CRANIAL NERVE PALSIES

YASSER E. ALHASAN, MD
DEPARTMENT OF OPHTHALMOLOGY
BAGUIO GENERAL HOSPITAL AND
MEDICAL CENTER
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 Cranial nerve III (Oculomotor Nerve)

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Case 1

50 y/o diabetic male

2 days sudden onset diplopia and reports that
his left eye got smaller

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CNIII palsy
• Dysfunction of the somatic muscles:
• Superior recti
• Inferior recti
• Medial recti
• Inferior oblique
• Levator palpebrae superioris

• Dysfunction of the autonomic muscles

• Pupillary sphincter
• ciliary

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CNIII palsy
• Complete
• With or without pupillary
involvement

• Partial
• Variable limitations in EOMs
and pupillary dysfunction

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PUPIL-INVOLVING CNIII palsy
• Mid-dilated pupil that responds poorly to
light

• ANEURYSM is the most common cause

• Junction of the Posterior

Communicating Artery (Pcom) and
Internal Carotid Artery (ICA)

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PUPIL-INVOLVING CNIII palsy
• Computed tomography angiography
(CTA) or Magnetic resonance
angiography (MRA)

• CTA is faster, great resolution, may show

subarachnoid hemorrhage

• MRA show nonaneurysmal lesions

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PUPIL-SPARING CNIII palsy
• Almost always BENIGN and secondary
to microvascular disease

• Usually improves within 3-6 months

• Associated with diabetes, hypertension

or hyperlipidemia

• Neuroimaging not necessary

• Work-up for DM, HPN and dyslipidemia

may be required

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Syndromes associated with CNIII palsy
• WEBER SYNDROME
• Damage to VENTRAL MIDBRAIN and CEREBRAL PEDUNCLE
• Contralateral HEMIPARESIS

• BENEDIKT SYNDROME
• Damage to RED NUCLEUS and SUBSTANCIA NIGRA
• Contralateral TREMOR

• CLAUDE SYNDROME
• Damage to DORSAL MIDBRAIN and SUPERIOR CEREBELLAR PEDUNCLE
• Contralateral ATAXIA

• NOTHNAGEL SYNDROME
• Damage to DORSAL MIDBRAIN
• Contralateral ATAXIA and features of SUPRANUCLEAR EYE MOVEMENT
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 Cranial nerve VI (Abducens Nerve)

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 Abducens nerve

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Case 2

62 y/o diabetic male

1 days sudden onset horizontal diplopia that is
worst on right gaze

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CN VI palsy
• Most commonly affected nerve

• ISCHEMIC MONONEUROPATHY is the

most common cause for patients > 50
y/o

• Usually improves within 3-6 months

• Cranial MRI if no improvement

• For younger patients (< 50 y/o),

neuroimaging may be required

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CN VI palsy
• Lesions in the
cerebellopontine angle may
affect CN V, CN VII and CN
VIII

• Decreased facial and corneal

sensation, facial paralysis,
and decreased hearing with
vestibular signs

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CN VI palsy
GRADENIGO SYNDROME
• Chronic inflammation of the
petrous bone

• Ipsilateral abducens palsy and

facial pain

• Common in children with

recurrent infections of the
middle ear

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Other syndromes associated with CN VI
FOVILLE SYNDROME

• Damage to CNVI NUCLEUS, CNVII

FASCICLE and descending tract
of CN V

• Ipsilateral abduction palsy, facial

weakness, loss of taste over
anterior 2/3 of tongue and facial
hypoesthesia

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Other syndromes associated with CN VI
MILLARD-GUBLER SYNDROME

• Damage to CNVI and CNVII

FASCICLES and CORTICOSPINAL
TRACT

• Ipsilateral abduction palsy,

ipsilateral facial nerve palsy and
contralateral hemiplegia

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 Cranial nerve IV (Trochlear Nerve)

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Case 3

65 y/o male
5 days history of head trauma
Vertical diplopia, lessened when is head is tilted

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CN IV palsy
PARK-BIELSCHOWSKY 3-STEP TEST

• A series of test done to identify patterns of ocular motility

that conform to dysfunction of specific vertically acting EOM

• Helpful in confirming the clinical suspicion of a 4th nerve

palsy

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PARK-BIELSCHOWSKY 3-STEP TEST

RSR RIO LIO LSR

RIR RSO LSO LIR

• Step 1: Primary Position, determine hypertropic eye and
IDENTIFY WEAK MUSCLES
• Step 3: Determine which head tilt the hypertropia is greater
• Step 2: Determine which gaze the hypertropia is greater
• Step 1: Primary Position, determine hypertropic eye and
IDENTIFY WEAK MUSCLES
• Step 3: Determine which head tilt the hypertropia is greater
• Step 2: Determine which gaze the hypertropia is greater
CN IV palsy
MADDOX ROD TEST

• A TEST FOR OCULAR TORSION (EXCYCLOTORSION)

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CN IV palsy
• HYPERTROPIA OF THE AFFECTED
EYE

• VERTICAL DIPLOPIA THAT IS WORSE

WHEN PALSIED EYE IS ADDUCTED

• HEAD TILT POSITION AWAY FROM

THE PALSIED EYE WITH THE CHIN
DOWN

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CN IV palsy
• CONGENITAL

• MICROVASCULAR ISCHEMIA FOR

PATIENTS > 50 Y/O

• HEAD TRAUMA

• TUMORS

• ANEURYSMS

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 MULTIPLE CRANIAL NERVE PALSIES

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MULTIPLE CRANIAL NERVE PALSIES
SIMULTANEOUS INVOLVEMENT OF MORE THAN 1
MOTOR CRANIAL NERVE (CN III, CN IV, CN V, CN VI)

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MULTIPLE CRANIAL NERVE PALSIES
CAUSES OF MULTIPLE CN PALSIES
• CAVERNOUS SINUS THROMBOSIS
• CAROTICO-CAVERNOUS FISTULA
• TOLOSA-HUNT SYNDROME
• INFILTRATIVE CARCINOMAS (E.G. LEUKEMIA OR
LYMPHOMA)
• MIDLINE MENINGEAL MASSES
• MYASTHENIA GRAVIS

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THANK YOU VERY MUCH

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