Hypoglossal nerve (cranial nerve XII) palsy is uncommon. Damage to this nerve produces characteristic clinical manifestations, of which unilateral atrophy of the tongue musculature is the most important. When these features are recognized, the radiologist, armed with knowledge of the normal anatomy of the area, can focus on each segment of the nerve in search of a cause.
The hypoglossal nerve is divided into five segments: the medullary, cisternal, skull base, nasopharyngeal/oropharyngeal carotid space, and sublingual segments. Because each segment is usually affected by different disorders, localizing a lesion to a particular segment allows the radiologist to narrow the differential diagnosis. In this way, the most efficient imaging strategy for evaluation of the symptoms can be developed. Both computed tomography and magnetic resonance imaging are useful in assessing dysfunction of the hypoglossal nerve; the choice depends on the status of the patient and the preference of the radiologist 1).