Clivus Bone Metastasis:
Review of Cranial Nerves
Morning Report
July 8, 2009
Chris Caulfield
Clivus Bone
Clivus Metastases: Report of seven
patients and literature review
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Of 46 patients that had surgery for clivus
bone tumors in a 12 year period, seven
patients proved to have metastasis
Wide variety of primary tumors:
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Lung Adenocarcinoma (2)
Prostate Carcinoma (2)
Skin Melanoma (1)
HCC (1)
Lung Squamous Cell Carcinoma (1)
Clivus Metastases: Report of seven
patients and literature review
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All patients had Sixth Cranial Nerve Palsy
Also had presentation with palsy of CN VII,
XII, and headaches
Upon further literature review, 27
additional examples were identified with
prostate and thyroid being most common
In spite of radiotherapy and chemotherapy,
the mean survival was 12 months
CRANIAL NERVES
CRANIAL NERVES
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Olfactory Nerve (CN I) — examined by having the
patient occlude one nostril and identify a common strong
scent (coffee, peppermint, cinnamon).
Optic Nerve (CN II) – examined by performing Visual
Fields (all four quadrants of each eye), Visual Acuity
(using Snellen Eye Chart/Card), and Fundoscopy
(evaluate optic disc and retinal vessels).
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Pupillary Light Reflex. Evaluate papillary constriction with
direct response and consensual response of opposite eye.
CRANIAL NERVES
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Extraocular Movements: Oculomotor Nerve (CN III),
Trochlear Nerve (IV), Abducens Nerve (VI)
 Oculomotor Nerve (CN III): evaluate for ptosis as it
controls the striated muscle in levator palpebrae
superioris
 Controls all extraocular muscles except for the
superior oblique muscle and the lateral rectus muscle
(“Down and Out”)
Ptosis and “Down and Out”
CRANIAL NERVES
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Extraocular Movements: Oculomotor Nerve (CN III),
Trochlear Nerve (IV), Abducens Nerve (VI)
 Oculomotor Nerve (CN III): evaluate for ptosis as it
controls the striated muscle in levator palpebrae
superioris
 Controls all extraocular muscles except for the
superior oblique muscle and the lateral rectus muscle
(“Down and Out”)
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Edinger-Westphal nucleus supplies parasympathetic
fibers to the eye via the ciliary ganglion, controlling
the sphincter pupillae muscle (affecting pupil
constriction) and the ciliary muscle (affecting
accomodation).
Pupillary Light Reflex
CRANIAL NERVES
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Trochlear Nerve (CN IV): innervates the superior
oblique muscle of the eye; nerve palsy usually
causes horizontal diplopia
Abducens Nerve (CN VI): innervates the lateral
rectus muscle of the eye, nerve palsy usually
causes diplopia
Diplopia
CN IV
CN VI
CRANIAL NERVES
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Trigeminal Nerve (CN V) is responsible for sensation in
the face as well as the motor function of mastication
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Ophthalmic nerve (CN V1) carries sensory information from the
scalp and forehead, the upper eyelid, and the nose (including
the tip of the nose).
Maxillary nerve (CN V2) carries sensory information from the
lower eyelid and cheek, the upper lip, the upper teeth and gums,
the palate and roof of the pharynx.
Mandibular nerve (CN V3) carries sensory information from the
lower lip, the lower teeth and gums, the chin and jaw.
Dermatome Distribution of the
Trigeminal Nerve
CRANIAL NERVES
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Facial Nerve (CN VII) controls muscles of facial
expression, and via the chorda tympani nerve, supplies
parasympathetic fibers to submandibular glands and
sublingual glands as well as taste sensation to anterior
two-thirds of the tongue.
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Perform wrinkling of the brow, closing eyes tightly, smiling,
puffing out the cheeks to test branches of the facial nerve.
With an UMN, only the lower part of the face on the
contralateral side will be affected, due to the bilateral control to
the upper facial muscles.
With a LMN, complete CN VII palsy resulting in both upper and
lower facial weakness on the same side of the lesion (Bell’s
palsy)
LMN vs UMN Lesion
CRANIAL NERVES
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Vestibulocochlear Nerve (CN VIII) responsible for transmitting sound
and balance; assess by holding fingers a few inches away from ear
canal and rubbing them together softly.
Glossopharyngeal Nerve (CN IX) receives sensory fibers from
oropharynx and special sensory fibers of taste from the posterior
one-third of the tongue; sends motor fibers to palate and is
responsible for gag reflex.
Vagus Nerve (CN X) sends motor fibers to palate and
parasympathetic fibers down to second segment of the transverse
colon. Nerve palsy results in hoarse voice, difficulty in swallowing,
loss of gag reflex, and uvula deviation away from side of lesion.
Palatal movement (CN IX and X) — Ask the patient to say "aaah"
and observe whether the two sides of the palate move fully and
symmetrically.
CRANIAL NERVES
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Spinal Accessory Nerve (CN XI) — responsible
for head rotation and shoulder elevation by
innervating the sternocleidomastoid and
trapezius muscles.
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Nerve palsy results in ipsilateral loss of muscle
function and could also result in atrophy or
fasciculations.
Hypoglossal Nerve (CN XII) — responsible for
tongue movement; if there is loss of
function/unilateral paralysis, the tongue will
deviate toward the affected side.
Spinal Accessory Nerve
Hypoglossal Nerve Palsy
How do these neurological deficits
relate?
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Right Eye Ptosis
Weakness of Facial Muscles on Right
Tongue Deviation to the Right Side
Vision Problems on Right Side/Diplopia
Miosis
Loss of Taste
Dysarthria
How are these presentations of
ptosis different?
How are these presentations of
ptosis different?
Horner’s Syndrome
CN III Palsy
PTOSIS
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Important to distinguish the ptosis caused
by Horner's syndrome from the ptosis
caused by an oculomotor (CN III) palsy.
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Horner’s Syndrome: ptosis occurs with a
constricted pupil, due to a loss of
sympathetics to the eye.
CN III Palsy: ptosis occurs with a dilated
pupil, due to a loss of innervation to the
sphincter pupillae muscle.
HORNER’S SYNDROME
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Lesion anywhere along the sympathetic pathway
causing classic neurological signs of ptosis,
miosis, and anhidrosis
Arm pain and/or hand weakness typical of
brachial plexus lesion suggests a lesion in the
lung apex
Pancoast Tumor involves the lung apex and
causes compression of a sympathetic ganglion
HORNER’S SYNDROME