the brainstem & cranial nerves - cvmamembers.cvma.net/images/cvmaimages/mackaybrainstem.pdf ·...
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The Brainstem & Cranial Nerves Relevant Exam Techniques
Rob MacKayAlec P. and Louise H. Courtelis Equine Teaching Hospital University of Florida
Anatomy
I
II III VI
V VII
VIII
IX X XII XI
Cerebrum Thalamus
Hypothalamus Midbrain Pons Medulla oblongata
Cerebellum IV
Midbrain Mesencephalon Midbrain
Pons Metencephalon
Hindbrain Cerebellum
Medulla Myelencepahlon
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2
Obtundation Blindness/strabismus Limb weakness Atrophy, jaw weakness Hypalgesia Facial paralysis Ataxia Dysphagia Tongue atrophy
Blindness/strabismus Alertness Vision/eye control Motor to limbs Chewing Facial sensation Facial movement Proprioception Swallowing Tongue movement
Vision/eye control
Functions of the brainstem & cranial nerves
Function Cardinal Sign
Limb weakness Motor to limbs Atrophy, jaw weakness Chewing Hypalgesia Facial sensation Facial paralysis Facial movement Ataxia Proprioception Dysphagia Swallowing Tongue atrophy Tongue movement
Functions of the brainstem & cranial nerves
Alertness Vision/eye control Motor to limbs Chewing Facial sensation Facial movement Proprioception Swallowing Tongue movement
Obtundation Blindness/strabismus Limb weakness Atrophy, jaw weakness Hypalgesia Facial paralysis Ataxia Dysphagia Tongue atrophy
Function Cardinal Sign
Obtundation Alertness
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3
Obtundation: Reticular activating system
Reticular activating system I II
V VIII
Spinal cord somatosensory pathways
Severe!!
Reticular activating system I II
V VIII
Spinal cord somatosensory pathways
Less Less
Obtundation
Obtundation: Reticular activating system
Diffuse/major injury
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4
Obtundation Blindness/strabismus Limb weakness Atrophy, jaw weakness Hypalgesia Facial paralysis Ataxia Dysphagia Tongue atrophy
Blindness/strabismus Alertness Vision/eye control Motor to limbs Chewing Facial sensation Facial movement Proprioception Swallowing Tongue movement
Vision/eye control
Functions of the brainstem & cranial nerves
Function Cardinal Sign
Vision/Eye control Pupillary light reflex Traumatic optic nerve injury
Eye position Eye retraction Sympathetic supply to the eye Horner’s syndrome
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5
Vision - Pupillary light reflex
2-yo QH coltAsymmetric optic neuropathy
Optic nerve (II)
Oculomotor nerve (III)
Traumatic optic nerve injury
Martin et al. Equine vet J 1986;18:133-7
OD OS
M
C
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6
Eye position (VIII, III, IV, VI) True strabismus
(III, IV, VI)
Vestibular strabismus (VIII)
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7
Eye retraction (VI)
1-yo Paso Fino colt Tetanus
Sympathetic supply to the eye
9-yo TB geldingLower cervical trauma
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Horner’s syndrome
right left
Obtundation Blindness/strabismus Limb weakness Atrophy, jaw weakness Hypalgesia Facial paralysis Ataxia Dysphagia Tongue atrophy
Blindness/strabismus Alertness Vision/eye control Motor to limbs Chewing Facial sensation Facial movement Proprioception Swallowing Tongue movement
Vision/eye control
Functions of the brainstem & cranial nerves
Function Cardinal Sign
Limb weakness Motor to limbs
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Spinocerebellar tracts
I
V VII IX X XII XI
Limb weakness (UMN)
II III VI
VIII
IV
Upper motor neurons
Brainstem: Limb weakness/ataxia
22-yo Arabian stallion Extramedullary melanoma
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10
Obtundation Blindness/strabismus Limb weakness Atrophy, jaw weakness Hypalgesia Facial paralysis Ataxia Dysphagia Tongue atrophy
Blindness/strabismus Alertness Vision/eye control Motor to limbs Chewing Facial sensation Facial movement Proprioception Swallowing Tongue movement
Vision/eye control
Functions of the brainstem & cranial nerves
Function Cardinal Sign
Limb weakness Motor to limbs Atrophy, jaw weakness Chewing
I
V VII IX X XII XI
Mastication, facial sensation (V)
II III VI
VIII
IV
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Unilateral cranial nerve Vm
12-yo TB mareEquine protozoal myeloencephalitis
Cranial nerve Vm - trismus
9-yo QH geldingTetanus
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12
Obtundation Blindness/strabismus Limb weakness Atrophy, jaw weakness Hypalgesia Facial paralysis Ataxia Dysphagia Tongue atrophy
Blindness/strabismus Alertness Vision/eye control Motor to limbs Chewing Facial sensation Facial movement Proprioception Swallowing Tongue movement
Vision/eye control
Functions of the brainstem & cranial nerves - guideFunction Cardinal Sign
Limb weakness Motor to limbs Atrophy, jaw weakness Chewing Hypalgesia Facial sensation
I
V VII IX X XII XI
Mastication, facial sensation (V)
II III VI
VIII
IV
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Sensory Vs - Reflex & central
22-yo Arabian stallionExtramedullary melanoma
CN Vs Trigeminal
Obtundation Blindness/strabismus Limb weakness Atrophy, jaw weakness Hypalgesia Facial paralysis Ataxia Dysphagia Tongue atrophy
Blindness/strabismus Alertness Vision/eye control Motor to limbs Chewing Facial sensation Facial movement Proprioception Swallowing Tongue movement
Vision/eye control
Functions of the brainstem & cranial nerves
Function Cardinal Sign
Limb weakness Motor to limbs Atrophy, jaw weakness Chewing Hypalgesia Facial sensation Facial paralysis Facial movement
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14
13-yo Thoroughbred geldingTHO
8-yo pony mare Equine protozoal myeloencephalitis
3-yo mixed breed geldingFractured stylohyoid
Peripheral – outside skull
T2-enhanced Transverse
Central Peripheral –skull
Facial paralysisSign – Localization
Stupor – RAS or forebrain L facial paralysis – VII L R lean/head tilt – VIII L/R
L hindbrain Jaw to right – Vm L
Obtundation Blindness/strabismus Limb weakness Atrophy, jaw weakness Hypalgesia Facial paralysis Ataxia Dysphagia Tongue atrophy
Blindness/strabismus Alertness Vision/eye control Motor to limbs Chewing Facial sensation Facial movement Proprioception Swallowing Tongue movement
Vision/eye control
Functions of the brainstem & cranial nerves
Function Cardinal Sign
Limb weakness Motor to limbs Atrophy, jaw weakness Chewing Hypalgesia Facial sensation Facial paralysis Facial movement Ataxia Proprioception
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I
II III VI
V VII
VIII
IX X XII XI
Proprioception – 3 components
IV
Spinocerebellar tracts
Proprioception – 3 components Spinal cord proprioceptive tracts Transmits position and movement of muscles and joints
Vestibular Orientation relative to gravity
Cerebellar “The great regulator of movement” Coordinates and smooths out UMN activity
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Proprioception Spinocerebellar tracts
22-yo Arabian stallion Extramedullary melanoma
Proprioception: Vestibular
18-yo Clydesdale geldingOtitis media/interna
8-yo pony mareEquine protozoal myeloencephalitis
PeripheralCentral
22-yo Arabian stallionExtramedullary melanoma
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True strabismus
2-yo mixed breed fillyEEE
Other signs of vestibular dysfunction
8-yo QH geldingTemporohyoid osteoarthropathy
Vestibular strabismus Spontaneous nystagmus Vestibular strabismus
Proprioception: Cerebellar
7-mo Arabian coltCerebellar abiotrophy
22-yo Arabian stallionExtramedullary melanoma
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18
Obtundation Blindness/strabismus Limb weakness Atrophy, jaw weakness Hypalgesia Facial paralysis Ataxia Dysphagia Tongue atrophy
Blindness/strabismus Alertness Vision/eye control Motor to limbs Chewing Facial sensation Facial movement Proprioception Swallowing Tongue movement
Vision/eye control
Functions of the brainstem & cranial nerves - guideFunction Cardinal Sign
Limb weakness Motor to limbs Atrophy, jaw weakness Chewing Hypalgesia Facial sensation Facial paralysis Facial movement Ataxia Proprioception Dysphagia Swallowing
17-yo QH mareLeft guttural pouch mycosis
Dysphagia: CNs X, IX, XI
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Guttural pouch mycosis
17-yo QH mareLeft guttural pouch mycosis
Location: L. XII hypoglossal
L. X vagus, IX,XI
L. Sympathetic, CCG
stylohyoid ICA
ECA
XII
IX
Guttural pouch anatomy
Right guttural pouch Medial compartmentRight guttural pouch
Rectus capitis ventralis
Not shown: XI, CCG
X
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Left
ICA
IX/XII
Guttural pouch mycosis
Right
Guttural pouch fibrosis
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Obtundation Blindness/strabismus Limb weakness Atrophy, jaw weakness Hypalgesia Facial paralysis Ataxia Dysphagia Tongue atrophy
Blindness/strabismus Alertness Vision/eye control Motor to limbs Chewing Facial sensation Facial movement Proprioception Swallowing Tongue movement
Vision/eye control
Functions of the brainstem & cranial nerves - guideFunction Cardinal Sign
Limb weakness Motor to limbs Atrophy, jaw weakness Chewing Hypalgesia Facial sensation Facial paralysis Facial movement Ataxia Proprioception Dysphagia Swallowing Tongue atrophy Tongue movement
Tongue weakness (XII)
3-yo QH geldingWest Nile encephalitis
13-yo Quarter horse mareGuttural pouch mycosis
Central - LMN Peripheral
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Tongue weakness
3-mo TB fillyJuvenile epilepsy
1-yo TB fillyBotulism
UMN Neuromuscular
THE END