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Multiple CranialNerve Palsy 
Surat Tanprawate, MD, FRCP(T)Northern Neuroscience CenterChiangmai University
Approachedskill
Needed Skills
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Approach skills
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Neurologicalexamination skills
Approach
Patient presents withsuspected multiple CN palsyMultiple CN palsy mimickersLocalized and identified causeof lesion
Patient suspectedmultile CN als
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Presentation
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Motor cranial nerve symptoms/signs
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Sensory symptoms symptoms/signs
Multiple Cranial Nerve Palsy Mimickers
Cranial nucleusand nerveNMJMuscle
UMN controlLMN control
 
Mimicker # 1
UMN Lesion
UMN control of motorfunction
Corticobulbar pathway 
UMN control of motor function
Homunculus
 Latin = "little human",plural "homunculi"
homo 
= "human"
Sensory and motor homunculi Photograph taken at the London Science Museum.
Bulbar VSPseudo bulbar palsy 
Bulbar = Bulb = Medullar
Bulbar palsy = LMNCranial nucleus, and nervePseudobulbar palsy = UMNCortex or corticobulbarpathway
BulbarPseudobulbar
WeaknessIpsilateral lesionContralateral lesionSpecialweak CN 7CN 7ReflexHyporeflexiaHyperreflexiaMuscleHypotonia, atrophy,fasciculationHypertonia
Associatedcorticospinaltract
Alternating hemiparesisHemiparesis: same side
 
Mimicker # II
Internuclear control ofocular motility 
Ocular motility 
Internuclear control of horizontal gaze
Mimicker # III
NMJ disorder
Neuromuscular junction disorder
Clinical clues
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Fluctuation of symptoms
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Distribution of weakness: don’t consistentwith cranial nerve lesion
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Associated with proximal muscle weakness
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Special test for myasthenia gravis
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ex. enhancing ptosis, sustain upward gazetest
Mimicker # IV
Muscle diseases
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