Cranial Nerve Syndromes

A look at the brainstem

Patient Evaluation
Signalment History Physical and Neurological Exams Localization of Lesion Differential diagnosis Diagnostic plan Diagnosis/Prognosis Treatment/Evaluate

Minimum Database
CBC Chemistry Abdominal ultrasound Heartworm test Fecal

Bile acids Cholinesterase

Urinalysis Chest and abdominal radiographs

Ancillary Neurologic Tests

Electrodiagnostics
EEG EMG BAER

Radiographs
Skull CT scan MRI

CSF tap & analysis

Cells & protein Pressure Cholinesterase Titers

Muscle Analysis

Enzymes 2M antibody Anti-ACH receptor Antiantibody Biopsy

Muscle Analysis
Comparative Neuromuscular Laboratory
Basic Science Building, Room 1107 University of California, San Diego La Jolla, CA 92093-0612 92093858.534.1537 858.534.7319 (fax) http://medicine.ucsd.edu/vet_neuromuscular musclelab@ucsd.edu

Electrodiagnostics
EMG
Evaluates the LM Unit

Motor nucleus of cranial nerves or ventral horn cell Ventral nerve root Motor cranial or spinal nerve Neuromuscular junction Muscle

Electrodiagnostics
EMG
Needle EMG looks for abnormal spontaneous potentials

Fibrillation potentials Fasciculation Complex repetitive potentials

Electrodiagnostics
EMG
Motor conduction velocity

Measured from several locations along the nerve Disstance/Time Disstance/Time delay for response

Electrodiagnostics
BAER

Evaluation of auditory system in the ear and brainstem Same instrument as for EMG

Cerebrospinal Fluid Tap

Routinely done on most neurological patients Collection from the cisterna magna (cerebellomedullary cistern) or L4-L5 lumbar space

Cerebrospinal Fluid Analysis

Analyze
RBC and WBC cell number Cytology Protein Increased types of cells Increased protein Increased pressure

Abnormalities

Titers for infectious disease

Species specific

Cerebrospinal Fluid Titers

Dog
Viral Bacterial
Lyme Canine Distemper

Viral

Cat

Protozoal

Rickettsial Fungal

Toxoplasmosis Neospora RMSF Ehrlichia Aspergillus Cryptococcus

Protozoal Fungal

FeLV FIV FIP

Toxoplasmosis Cryptococcus

Neuroradiology
Plain X-rays of head
Bone fractures, infection, neoplasia

CT and MRI lesions of the head or vertebrae CT better for bone; MRI better for soft tissue

When all else fails Look at the patient!!!

Cranial Nerve Disorders

Unilateral- -No long tract signs
Trauma Idiopathic Infection Neoplasia

Unilateral- -Long tract signs

Infection Inflammatory disease Neoplasia Trauma

Peripheral problem

Central Problem

Cranial Nerve Disorders

Bilateral
Idiopathic Toxic Perineoplastic syndrome

Polyneuropathy
Infection Inflammatory Disease Neoplasia (perineoplastic syndrome)

Long Tract Signs

UMN (descending) signs
Hyperactive reflexes Babinskis sign Crossed extensor response

Ascending sensory signs

Conscious Proprioceptive deficits Dysmeteria Altered pain perception

Babinskis Sign

Crossed Extensor Response

Olfactory- -CNI
Food Presentation
CNI / complex behavior

If a cat cant smell, it wont eat

Optic- -CNII
Vision
CNII / complex behavior

Menace
CNII / CNVII

Cotton Balls
CNII / complex behavior

Dazzle Response
CNII / complex behavior (CNVI)

Pupillary Light Response

CNII / CNIII

Optic Neuritis
Acute onset of blindness Infectious or inflammatory disease
Treat cause

Idiopathic

Immunosuppression

Optic Neuritis

MRI showing swelling & edema of optic nerve (arrows)

Barney
10 yr old DSH Acute onset of blindness, dementia and circling Pupils fixed and dilated

Barney
Neurologic exam
Compulsive pacing Right hemiparesis Bilateral CP deficits in rear legs Babinskis sign in right rear leg

Barney

Post-Contrast CT Scan Post-

CNIII, CNIV & CNVI

Eye Position
CNIII- -down & out CNIII CNIV- -lateral CNIV CNVI- -down & in CNVI-

Pupillary Light Response

CNII / CNIII CNIII / Sympathetics CNV / CNVI

Pupil Symmetry Corneal Reflex

Strabismus
Oculomotor nerve
Peripheral
Trauma Retrobulbar masses Neurofibroma Lymphosarcoma

Central

Infection Inflammatory disease Neoplasia

Anisocoria
Imbalance between parasympathetic (CNIII) and sympathetic (vagosympathetic trunk) innervation to the eye

Dilated Eye (CNIII)

Fixed pupil
No direct PLR No indirect PLR

(from the other eye)

Other Eye

Direct PLR Indirect PLR (from

the other eye)

Normal Vision

Horners Syndrome
Small Animals
Ptosis Myosis Enophthalmos

Large Animals

Facial sweating (horse) Lack of muzzle sweating (cow)

Trigeminal- -CNV
Facial Sensation
CNV / CNVII

Eye, ear & lip responses Corneal reflex

CNV / CNVI

Nose reaction
CNV / complex behavior

Muscles of Mastication
Palpation
Motor CNV

Jaw reflex
CNV / CNV

Trigeminal Problems
Cant open Mouth
Muscle

Cant close Mouth

Nerve

Masseter Muscle Myositis

Immune-mediated
Acute, painful muscles of mastication

Chronic, atrophy with fibrosis

Pain on opening mouth Muscle swelling

Elevated 2M antibody levels

Trigeminal Neuritis
Acute drop-jaw Prednisolone 1-2 mg/kg/day divided for 1 week, then taper
Also use gastroprotectants

Nursing care

Neurofibroma of CN V
Unilateral muscle atrophy Chronic in nature Evident on CT or MRI scans

Neurofibroma of CN V
Neurologic exam

No long tract signs Long tract signs may develop over time

MDB normal

Neurofibroma of CN V

Contrast MRI shows enlarged CNV (arrows) with muscle atrophy on affected side

Facial- -CNVII
Lip, Eye & Ear Movements
CNV / CNVII

Lip Tone
CNVII

Menace

CNII / CNVII

Tear Production

CNVII (parasympathetics)

Idiopathic Facial Nerve Paralysis

Unilateral or Bilateral
Inability to move eyelid, lip and ear Loss of palpebral reflex Decreased tear production

Treatment

Prednisolone Acupuncture

Facial Nerve Paralysis

CNVIII
Vestibular portion
Head Tilt Nystagmus
Physiologic Spontaneous

Circling (tight) Imbalance & Incoordination

Auditory

Hearing Startle response

Bilateral Vestibular
Lacks classical signs Wide head excursions No physiologic nystagmus

CNVIII- -Audition
Congenital deafness Acquire deafness

Infection Neoplasia Degeneration of old age

BAER

BAER
Deafness in puppies

Particularly useful in unilateral disease

CNIX, CNX, CNXI

Swallowing
Complex interaction of all 3 nerves CNIX / CNX

Gag reflex

Eye pressure- -heart pressurerate response

CNX CNX

Laryngeal muscles Trapezius muscle

CNXI

Hypoglossal- -CNXII

Tongue Movement