Cranial Nerves

dr. Kusumo Dananjoyo, M.Sc, Sp.S Bagian Neurologi FK UGM - SMF Saraf RSUP Dr Sardjito

Introduction
There are 12 cranial nerves which pass to and from the brain through foramina and fissures in the skull. All cranial nerves are distributed in head and neck except the Vagus (10th) which extends down to supply other structures in the thorax and the abdomen. Cranial nerves are either sensory, motor or mixed and they have central nuclei situated in the brain stem.

Cranial Nerve: I Olfactory smell

Major Functions:

II Optic
III Oculomotor IV Trochlear V Trigeminal

vision
eyelid and eyeball movement

innervates superior oblique turns eye downward and laterally chewing face & mouth touch & pain turns eye laterally controls most facial expressions secretion of tears & saliva taste hearing equillibrium sensation taste senses carotid blood pressure senses aortic blood pressure slows heart rate stimulates digestive organs taste controls trapezius & sternocleidomastoid controls swallowing movements
controls tongue movements

VI Abducens
VII Facial VII Vestibulocochlear (auditory) IX Glossopharyngeal X Vagus XI Spinal Accessory XII Hypoglossal

I II

III, IV V, VI, VII, VIII

IX, X, XI, XII

I. Olfactory
The olfactory nerve has only a special

sensory component. Special sensory (special afferent)Functions in the special sense of smell or olfaction. The olfactory system consists of the olfactory epithelium, bulbs and tracts along with olfactory areas of the brain collectively known as the rhinencephalon.

Results of Olfactory nerve testing

Subject identifies smells appropriately Normal Subject is unable to recognize scents offered but

recongnizes ammonia Anosmia

Subject recognizes no smell including ammonia

Psychologic causes

II. Optic nerve

Visual information enters the eye in the form of

photons of light which are converted to electrical signals in the retina These signals are carried via the optic nerves, chiasm, and tract to the lateral geniculate nucleus of each thalamus and then to the visual centers of the brain for interpretation.

II - Optic

Optic chiasm bitemporal hemianopia e.g. pituitary tumour Optic radiation homonymous hemianopia or quadrantanopia (lower parietal, upper temporal) e.g. stroke

Functions of the Optic Nerve

General Eyelids, orbital globe Pupils Light reflex, accomodation reflex Acuity due to ocular, optic, or retinal abn. If reduced

acuity correctable by pinhole then ocular Fields Fundi

 The right half of the retina receives stimuli from the left visual field. The left half of the retina receives stimuli from the right half of the visual field. The upper half of the retina receives stimuli from the lower half of the visual field. The lower half of the retina receives stimuli from the upper half of the visual field.

III. Oculomotor
A. Somatic motor (general somatic efferent) Supplies four of the six extraocular muscles of the eye and the levator palpebrae superioris muscle of the upper eyelid. B. Visceral motor (general visceral efferent) Parasympathetic innervation of the constrictor pupillae and ciliary muscles.

The somatic motor component of CN III innervates the following four extraocular muscles of the eyes:

Ipsilateral inferior rectus muscle Ipsilateral inferior oblique muscle Ipsilateral medial rectus muscle Contralateral superior rectus muscle

Lower motor neuron lesion of Oculomotor nerve:

Downward, abducted eye on the

affected side rectus muscles. Strabismus Ptosis (eyelid droop) on the affected side Dilation of the pupil on the affected side Loss of the accomodation reflex on the affected side.

IV. Trochlear Nerve

Somatic motor (general somatic efferent) Somatic motor innervates the superior oblique muscle of the contralateral orbit.

IV. Trochlear Nerve lesion

Extorsion (outward rotation) of the affected eye. Vertical diplopia (double vision) due to the extorted eye. Weakness of downward gaze most noticeable on medially-directed eye. This is often reported as difficulty in descending stairs.

Pupillary response to light

Inbound (afferent): II to midbrain Outbound (efferent): Parasympathetic on surface of III to both eyes So, testing the left pupil: Direct (left II and III working) Consensual (right II and left III working) Pupil-sparing III lesion: localises origin of pathology

Eye movements III, IV and VI

VI (Abducens) Lateral rectus: abducts eye IV (Trochlear) Superior oblique: depresses abducted eye III (Oculomotor) everything else and eyelid retraction So, III palsy: down and out and ptosis:

Left complete IIIrd nerve palsy

VI. Abducent Nerve

Supplies the ipsilateral lateral rectus extraocular muscle

Abducent Nerve Lesion

1. Medially directed eye on the affected side due to the unopposed action of the medial rectus muscle 2. Inability to abduct the affected eye beyond the midline of gaze (up to approximately the midline, the superior and inferior oblique muscles can abduct the eye). 3. Strabismus - the inability to direct both eyes to the same object. When asked to look at an object located laterally to the side of the lesion, the patient's affected eye will be unable to be abducted beyond the midline of gaze. The opposite normal eye will be adducted to effectively fixate on the object.

Abducent Nerve Lesion

3. Strabismus - the inability to direct both eyes to the same object. When asked to look at an object located laterally to the side of the lesion, the patient's affected eye will be unable to be abducted beyond the midline of gaze. The opposite normal eye will be adducted to effectively fixate on the object. 4. Horizontal diplopia (double vision) due to the strabismus. Patients may compensate by turning their head so that the affected eye is focused on an object and then moving the normal eye so as to fixate on the object. 5. CN VI paralysis is the most common isolated palsy due to the long peripheral course of the nerve.

Damage to the pontine lateral gaze center

may result in conjugate paralysis of lateral gaze to the affected side. This is indicated by an inability of the patient to fixate on an object placed laterally to the affected side. specifically it is: Inability to abduct the eye on the affected side past approximate midline gaze. Inability to adduct the eye opposite the lesion past midline gaze. The end result is that neither eye is moved to effectively fixate on the target object.

MLF syndrome
Lesion of medial longitudinal fasciculuc leads to:Due to loss of input to the occulomotor nucleus from the lateral gaze center, the adducting eye is unable to move medially past approximately the midline of gaze.
Monocular horizontal nystagmus is observed for the abducting eye. The abducting eye moves smoothly laterally followed by a rapid movement (saccade) back to midline gaze.

Terima kasih ...SEMOGA BERMANFAAT

Hemisfer kiri vs Hemisfer kanan