Cranial Nerve Examination Research Articles

An exotic cause for confusion in the garden

A 70-year-old retired accountant presented with progressive confusion. He was unable to give a clear account of recent events so his wife provided most of the history. She had first...

Dysphagia Caused by Multilevel Cervical Osteophytes

An 85-yr-old man complaining of swallowing difficulties was referred for a videofluoroscopic swallowing test for the evaluation of dysphagia. He had experienced swallowing difficulties for 7 yrs, but he had no complaint of dyspnea or dysphonia. Specifically, he complained of intermittent aspiration symptoms when drinking water or eating semisolid food, and he felt considerable discomfort when swallowing solid food. On physical examination, his gross motor and sensory functions were normal, and no pathologic reflex was detected. In addition, a cranial nerve examination that included gag reflex, mastication, and tongue movement evaluations produced normal findings. However, a videofluoroscopic swallowing test revealed epiglottic closure failure attributable to anterior bony spurring at the C3–6 levels, which presumably explained his complaint of aspiration. In addition, a diffuse osteophyte was found anteriorly encroaching the posterior aspect of the oropharynx and esophagus (Fig. 1). However, his swallowing reflex was prompt, and other swallowing movements were normal.FIGURE 1: A diffuse osteophyte at the C3–6 level anteriorly encroaching the posterior aspect of the oropharynx and esophagus.Dysphagia can be caused by hypertrophic anterior cervical osteophytes,1 and about 100 such cases have been reported in the literature.2 Large bridging anterior osteophytes of the cervical spine causing compression of the oropharyngeal swallowing structure are usually the result of diffuse idiopathic skeletal hyperostosis. Diffuse idiopathic skeletal hyperostosis is more frequent in men than in women. It affects up to 10% of patients older than 65 yrs of age, and dysphagia is the most common complaint associated with diffuse idiopathic skeletal hyperostosis.3 Moreover, 17% of patients with diffuse idiopathic skeletal hyperostosis complain of dysphagia,4 whereas anterior cervical bony protrusion is found in only about 10.6% of patients older than 60 yrs undergoing dysphagia evaluations.1 According to our review of 31 reported cases in 19 recent case reports issued from 2002, patients are usually men (81%), and the mean patient age is 68 yrs. Typically, patients have a long history of dysphagia, and the C3–6 levels are most commonly involved. Therefore, cervical osteophytes should be suspected as a cause of swallowing difficulties when other explainable causes are absent. Moreover, although rarely encountered, these osteophytes are most commonly found between C3 and C6.

Hemiplegic migraine associated with interscalene block and general anaesthesia

We report a case of new onset hemiplegic migraine following general anaesthesia and an interscalene block, the first reported case in the literature. A middle-aged man underwent manipulation of the left shoulder under anaesthesia. An awake left interscalene block under sedation was performed. The plexus was located easily with a 25 Stimiplex needle and 30 ml 0.5% levobupivicaine injected at an end point of 0.4 mA (biceps twitch) uneventfully. General anaesthesia was then induced with 50 μg fentanyl and 200 mg propofol. A laryngeal mask airway was placed and the patient ventilated spontaneously with oxygen, air and sevoflurane. The patient was positioned in the right decubitus position. There were no adverse events during the 40 min procedure. In recovery he was unable to move or feel the left side of his body and had difficulty responding to questions with slurred speech. Cranial nerve examination revealed reduced sensation of the left cheek, flaccid paresis of the left cheek, and left hypoglossal nerve impairment. A dense left-sided hemiplegia and hemisensory loss was found on peripheral nervous system examination. Symptoms resolved gradually. Within 4 h he was able to move his foot but sensation was still impaired on the left side of his body. Cranial nerve assessment at this time showed tongue movement and speech back to normal. At 15 h upper limb movement had partially recovered, he was able to lift the arm, but still unable to move the fingertips. By 24 h the upper limb signs had almost completely resolved, and the leg weakness appeared to be resolving. Cranial nerve examination demonstrated ongoing numbness of the left side of the tongue. He notes having very slight generalised weakness thereafter which lasted for a further 3 days. Immediate MRI of the cervical spinal cord was normal. Carotid duplex scans and cranial MRI performed later revealed no abnormality. Since the initial episode he had six further attacks of left-sided weakness. Severe stabbing pains in the head followed by mild to moderate headache have preceded each episode. Both his left arm and leg are affected. Symptoms resolve after 3 days. A diagnosis of hemiplegic migraine was made following neurological consultation. Propranolol was commenced and he was reviewed after 3 months. At this stage he reports suffering headaches every 2 weeks which were more tolerable. He had no further attacks of associated left-sided weakness or numbness. EEG undertaken was normal. Our case highlights the diagnostic dilemma posed by a neurological deficit following anaesthesia with interscalene block. A number of central and peripheral diagnoses should be considered. A left interscalene block could lead to left-sided neurology if injected directly into the substance of the spinal cord. A total spinal is likely to have occurred simultaneously. Literature describing this complication describes predominantly upper limb neurological loss, all being in individuals where interscalene block was performed under general anaesthesia [1]. Spontaneous right-sided stroke under anaesthesia is a possible differential diagnosis, but no radiology supported this, and the recurrent nature of the symptoms confirmed this. General anaesthesia is known to precipitate migraine in sufferers. Ten per cent of migraine sufferers have neurological deficits and in 4% this persists beyond the duration of the headache. Hemiplegia associated with migraine post general anaesthesia has to date only been reported in individuals with a prior history of the condition or a known strong family history of hemiplegic migraine [2]. Hemiplegic migraine is a rare disorder characterised by attacks of transient hemiparesis followed by migraine headache. Classically there is an aura, followed by development of neurological signs lasting a mean of 60 min followed by headache lasting 30 min to 5 days. Motor signs occur unilaterally in approximately 60% of cases and are never isolated – most commonly associated with sensory signs and language disturbance, and least commonly with visual disturbances – in contrast to classic migraine. Triggers for the development of migraine in these individuals are commonly minor stressful events, which is the postulated mechanism in this gentleman [3]. This case highlights that hemiplegic migraine should be considered as a possible differential when faced with neurological deficit postoperatively.

Surgical treatment of a traumatic intracranial epidural haematoma in a dog

A 10-month-old Czech wolf dog was unconscious after being kicked in the head by a horse. The following day, the dog was ataxic and collapsed after several steps. The level of consciousness was decreased. Cranial nerve examination was normal and right postural reactions were decreased. Spinal reflexes were intact in all limbs. The diagnostic work-up included a computed tomography (CT) scan of the head with IV contrast. A lenticular shaped, hyperdense, non-enhancing lesion was observed in the left fronto-parietal region. A diagnosis of intracranial epidural haematoma was made. Two craniotomies were performed on a different day and most of the haematoma was removed. Corticosteroids and antimicrobial therapy were administered. Fifteen days after the surgery, the clinical examinations were unremarkable. Fifteen months later, the owners considered the dog normal. Intracranial subdural or intraparenchymal haematomas have been described in the veterinary literature. To the authors' knowledge, this is the first report of the successful management of an intracranial epidural haematoma in the dog. In humans, these lesions are well described. Common locations are temporal, parietal and frontal regions or a combination of these regions. Patients can be asymptomatic, present with varying clinical signs, or be unconscious. Based on the human literature, following trauma to the head, a CT scan should be performed even if the patient is asymptomatic. Some authors believe that there are not any absolute indications for conservative management versus surgical management.

Facial Palsy and Fallopian Canal Expansion Associated With Idiopathic Intracranial Hypertension

Describe neurotologic findings associated with idiopathic intracranial hypertension (IIH). Retrospective. Tertiary referral center. Case of IIH (>250 mm water) presenting with unilateral facial palsy and enlargement of the fallopian canal on computed tomography and magnetic resonance imaging. Oral acetazolamide, corticosteroids, and cerebrospinal fluid drainage. Intracranial pressure measurement, cranial nerve examination, audiometry, and symptom assessment. Audiometry revealed asymmetric sensorineural hearing loss. Enlargement of the fallopian canal with cerebrospinal fluid was evident on imaging studies. Partial resolution of IIH symptoms was achieved. IIH is an enigmatic disease entity. Increased intracranial pressure usually presents with headache and pulsatile tinnitus and is occasionally associated with cranial neuropathies. Abducens palsy is most common, producing diplopia. Cranial nerve involvement is often asymmetric, producing false localizing signs. Facial paralysis is an uncommon sequela of IIH. Treatment of IIH consists of reducing intracranial pressure. Corticosteroids are recommended for treatment of facial paralysis.

Depression and chorea

3. Wilson’s disease. Depression and choreaJournal of Clinical NeuroscienceVol. 14Issue 9PreviewA 43 year old woman with a history of borderline personality disorder and depression presented with a debilitating movement disorder and leg weakness, progressive over a number of years. She described involuntary limb movements, decreased mobility with frequent falls as well as dysarthria and dysphagia. On examination she was alert and orientated, although emotionally labile. Her speech was slurred. Cranial nerve examination was unremarkable. Choreiform movements of her upper limbs were identified. Full-Text PDF

Exaggerated Crying and Tremor With a Cerebellar Cyst

Exaggerated Crying and Tremor With a Cerebellar Cyst

Isolated Sixth Cranial Nerve Palsy in Preeclampsia

Isolated Sixth Cranial Nerve Palsy in Preeclampsia

Endoscopic transnasal approach for retrieval of foreign bodies from the pterygomaxillary fossa

Foreign bodies within the aerodigestive tract are common clinical entities, especially in children. Although foreign bodies can be located anywhere along the aerodigestive tract, there are no case reports describing a foreign body within the pterygomaxillary fossa. This area contains numerous vascular and neural structures and can be quite difficult to access. We describe the case of a patient who sustained a gunshot wound to the cheek, wherein the bullet entered the pterygomaxillary fossa. Foreign bodies isolated to the pterygomaxillary fossa can be a challenge to retrieve. Open approaches have been most commonly used, but these approaches often provide limited exposure and can be fraught with complications. We propose the use of a transnasal endoscopic approach for the retrieval of foreign bodies from the pterygomaxillary fossa. 2. Case report The patient is an 18-year-old African American male, who presented to the emergency department at SUNY Upstate Medical University after sustaining a gunshot to the left cheek. The patient complained of left-sided nasal congestion and cheek pain. He denied visual changes, headaches, epistaxis, facial hypoesthesia, difficulty in chewing, dysphagia, malocclusion, or neurological symptoms. Physical examination demonstrated that the patient was awake, alert, and in no acute distress. A 1.5-cm-bullet entry wound with surrounding soft tissue swelling was noted in the left cheek, approximately 4 cm anterior to the tragus. Anterior rhinoscopic examination was normal. The oral cavity examination demonstrated a palpable submucosal firm tooth at the junction of the left hard and soft palate. The tooth socket of the left second upper molar was palpated and noted to be missing a tooth. Cranial nerve exam was normal bilaterally. Rigid nasal endoscopy using a zero-degree, 4-mm endoscope was then carried out on the left side. This demonstrated a shiny bullet lodged within the left lateral nasopharyngeal wall. A computed tomography (CT) scan of the maxillofacial region demonstrated a metallic foreign body wedged in the left pterygomaxillary fossa and lateral aspect of the nasopharynx (Figs. 1 and 2). A molar tooth was noted to be lodged at the junction of the left hard and soft palate. The patient was taken to the operating room for endoscopic removal of the bullet. After the patient was placed under general anesthesia and the endotracheal tube secured in place, a zero-degree, 4-mm endoscope was introduced into the left nasopharynx. The bullet was noted to be wedged in the pterygomaxillary fossa and was visible through a disruption in the lateral nasopharyngeal wall mucosa. A freer elevator was used to dissect the embedded bullet from the lateral nasopharyngeal wall and pterygomaxillary fossa. The bullet had some very sharp edges and was unable to be removed anteriorly because of obstruction from the posterior aspect of the inferior turbinate. A partial inferior turbinectomy was then performed. Despite this, the bullet was still unable to be removed anteriorly without causing significant mucosal lacerations within the nasal cavity. The bullet was then firmly grasped in the nasopharynx using Ferris-Smith forceps. The 30-degree endoscope was then inserted into the posterior oropharynx, and the bullet was visualized in the nasopharynx. The bullet was then delivered into the oropharynx and grasped with another set of forceps. It was then brought out of the oral cavity under endoscopic guidance. It measured approximately 1.5 cm in its greatest dimension (Fig. 3).

Anterior Spinal Artery Infarction at the Cervicomedullary Junction

An 81-year-old right handed man presented with bilateral leg weakness. The patient had been previously independent and was medicated with warfarin for atrial flutter. He had longstanding type 2 diabetes, controlled by oral hypoglycemic medication. At presentation, he reported sudden onset left sided weakness with accompanying neck pain at 22h00 the previous evening. Pertinent findings on neurological examination included a left pronator drift and profound left leg weakness with unsustained antigravity strength. Deep tendon reflexes were brisk throughout but absent at the ankles and there was a left extensor plantar response. Cranial nerve and sensory examinations were normal.

Administration of testosterone results in reversible deterioration in Kennedy’s disease

Kennedy’s disease, or spinal and bulbar muscular atrophy (SBMA), is an X-linked neurodegenerative disease characterised by slowly progressive muscle weakness and atrophy of bulbar, facial and limb muscles accompanied by...

Persistent Orodental Pain, Atypical Odontalgia, and Phantom Tooth Pain: When Are They Neuropathic Disorders?

Patients with unrelenting pain in the teeth, gingival, palatal or alveolar tissues often see multiple dentists and have multiple irreversible procedures performed and still have their pain. Up to one-third of patients attending a chronic facial pain clinic have undergone prior irreversible dental procedures for their pain without success. In these cases, if no local source of infectious, inflammatory, or other pathology can be found, then the differential diagnosis must include a focal neuropathic pain disorder. The common diagnoses given include the terms atypical odontalgia, persistent orodental pain, or if teeth have been extracted, phantom tooth pain. One possibility is that these pain complaints are due to a neuropathic alteration of the trigeminal nerve. There are several diagnostic procedures that need to be performed in any patient suspected of having a trigeminal neuropathic disorder including (1) cold testing of involved teeth for pulpal nonvitality; (2) a periapical radiograph examining the teeth for apical change; (3) a panoramic radiograph examining for other maxillofacial disease; (4) a thorough head and neck examination also looking for abnormality; (5) a cranial nerve examination including anesthetic testing which documents any increased or decreased nerve trigeminal nerve sensitivity and rules out other neurologic changes outside the trigeminal nerve; and (6) MRI imaging in some cases. Finally, when a nonobvious atypical toothache first presents, direct microscopic examination of the tooth for incomplete tooth fracture is also suggested. The majority of these patients are women over the age 30 with pain in the posterior teeth/alveolar arch. Multiple causes exist for sustained neuropathic pain including direct nerve injury (e.g., associated with fracture or surgical treatment), nerve injection injury, nerve compression injury (e.g., implant, osseous growth, neoplastic invasion) and infection-inflammation damage to the nerve itself. Sustained nerve pain is commonly seen in patients with psychiatric impairment. It may be that the unrelenting nature of the pain itself alters the patient's personality. Treatment includes pharmacologic medications which suppress nerve activity. The common medications used for atypical odontalgia and phantom tooth pain include gabapentin, tricyclics, topical anesthetics, and opioids. A list of these medications is provided in table form. Data suggest that once the patient has failed dental treatment and pain persists, the long-term outcome is less than 25 percent will have complete pain relief with treatment. With earlier treatment, better pain control, and improved nerve activity suppression medications, this should also prevent secondary psychiatric disease from developing and lower the number of inappropriate treatments.

Mutations in the Gene Encoding Peroxisomal Sterol Carrier Protein X (SCPx) Cause Leukencephalopathy with Dystonia and Motor Neuropathy

In this report, we describe the first known patient with a deficiency of sterol carrier protein X (SCPx), a peroxisomal enzyme with thiolase activity, which is required for the breakdown of branched-chain fatty acids. The patient presented with torticollis and dystonic head tremor as well as slight cerebellar signs with intention tremor, nystagmus, hyposmia, and azoospermia. Magnetic resonance imaging showed leukencephalopathy and involvement of the thalamus and pons. Metabolite analyses of plasma revealed an accumulation of the branched-chain fatty acid pristanic acid, and abnormal bile alcohol glucuronides were excreted in urine. In cultured skin fibroblasts, the thiolytic activity of SCPx was deficient, and no SCPx protein could be detected by western blotting. Mutation analysis revealed a homozygous 1-nucleotide insertion, 545_546insA, leading to a frameshift and premature stop codon (I184fsX7).

Dementia With Mood Symptoms in a Fragile X Premutation Carrier With the Fragile X-Associated Tremor/Ataxia Syndrome: Clinical Intervention With Donepezil and Venlafaxine

Dementia With Mood Symptoms in a Fragile X Premutation Carrier With the Fragile X-Associated Tremor/Ataxia Syndrome: Clinical Intervention With Donepezil and Venlafaxine

Bilateral hearing loss following a retrobulbar block

Regional anesthesia is the most commonly used ophthalmological anesthetic technique in Canada and the United States. Brainstem anesthesia is not an uncommon complication of retrobulbar blocks. Anesthesiologists are a prominent element in the ophthalmology suite, in part due to the complications possible with regional anesthesia. This is the first reported case of complete bilateral hearing loss following a retrobulbar block. A 46-yr-old male with type 1 diabetes mellitus presenting for ophthalmological surgery had a retrobulbar block performed by the ophthalmologist. Local anesthetic was injected through a 25 G, 1.5 inch needle, entering the orbit inferiorly on the temporal third of the lower lid. Shortly after the block was completed the patient experienced sudden hearing loss. On examination the hearing loss appeared to be complete and bilateral. The patient was alert and oriented; the remainder of the cranial nerve exam was normal. The patient's hearing loss gradually improved and three hours after the block his hearing had subjectively returned to normal. Brainstem anesthesia is not a rare complication of regional anesthesia for ophthalmological surgery. Symptoms include confusion, mental agitation, dizziness, blurred vision or blindness, ophthalmoplegia, deafness, tinnitus, dysphagia, dysarthria, respiratory depression to apnea, and/or limb paralysis. A connection between the subdural and subarachnoid spaces and the optic sheath exists. The effect on the central nervous system depends upon the amount of local anesthetic injected and the area to which it spreads.

Tentorial Schwannoma: A Case Report and Review of the Literature

Schwannomas are most often found in association with the eighth cranial nerve, but may also arise from any other cranial nerve. They are rarely found in an intra-parenchymal location. Unusual locations for intracranial schwannomas have also been reported in association with neurofibromatosis. A 23-year-old male without von Recklinghausen's disease presented with intermittent dizziness and difficulty swallowing. Past medical history was significant for a motor vehicle accident (MVA) without loss of consciousness 6 months prior. Magnetic resonance imaging revealed a large tentorial-based tumor. At surgery the origin of the tumor was clearly the tentorium, and while the trigeminal nerve was displaced, it easily separated from the mass. There was no attachment to any other cranial nerve in the immediate vicinity and postoperative cranial nerve examination was unremarkable. Pathological review was consistent with schwannoma. While there are few reported cases of tentorial-based schwannoma, these tumors have been noted in unusual locations within the intracranial vault, and clinicians should be aware of this diversity of origin.

Paraneoplastic limbic encephalitis presenting as lingual epilepsia partialis continua

Sirs: Paraneoplastic limbic encephalitis (PLE) is a rare neurological syndrome characterised by progressive dementia, psychiatric disturbance and seizures occurring as a remote effect of cancer. Seizures are reported to occur in 50–58 % [1, 2]. They are typically complex partial in nature, originating from the affected medial temporal lobe, but may generalise. Small cell lung carcinoma is the main associated tumour (50–60 %), though many others have been described [1]. Here we report an unusual case of PLE presenting with lingual epilepsia partialis continua. A 48-year-old woman presented initially to the Accident and Emergency department with a twomonth history of low back pain. She had no significant past medical history but had a 30-pack a year smoking history.While being assessed she was witnessed to have two generalized tonic-clonic convulsions. On questioning she admitted that her speech had become slurred over the previous two weeks and at times she would be unable to speak for about ten seconds at a time. She also admitted to intermittent sensory disturbance of the left side of the lips and fingers of the left hand and occasional brief episodes of left arm jerking over the same period. On examination she was mildly disinhibited. Tests of cognitive function revealed minor deficits of attention and verbal memory. She had a fluctuating dysarthria but speech content was normal and there was no impairment of comprehension, reading or writing. On inspection of the oral cavity she had continuous rhythmic myoclonic jerking of the tongue and palate bilaterally at a rate of 2–3Hz. This varied somewhat in intensity, being more prominent when the tongue was resting on the floor of the oral cavity than when protruded. There was no involvement of the perioral facial muscles. During the examination her speech became particularly slurred and was followed by an episode of anarthria lasting approximately 15 seconds. The rest of the cranial nerve exam was unremarkable. On examination of the limbs she had absent knee and ankle jerks and decreased pinprick sensation to mid-calf level bilaterally. On gait testing she had a mild heel-toe ataxia. On general examination the patient’s abdomen was distended and there was a large mass palpable in the suprapubic region. Routine blood tests were normal. Chest radiographs were reported to be normal. CT of the brain was also reported normal. EEG showed bilateral background theta slowing with frequent runs of rhythmical sharpened activity, at 6–9/s, in the right anterior temporal region (Fig. 1), suggestive of focal seizure activity. The patient had initially been treated with phenytoin in the Accident and Emergency department and was now commenced on carbamazepine (800 mg/day) with some improvement in her symptoms. T2weighted MRI scan of brain revealed high signal intensity in the mesial temporal structures bilaterally, predominantly on the right (Fig. 2). The appearances were felt to be consistent with limbic enLETTER TO THE EDITORS

Post-traumatic cranial nerve injury

Injury to the cranial nerves is a common accompaniment of head trauma. Incidence of cranial nerve injury in head injury varies in various published literature. Indian literature on post-traumatic cranial nerve injuries as whole is scanty. Aims of this study are to document the incidence of cranial nerve injuries in head injuries, to correlate incidence with radiological findings, to assess recovery time with respect to signs and symptoms at initial presentation and to stress the importance of clinical examination in head injured patients. We studied 794 consecutive cases of head injured patients from May 2002 to November 2004. One hundred patients were found to have cranial nerve injuries and were included in this study. Clinical examination of cranial nerves was done meticulously on a daily basis. Patients were followed up at monthly interval for a minimum of six months.

Aortic dissection presenting with transient global amnesia-like symptoms

Diagnostic criteria of transient global amnesia (TGA) are witnessed attacks, clear-cut anterograde amnesia during the attack, absent clouding of consciousness and loss of personal identity, no accompanying focal neurologic symptoms or epileptic features, resolution of attacks within 24 hours, and no recent head injury or active epilepsy.1 For the etiology of TGA, four main hypotheses have been considered: TIA, epilepsy, migraine, and transient venous ischemia.1–3⇓⇓ None of these hypotheses fully explains the mechanism of this episodic disease, but the accepted neuroanatomic correlate of TGA is the mediobasal temporal lobe and hippocampus. We present two patients with aortic dissection who provide evidence for an ischemic pathogenesis in TGA. ### Patient 1. A 47-year-old man was found confused and disoriented. On examination at admission, he asked repetitive questions and was alert but completely disoriented to time and place and only partially oriented to person. The cranial nerve examination showed only a slight anisocoria. The …

Bilateral lymphosarcoma of the nictitating membrane in a Quarter Horse

SUMMARY A 21-year-old Quarter Horse mare presented for a mass of the right nictitating membrane. The entire right nictitating membrane was surgically removed and diagnosed as a mixed cell lymphosarcoma and squamous cell carcinoma. The horse had no systemic signs of lymphosarcoma. Approximately 1.5 years later, the horse presented with a similar mass in the left nictitating membrane. The entire left nictitating membrane was surgically removed and diagnosed as a mixed cell lymphosarcoma. In this case, complete surgical removal of the masses resulted in a cure. The horse has remained free of systemic lymphosarcoma for over 3 years. CASE REPORT A 21-year-old gray Quarter Horse mare was presented to the Kansas State University Veterinary Medical Teaching Hospital for evaluation of a mass involving the right nictitating membrane. The mass was first noticed 5 weeks before presentation and had been treated by the referring veterinarian with a topical steroid solution twice daily. Administration of the topical steroid caused some decrease in the swelling, but it quickly returned once medication was discontinued. The horse had no other medical complaints and appeared to be otherwise healthy. On ocular examination, chemosis of the third eyelid and conjunctiva of the right eye was evident. Direct and indirect pupillary light reflexes, Schirmer tear test, and intraocular pressures were normal in both eyes. Fluorescein stain uptake was negative in both corneas. Cranial nerve and vision examinations did not reveal any