Basic and clinical Neuroanatomy of Cranial nerves 5,7 and 8. trigeminal facial and vestibulocochlear nerve.

1. Welcome to Clinical Neuroanatomy
Presentation : Cranial nerve 5, 7, & 8
Presented by:
Dr.Md. SaiduzzamanMunna
MedicalOfficer
Departmentof Neurology
MymensinghMedicalCollege,
Bangladesh.

3. TRIGEMINAL NERVES
(CRANIAL NERVE V)

4. Trigeminal Nerve (Cranial Nerve V):
•It is the largest cranial nerve
•It is a mixed nerve (sensory and motor)
•Sensory to - skin of face
- mucosa of cranial viscera
except base of tongue and pharynx
•Motor to – muscles of mastication

5. Trigeminal nerve nuclei

6. Trigeminal Nerve Nuclei:

7. Trigeminal Nerve Nuclei:
 Motor nucleus
Sensory nuclei
(1) The main sensory nucleus,
(2) The spinal nucleus,
(3) The mesencephalic nucleus,

8. Sensory Nuclei
Mesencephalic
nucleus
Relay proprioception from
muscles of mastication,
EOM, facial muscles
Principal
sensory
nucleus
Relays touch sensation
Spinal Nucleus
Relays pain and
temperature sensation

10. Trigeminal nerve nuclei seen in a
coronal section of the pons.

11. Sensory Components of the
Trigeminal Nerve:
The sensations of pain, temperature, touch, and pressure from
the skin of the face and mucous membranes travel along
axons whose cell bodies are situated in trigeminal ganglion.
 The central processes of these cells form the large sensory
root of the trigeminal nerve.
 About half the fibers divide into ascending and descending
branches when they enter the pons; the remainder ascend or
descend without division.
 The ascending branches terminate in the main sensory
nucleus, and the descending branches terminate in the spinal
nucleus.

14. The sensory fibers from the ophthalmic division of the
trigeminal nerve terminate in the inferior part of the spinal
nucleus
Fibers from the maxillary division terminate in the middle of the
spinal nucleus
And fibers from the mandibular division end in the superior
part of the spinal nucleus.

15. The axons of the neurons in the main sensory, spinal nuclei
and mesencephalic nucleus now cross the median plane and
ascend as the trigeminal lemniscus to terminate on the
ventral posteromedial nucleus of the thalamus.
 The axons of these cells now travel through the internal
capsule to the postcentral gyrus (areas 3, 1, and 2) of the
cerebral cortex.

16. Motor Component of the Trigeminal
Nerve:
 The motor nucleus receives corticonuclear fibers from both
cerebral hemispheres.
 It also receives fibers from the reticular formation, the red
nucleus, the tectum, and the medial longitudinal fasciculus.
 In addition, it receives fibers from the mesencephalic nucleus,
thereby forming a monosynaptic reflex arc.

17. Trigeminal nerve nuclei in brainstem
and their central connections:

18. Course of the Trigeminal Nerve
 The trigeminal nerve leaves the anterior aspect of the pons as
a small motor root and a large sensory root. The nerve passes
forward out of the posterior cranial fossa and rests on the
upper surface of the apex of the petrous part of the temporal
bone in the middle cranial fossa.
 The large sensory root now expands to form the crescent-
shaped trigeminal ganglion, which lies within a pouch of dura
mater called the trigeminal or Meckel cave.
 The ophthalmic, maxillary, and mandibular nerves arise from
the anterior border of the ganglion.

20.  The ophthalmic nerve (V1) contains only sensory fibers and
leaves the skull through the superior orbital fissure to enter the
orbital cavity.
 The maxillary nerve (V2) also contains only sensory fibers
and leaves the skull through the foramen rotundum.
The mandibular nerve (V3) contains both sensory and motor
fibers and leaves the skull through the foramen ovale.
The sensory fibers to the skin of the face from each division
supply a distinct zone, with little or no overlap of the
dermatomes.
 The motor fibers in the mandibular division are mainly
distributed to muscles of mastication.

21. Distribution of the trigeminal nerve:

22. The three major
sensory divisions
of the trigeminal
nerve consist of the
ophthalmic,
maxillary, and
mandibular nerves.

24. FACIAL NERVES
(CRANIAL NERVE VII)

25. 7TH NERVE
MIXED NERVE
HAVING MOTOR,
SENSORY AND
AUTONOMIC
COMPONENTS
25

26. Facial Nerve Nuclei
The facial nerve has three nuclei:
(1) the main motor nucleus,
(2) the parasympathetic nuclei, and
(3) the sensory nucleus.
27

27. Facial nerve neuclei
28

28. Main Motor Nucleus
Lies deep in the reticular formation of lower part of pons.
The part of the nucleus that supplies the muscles of the upper
part of the face receives corticonuclear fibers from both
cerebral hemispheres but the part that supplies the muscles
of the lower part of the face receives corticonuclear fibers only
from the opposite cerebral hemisphere.
29

29. Motor innervation
30

30. Parasympathetic Nuclei:
 They are the superior salivatory and lacrimal nuclei that
receives afferent fibers from the hypothalamus through the
descending autonomic pathways.
The lacrimal nucleus receives afferent fibers from the
hypothalamus for emotional responses and from the sensory
nuclei of the trigeminal nerve for reflex lacrimation
secondary to irritation of the cornea or conjunctiva.
31

31. Parasympathetic pathway
32

33. Sensory Nucleus:
It is the upper part of the nucleus of the tractus solitarius .
Sensations of taste travel through the peripheral axons of
nerve cells situated in the geniculate ganglion and the central
processes of these cells synapse in the nucleus.
Efferent fibers cross the median plane and ascend to the
ventral posterior medial nucleus of the opposite thalamus and
hypothalamic nuclei.
From the thalamus, the axons pass through the internal
capsule and corona radiata to end in the taste area of cortex in
the lower part of the postcentral gyrus.
34

34. Facial nerve nuclei and their
central connections:
35

35. COURSE FACIAL NERVE

36. course
37

37. Major subdivisions and their
principle functions:
38

38. Course of the Facial Nerve
The facial nerve consists of a motor and a sensory root.
 Fibers of motor root first travel posteriorly around the medial
side of abducent nucleus, then pass around the nucleus
beneath the colliculus facialis in the floor of the fourth
ventricle ,pass anteriorly to emerge from the brainstem.
The sensory root (nervus intermedius) is formed by the
central processes of the unipolar cells of the geniculate
ganglion. It also contains the efferent preganglionic
parasympathetic fibers from the parasympathetic nuclei.
The two roots of facial nerve emerge from the anterior
surface of the brain between pons and medulla oblongata.
39

39. ……..Course of the Facial Nerve
They pass laterally in the posterior cranial fossa with the
vestibulocochlear nerve and enter the internal acoustic
meatus.
then enters the facial canal, On reaching the medial wall of
the tympanic cavity, the nerve expands to form the sensory
geniculate ganglion.
At the posterior wall of the tympanic cavity, the facial nerve
turns downward on the medial side of the aditus , and
emerges from the stylomastoid foramen.
40

40. ………Course:
After exiting the stylomastoid foramen, the motor nerve enters
the substance of parotid gland before branching into:
 temporal,
zygomatic,
buccal,
mandibular, and
cervical branches
41

41. course
42

42. Distribution of facial nerve:
43

43. Distribution of the Facial Nerve
The motor nucleus supplies:
the muscles of facial expression,
the auricular muscles,
the stapedius,
the posterior belly of the digastric, and
the stylohyoid muscles .
The superior salivatory nucleus supplies
the submandibular and sublingual salivary glands and
the nasal and palatine glands.
44

44. Distribution of the Facial Nerve
The lacrimal nucleus supplies the lacrimal gland.
The sensory nucleus receives taste fibers from:
the anterior two-thirds of the tongue,
the floor of the mouth, and
the palate.
45

45. CISS imaging of posterior fossa
46

46. VESTIBULOCOCHLEAR
NERVES
(CRANIAL NERVE VIII)

47. Introduction:
This nerve consists of two distinct parts:
 The vestibular nerve and
 The cochlear nerve,
which are concerned with the transmission of afferent
information from the internal ear to the central nervous
system .

48. 49
First order vestibular neurons lie in the vestibular division of the VIII nerve
and relay information from the utricle, saccule and semicircular canals to
the vestibular nuclei (superior, inferior, medial and lateral). Bipolar cell
bodies lie in the vestibular ganglion.

49. The cochlear (acoustic) and vestibular divisions travel
together through the petrous bone to the internal auditory
meatus where they emerge to pass through the subarachnoid
space in the cerebellopontine angle, each entering the brain
stem separately at the pontomedullary junction.
50

50. Central connection of auditory
nerve:
51

51. Central connection:
Auditory:
From the cochlear nucleus, second order neurons either pass
upwards in the lateral lemniscus to the ipsilateral inferior
colliculus or decussate in the trapezoid body and pass up in
the lateral lemniscus to the contralateral inferior colliculus.
Third order neurons from the inferior colliculus on each side
run to the medial geniculate body on both sides.
Fourth order neurons pass through the internal capsule and
auditory radiation to the auditory cortex.
The bilateral nature of the connections ensures that a
unilateral central lesion will not result in lateralized hearing
loss.
52

52. Central connection of vestibular
nerve:
53

53. ……..Central connection:
Vestibular:
1. Directly to cerebellum.
2 . Second order neurons arise in the vestibular nucleus and
descend in the ipsilateral vestibulospinal tract.
3. Second order neurons project to the oculomotor nuclei (III, IV,
VI) through the medial longitudinal fasciculus.
4. Second order neurons project to the cortex (temporal lobe).
The pathway is unclear.
5. Second order neurons project to the cerebellum. (There is a
bilateral feedback loop to the vestibular nuclei from the
cerebellum though the fastigial nucleus.)
54

54. Mechanism of Vestibular function:
The vestibular system responds to rotational and linear
acceleration along with a visual and proprioceptive input
maintains equilibrium and body orientation in space.
 Within the semicircular canals, during angular
acceleration displaces & activates the hair cells and transmits
action potentials to the vestibular division of the VIII cranial
nerve.
Linear acceleration results in displacement of the otoliths
within the utricle or saccule. This distorts the hair cells and
increases or decreases the frequency of action potentials in
the vestibular division of the VIII cranial nerve.
55

55. Mechanism of Auditory function:
The cochlea converts sound waves into action potentials in
cochlear neurons. Sound waves are transmitted by the
tympanic membrane and the ossicles to the oval window,
setting up waves in the perilymph of the cochlea.
The action of the waves on the spiral organ (of Corti)
generates action potentials in the cochlear division of the VIII
cranial nerve.
56

56. CRANIAL NERVES
V, VII & VIII
(APPLIED)

57. CLINICAL EXAMINATION OF CRANIAL NERVE V
•Sensory examination
•Motor examination
•Corneal reflex
•Jaw jerk

58. SENSORY EXAMINATION
Divisional pattern of sensory loss (A), segmental pattern of sensory loss (B), and
schematic diagram of the trigeminal system in the brainstem (C) . reflects the
rostral-caudal somatotopic arrangement in the spinal nucleus of the trigeminal
nerve with the perioral area represented rostrally and the lateral face caudally.

59. Motor examination
•Inspection for wasting (mostly
temporalis)
•Clenching teeth (palpating masseters
& temporalis)
•Forceful opening of jaw against
resistance (pterygoids)

60. Corneal reflex
•Afferent--VI
•Efferent--VII

61. Jaw jerk
• Stretch reflex of cranial
nerve V
• Placing a finger on the chin
below lower lip, with mouth
slightly open.
• Tapping over the finger with
a tendon hammer.
• Afferent.--V3(Sensory)
• Efferent---V3(Motor)

62. Jaw jerk
•Brisk jaw jerk -
Pseudobulbar palsy:
In young: MS
In elderly: MND
•Absent Jaw jerk-
Bulbar palsy:
In young: MG
In elderly: MND

63. Lesions of cranial nerve V at different levels
At V Nucleus(i.e. brainstem):
 Demyelinating(MS)
 Vascular(e.g. LMS)
 Syringobulbia
 Infections
 Inflammation-sarcoidosis
 Neoplasms (Lymphoma, glioma)
Preganglionic lesions(Roots):
 Trigeminal neuralgia
 C-P Angle tumors
 Metastasis

64. Lesions of cranial nerve V at different levels
At Trigeminal ganglion:
 Herpes Zoster Ophthalmicus
 Neoplasm
V Branch lesions:
Inside cranium-
 Gradenigo syndrome—V1+VI (ipsilateral-petrous apex
lesion, following otitis media in children)
 Cavernous sinus thrombosis- V1+V2+III+IV+VI+proptosis
with eye congestion+papilloedema

65. Lesions of cranial nerve V at different levels
Lesions at foramina of exit or entry:
Sphenoid bone tumors- Metastasis
 Nasopharyngeal carcinoma
Lesions at terminal branches in face:
Trauma
Infections-Leprosy
Sjogren’s syndrome
Sarcoidosis
Connective tissue diseases
Mental neuropathy, Numb cheek syndrome
Idiopathic trigeminal neuropathy.

66. Case 1
A 55 years old female presented with paroxysmal, severe
lancinating pain in left side of her face. Clinical examination
is normal.

67. Diagnosis:
•Trigeminal neuralgia

68. White and Sweet Criteria for
Trigeminal Neuralgia
1. The pain is paroxysmal.
2. The pain may be provoked by light touch to the
face (trigger zones).
3. The pain is confined to the trigeminal
distribution.
4. The pain is unilateral.
5. The clinical sensory examination is normal.

69. Treatment:
A. Drug therapy
1st choice- Carbamazepine
Other drugs- Oxcarbazepine, Lamotrigine,
Gabapentine, phenytoin, baclofen.
B. Other options (surgery)
-Nerve block with alcohol/phenol
-Rhizotomy
- Microvascular decompression
- Percutaneous radiofrequency thermocoagulation
-Gamma Knife radiosurgery

70. Case 2
A 49-year-old caucasian woman presenting with
excruciating paroxysmal electrical pain within the right
maxillary division of the trigeminal nerve.
 The neurological exam revealed hypoesthesia to touch
and pinprick
 hypoalgesia in the maxillary division of the trigeminal nerve
on the right side.
 Internuclear ophthalmoplegia.
 Brisk tendon reflexes.

71. FLAIR image showing a hyperintense lesion in
the lower part of pons

72. Diagnosis:
Painful trigeminal neuropathy
attributed to multiple sclerosis.

73. Trigeminal Neuralgia (classic
TN)
Trigeminal Neuropathy
(symptomatic TN)
Age 52 to 58 years 30 to 35 years
Cause Idiopathic vascular, neoplastic, and
demyelinating disease(MS)
Pain Characteristic paroxysmal pain Persistent pain.
Examination No neurological deficit Most present with sensory
loss on the face or with
weakness of the jaw muscles
Imaging Unremarkable MS plaques, tumor, and
subtle vascular anomalies.
Treatment Carbamazepine is the first choice. Treatment of cause.

74. A 78-year-old woman presents with a 4-week history
of vesicular eruption on the left side of her upper
forehead and scalp, pain in her left forehead.
The cornea of the left eye is hazy and edematous
with oedematous eyelid
Case 3

76. Herpes Zoster Ophthalmicus
• Reactivation of latent Varicella-Zoster Virus in the trigeminal
ganglion along the trigeminal ophthalmic branches later in life
causes herpes zoster ophthalmicus.
• C/F:
- Painful vesicular eruption
- Involves upper eyelid, bridge of nose and forehead
- Hutchinson sign-skin lesions at side of nose
(predicts ocular complication)
- Strictly unilateral
• Sequelae:
10% patients with herpes zoster ophthalmicus goes on to develop
post herpetic neuralgia

77. Case 4
A 45 year old male presented with vertigo, facial numbness and
difficulty in swallowing
On examination:
- Lt sided Horner’s syndrome
- Lt sided palatal palsy
- Decreased pain sensation in Lt side of face & Rt sided
hemianaesthesia involving limbs & trunk
- MRI of Brain was done

78. MRI of brain: hyperintense lesion on the left
lateral aspect of medulla

79. Lateral medullary syndrome
Occlusion of PICA or vertebral artery
Infraction of lateral part of medulla
Ipsilateral;
Horner’s syndrome
Facial numbness(V)
Palatal palsy(IX,X)
Cerebellar signs
Contralateral:
↓ pain & temp over half the body

80. Case 5
A 40 years old male presented with vertigo, facial numbness and
difficulty in walking for 2 years.
On examination:
left sided absent corneal reflex
left sided S-N deafness.
left sided cerebellar ataxia
MRI of Brain was done

81. Contrast image shows homogenous
enhanced area at left C-P angle

82. CP angle tumor
 Most common neoplasm of posterior fossa.
 About 5-10% of all intracranial tumor.
 Cause:
o Vestibular schwannoma (85%)
o Meningiomas (3-13%)
o Epidermoids (2-6%)
o Facial and lower cranial nerve schwannomas (1-2%)
o Arachnoid cysts (1%)
o Lipoma, dermoid tumor, cyst
o Medulloblastoma
o Arteriovenous malformation

83. Facial Nerve (VII)

84. CLINICAL EXAMINATION OF CRANIAL NERVE VII
•Inspection
•Motor function
•Taste sensation
•Hearing

85. SUPRANUCLEAR CONTROL OF FACIAL
MUSCLES

86. Difference between UMNL & LMNL

87. Causes of unilateral facial palsy
(UMN type)
-Stroke
-Demyelination
-Tumor
Causes of unilateral facial
palsy (LMN type)
-Bell’s palsy (post viral)
-CSOM
-Post traumatic
-Parotid tumor
-Parotid surgery
-Ramsay Hunt Syndrome
-C-P angle tumor
-Brain-stem stroke
(Millard-Gubler )

88. Causes of bilateral facial palsy
GBS
Sarcoidosis
Lyme disease
HIV
(LMN type)

89. Lesion of Facial nerve
1. UMNL:
- Above the nucleus
2. LMNL :
-Nucleus
- Nerve root
-In Facial canal
-Distal branches

91. Lesion localisation & associated C/F
Associated Features Site of lesion Causes
VI nerve palsy,
contralateral limb
weakness
Pons Vascular( Millard –
Gubler syndrome)
Demyelination,
Tumour, Encephalitis
V, VIII nerve palsies;
-loss of taste, salivation
and lacrimation;
hyperacusis
CP angle or Internal
Auditory Meatus
Acoustic tumours,
Meningioma

92. Lesion localization & associated C/F
Associated Features Site of lesion Causes
Hyperacusis,
loss of taste and
salivation, lacrimation
preserved
Facial Canal,
(proximal to
nerve to
stapedius)
Bell’s palsy, Ramsay-Hunt
syndrome, Fractures of skull
base, spreading middle ear
infection, petrous temporal
carcinoma
Lacrimation, taste and
salivation preserved,
weakness localised to
specific muscle group
Facial Nerve
distal branches
Parotid gland lesion, parotid
operation, facial trauma,
Lyme disease, sarcoidosis,
Melkersson-Rosenthal
syndrome

93. Bell’s palsy
The most common form of facial paralysis is
Bell’s palsy.
The onset of Bell’s palsy is fairly abrupt, maximal
weakness being attained by 48 hr as a general
rule.
Pain behind the ear may precede the paralysis
by a day or two.
Taste sensation may be lost unilaterally,
Hyperacusis may be present.

94. Contrast MRI shows swollen and
hyperintense left facial nerve

95. Bell’s Palsy
•Sequelae:
Persistent severe facial weakness- 4%
Synkinetic contraction & twitching of
upper & lower facial muscles- 17%
Crocodile tear
Movement of angle of mouth on closing
eyes (jaw winking)
Corneal ulceration
Hemi facial spasm

96. Ramsay–hunt syndrome
• Caused by reactivation of varicella
zoster virus in the geniculate
ganglion,
• Consists of a severe facial palsy
• Associated with a vesicular
eruption in the external auditory
canal and sometimes in the
pharynx
• Eighth cranial nerve may be
affected as well.

97. Hemi facial spasm(HFS)
Involuntary, unilateral, pain-less, episodic contraction of
facial muscles.
Compression of motor nerve root by vascular loop may
be responsible
Following Bell’s palsy
Neoplasm, demyelination

98. Facial myokymia
 Continuous twitching of individual facial muscles
 Cause:
o MS
o Brainstem glioma
o Recovery from GBS
 Feature:
o Gives an undulating or rippling appearance to overlying
skin, descriptively called as `bag of worms' appearance.

99. Vestibulocochlear Nerve
(VII)

100. Vestibulocochlear Nerve(VII)
Clinical Examination
Cochlear part
•Test hearing in each
ear separately
- Rinne’s test
-Weber’s test
•External auditory
meatus (auroscope)
Vestibular part
-Dix-Hallpike’s test
-Vestibulo-ocular reflex

101. Cochlear Nerve(VII)
Clinical Examination

102. Cochlear Nerve(VII)
Clinical Examination
Interpretations of Rinne’s test
Rinne positive:
Normal condition. (A.C.> B.C.)
Rinne negative:
Conductive deafness.(B.C.>A.C.)
False negative Rinne:
B.C. is heard on normal side cochlea by skull
cross over---severe sensorineural loss

103. Cochlear Nerve(VII)
Clinical Examination
Normal:
 Central or bilaterally
symmetrical
Lateralized:
 Sensorineural defect
on the opposite side
 Conductive deafness
on the same side

104. Deafness
Three types of deafness:
1. Conductive deafness- failure of sound conduction to cochlea
2. Sensorineural deafness- failure of action potential production
or transmission due to disease of the cochlea, cochlear nerve,
cochlear central connections.
3. Cortical or pure word deafness- a failure to understand
spoken language despite preserved hearing due to bilateral or
dominant posterior temporal lobe (auditory cortex) lesion

105. Causes of deafness
1.Conductive deafness: (failure of sound conduction to cochlea)
 Wax
 Infection- otitis media, cholesteatoma
 Trauma- tympanic membrane rupture, ossicular disruption
 Otosclerosis
 Tumours- carcinoma, glomus jugulare

106. 2. Sensorineural deafness:
a) Cochlear −
 Congenital- aplastic, maternal rubella
 Infection- mumps, measles, meningitis, suppurative
labyrinthitis
 Trauma- petrous temporal fracture
 Drugs- streptomycin, quinine, salicylates
 Meniere’s disease
 Tumors- carcinoma, glomus jugulare
 Vascular

107. b) Retro cochlear
 CP angle tumour- acoustic neuroma, meningioma
 Brainstem disease (associated brainstem signs)-
demyelination, vascular insufficiency, syringobulbia,
astrocytoma

108. Vestibular Nerve(VII)
Clinical Examination
Dix-Hallpike Test:
 Warning the patient about
vertigo or nausea.
 The patient should be instructed
to keep their eyes open.
 While still upright, turning the
patient's head 45 degrees to one
side, then lying it back with neck
extended over the head of the
table/bed or pillow.

109. Vestibular Nerve(VII)
Clinical Examination
•A positive test must comprise a voluntary report of
acute vertigo, and torsional nystagmus.
•Sitting the patient up
•Repeating the test on the opposite side.
•Testing the suspected normal ear first and the
suspected symptomatic ear second.

110. Vertigo
• Central vertigo: Indicates the lesion in the brainstem or
cerebellum.
• Peripheral vertigo: When the pathology in the labyrinth or
vestibular nerve.

111. Peripheral (labyrinth or vestibular nerve):
Benign paroxysmal positional vertigo,
infection (labyrinthitis),
vestibular neuritis,
Meniere’s disease,
ischemia,
trauma,
-Toxin
Central (brainstem or cerebellum):
Vascular
demyelinating
neoplasm

112. Central VS Peripheral vertigo
• Peripheral vertigo
More sudden & severe
Tinnitus/deafness +ve
Focal deficits absent
Other CNS features
(Cerebellar,Brainstem-
diplopia,dysarthia,cranial
palsy, papilloedema) absent.
 Nystagmus usually
horizontal which disappears
on time
Dix-Hallpike test +ve
Central vertigo
 Sudden but less severe
 Tinnitus/deafness –ve
 Focal deficits present
Other CNS features usually
present (Red-Flag signs for
vertigo)
 Nystagmus
horizontal/vertical/rotatory
Usually long lasting
Dix-Hallpike test -ve

113. Vestibular neuronitis
Etiology:
Probably viral
C/F:
 Sudden severe vertigo
lasting days to weeks
 Nausea, vomiting
 Imbalance
Treatment:
Vestibular sedatives e.g. cinnarizine, prochlorperazine, betahistine

114. BPPV
 Commonest cause of
recurrent vertigo.
 Attacks provoked by head
position changes.
 Otoliths are dislodged
from utricle to
semicircular canal.
 Dix-Hallpike test is
diagnostic .
 Rx-Vestibular sedatives
& repositioning maneuver.

115. Case 6
• A 34-year-old male presented with progressive bilateral
hearing loss.
• The patient also complained of chronic headache associated
with vertigo.
• An audiometric exam showed bilateral sensoneural hearing
loss (more on the right)

116. Axial (A) and coronal (B) enhanced T1-weighted MR images
demonstrating bilateral solid masses in the cerebellopontine angles

117. Diagnosis
•Bilateral CN VIII schwannoma
(I.e. Neurofibromatosis type 2)

118. THANK YOU