curs nervi cranieni
TRANSCRIPT
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Nervii cranieni
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Paraliziile de n oculomotori
• Oculomotor comun III
• Trohlear IV
• Abducens VI
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Nervul oculomotor comun III
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• Componenta motorie somatica: controlul musculaturii extrinseci a globului ocular:
• Ridicatorul pleoapei superioare,
• Drept intern,
• Drept superior si inferior,
• Oblic inferior.
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• Componenta motorie viscerala implicata in controlul musculaturii pupilare (reflex fotomotor si de acomodare)
• Inerveaza muschii constrictori ai pupilei si muschii ciliari.
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Traseu intracranian
• Paraseste trunchiul cerebral pe fata anterioara fiind in strins contact cu stanca temporala.
• Are un traseu de-a lungul sinusului cavernos superior de nervul trohlear si abducens; patrunde in orbita prin partea superioara a fisurii orbitale.
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Clinic
• Ptoza palpebrala
• Strabism divergent
• Limitarea miscarii globului ocular
• Diplopie
• Modificari pupilare: midriaza
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Trohlear IV
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• Inerveaza muschiul oblic superior.
• Determina rotatia interna si partial abductia globului ocular.
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Clinic
• Rotatia externa a globului ocular.
• Diplopie verticala.
• Dificultate in mentinerea privirii in jos si in interior (frecvent raportata ca dificultate la coboritul scarilor).
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Nervul abducens VI
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• Inerveaza muschiul drept extern al globului ocular.
• Strabism convergent.
• Diplopie in privirea laterala.
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Paraliziile supranucleare• Sindroamele Foville:
– Leziuni de arie frontala 8;– Paralizii ale miscarii conjugate orizontale– Paralizia ipsilaterala a privirii laterale si hemiplegie
controlaterala.
• Sindromul Parinaud– Leziune mezencefalica– paralizia conjugata a miscarii pe verticala
• Sindromul Balint: – Leziune occipito-parietala bilaterala– Paralixia “psihica” a privirii
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Paralizia internucleara
• Paralizia adductiei cu pastrarea reflexului de convergenta;
• Nistagmus monoculasr controlateral;
• Pozitionarea in abductie a globului ocular controlateral.
• Poate fi prezenta in scleroza multipla.
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Nervul trigemen
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• Fibrele senzitive au originea in ganglionul Gasser.
• Se distribuie sub forma a trei brate:– Oftalmica– Maxilara– Mandibulara.
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• Componenta senzitiva asigura inervatia fetei, mucoasa jugala, limba (termo-algezic), dintii, pielea scalpului si meningele in 2/3 anterioare.
• Componenta motorie asigura inervatia muschilor masticatori, milohioidieni si burta anterioara a digastricului.
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Nevralgia esentiala de trigemen
• Ticul dureros al fetei• Durere paroxistica, unilaterala, severa, recurenta
care intereseaza de obicei un ram, rareori mai multe ramuri ale trigemenului.
• Debut brusc; intre crize asimptomatic.• Durata scurta, repetate de mai multe ori pe zi. • Zona “trigger” care declanseaza durerea la
stimuli mecanici, termici, etc.
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Nevralgia esentiala de trigemen
• Mecanismul inca necunoscut poate fi datorat prezentei unor sinapse anormale (efapse), ce determina un scurt circuit electric, posibil secundar demielinizarii, sau unor modificari la nivelul vasa nervorum.
• Tratament: antiepileptice. – Interventii chirurgicale
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Nevralgia secundara de trigemen
• Meningioame, tumori primare sau metastatice care intereseaza baza craniului, leziuni ale sinususului cavernos, schwanoame te nerv trigemen, etc.
• Prezenta de paroxisme dureroase pe un fond dureros continuu.
• Modificari ale examenului clinic cu diminuarea reflexului de clipire.
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Paralizia de trigemen
• Frecvent unilaterala.
• Hipotonie si atrofie in teritoriul muschilor maseteri si temporali.
• La inchiderea gurii mandibula deviaza de partea afectata.
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Nervul facial
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1. Motor
2. Senzitiv
3. parasimpatic
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Paralizia faciala periferica• Semne statice:
– Paralizia musculaturii la nivelul hemifaciesului– Comisura bucala mai coborata– Sant nazo-genian mai sters– Ochiul pare mai mare (Semnul Negro)
• Semne dinamice:– Accentuarea asimetriei faciale– Imposibilitatea ocluziei palpebrale– Dificultati in pronuntarea consoanelor labiale (“m”, “b”,
“p”)– Absenta contractiei pielosului gatului.
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Etiologia paraliziei faciale periferice
• Traumatisme
• Inflamatorie
• Tumoral
• Metabolic
• Vasculite
• Idiopatic (paralizia Bell)
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Complicatiile paraliziei faciale
• Sindromul lacrimilor de crocodil
• Hemispasmul facial
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Tratament
• Corticoterapie
• Masaj facial
• Fizioterapie
• In anumite conditii poate necesita interventii chirurgicale: – Decompresii– neurorafie
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Paralizia faciala periferica• Afectarea la nivelul conductului auditiv intern
se asociaza cu hipoacuzie si vertij (afectare n VIII).
• Leziunea la nivelul ganglionului geniculat: dureri in teritoriul senzitiv (zona Ramsay-Hunt).
• Hiperacuzie prin afectarea muschiului stapedius.
• Afectarea gustului in 2/3 anterior al limbii ( n coarda timpanului).
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SINDROAME DE TRUNCHI CEREBRAL
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Vascularizatia trunchiului cerebral
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Sindroame bulbare
• Sindromul decusatiei piramidale: hemiplegia cruciata
• Sindromul decusatiei senzitive:– hemianestezie ipsilaterala– Hemiplegie controlaterala (fara afectarea fetei)
• Sindromul interolivar:– Hemiplegie controlaterala, posibil asociata cu
hemianestezie de tip disociatie tabetica.– Hemiparalizia limbii ipsilateral
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• Sindromul Wallenberg:
• Ipsilateral: – paralizie de nervi V, IX, X, XI (tulburari de
deglutitie, fonatie, sughit)– Sdr. Claude-Bernard-Horner– Hemiataxie cerebeloasa
• Controlateral:– Hemianestezie termica si dureroasa
Sindroame bulbare
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Sindroame bulbare
• Sdr. Avelis:– IX, X ipsilateral– Hemiplegie controlateral
• Sdr. Schmidt:– IX, X, XI ipsilateral– Hemiplegie controlateral
• Sdr. Jackson:– IX, X, XI, XII ipsilateral– Hemiplegie controlateral
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Sindroame pontine
• Sdr. Millard-Gubler– Ipsilateral pareza VI, VII– Controlateral: hemiplegie/hemipareza
• Sdr. Raymond:– Ipsilateral pareza VI– Controlateral: hemiplegie/hemipareza
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Sindroame pedunculare• Sdr. Weber:
– Ipsilateral: pareza completa/partial n III– Controlateral: hemiplegie
• Sdr. Benedickt:– Ipsilateral: pareza completa/partial n III– Controlateral: hiperkinezie (tremor, coree,
atetoza)
• Sdr. Parinaud:– Paralizia verticala a privirii, paralizia
convergentei si areflexie pupilara.