KKD SYARAF KRANIAL

Dr Herman Setiawan, MSc

NERVUS SYSTEM
CENTRAL NERVUS SYSTEM PERIPHERAL NERVUS SYSTEM
The Cranial Nerves ( I XII) The Spinal Nerves (C8, T12, L5, S5, Co1)

AUTONOMIC NERVUS SYSTEM

PARASYMPATHETIC (Cranio-sacral) SYMPATHETIC (Thoraco-lumbal)

CENTRAL NERVUS SISTEM

1. The Brain 1. Cerebral hemisphere 2. Basal ganglia 3. Diencephalon (Thalamus, Subthalamus, Epithalamus, Hypothalamus) 4. Midbrain 5. Pons 6. Medulla Oblongata 7. Cerebellum 2. The Spinal Cord

Central Connection
1. Transverse fibers 1. Corpus Callosum 2. Commisura ant & post 2. Association fibers 1. Short 2. Long: fasc. longitudinalis 3. Projection fibers 1. Corticospinal, cortico bulbar etc.

NEUROANATOMY
Ascending: Spinothalamic, spinocerebellar, Spinoolivary, gracillis, cuneatus
BG T BG T

Descending: Cortex corticospinal, rubrospinal, olivospinal, vestibulospinal,tectospinal, reticulospinal, fasc interfasicularis

MB CB Cranial Nerves I, II, V, VII, VIII, IX,X Pons MO

Cortico bulbar (UMN) Cranial Nerves (LMN) III, IV, V, VI, VII, IX, XII

Cortico spinal tract (UMN) -Lateral crossed (80%) -Anterior uncrossed (10%) Spinal nerve C8, T12, L5, S5, Cc1 Spinal cord (LMN)

Spinal cord C8, T12, L5, S5, Cc1

FUNCTIONAL NEUROLOGY
Sensory Cortex Assoc. Cortex Motor Cortex

Sensory Ascending Central connection Cranial Nerves Peripheral Spinal Nerves

Thalamus

Motor Descending Cranial Nerves Lowe M.N Spinal Nerves

Brainstem

Upper M.N

Spinal Cord

Reflex

Sensorik: Afferent, Ascending, centrifugal 1. General somatic sensory

1. 2. 3. Pain & Temp Proprioception Discrim. Touch & light touch

Central Nervus Sistem 1. Otak 2. Ascending: Spinothalamic, spinocerebellar, Spinoolivary, gracillis, cuneatus 3. Descending: corticospinal, rubrospinal, olivospinal, vestibulospinal,tectospi nal, reticulospinal, fasc interfasicularis 4. Medula spinalis (C8,T12,L5,S5,Coc1)

Motor : Efferent, Descending, Centrifugal 1. 2. Somato motor Viscero motor

1. 2. Parasympathetic Sympathetic

2. 3.

Special Somatic sensory Viscero sensory

Receptors: 1. Exteroceptors 2. Teleceptors 3. Proprioceptors 4. Visceroceptors

Effectors 1. Striated muscles 2. Smooth muscles 3. Glands

Sistem Sensorik : Tractus Spino-, Bulbo Dan Nucleus Thalamici

Sistem Motorik : Tractus Corticospinalis Dan corticobulbaris

Cranial Nerves Examination

Tujuan Umum
Mhs kompeten melakukan pemeriksaan syaraf kranial dan menginterpretasikan hasil

Tujuan Khsus
Kompetensi dalam Pemeriksaan syaraf kranial I XII Pemeriksaan reflex syaraf kranisl Pemeriksaan MBO (mati batang otak) Menginterpretasi dan menganalisa hsl pemeriksaan

Metode
1. 2. 3. 4. Presentasi oleh instruktur Demonstrasi oleh instruktur Pelatihan mhs dengan bimbingan Latihan mhs mandiri

BRAINSTEM CRANIAL NERVES Cortico Bulbar Tract

EW N. NIII N. NIV Coll. Sup Cop Gen Med Coll. Inf Mesencep Nuc. N V Mot. Nuc. N V Nuc. N VI Mot. Nuc. N VII Vest Nucl N VIII Nuc. Sal Sup Nuc. Sal Inf Dors.M.Nuc N X Nuc. Ambig N IX,X,XI Nuc. N XII Coch Nucl N VIII Nuc. Tract. Solit N VII & IX Main Sensory Nuc. N V

Spinal Nucl N V

Contra lateral 1. Pars superior N. VII 2. N. XII Bilateral: Other cranial nuclei

OLFACTORY NERVE
Symptoms & Signs and Tests S&S Anosmia Parosmia Cacosmia Test Each nostril test separately. (tobacco, coffee)

S&S

OPHTAHALMIC NERVE

1. Visual acuity 2. Visual field 3. Diplopia (coloured glass) 4. Color blindness (RBG)

Tests
1. Visual acuity (snellen, jaeger, jari 1/60) 1. Perimetri (Goldman), confrontation 1. Color blindness 2. Light reflex 3. Funduscopy

Cranial nerve III, IV, VI Oculomotor, Trochlear, Abducens

Symptoms and Signs 1. Squint or strabismus 2. Diplopia (double vision) 3. Tilting of head to compensate diplopia 4. Conjugate deviation 5. Nystagmus (fast phase) 6. Ptosis 7. Midriasis 8. Dizziness 9. Limitation of movement Loss of reflexed, etc Classification of Disorder Nerves III, IV, VI 1. Ophthalmoplegia III 1. External (M.nucl) 3. Internal (EW Nucl) 1. Opthalmoplegia IV, VI. 2. Supranuclear lesions,lesi frontal or occip lobe - paralysis of conj gaze to the opposite side and deviation to the side of the lesion 5. Nystagmus 1. Peripheral + vertigo 2. Central seldom + vertigo Test 1. Ocular muvement (finger following) 2. Pupil (size, shape, equality, Reaction light reflex & consensual light reflex, accomodation )

Cranial nerve V (mixed nerve)

Symptoms & Signs 1. Pain 2. Loss of sensation 3. Dissociate anesthesia loss of pain but not touch 4. Paresthesia 5. Paralysis: loss of jaw jerk, sneeze, and lid, conj, corneal reflexes. 6. Impaired hearing paralysis of tensor tympani. 7. Trismus 8. Trophic and secretory disturbances Tests 1. Sensation (touch, pain, temperature) 2. Reflexes; cornea, conj., jaw, sneeze 3. Motor status, palpation of masseter & temp musc. Deviation of mandible.

Cranial nerve VII : FASCIAL (Mixed Nerve, Mainly Motor

S&S Nuclear type. Bells palsy Millard Gubler synd: facial hemiplegia alternans. Outside of stylomastoid foramen Fovilles synd: Millard Gubler + Lesion involving chorda tympani loss of taste, ipsilateral paralysis of conjugate gaze. reduced salivation. Higher involving m. stapedius hyperacusis Supra nuclear associcated with hemiplegia or Higher involving geniculate ganglion pain monople- gia, spastic type, frontal normal. within the ear. Ramsy Hunt syndrome = Bells palsy + H. Zoster of the geniculate Geniculate neuralgia. gl. Crocodile tears synd. Injury prox to the geniculate ganglion Lesion in the internal auditory meatus bell;s palsy and deafness. Striatum lesions; grimace, choreiform etc Lesion at the emergence of N VII from the pons involves N V, VIII and at times, VI, XI, and XII.

Test Motor status; smile, whistle,etc EMG. Reflex; cornea, conjuntival and lid. Sensosy Status. Taste (sweet, salty, sour, bitter), Facial asymitry

Cranial nerve VIII : ACOUSTIC NERVE (Composite Sensory Nerve) Symptoms and signs Cochlear Tinnitus Deafness Hearing scotomas Supra nucl dis Vestibular Vertigo NystagmusTests Tests Hearing acuity Weber (lateralisasi), Rinne, Swabach, Bing. Otoscopic Audiometry Caloric test Hallpike Electric test Dix Hallpike Prinsip: konduksi udara lebih baik dari konduksi tulang. Gunakan garpu tala frekuensi 256 Weber : garpu tala di vertex, normal tak ada suara. Suara terdengar (lateralisasi) di telinga dengan gangguan konduksi. Rinne : garpu tala di mastoid sesudah suara tak terdengan pindahkan kedepan liang telinga. Bila tidak mendengar suara pasien menderita gangguan konduksi. Swabach : bandingkan konduksi tulang pasien dengan normal. Taruk garpu tala di mastoid orang normal sampai suara hilang kemudian pindahkan ketelinga pasien masih terdengar > pasien menderita gangguan konduksi. Bings test : garupu tala di vertex kemudian tutup satu telinga lateralisasi ketelinga ditutup bila tak terdengar > gangguan syaraf.

Cranial Nerve IX: GLOSSOPHARYNGEAL (Mixed Nerve)

Symptoms Glossopharingeal neuralgia. Neuralgia of tympanic branch (Jacobsons nerve) Vernets syndrome Boniers syndrome Tests: Pharyngeal gag refex. Vernets rideau (ah) constrict ph deviation of the uvula, Loss of sensation Increased salivation (Timp cord) Visceral reflex

Cranial Nerve X: VAGUS (Mixed Nerve)

Symptoms & Signs A Motor disturbances aphonia, 2) dysphonia, 3) altered position of vocal cords, dysphagia, 5) Spasm esophageal, cardiac, pyloric, 6) paralysis of soft palate with loss of gag reflex B. Sensory disturbances Pain of paresthesias in the parynx, larynx and external auditory meatus irritative lesion. Anesthesia of the lower pharynx, larynx. Cough, dyspnea, salivary hypersecretion and hyposecretion. Tests Laryngoscopic examination Sensory status Pharyngeal gag reflex

Cranial Nerve XI : ACCESSORY (Motor Nerve)

Tests Shrug shoulder, deviation on bending chin downward against resistance. Muscle atrophy, Shoulder drop etc. Electromyography

Cranial Nerve XII: HYPOGLOSSAL (Motor Nerve)

Lesions 1. Peripheral (usually from mechanical causes) 2. Nuclear and Supranuclear Tests Motor: power, atrophy, tremor, fasciculation. Note the deviation. Electrical exam.