Download - Cranial nerves 3,4,6-Neuroradioology
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CRANIAL NERVES III,IV AND VI
Dr Parvathy S Nair
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CRANIAL NERVE III(OCCULOMOTOR)
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• Occulomotor nucleus (in front of cerebral aqueduct at level of superior colliculus of midbrain and exits ventrally in interpeduncular fossa)
• Four lateral paired subnuclei that innervate the superior, inferior, and medial rectus, as well as the inferior oblique muscles.– Axons from one superior rectus (SR) nucleus cross and pass through
the opposite SR subnucleus; thus, a lesion of one SR subnucleus results in bilateral superior rectus palsy.
– LPS has also bilateral supply– All other EOM gets ipsilateral supply
• Edinger-Westphal (parasympathetic)nucleus, which contains preganglionic, parasympathetic neurons whose axons project to the ciliary ganglion and postganglionic paraympathetic fibres supply sphincter pupillae and ciliaris muscle
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Course• The oculomotor nerve exits the ventral midbrain in
the interpeuncular fossa-> pierces the dura mater-> between PCA above and SCA below
• Through the lateral wall of the cavernous sinus, enters orbit through superior orbital fissure.
• Within the orbit it branches into a superior ramus (to the superior rectus and levator muscles) and an inferior ramus (to the medial and inferior rectus, the inferior oblique, and the ciliary ganglion).
• Postganglionic fibres from the ciliary ganglion innervate the sphincter pupillae muscle of the iris as well as the ciliary muscle.
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Functions
• EOM- all movements except lateral and down-and-out movements
• Levator palpabrae superioris-same branch as that of SR- elevation of lid
• Parasymp. innervation- miosis,accomodation and light reflex
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CRANIAL NERVE IV(Trochlear)
• Long course• Emerges from trochlear nu at the level of
inferior colliculus• Connections-same as CN3• COURSE-After winding around the
periaqueductal grey matter and comes out posteriorly through the opposite side
• Crosses the tentorium->enters middle cranial fossa->lat wall of cavernous sinus->enters SOF->supplies Sup. Oblique muscle.
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Functions
• Down and out movement of eyeball• “Reading muscle” • Intorsion – axis of vision is kept parallel
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CRANIAL NERVE VI(ABDUCENS) • The abducens nucleus is located in the pons, on the floor
of the fourth ventricle, at the level of the facial colliculus. • Connections-same as CN3– PPRF connections-lateral conjugate gaze
• Course- exits from pontomedullary jn->runs between AICA and labrynthine artery->At the tip of the petrous temporal bone it makes a sharp turn forward to enter the cavernous sinus.
• In the cavernous sinus it runs alongside the ICA. It then enters the orbit through the SOF and innervates the lateral rectus.
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• Abducent palsy is seen in increased ICT- due to compression against the petrous apex causing “false localization sign”
• FUNCTION-– Lateral movement of eye– Lat conjugate gaze
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Examination
• 3,4,6 can be examined together– Ask patient to look up, down, obliquely up and
down– Each eye separately
• Parasympathetic function-only for CN 3– Pupillary light reflex – Accomodation reflex
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MR Imaging of normal CN3,4,6
• Difficult to evaluate the cisternal segments of the cranial nerves, which are small in diameter and are located in close proximity to many other anatomic structures.
• Thin T2WI(1mm thickness)• SSFP/PSIF sequences depict these nerve
segments in greater detail• Type of coherent GRE sequence• 0.8mm thick-ideal
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LESIONS
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CN III
• Diabetic occulopathy– External ophthalmoplegia– Pupils are spared
• Compressive lesions– Aneurysms –PCA,Pcom,SCA– Tumors– Outer fibres-pupillary paralysis
• Inflammation-CST, Tolosa Hunt• Demyelination• Infections-TB
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• External ophthalmoplegia– All EOM except LR and SO are affected– Eye turned down and out– Diplopia becoming better on looking to paralysed
side• Ptosis- LPS• Lateral gaze palsy – Medial longitudinal
fasciculus• Parasympathetic loss- – Mydriasis– Cycloplegia
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CN IV
• Aneurysm of internal carotid• Cavernous sinus thrombosis
• Diplopia-on looking down• Medial deviation of affected eye• Head tilted towards the normal side
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CN VI
• Medial deviation of eye• Diplopia –becoming worse on looking to the
paralysed side
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