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43 yo guy w/ L sided weakness/neglect. exam w/ mild R ptosis. eyes midposition. R pupil reduced in diameter compared to L. what muscle is involved? Tarsal (Muller's muscle)
what are the extraocular muscles controlled by the oculomotor nerve? superior rectus medial rectus inferior rectus inferior oblique levator palpebrae
what's the function of CN III? extraocular muscles constricts pupil accomodates converges sympathetic innervation
what's the major function of the oculomotor nerve? raises eyelid (major) tarsal (Muller's muscles) are a minor contributor
what's the pathway for CN III? exits medial midbrain b/w midbrain and pons runs between SCA and PCA parallel to posterior communicating artery: through cavernous sinus exits through superior orbital fissure
what's the presentation of the classic 3rd nerve palsy? eye is "down and out" dilated pupil paralysis of accomodation ptosis
what's the pathology name of CN III based on the location? nuclear: Parinaud's syndrome fascicular lesions: Weber, Claude, Benedikt SAH lesions cavernous sinus lesions: Tolosa Hunt syndrome
where is the lesion in Parinaud's syndrome? dorsal midbrain periaqueductal grey
what are the clinical features of Parinaud's syndrome? supranuclear upgaze paralysis setting sun sign: conjugate downgaze convergence and eyelid retraction: Collier's sign
what causes Parinaud's syndrome? pinealomas ms stroke hydrocephalus: VP shunt failure
where is weber's syndrome? base of midbrain CN III cortical spinal tracts
what are the clinical features of weber's syndrome? ipsilateral 3rd n palsy contralateral hemiplegia
where is claude syndrome? CN III red nucleus brachium conjunctivum
what are the symptoms of claude syndrome? ipsi 3rd n palsy contra ataxia contra tremor
where is benedikt? CN III red nucleus cortical spinal tract
any tumor in subarachnoid space presses on what? CN III: dilated, unresponsive pupil
what's the most common aneurysm to cause a CN III palsy? posterior comm aneurysm
if pt has uncal herniation, what can you see? hutchinson pupil pupillar dilatation w/ poor response to light, but preserved convergence ischemic lesions
what if you have a CN III lesion that is pupil sparing related to diabetes? will resolve in 3-6 mos
if CN III, IV, and VI are affected, where are you? cavernous sinus
how do cavernous sinus lesions present? oculomotor paresis fixed and dilated pupil horner's syndrome b/c of postganglioninc sympathetic fibers wrapped around ICA V1, V2 numbness
if CN II-V2 involved, what is it? orbital apex syndrome: cavernous syndrome w/ visual loss
how does tolosa hunt syndrome present? episodic paralysis of CN 3, 4, 6 (not always together) episodic orbital pain
how do you dx tolosa hunt? granuloma on MRI or bx ESR/CRP elevated CSF normal other causes excluded
tolosa hunt tx? steroids
what does the superior oblique muscle do? depresses, intorts and abudcts the eye
what's the only CN to exit dorsally? CN IV
what's the path of CN IV? nucleus at level of inferior colliculus exits midbrain dorsally & decussates runs along undersurface of tentorium along lateral wall of cavernous sinus enters orbit through superior orbital fissure slender and long (prone to injury)
what's the most common cause of CN IV injury? head trauma
what dx should you think about in an adult w/ a new 4th n palsy? decompensation of a congenital palsy as it's the most common cause of CN IV palsies in kids
what are the clinical features of CN IV? vertical diplopia- worse w/ downgaze head tilting extorsion impairment of depression of adducted eye hypertropia (elevated eye) weakness of down gaze
w/ CN IV palsy, which way do you tilt head? where are symptoms worse? tilt head away from palsy tilting head to the same side of the lesion makes it worse (Bielschowsky test)
what's the path of CN VI? nucleus in lower dorsal pons emerges b/w pons & medulla lateral cavernous sinus exits out superior orbital fissure
what are the syndromes you can have w/ CN VI palsies? mobius Duane's Millard-Gubler syndrome Foville syndrome
how does mobius syndrome present? horizontal gaze disturbance facial diplegia
what other issues can mobius be associated w/? limb abnorm chest wall abnorm crossed eyes corneal abrasions
how does Duane's syndrome present? limitation of adduction retraction of eyeball into socket on adduction poor convergence face turns to affected side to compensate for ltd mvmnts
what's the pathology in Duane's syndrome? aplasia of 1 or both CN VI nuclei lateral rectus palsy
what's the pathology in Mobius syndrome? bilateral abducens palsies CN VII palsies
what other issues can be ass w/ Duane's? ocular, ear and systemic malformations
how does Millard-Gubler syndrome present? ipsi horizontal gaze palsy (VI) ipsi weak face (VII) contra hemiparesis (cortical spinal tracts)
how does Foville syndrome present? ipsi horizontal gaze palsy (VI) ipsi weak face (VII) contra hemiparesis contra sensory loss INO
where is Millard-Gubler syndrome localized to? CN VI and pons
what causes Foville syndrome? AICA infarct
what's the anatomy of yoked eye movements? internuclear neurons exit the abduscens nucleus cross midline and arise in MLF terminate in MR nucleus
what are the clinical features of Internuclear ophthalmoplegia? inability to adduct one eye w/ contralateral nystagmus adduction w/ convergence movements are intact
what are common causes of INO? MS vascular d/o head trauma
how does one and a half syndrome present? conjugate horizontal gaze palsy in one direction INO in the other direction
what causes one and a half syndrome? PPRF lesion lesion in ipsi MLF
Created by: Syndenham
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