1. Cerebellar dysfunction, syndromes, signs, examination doc. MUDr. Valja Kellerová, DrSc. Department of Neurology

2. Causes od cerebellar dysfunction cerebrovascular disease multiple sclerosis alcohol, the acute intoxication inflammatory diseases (encephalitis) drugs (i.e. anticonvulsant intoxication) posterior fossa tumours: –in children - primary malignant tumours –in adults - acoustic neuroma, meningeoma, metastasis

3. Lesion location 1 vermis (damage to midline structures) - paleocerebellar syndrome - disturbance of equilibrium hemisphere structures of the cerebellum - neocerebellar syndrome - impaired limb co- ordination cerebellar connections to other areas –nystagmus –ocular dysmetria - an overshoot during fixation of gaze –scanning dysarthria, explosive speech

4. Lesion location 2 vermis – paleocerebellar sy disturbance of equilibrium: –unsteadiness on standing, walking, sitting - truncal ataxia –gait is broad based and reeling –eye closure does not affect balance

5. Lesion location 3 cerebellar hemisphere - neocerebellar sy impaired limb co-ordination (ipsilateral to the side of the lesion): – ataxia – dysmetria, overshooting – dysdiadochokinesia – intention tremor – pendular reflexes – rebound phenomenon…

6. Signs of cerebellar dysfunction, examination 1 passivity (hypotonia) during passive movements: –resistance to passive movements is diminished –the joints may be passively hyperextended –pendulousness is increased Examination: (head: flexion, rotation, inclination is in a greater extent) upper limbs: – passive shaking of the hand larger excursions larger number of swings

7. Signs of cerebellar dysfunction, examination 2 Passivity – examination: "ressaut" ( arm bounce) – after release of the arms they fall and rebound from the trunk –many rebounds –excessive swinging "succusion of the trunk" – passive rotation of the trunk (by moving the standing patient´s shoulders back and forth) –excessive arm swings –larger number of swings

8. Signs of cerebellar dysfunction, examination 3 Passivity: upper limbs: pendular reflexes, pendulousness in the triceps reflex (larger number of oscillations) lower limbs: –passive shaking the foot (larger excursions and number of swings) –passive rotation of thighs (larger extent) –pendular reflexes in the knee jerk (patellar reflex) in the sitting position (larger number of oscillations)

9. Signs of cerebellar dysfunction, examination 4 Dysmetria: –finger-nose test (nose- finger-nose test) ataxia, past pointing, overshooting intention tremor –grasp of a pencil, of a glass – fingers spread out –hand reversal (from supination to pronation) – overshooting –heel-knee (shin) test - ataxia

10. Signs of cerebellar dysfunction, examination 5 rebound phenomenon (Stewart-Holmes) – flexion of the forearm against resistance, sudden release, normal reaction – prompt control, abnormal - insufficient control, dysmetria (striking the head)

11. Signs of cerebellar dysfunction, examination 6 Dysdiadochokinesia: of the tongue upper limbs : –classic (pronation-supination of the forearms) – chaotic –flexion-extension of the fingers or of the forearm –knee pat test (pat a cake) – pronation and supination, to pat the knee with the palm and dorsum of one hand lower limbs: –heel-buttock test

12. Signs of cerebellar dysfunction, examination 7 Dyssynergia: combined flexion of lower limbs and the trunk ("small dyssynergia") – lifting legs during sitting up (without hand support)

13. Signs of cerebellar dysfunction, examination 8 Dyssynergia: retroflexion of the trunk (while standing) –normal: flexion of knees –dyssynergia: without flexion of knees, falling backward "like a board"

14. Signs of cerebellar dysfunction, examination 9 Dyssynergia: truncal ataxia – when seated, falling to one side or backwards axial dysfunction ("great dyssynergia") – disturbance of equilibrium with unsteadiness on standing and walking: –standing – broad based, swaying (even with eyes open) –walking – broad based gait, reeling, ataxic gait, irregular

15. Signs of cerebellar dysfunction

16. Signs of cerebellar dysfunction, examination 10 Writing and drawing: writing a short sentence – large, macrographia writing large block letters, large diameter writing without support of the hand – intention tremor – hooks at the beginning of lines

17. Signs of cerebellar dysfunction, examination 11 Writing and drawing: zig-zag line – horizontal – vertical - irregular connecting two points – horizontal line – vertical line past pointing overshooting

18. Signs of cerebellar dysfunction, examination 12 Speech: –scanning dysarthria, explosive speech, ataxic dysarthria, staccato –excessive loudness Eye movement abnormalities: nystagmus (a coarse nystagmus toward the side of the lesion, involvement of cerebellar connections to the vestibular nuclei) ocular dysmetria when the eyes voluntary fixate, overshooting

19. Conclusion Right or left handed patient? Dominance of one cerebellar hemisphere ! In the right handed patient, the dominant cerebellar hemisphere is the right (ipsilateral) ! Conclusion: (according prevalence of signs) paleocerebellar syndrome neocerebellar syndrome mixed (global)