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 Brain1. Cerebral hemisphere2. Basal ganglia3. Diencephalon (Thalamus, Subthalamus,

Epithalamus, Hypothalamus)4. Midbrain5. Pons6. Medulla Oblongata7. Cerebellum

2. The Spinal Cord

Central Connection

1. Transverse fibers1. Corpus Callosum2. Commisura ant & post

2. Association fibers1. Short2. Long: fasc. longitudinalis

3. Projection fibers1. Corticospinal, cortico bulbar etc.

Pons

Cortex

MO

Spinal cord C8, T12, L5, S5, Cc1

MB

BG BG

T T

CBCranial Nerves (LMN)III, IV, V, VI, VII, IX, XII

Spinal cord (LMN)

Cortico bulbar (UMN)

Descending:

corticospinal, rubrospinal, olivospinal, vestibulospinal,tectospinal, reticulospinal, fasc interfasicularis

Cortico spinal tract (UMN)-Lateral crossed (80%)-Anterior uncrossed (10%)

NEUROANATOMY

Cranial NervesI, II, V, VII, VIII, IX,X

Ascending:

Spinothalamic, spinocerebellar, Spinoolivary, gracillis, cuneatus

Spinal nerveC8, T12, L5, S5, Cc1

FUNCTIONAL NEUROLOGY

Sensory Cortex

Cranial Nerves Cranial Nerves

Assoc.Cortex

Motor Cortex

Thalamus

Brainstem

SpinalCord

Spinal Nerves Spinal Nerves

MotorDescending

Sensory Ascending

Peripheral Lowe M.N

Upper

M.N

Reflex

Central

connection

1. General somatic sensory

1. Pain & Temp2. Proprioception3. Discrim. Touch

& light touch2. Special Somatic

sensory3. Viscero sensory

Receptors:1. Exteroceptors2. Teleceptors3. Proprioceptors4. Visceroceptors

1. Somato motor

2. Viscero motor1. Parasympathetic

2. Sympathetic

Effectors

1. Striated muscles

2. Smooth muscles

3. Glands

1. Otak

2. Ascending: Spinothalamic, spinocerebellar, Spinoolivary, gracillis, cuneatus

3. Descending: corticospinal, rubrospinal, olivospinal, vestibulospinal,tectospinal, reticulospinal, fasc interfasicularis

4. Medula spinalis (C8,T12,L5,S5,Coc1)

Sensorik: Afferent, Ascending, centrifugal

Central Nervus SistemMotor : Efferent, Descending, Centrifugal

Sistem Sensorik : Tractus Spino-, Bulbo

Dan Nucleus Thalamici

Sistem Motorik : Tractus CorticospinalisDan corticobulbaris

Cranial Nerves Examination

Tujuan UmumMhs kompeten melakukan pemeriksaan syaraf kranial dan menginterpretasikan hasil

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

Metode1. Presentasi oleh instruktur2. Demonstrasi oleh instruktur3. Pelatihan mhs dengan bimbingan4. Latihan mhs mandiri

N. NIV

Mot. Nuc. N V

Nuc. N VI

Nuc. Sal Sup

Mot. Nuc. N VII

Nuc. Sal Inf

Dors.M.Nuc N X

Nuc. Ambig N IX,X,XI

Nuc. N XII

Coll. Sup

Cop Gen Med

Coll. Inf

Mesencep Nuc. N V

Main Sensory Nuc. N V

Vest Nucl N VIII

Coch Nucl N VIIINuc. Tract. Solit N VII & IX

Spinal Nucl N V

EWN. NIII

Contra lateral1. Pars superior N. VII2. N. XIIBilateral:Other cranial nuclei

BRAINSTEM CRANIAL NERVESCortico Bulbar Tract

OLFACTORY NERVE

Symptoms & Signs and TestsS & S

•Anosmia•Parosmia•Cacosmia

TestEach nostril test separately. (tobacco, coffee)

OPHTAHALMIC NERVES & S

1. Visual acuity

2. Visual field

3. Diplopia (coloured glass)

4. Color blindness (RBG)

Tests1. Visual acuity

(snellen, jaeger, jari

1/60)

2. Perimetri (Goldman),

confrontation

3. Color blindness

4. Light reflex

5. Funduscopy

Symptoms and Signs1. Squint or strabismus2. Diplopia (double

vision)3. Tilting of head to

compensate diplopia4. Conjugate deviation5. Nystagmus (fast

phase)6. Ptosis7. Midriasis8. Dizziness9. Limitation of

movement Loss of reflexed, etc

Classification of DisorderNerves III, IV, VI1. Ophthalmoplegia III

1. External (M.nucl)3. Internal (EW Nucl)

2. Opthalmoplegia IV, VI. 3. Supranuclear

lesions,lesi frontal or occip lobe - paralysis of conj gaze to the opposite side and deviation to the side ofthe lesion

5. Nystagmus1. Peripheral + vertigo2. Central seldom +

vertigo

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

Test1. 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

Tests1. 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

Bell’s palsy

Outside of stylomastoid foramen

Lesion involving chorda tympani – loss of taste, reduced salivation.

Higher involving m. stapedius – hyperacusis

Higher involving geniculate ganglion – pain within the ear. Ramsy Hunt syndrome = Bell’s palsy + H. Zoster of the geniculate gl.

Lesion in the internal auditory meatus – bell;s palsy and deafness.

Lesion at the emergence of N VII from the pons – involves N V, VIII and at times, VI, XI, and XII.

Nuclear type.

Millard Gubler synd: facial hemiplegia alternans.

Foville’s synd: Millard Gubler + ipsilateral paralysis of conjugate gaze.

Supra nuclear

associcated with hemiplegia or monople- gia, spastic type, frontal normal.

Geniculate neuralgia.

Crocodile tears synd. Injury prox to the geniculate ganglion

Striatum lesions; grimace, choreiform etc

TestMotor 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 signsCochlearTinnitusDeafnessHearing scotomasSupra nucl disVestibular

VertigoNystagmusTests

TestsHearing acuityWeber (lateralisasi), Rinne, Swabach, Bing.OtoscopicAudiometryCaloric test HallpikeElectric testDix Hallpike

Prinsip: konduksi udara lebih baik dari konduksi tulang. Gunakan garpu tala frekuensi 256Weber : 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.Bing’s test : garupu tala di vertex kemudian tutup satu telinga – lateralisasi ketelinga ditutup bila tak terdengar > gangguan syaraf.

Cranial Nerve IX: GLOSSOPHARYNGEAL(Mixed Nerve)

SymptomsGlossopharingeal neuralgia. Neuralgia of tympanic branch (Jacobson’s nerve)Vernet’s syndromeBonier’s syndrome

Tests:Pharyngeal gag refex. Vernet’s rideau (“ah”) – constrict ph deviation of the uvula, Loss of sensation Increased salivation (Timp cord)Visceral reflex

Cranial Nerve X: VAGUS (Mixed Nerve)

Symptoms & SignsA 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 disturbancesPain of paresthesias in the parynx, larynx and external auditory meatus – irritative lesion. Anesthesia of the lower pharynx, larynx. Cough, dyspnea, salivary hypersecretionand hyposecretion.

TestsLaryngoscopic examinationSensory statusPharyngeal gag reflexOcculocardiac reflexCarotid sinus Reflex

Cranial Nerve XI : ACCESSORY (Motor Nerve)

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

Cranial Nerve XII: HYPOGLOSSAL (Motor Nerve)

Lesions1. Peripheral (usually from

mechanical causes)2. Nuclear and

Supranuclear

TestsMotor: power, atrophy,

tremor, fasciculation. Note the deviation.

Electrical exam.