MRCP PACES Multiple Cranial Neuropathies Chronic Meningitis
  • Always in the differential diagnosis of multiple cranial neuropathies
  • Infections
    • Tuberculous meningitis: most commonly affects abducens nerve
    • Lyme disease (2nd stage): classically bilateral / unilateral facial nerve palsy; may affect II, V and VIII
    • Neurosyphilis: classically the Argyll-Robertson pupil (pupillary constriction to accommodation but not light). Thought to be due to a lesion in the pre-tectal nucleus, disrupting the consensual light reflex. Accommodation spared as it is a cortical response, with afferent fibres ascending to the visual cortex, and efferent fibres descending to the Edinger-Westphal nucleus and the vergence cells of the reticular formation.
    • Fungal: cryptococcal meningitis, neurocysticercosis
    • Viral: human immunodeficiency virus, Epstein-Barr virus, cytomegalovirus
  • Inflammatory
    • Neurosarcoidosis: typically bilateral facial nerve palsy
      • May also involve II, VIII, IX, and X
    • Behçet’s syndrome: II and VII
    • Wegner’s granulomatosis: II, VI, VII and VIII
      • Typically, patients have renal involvement when cranial nerves are involved
      • Granulomatous masses compressing on globe may cause a restrictive ophthalmoplegia which simulates cranial nerve palsies
    • Polyarteritis nodosa: III, VIII
    • Giant cell arteritis: anterior ischaemic optic neuropathy
      • Ophthalmoplegia from involvement of extra-ocular muscles
      • Other cranial nerves usually spared
  • Neoplastic (more typically painless than the other two above)
    • Lymphomatous meningitis (systemic or primary CNS lymphoma)
    • Carcinomatous meningitis (small cell lung cancer, melanoma, breast cancer)
    • Lymphomatoid granulomatosis
      • EBV-associated systemic angiodestructive lymphoproliferative disease
      • Mimics Wegner’s granulomatosis
      • Classic pulmonary findings – disease extremely unlikely in the absence of pulmonary lesions
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