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Cranial Nerve Disorders

Last Updated: September 27, 2018

Table 1: Anosmia
Differential list for anosmia
Neoplastic
  • Esthesioneuroepithelioma
  • Olfactory groove meningioma
  • Suprasellar meningioma
  • Frontal lobe glioma
Vascular
  • Subarachnoid hemorrhage
  • ACA aneurysm
  • Sheehan’s syndrome
  • Scleroderma
Infectious
  • Upper respiratory infection (e.g. Influenza which damages neuroepithelium)
  • Intracranial abscess
  • Meningitis
  • Herpes encephalitis
  • Osteomyelitis (frontal, ethmoid)
  • Syphilis (impact membranes)
Endocrine
  • Diabetes mellitus
Metabolic
  • Hypothyroidism
  • Vitamin deficiency
Toxic
  • Aminoglycosides
  • Amphetamines
  • Cocaine
  • Lead
  • Cadmium
  • Hypercalcemia
  • Heavy smoking
Inflammatory
  • Chronic rhinitis
  • Chronic sinusitis
  • Nasal polyposis
Miscellaneous
  • Traumatic neuropathy (2nd most common cause)
  • Alzheimer’s disease
  • Kallmann syndrome
  • Paget’s disease
  • Chronic atrophic rhinitis
  • Albinism
Table 2: Oculomotor Nerve Palsy
Differential for oculomotor nerve palsy
Neoplastic
  • Meningioma (extra-/intra-orbital)
  • Glioma
  • Pituitary adenoma
  • Orbital hemangioma
  • Carcinomatous meningitis
  • Orbital epidermoid
  • Neurofibroma
  • Orbital lipoma
  • Nasopharyngeal extension
  • Melanoma metastasis to the orbit
  • Other metastasis
Vascular
  • Aneurysm (P-comm, SCA, PCA, ICA, basilar tip)
  • Midbrain infarction (paramedian PCA branches or basilar bifurcation perforators)
  • Nerve trunk infarction (Diabetes mellitus)
  • Cavernous sinus thrombosis
  • Caroticocavernous fistula
  • Hemorrhage (SAH, epidural, subdural)
  • Dural AVM
  • Arteritis
  • Pituitary apoplexy
Infectious
  • Meningitis (bacterial, fungal)
  • Mucormycosis
  • Mononucleosis
  • Meningovascular syphilis
  • Herpes zoster encephalitis
Endocrine
  • Thyrotoxicosis (mimic)
Inflammatory
  • Multiple sclerosis
  • INO (mimic)
  • Sarcoidosis
  • MG (mimic)
  • GBS (including Miller-Fisher variant)
Miscellaneous
  • Traumatic neuropathy (blowout fracture of the orbit)
  • Latent strabismus (mimic)
  • Orbital fibrous dysplasia
  • Tolosa-Hunt syndrome
Table 3: Trochlear Nerve Palsy
Differential list for trochlear nerve palsy
Neoplastic
  • Pituitary adenoma
  • Glioma
  • Trochlear schwannoma
  • Tentorial/parasellar/tuberculum sella/diaphragma sella meningioma
  • Choriocarcinoma
  • Teratoma
  • Germinoma
  • Dysgerminoma
  • Carcinomatous meningitis
  • Metastasis
Vascular
  • Hemorrhage (SAH, epidural, subdural)
  • Aneurysm (intracavernous ICA)
  • Cavernous sinus thrombosis
  • Caroticocavernous fistula
  • Infarction
Infectious
  • Meningitis
  • Mastoiditis
  • Herpes zoster encephalitis
Endocrine
  • Diabetes mellitus (related infarction, most common cause)
  • Thyrotoxicosis (mimic)
Inflammatory
  • Multiple sclerosis
  • MG (mimic)
Miscellaneous
  • Traumatic neuropathy
  • Latent strabismus (mimic)
  • Tolosa-Hunt syndrome
  • Brown’s syndrome
Table 4: Trigeminal Neuropathy
Differential for trigeminal neuropathy
Neoplastic
  • Glioma (pontine, orbital)
  • Vestibular schwannoma (CPA)
  • Trigeminal schwannoma
  • Meningioma (orbital and non-orbital)
  • Orbital hemangioma
  • Neurofibroma
  • Dermoid cyst (CPA)
  • Epidermoid cyst (CPA)
  • Lipoma
  • Metastatic melanoma
  • Metastasis
Vascular
  • Infarction (cerebral or brainstem)
  • Aneurysm (intracavernous ICA)
  • Cavernous sinus thrombosis
  • Vasculitis (SLE, PSS, Scleroderma, Sjogren’s syndrome, Amyloidosis)
Infectious
  • Petrositis (Gradenigo’s syndrome)
Endocrine
  • Diabetic neuropathy
Inflammatory
  • Multiple sclerosis
  • Orbital pseudotumor
Miscellaneous
  • Traumatic neuropathy
  • Fibrous dysplasia
  • Trigeminal neuralgia
  • Tolosa-Hunt syndrome
  • Chiari malformation
Table 5: Abducens Nerve Palsy
Differential for abducens nerve palsy
Neoplastic
  • Glioma (pontine)
  • Pituitary adenoma
  • Vestibular schwannoma (CPA)
  • Meningioma (CPA, diaphragm sella, tuberculum sella, parasellar)
  • Chordoma (clival)
  • Chondroma (clival)
  • Epidermoid tumor (CPA)
  • CNS lymphoma
  • Carcinomatous meningitis
  • Metastasis
Vascular
  • Infarction
  • Aneurysm (CPA, intracavernous ICA)
  • Cavernous sinus thrombosis
  • Caroticocavernous fistula
  • Hemorrhage (SAH)
Infectious
  • Meningitis (bacterial, fungal)
  • Meningovascular syphilis
  • Herpes zoster encephalitis
  • Petrositis (Gradenigo’s syndrome)
Endocrine
  • Diabetes mellitus (related infarction)
  • Thyrotoxicosis (mimic)
Toxic
  • Wernicke’s encephalopathy
Congenital
  • Mobius syndrome
Inflammatory
  • Multiple sclerosis
  • INO
  • MG (mimic)
  • Sarcoidosis
Miscellaneous
  • Traumatic neuropathy
  • Arachnoid cyst
  • Migraine (mimic)
  • Paget’s disease
  • Tolosa-Hunt syndrome
Table 6: Facial Nerve Palsy
Differential diagnosis for facial nerve palsy
Neoplastic
  • Glioma (pontine)
  • Meningioma
  • Vestibular schwannoma (CPA)
  • Trigeminal schwannoma
  • Facial schwannoma
  • Cholesteatoma
  • Glomus tumor
  • Dermoid cyst
  • Epidermoid cyst
  • Metastasis
  • Post-parotid surgery (lesion mandibular branch)
Vascular
  • Infarction (pontine tegmentum)
  • Aneurysm
  • Post-carotid endarterectomy (mandibular branch)
  • Basilar dolichoectasia
Infectious
  • Poliomyelitis
  • Herpes zoster (Ramsey-Hunt syndrome)
  • Lyme disease
  • Epstein-Barr virus
  • Mumps
  • Rubella
  • HIV
  • Meningovascular syphilis
Metabolic
  • Porphyria
Inflammatory
  • Multiple sclerosis
  • Sarcoidosis
Miscellaneous
  • Traumatic neuropathy
  • Melkersson-Rosenthal syndrome
  • Progressive supranuclear palsy
  • Bell’s palsy
  • Benign recurrent cranial nerve paralyses
Table 7: Glossopharyngeal, Vagus, and Accessory Nerve Pathology
Differential diagnosis for glossopharyngeal, vagus, or accessory nerve pathology
Neoplastic
  • Glioma
  • Schwannoma
  • Neurofibroma
  • Meningioma
  • Paraganglioma (Glomus jugulare)
  • Cholesteatoma
  • Non-Hodgkin’s lymphoma
  • Rhabdomyosarcoma
  • Nasopharyngeal carcinoma
  • Metastasis
Vascular
  • Infarction (medulla)
  • Hemorrhage (AVM, HTN)
  • Aneurysm (vertebral)
  • Vertebral artery ectasia
Infectious
  • Meningitis
  • Malignant otitis externa
Metabolic
  • Central pontine myelinolysis
Inflammatory
  • Multiple sclerosis
Miscellaneous
  • Traumatic neuropathy
  • Glossopharyngeal neuralgia
  • Iatrogenic injury post-radical neck dissection
  • Benign recurrent cranial nerve paralyses
  • Extracranial causes for vagus neuropathy (jugular vein thrombosis, aortic aneurysm, malignancy, infection)
Table 8: Hypoglossal Nerve Palsy
Differential diagnosis for hypoglossal nerve palsy
Neoplastic
  • Glioma
  • Meningioma
  • Schwannoma
  • Neurofibroma
  • Osteoma
  • Chordoma
  • Paraganglioma (Glomus jugulare)
  • Sarcoma
  • Metastasis
Vascular
  • Infarction (basal/paramedian medulla)
  • Hemorrhage (brainstem, SAH)
  • Aneurysm
  • Vertebrobasilar dolichoectasia
  • Basilar invagination
  • Post-carotid endarterectomy
Infectious
  • Malignant otitis externa
  • Abscess
  • Mucormycosis
  • Aspergillosis
  • Poliomyelitis
  • Diphtheria
  • Botulism
Inflammatory
  • Multiple sclerosis
  • Shy-Drager syndrome
Miscellaneous
  • Traumatic neuropathy
  • Chiari malformation
  • Multiple systems atrophy
  • Post-radical neck dissection
  • Benign recurrent cranial nerve paralyses
Table 9: Multiple Cranial Neuropathies
Differential list for cranial neuropathies
Neoplastic
  • Pituitary macroadenoma
  • Meningioma (sphenoid ridge)
  • Glioma
  • Paraganglioma
  • Orbital tumors
  • Chordoma
  • Osteoma
  • Sarcoma
  • Schwannoma
  • Teratoma
  • Glomus tumor
  • Epidermoid/dermoid cyst
  • Dysgerminoma
  • Nasopharyngeal carcinoma
  • Neurofibroma
  • Lymphomatous meningitis
  • Multiple myeloma
  • Metastasis
Vascular
  • Aneurysm (intracavernous internal carotid, P-Comm, PCA, basilar tip, SCA, vertebral)
  • Dural AVM
  • Carotid-cavernous fistula
  • Cavernous sinus syndrome (CN III, IV, V1, V2, VI)
  • Infarction (nucleus or tract involvement)
  • Basilar dolichoectasia
  • Basilar invagination
  • Hemorrhage (SAH, epidural, subdural)
  • Pituitary apoplexy
  • Vertebral artery ectasia
  • PAN
  • Granulomatosis with polyangiitis (CN VIII)
Infectious
  • Acute or Chronic Meningitis (bacterial, viral, fungal)
  • Herpes zoster
  • Diphtheria
  • Botulism intoxication
  • Aspergillosis
  • Mucormycosis
  • Cryptococcal meningitis
  • Mastoiditis
  • Neurocysticercosis
  • Neurosyphilis
  • Lyme disease (CN VII)
Inflammatory
  • GBS
  • Miller-Fisher syndrome
  • Sarcoidosis
  • Multiple sclerosis
  • Myasthenia gravis
  • Lambert-Eaton syndrome
  • Shy-Drager syndrome (CN XII)
  • Multiple system atrophy (CN XII)
  • Petrositis
  • Cholesteatoma
Metabolic
  • Wernicke’s encephalopathy (CN VI)
  • Porphyria (CN VII, X)
  • Leigh’s disease
  • Central pontine myelinolysis (CN VI, VII)
Genetic or Congenital
  • Mobius syndrome (CN VI, VII)
  • Progressive supranuclear palsy
  • Chiari malformation
  • Osteopetrosis
Miscellaneous
  • Traumatic neuropathy (including surgical)
  • Status post-lumbar puncture
  • Amyloid
  • Fibrous dysplasia
  • Paget’s disease (VIII > II, III)
  • Hyperostosis cranialis interna
  • Polyneuritis cranialis
  • Idiopathic cranial polyneuropathy (III, IV, V)

DOI: https://doi.org/10.18791/nsatlas.v2.02.1.3

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