Common neuro conditions (cranial) - Ophthalmoplegia, field defects, facial nerve palsy Examination sequence STANDARD examination sequence (WIPER, observe, inspect, palpate, percuss, auscultate, thank) Particulars: 1 (smell), 2 (visual acuity, fields, pupils), 3/4/6 (eye movements, pupils, accommodation, nystagmus), 5 (facial sensation), 7 (facial movements, taste), 8 (hearing), 9 (uvula), 10 (cough), 11 (SCM, shoulder), 12 (tongue) Commonly missed: smell, covering OWN eye for visual fields and not being 1m away, sternum for sensation, hearing Completion: formal tests (1 – scents, 2 – Snellen and Ischiara charts, 3/4/6 – fundoscopy, corneal reflex, 7 – jaw jerk, 9 – gag reflex), full neurological examinations (upper/lower, cerebellum) Presentation - WHAT; KEY positive; IMPORTANT negative: meningism; completion • I was asked to examine the cranial nerves of this elderly lady • On examination I found – failure of lateral gaze in the right eye. • There was no evidence of meningism; all other eye movements were intact, visual acuity was normal and there were no visual field defects, nor abnormalities in any of the other cranial nerves. • DDx – 6th nerve palsy • I would like to perform tests for completion as above. Common findings and viva questions - Investigations: o Bedside: urine dip (glucose, blood) o Bloods: FBC, U&E, LFTs, ceruloplasmin, INR, auto-antibodies, glucose, B12/folate o Culture: Blood, CSF o Imaging: CXR (paraneoplastic), CT, MRI (posterior lesions, cord), DAT scan o Special: LP (cells, oligoclonal bands, xanthochromia); nerve biopsy; nerve conduction studies Anatomy of the cranial nerves - Name/function of all 12 - DDx of cranial nerve palsies: vascular, inflammatory, SOL, infection, mononeuritis multiplex o OR lesions along the path of the nerve: central, intra-cranial, cranium, extra-cranial Vision - Visual fields: patterns of loss and location of the lesion o Monocular, bitemporal hemianopia, contralateral homononomous hemianopia - Muscles/nerves controlling eye movements: CN3, then 4/6 - Causes/patterns of ophthalmoplegia: CN 3/4/6 palsies - Intra-nuclear ophthalmoplegia: description, causes Pathology - Medical v surgical 3rd nerve palsy – pupil sparing - False localising sign - Ptosis: Unilateral (3rd palsy, Horner’s, congenital/idiopathic) vs bilateral (Mg, myopathy, congenital, syringomy) o Partial vs complete - Causes of a facial nerve palsy: UMN vs LMN, WHY is for forehead spared in UMN - Pseudo-bulbar vs bulbar palsy - Causes of cerebellopontine angle lesions: neoplastic, infective - Horner’s Syndrome: description, causes o Hemisphere/brainstem, cervical cord, T1 root, sympathetic chain in neck, carotid artery, misc Hearing - Description of Rinne and Weber’s tests Overview - CNS: Horner’s Syndrome, 3rd nerve palsy, Cavernous Sinus Thrombosis, facial nerve palsy, MS (eye) Groups of nerve palsies: • III and IV – midbrain nuclei; V, VI, VII, VIII – pons nuclei; IX, X, XI, XII – medulla nuclei • Unilateral III, IV, VI, Va – cavernous sinus lesion; superior orbital fissure lesion (Tolosa-Hunt syndrome) • Unilateral V, (VI), VII, VIII, (IX) – CPA lesion (~tumour); unilateral IX, X, XI – jugular foramen lesion • Eye and facial muscles, worse on exertion – MG; UMN IX, X, XII – pseudobulbar palsy • LMN IX, X, XII – bulbar palsy Preparation For Finals 2017 .