopharyngeal neuralgia

D# 5agus nerve
Motor branches from nc# ambiguus supply the somatic muscles of the pharynx an larynx Autonomic motor fibers from the orsal motor nucleus innervate heart( lung( esophagus an stomach Sensory fibers ' from the mucosa of the oropharynx an the upper part of the F" tract( from thoracic an ab ominal organs ' into the tractus solitarius

$he vagus nerve

5agus nerve palsy

Knilateral lesion of the vagus nerve: ysarthria an ysphagia( the soft palate roops ipsilaterally an oes not rise in phonation# $here is loss of the gag reflex on the affecte si e( as well as of the 7curtain movement7 of the lateral wall of the pharynx( whereby the faucial pillars move me ially as the palate rises in saying 7ah#7 $he voice is hoarse an slightly nasal( an the vocal cor lies immobile in the ca averic position( i#e#( mi way between ab uction an a uction#

D"# Accesory nerve

Motor fibers ' from nucleus ambiguus an first 6 cervical segments of the cervical spinal cor ?xits s>ull through *ugular foramen (with "D an D) "nnervates the laryngeal muscles( sternoclei omastoi muscle an superior portion of the trape:ius

$he accesory nerve

$he hypoglossal nerve

Abnormal Cranial %erve ?xam - Cranial %erve ++- Motor - Lou$ube#flv

<ypoglossal nerve palsy ' clinical picture