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8/8/2019 ClinExamCblm com

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The Cerebellum

Clinical Examination


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Objectives

To be knowledgeable about the aspects of the neurologicalexamination pertaining to the cerebellum

To understand how to localize lesions within the cerebellum on thebasis of clinical findings

To develop a framework about the presentation of nervous systemillness


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Cerebellar Examination Midline cerebellar function

Cerebellar hemispheric function


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Clinical localization in the cerebellum For purpose of localization, cerebellum can be viewed as a

saggitally-oriented structure containing 3 zones on each side:

Midline

Intermediate

Lateral


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Midline zone

Consists of the anterior and posterior parts of the vermis,fastigial nucleus and associated input and output projections

concerned with posture, locomotion, position of head relative totrunk, control of EOMs

Cerebellar signs resulting from midline cerebellar disease

disorders of stance/gait, truncal postural disturbances, rotated

postures of the head, disturbances of eye movements


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Intermediate zone

Consists of paravermal region of cerebellum and interposednuclei (emboliform, globose)

concerned with control of velocity, force and pattern of muscleactivity

Clinical disorders related to disease of this zone not clearlydelineated


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Lateral zone

cerebellar hemisphere and dentate nucleus on each side

concerned with the planning of movement in connection with

neurons in the Rolandic region of the cerebral cortex (fine,skilled)

Lesions result in abnormalities of skilled voluntary movements:hypotonia, dysarthria, dysmetria, dysdiadochokinesia, excessive

rebound, impaired check, kinetic and static tremors, past-pointing


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Midline Cerebellar Function Observation

Posture, head position

Gait

Eye movements

Rhomberg Test

Tests of gait- tandem, toe + heel walking, walking backward

Hop on each foot


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Cerebellar Hemispheric Function Finger-to-nose test

Rapidly alternating movements

Heel-to-shin test


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Cardinal Features of Cerebellar Dysfunction

Hypotonia

Ataxia

Dysarthria

Tremor

Ocular Motor Dysfunction


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Classic signs of cerebellar damage

Depending on extent, an individual may have one symptom or a

combination

In all cases, symptoms from unilateral damage appear on the sideipsilateral to the injury

Ascending spinocerebellar pathways are uncrossed and descending

corticoopontocerebellar fibers are crossed; thus motor deficits fromcerebellar damage are ipsilateral to the lesion whereas motordeficits from damage to motor areas of the cerebral cortex are

contralateral to the lesion


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postural instability

delayed initiation and termination of motor actions

inability to perform continuous, repetitive movements

errors in smoothness and direction of a movement

lack of coordingation or synergy of movement, especially complex

movements

lack of motor plasticity or learning


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Hypotonia usually accompanies acute hemispheric lesions

Interestingly less often seen in chronic lesions

Ispilateral to the side of a cerebellar lesion

More noticeable in upper limbs and proximal muscles

(beware of increased tone with a cerebellar lesionmay reflectcompression of brainstem/corticospinal tracts)!!

Probably due to q fusimotor activity, secondary to cerebellar injury(especially the dentate), with a q response to stretch in muscle

spindle afferents


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Ataxia

Defective timing of sequential contraction of agonist /antagonistmuscles

Results in a disturbance in smooth performance of voluntary acts(errors in rate, range, force, duration)

Without cerebellar modulation, skilled movements originating incerebral cortex are inaccurate, poorly controlled

May affect limbs, trunk, gait (depends on part of cerebelluminvolved)

usually persists despite visual cues (unlike ataxia due to posteriorcolumn disease affecting the spinal cord)


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Asynergia= lack of synergy of various muscles while performing

complex movements ( movements are broken up into isolated,

successive parts-- decomposition of movement)

Dysmetria= abnormal excursions in movement

Dysdiadochokinesia= impaired performance of rapidly alternatingmovement

Past-pointing

Excessive rebound when an opposed motion is suddenly released


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Cerebellar Dysarthria

Abnormalities in articulation and prosody (together or independent)

scanning, slurring, staccato, explosive, hesitant, garbled

May result from a generalized hypotonia (disorder of muscle spindlefunction)

Hemisphere lesions are associated with speech disorders moreoften than vermal lesions


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Posterior Fossa Syndrome

Acute, bilateral injury to both cerebellar paravermal regions,including the dentate, may lead to transient muteness

Seen in up to 20% of posterior fossa tumor resections in children(cerebellar mutism syndrome)

May last for several months, with severe dysarthria after return ofspeech


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Cerebellar affective disorder

Impaired executive function, personality, emotional andbehavioral changes

Can be seen as part of the mutism syndrome


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Tremor

rhythmic, alternating, or oscillatory movements

can be a normal exaggeration of movement, a primary disorder, or a

symptom of a cerebellar disorder or Parkinson's disease

Diagnosis is usually clinical

Treatment varies by etiology


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Tremor- Framework/ Categories

Trigger: Resting or action-- includes postural tremors

and intention tremors (triggered by a purposefulmovement)

Cause: Physiologic, essential, parkinsonism, or

secondary to drugs or other disorders (including

cerebellar disorders)

Amplitude of oscillation: Fine or coarse


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Tremor- General features

Resting tremor : maximal at rest, decreases with activity; usually asymptom of Parkinson's disease

Postural tremor : maximal with limb in a fixed position againstgravity; gradual onset suggests physiologic or essential tremor;

acute onset suggests toxic / metabolic disorder

Intention tremor : maximal during movement toward a target (finger-

to-nose testing) ; suggests a cerebellar disorder but may resultfrom other diseases (MS, Wilsons)


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Tremor- Physiologic

Physiologic tremor: present normally -- usually so slight that it isnoticeable only under certain conditions ; predominantly postural,fine and rapid (8 to 13 Hz)

most visible when hands are outstretched

Amplitude may be increased (enhanced) by Anxiety Stress Fatigue Metabolic disorders (eg, hyperadrenergic states such as alcohol

or drug withdrawal or thyrotoxicosis) Certain drugs (eg, caffeine, other phosphodiesterase inhibitors,

-adrenergic agonists, corticosteroids) Alcohol and other sedatives usually suppress it


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Tremor- Essential tremor

benign hereditary tremor, senile tremor coarse or fine, medium frequency (4 to 8 Hz); min or absent at rest usually bilateral can affect the hands, head, voice tends to increase with aging In 50% of patients, inheritance is autosomal dominant

may be enhanced by any factor that enhances physiologic tremor(not always required)

Some consider essential tremor a variant of physiologic tremor


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Tremor- Cerebellar Disease

an intention tremor; no effective drug available; physical measures(eg, weighting the affected limbs or teaching patients to brace theproximal limb during activity) sometimes helps

Asterixis: not a tremor; muscle tone lapses when wrist extension isattempted, resulting in repetitive, nonrhythmic, non-oscillatory wristflexion; a sign of chronic renal or liver failure (differentiate fromtremor) 3-5 Hz

Usually bilateral Can be a sign of hepatic encephalopathy (inability of liver to metabolize

ammonia to urea) Patient is usually drowsy or stuporous


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Oculomotor dysfunction

Nystagmus frequently seen in cerebellar disorders

Gaze-evoked nystagmus, upbeat nystagmus, rebound nystagmus,

opticokinetic nystagmus may all be seen in midline cerebellar

lesions

Other ocular lesions seen include opsoclonus, skew deviation,

ocular bobbing

Most of the disorders giving rise to these affect brainstem structures,

too: cerebellar role in their onset not well-defined

Overall, most cerebellar eye signs cannot be localized to specific

areas of the cerebellum


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Features to Examine


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Gait

Ataxia

In cerebellar disease, the walk is staggering/lurching/wavering

Not benefitted by patients view of his surroundings

Lesion in mid-cerebellum: movements are in all directions

Lesion in lateral cerebellum: staggering/falling are toward the side of the

lesion

Somewhat steadied by standing or walking on a wide base (ataxia secondary to vestibular disease may appear similar)


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Gait

Gait

have patient walk across room under observation

Watch for normal posture + coordinated arm movements

ask patient to walk heel-to-toe across room, walk on toes to test

for plantar flexion weakness, and on heels to test for dorsiflexionweakness

Abnormalities in heel to toe walking: ethanol intoxication,

weakness, poor position sense, vertigo -- exclude before poor

balance is attributed to a cerebellar lesion

elderly patients have difficulty with tandem gait (heel to toewalking) -- general neuronal loss impairs combination of position

sense, strength, coordination


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blumentandemgait


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blumenTipToeGaitandHopping


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impairedTandemGait.flv


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CerebGait.flv


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Testing of Station (equilibratory

coordination)

Position of Feet Ataxia from spinocerebellar disease is less when the patient

stands on a broad base (feet widely apart)

Eyes open or closed Cerebellar ataxia is not improved by visual orientation; ataxia

from posterior column disease (disordered proprioception) isworsened with the eyes closed

Direction of Falling Disease of lateral lobe of cerebellum causes falling to ispilateral

side

Lesions of midline/vermis cause indiscriminate falling,depending on initial stance of the patient


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blumenRhombergTest


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Diadochokinesia

Normal coordination includes ability to arrest one motor impulse andsubstitute the opposite

Loss of this = dysdiadochokinesia

Characteristic of cerebellar disease

Many simple tests for this:

Alternating movements (pronate and supinate forearm + handquickly): in cerebellar disease, movements overshoot, undershoot

be irregular or inaccurate

Rapidly tap fingers on table

Open and close fists

Stewart-Holmes rebound sign


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blumenFineFingerTap.rm


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blumenRapidlyAltMovements.rm


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dysdiadochokinesiamovie


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Dysmetria

Finger to nose test

With eyes open, have pt partially extend elbow and rapidly bring tip of

index finger in a wide arc to tip of his nose

In cerebellar disease, the action may have an intention tremor With eyes closed, sense of position in the shoulder and elbow is tested

Heel to Shin test

Pt places one heel on opposite knee and slides heel down the tibia withfoot dorsiflexed

Movement should be performed accurately

In cerebellar disease, the arc of the movement is jerky/wavering

The slide down the shin has an action tremor


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blumenFingerNoseTest.rm


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Coordinationwithpuppets.mp4


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Cerebellarintentiontremor.mp4


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Heelshintest.mp4


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Heelshinabnormal.mp4


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Checkreflexmovie.mp4


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Checkreflexabnorvideo.mp4


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Spasticspeech.flv


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Cerebellar Syndromes

In general, precise clinical localization is difficult in the cerebellum

Some syndromes can be classified anatomically:

Rostral vermis syndrome (anterior lobe)

Caudal vermis syndrome (flocculonodular, posterior lobe)

Hemispheric syndrome (posterior lobe, variably anterior too)

Pancerebellar syndrome


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Cerebellar Syndromes- rostral vermis

Wide-based stance and gait

Ataxia of gait, proportionally little ataxia on heel-shin with pt lying

down Normal or slightly impaired arm cooordination

Infrequent hypotonia, nystagmus, dysarthria

alcoholics (restricted form of cerebellar cortical degeneration)


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Cerebellar Syndromes- caudal vermis

Axial dysequilibrium, staggering gait

Little or no limb ataxia

Sometimes spontaneous nystagmus

Rotated postures of head

Seen in diseases that damage the flocculonodular lobe (espmedulloblastoma in children)as tumor grows, a hemispheric

cerebellar syndrome may be superimposed

Need to also consider other signs ofo ICP (obstruction of CSF)


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Cerebellar Syndromes- hemispheric

Incoordination of ipsilateral limb movements

More noticeable with fine motor skills

Incoordination affects most noticeably muscles involved in

speech and finger movements

Etiologies include infarcts, neoplasms, abscesses


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Cerebellar Syndromes- pancerebellar

Combination of all the other syndromes

Bilateral signs of cerebellar dysfunction involving trunk, limbs,

cranial musculature

Etiologies usually infectious/parainfectious processes,hypoglycemia, paraneoplastic disorders, toxic-metabolic disorders


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Cerebellum: 4th ventricle

The fourth ventricle is ventral to the cerebellum

Anatomically and clinically important

Mass lesions located in the cerebellum, or swelling of thecerebellum (eg. Edema from an infarct) can compress the 4th

ventricle and result in obstructive hydrocephalus


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My patient: Tamra

15 yr, R15 yr, R--handedhanded previously healthy from Woodstockpreviously healthy from Woodstock

3 wk progressive gait unsteadiness, ataxia, dizziness3 wk progressive gait unsteadiness, ataxia, dizziness

6 wk H/A, holocephalic, worse when coughing or sneezing, 5/10,6 wk H/A, holocephalic, worse when coughing or sneezing, 5/10,takes Adviltakes Advil

20 lbs weight loss over 3 wks20 lbs weight loss over 3 wks

admitted to Woodstock Generaladmitted to Woodstock General

Dx Mono, D/C home,next day H/A 10/10Dx Mono, D/C home,next day H/A 10/10


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Cerebellar dysarthria video clip


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Nystagmus video clip


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Finger to nose- Tamra


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Heel to shin- Tamra


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Lower extremity ataxia- Tamra


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Upper extremity ataxia- Tamra

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