CRANIAL NERVES

Dr.Ahmed Gaber Ass. Prof of Neurology Ain Shams University

Dr. Ahmed Gaber

OBJECTIVES
LMNL VS UMNL facial and Hypoglossal Supranuclear, nuclear, infranuclear lesion

Dr. Ahmed Gaber

HISTORY & EXAMINATION

Dr. Ahmed Gaber

OLFACTORY
HOW TO ASK
Diminished olfaction Change in quality of olfaction Abnormal olfaction not present

FINDINGS & INTERPRETATION

Anosmia: Bilateral (not significant), unilateral (signify a lesion any where in the pathway) Parosmia (abnormality in olfactory cortex) Olfactory hallucinations mostly epileptic in uncus, orbitofrontal surface

Dr. Ahmed Gaber

EXAMINATION
HOW: eye closed Unilat Any substance + Amonia
.

Findings: Identify all-- Normal Unable to identify except ammonia --- Anosmia (specific, non specific)/ Unable to identify all including ammonia--functional Hyperosmia, Parosmia (dysosmia), Olf agnosia, Olf hallucinations

Dr. Ahmed Gaber

Interpretation
Anosmia Bilateral Local Parkinsonism Unilateral Focal

Dr. Ahmed Gaber

OPTIC
How to ask? VA Optic n Color vision-- Macula Field of vision-- retino cortical pathway Blurring of vision -- non specific, migraine Visual hallucinations, illusions: complexity , coloring, hemifield -- pileptic, migraine, psychotic
Dr. Ahmed Gaber

EXAMINATION
VA Field (confrontation) Color v Fundus (disc, retina, vessels) Reflex (light, accomodation)

Dr. Ahmed Gaber

VA
How? Counting fingers Snellen Chart
Interpretation: Integrity of macular vision

Dr. Ahmed Gaber

Field Examination
How? Confrontation method

Dr. Ahmed Gaber

Dr. Ahmed Gaber

Dr. Ahmed Gaber

Dr. Ahmed Gaber

Dr. Ahmed Gaber

Interpretation
Monocular blindness- optic n
Binocular blindness- occipital cx Homonymous hemianopia- optic tract, occ cx (mac sparing)

Homonymous quadrantanopia- optic radiation

Bitemporal hemianopia- optic chiasma Concentric field defect- papilledema retinal

Dr. Ahmed Gaber

Fundus Examination
Optic disc (edge, cup,color, vessels) Retina (pallor, vessels, pigmentation) Macula (colour)

Dr. Ahmed Gaber

FINDINGS & INTERPRETATION

Dec VA

Loss of Color Vision

Field Defect

Visual il usions

Viisual Hallucinations

Acute

Chronic

Optic Neuritis

To one side

Concentric

Occipital Cx

Il formed

Wellformed

Optic Neuritis Error of refraction (pain on eye mov) Optic neuritis

Hemianopia Quadrantanopia

Papil edema

Flashes, patterns animals, persons Black and white coloured may be hemifield both fields

Dr. Ahmed Gaber

Occipital

Post temporal

OCCULO MOTORS

Diplopia

Ptosis

Dazzling

Squint

Binocular/Mono

Partial/Complete

Divergent

HZ/ Vertical

Correctability

Convergent

Direction

Fatigue

Headache

Dr. Ahmed Gaber

Ptosis Squint Pupils: equality, reactivity (light, accomodation) Single eye movement Conjugate eye m: Hz/Vr, Saccadic/pursuit (command , refix, reflex saccades) (Bells= reflex vertical saccade) + VOR Disconjugate movements: convergence, skew Nystagmus: Hz (cll, vestibular), Vertical, dissociative.

OCCULOMOTORS EXAMINATION

Dr. Ahmed Gaber

DIPLOPIA
Direction of maximum separation between images is the side of nerve lesion False image= Outer image
Horizontal Images Double vision + Single Eye Closure

Corrected

Non Corrected

Binocular Diplopia

Monocular Diplopia

Oblique Images

On Looking Down words

Local Eye Cause

Occipital cortex Lesion

Divergent Squint

Convergent squint

No Squint

Occulomotor n
Dr. Ahmed Gaber

Trochlear nerve

Medial rectus (3 rd)

Abducent n

Median Long Bundle

SQUINT
SQUINT

Divergent

Convergent

Unilateral or Bilateral Occulomotor

Unilateral or Bilateral Abducent

DAZLING:

Dilated pupils due to third nerve lesion

Dr. Ahmed Gaber

PTOSIS
Ptosis Bilateral Eye Lid Pufffiness Unilateral

WeaK Orbicularis Occuli

Intact Orbicularis Oculi

Lid Oedema

Correctable

Non correctable

Myogenic, MNJ

Neurogenic

Horner Syndrome

Occulomotor

Diurnal Variation

No diurnal Variation

Nuclear third lesion

Never Complete ptosis May be complete ptosis

Myasthenia Gravis

Myopathy

Dr. Ahmed Gaber

TRIGEMINAL N

Dr. Ahmed Gaber

Dr. Ahmed Gaber

TRIGEMINAL

Mastication/Biting/ Mouth Deviation

Wasting/ Fasciculations

Facial Sensations

Superficial
Dr. Ahmed Gaber

Deep

Neuralgia

EXAMINATION
Motor: masseter, pterigoids, temporalis (power, wasting, fasciculations), deviation, drooping of jaw S: ref, both sides, divisions, in/out R: Corneal, Conjunctival, jaw

Dr. Ahmed Gaber

INTERPRETATION
Motor Weak biting Bilateral atrophy Mouth deviation Unilateral atrophy

Bilateral LMNL
Systemic

Unilateral LMNL
Focal MND Extraxial

FSH
Myotonic Dyst
Dr. Ahmed Gaber

Intraaxial

SENSORY IRRITATION DESTRUCTION

Burning, electric
Division

See exam
Whole n

V3

TG Neuralgia

TG Neuralgia

Migrainous Neuralgia
R Structural Pathology
Dr. Ahmed Gaber

Not V3

Structural Pathology

FACIAL NERVE
HOW? Eye closure Eye brow elevation Epiphoria Dry eye, eye burning Mouth deviation Driplling of saliva Food accumulation Taste Hyperacusis Fasciculations and wasting Emotional expression CORRECTION BY EMOTION RELATION TO THE SIDE OF WEAKNESS

Dr. Ahmed Gaber

FACIAL NERVE

Dr. Ahmed Gaber

EXAMINATION: Eye brow, forehead (frontalis) Eye closure (O. oculi) Nasolabial fold (nasalis) Mouth deviation (retractor ang) Buccinator (blowing) O. oris (whisteling) Glabellar Taste: mouth ant 2/3 NB other corneal, conjunctival

Dr. Ahmed Gaber

FACIAL N Abnormality

VOLUNTARY

ASSOCIATIVE

LMNL

Reduced

No Correction by emotions Contralateral to limb Wk Lost Glabellar

Extrapyramidal

UMNL

Exagerated

Corrected by emotions Epsilateral to Limb Wk Intact Glabellar

BIL Pyramidal
Dr. Ahmed Gaber

VESTIBULOCHOCLEAR N
HOW? A. Choclear Tinnitus Deafness Auditory hallucinations: formed, illformed B. Vestibular Vertigo Dissociation Phenomena
Dr. Ahmed Gaber

EXAMINATION
o o o Hearing acuity (whispering test, watch test) Weber test (2 sides) Rinne test (air and bone conduction) Schwabach test (Bone cond with dr) Finger to index finger test Finger to index eye closed test Rotation chair test, galvanic, caloric test

Dr. Ahmed Gaber

VIII

Choclear

Vestibular

Irritation

Destruction

VERTIGO

PN Tinnitus

Deafness

Epileptic

CX Hallucination

Central BSTem

Peripheral

Migrainous Dr. Ahmed Gaber

Hypoglossal and Vagus N

Dr. Ahmed Gaber

IX, X
Nasal tone Nasal regurgitation Choking Dysphagia Hoarseness, dysphonia Emotional lability

Dr. Ahmed Gaber

EXAMINATION
Sagging uvula Movement uvula Palatal and Pharyngeal reflexes (superficial and deep) S: post 1/3 tongue

Dr. Ahmed Gaber

INTERPRETATION
Three Levels: Neurological vs Mechanical ( Mechanical More to solid) If Neurological , Myogenic Vs neurogenic (Neurogenic more to fluid, Myogenic either) If Neurogenic Bulbar Vs Pseudo Bulbar
Dr. Ahmed Gaber

Neurogenic IX, X Bulbar Severe Pseudo bulbar Less

No
Nasal Regurge Atrophy, fascic No
Dr. Ahmed Gaber

Emotional Lability
NO NO Brisk Jaw

XI
HOW? Head tilt Shoulder depression Head falling back or forward Fasciculation or atrophy in neck

Dr. Ahmed Gaber

Examination
Sternomastoid (single, both) (head tilt to side or back) fascic, atrophy Upper trabezius (shoulder drop)--- fascic atrophy

Dr. Ahmed Gaber

XII
HOW? Dysarthria tongue syllables Movement of food by tongue Tongue deviation unable to protrude tongue Wasting , fasciculation of tongue

Examination: Tongue fasciculations Tongue atrophy Deviation inside Deviation outside Tremors Power

Dr. Ahmed Gaber

Thank you

Dr. Ahmed Gaber