Cranial Nerves
Conforming
 Superior Orbital syndrome (see VI nerve palsy)
 Cavernous sinus syndrome (see VI nerve palsy)
 Cerebellar Pontine Angle syndrome
o Involvement
 V1-3 (tinnitus and deafness earliest symptom then vertigo; loss of
corneal reflex is the earliest sign)
 VI
 VII
 VIII
 IX
 Cerebellar
o Causes
 Tumor
 Primary
o “Acoustic neuromas” – schwannomas of the vestibular
o Meningiomas, haemangioblastomsa, medulloblastomas
o Choleastoma
 Secondaries
o NPC ( loss of corneal reflex and V2 early)
o Lymphoma
 Aneurysm
 For bilateral lesions
 Bilateral “acoustic neuromas” in NF type 2
o Examination
 Examine CNs
 ULs for cerebellar signs
 Proceed to check neck for LNs
 Look for NF features (café au lait spots, neurofibroma, freckling and
Lisch nodules)
o Presentation
 Sir, this patient has righ/left CPA lesion as evidenced by
 There is no enlarged Cx LNs to suggests secondaries
 There is also no evidence of NF
 Possible etiologies includes
o Questions
 What is the CPA?
 Shallow trangular fossa lying between the cerebellum, lateral
pons and the petrous temporal bone
 Histology?
 Schawannoma
 Ix?
 Imaging – CT/MRI/Angio
 Audiography
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ENT to exclude NPC
Mx
 Microsurgical resection
 Stereotaxic radiosurgery (Cx rate same as surgery)
Lateral medullary syndrome
o 5 vessels involved (wedge shaped infarction of the lateral aspect of the
medulla and the inferior surface of the cerebellum)
 PICA
 Vertebral artery (most common artery that is involved)
 Lateral medullary artery (superior, middle, inferior)
o Areas affected
 Descending sympathetic fibres
 Ipsilateral Horner’s syndrome
 Ptosis, meiosis and anhidrosis
 Spinothalamic tract
 Contralateral hemi-sensory loss of pain and temperature
 Descending tract and nucleus of V
 Ipsilateral loss of pain and temperature of the face
 Nucleus ambiguus(X) and IX
 Hoarsenss of voice, dysphagia, hiccups
 Vestibular nuclei
 Nystagmus, vertigo, nausea
 Cerebellar (restiform body of the inferior cerebellar peduncle)
 Ipsilateral ataxia and gait ataxia
o Examination
 CN examination
 Go to ULs for loss of pain and temperature and cerebellar
 Check for AF and DM dermopathy
 Visual Fields for homonymous hemianopia (posterior circulation)
o Sir this patient has right/left LMS as evidenced by
 State the findings
 Mention NG
 Aetiology – infarction affecting the vertebral artery or the PICA, LMA
 Did not find any xanthelesma or DM dermopathy, or AF
 Request for BP and asking patient on symptoms of dysphagia
Medial medullary syndrome
o Triad of XII, medial lemniscus and pyrimidal tract
o Ipsilateral wasted tongue, contralateral loss of vibration and propioception and
contralateral hemiparesis respectively
o Either vertebral artery or lower basilar
Bulbar palsy
o Bilateral involvement of LMN IX, X, XI and XII
o Examination
 Proceed with CN
 Do Jaw jerk
 Requests to examine speech, and gag reflex
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Requests to examine ULs for fasciculations and dissociated sensory
loss
o Presentation
 Patient has bulbar palsy as evidenced by weakness of the soft palate,
wasted tongue with fasciculations a/w a nasal voice and a normal or
absent jaw jerk
o Causes (MGS, NNNP)
 MND
 GBS
 Syringomyelia
 Poliomyelitis, NPC, neurosyphilis and neurosarcoid
Pseudobulbar palsy
o Bilateral UMN lesions of the IX, X and XII, V and VII (III/IV and VI are
spared)
o Examination
 Proceed with CN
 Do jaw jerk
 Request for speech, gag reflex and enquire emotional lability
 Request for AF, DM dermopathy and xanthelesma
 Requests for ULs to look for UMNs
o Presentation
 Patient has PBP as evidenced by presence of sluggish palatal
movement, small, stiff and spastic tongue a/w brisk jaw jerk with
“Donald duck” speech (slow, thick and indistinct)
 No AF, DM or xanthelasma
 No evidence of mix UMN and LMN signs to suggest MND
 No RAPD or INO to suggest multiple sclerosis
 Possible causes (BMM)
 Bilateral stroke
 MND
 Multiple sclerosis
Syringobulbia
o See syringomyelia
o Extension of syrinx to involve the brainstem
o V(descending tract of V), VII, IX, X, XI, XII and Horner’s syndrome
o Usually unilateral
Jugular foramen syndrome
o Involvement of the IX, X, XI (XII maybe affected due to proximity)
o Unilateral
o Examination
 CN exams
 Proceed to check for enlarged Cx LNs
 And request to assess speech for husky voice and bovine cough
o Presentation
 Sir, this patient has right/left JFS as evidenced by
 Notice that this patient is on NG
 No enlarged Cx LNs
 Possible etiologies includes
o Questions
 Causes
 Ca of the pharynx (commonest cause), tumor, neurofibroma
 Basal meningitis
 Paget’s disease, trauma
 Thrombosis of the jugular vein
 IX, X and XI leaves the skull via jugular foramen (between the lateral
part of occiput and the petrous part of the temporal bone)
 XII leaves via the anterior condylar foramen
 Isolated XI implies injury to XI in the neck eg stab wounds
Non-Conforming
 Myasthenia Gravis (see Myasthenia Gravis)
 Miller Fisher Syndrome
o Variant of Guillain Barre syndrome
o Characterise by triad of ophthalmoplegia, ataxia and areflexia
o Cs by anti G1Qb antibodies
o Rare
o Good prognosis with recovery beginning within 1 month of onset and
complete recovery within 6 months
o Some maybe left with residual weakness and 3% will have relapses
 Guillain-Barre syndrome
 Mononeuritis multiplex
 Migraine (paralytic)
 Paget’s
 Base of skull (trauma)
 Basal meningitis
 Brainstem strokes or multiple sclerosis