Armando Hasudungan

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Cerebellar Presentation

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Cerebellar Presentation

Overview Signs and symptoms of cerebellar disease presents on the same side (ipsilateral). Symptoms and signs consist of gait impairment, unclear (“scanning”) speech, visual blurring due to nystagmus, hand in-coordination, and tremor with movement.

Remember

 

CAUSES OF CEREBELLAR DISEASE BASED ON ONSET
Acute Subacute Chronic
Drugs (phenytoin, lithium) Alcohol Chronic infection
Alcohol intoxication Malnutrition (Vitamin B12 and B1 deficiency Friederichs ataxia
Paraneoplastic syndrome Hypothyroidism
Hyponaturaemia

 

CAUSES OF CEREBALLAR DISEASE BASED ON LOCATION
Unilateral Bilateral Midline Vermis
Space occupying lesion Drugs (phenytoin) Paraneoplastic Syndrome Alcohol
Ischaemia Alcohol
Multiple sclerosis Friederichs ataxia
Trauma Hypothyroidism
Large space occupying lesion
Multiple Sclerosis
Trauma

 

Frederichs ataxia is a autosomal recessive ataxia, comprising one-half of all hereditary ataxias. Two forms classic (frataxin) and association with vitamin E deficiency.

Cerebellar Examination

General

  • Titubation
  • Gait - ataxia, unable to tanden gait (heel to shin)
  • Intention tremor

Head

  • Auscultate over cerebellum for bruits
  • Auscultate carotids - lateral medullary syndrome (Wallenburg syndrome)
  • Cerebellopontine angle tumour - 5, 7, 8 cranial nerve affected
  • Nystagmus
  • Speech - explosive, jerky and loud with irregular seperation of syllables

Arms and legs

  • Shake hands - tone
  • Upward arm drift (due to hypotonia of the agonist muscles)
  • Rebound - ask patient to raise arm quickly and stop (incoordination between antagonist and agonist muscles)
  • Hypotonia - due to loss of facilitatory muscles
  • Coordination
    • Finger to nose - past pointing due to no connection between brainstem and cerebellum
    • Heel-to-shin
  • Dysdiadochokinesis - inability to perform rapid alternating movements

Special tests

  • Trunkal ataxia (usually assocated with vermis pathology of the cerebellum)
  • Reflex - pendular knee
Side note There are many connections between the cerebellum and the parietal and frontal lobes of the brain and thus explains the clinical presentation that is associated with cerebellar disease

Pathways in the CNS

Pyramidal Pathways (through medulla) 

  • Anteriorcorticospinal tract
  • Lateralcorticospinal tract

Extrapyramidal Pathways  

  • Rubrospinal tract
  • Vestibulospinal tract
  • Reticulospinal tract
  • Tectospinal tract
  • Olivospinal tract

Cerebellar Pathway 

  • Spinocerebellar tract
CLINICAL DIFFERENCES BETWEEN THE CENTRAL NERVOUS SYSTEM PATHWAYS
Clinical signs Pyramidal Extrapyramidal Cerebellar Functional
Power Weak No weakness No weakness Give-way weakness
Wasting None (overtime no use maybe) None None None
Tone Spastic increase Rigidity Normal/reduced Normal
Reflexes Increased Normal Normal Normal
Plantar response Extensor Flexor Flexor Normal
Coordination Reduced by weakness Normal but slow Impaired Normal (laborious)

 

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