Cerebellar examination

Question 1

What are the causes of cerebellar syndrome?

Answer 1

Cerebellar syndrome

causes ipsilateral DANISH signs

D - Dysdiadochokinesia, Dysmetria (past-pointing), patients may appear ‘Drunk’

A - Ataxia (limb, truncal)

N - Nystamus (horizontal = ipsilateral hemisphere)

I - Intention tremour

S - Slurred staccato speech, Scanning dysarthria

H - Hypotonia

Causes:

Friedrich ataxia, ataxic telangiectasia

cerebellar haemangioma

alcohol

stroke- older with Afib

phenytoin, lead poisoning

multiple sclerosis-especially if young, female

paraneoplastic syndromes-anti Hu antibody in lung cancer

Question 2

What are the things you want to be looking out for in a cerebellar examination?

Answer 2

Environment:

• walking aids (truncal ataxia will affect walking)
• hearing aids (vestibular schwanoma may compress cerebellum)
• medication

Patient:

• truncal ataxia (incoordination with the trunk, “drunk”-problem with cerebellar vermis)
• appendicular ataxia(incoordination with the limbs-problem with the cerebellar hemispheres)
• speech abnormalities (slurred staccator speech indicates cerebellar problem)

Question 3

What are the things you want to be assessing?

• gait
• romberg’s test

Answer 3

Gait

• ask them to walk from heel to toe-> inability of heel-to-toe gait suggests degeneration of cerebellar vermis (alcoholism, B12 deficiency, multiple sclerosis)

Romberg’s test

• ask them to stand with feet together
• put your hands by their front and back to support them if they were to fall
• ask them to close their eyes
• fall without correcting-> problems with proprioception or vestibular function
• fall with correcting-> ataxia ?

Question 4

How do you assess:

• speech
• eye movements

Answer 4

Speech in cerebellar exam

• ask them to repeat these phrases
• british constitution
• baby hippopotamus
• babababa: lip movement
• tatatatat: tongue movement
• kakakaka: soft palate movement

Types of speech:

• slurred speech-intoxication or cerebellar disease
• staccato speech-syllables are broken

slurred staccato speech

Eye movements:

• draw H ask them to keep head still
• note any nystagmus (cerebellar nystagmus-increases towards the side of lesion; decreases away from side of lesion-alexander law)
• vertical gaze by moving finger up and down

Question 5

What are the things you want to be assessing in upper limb?

Answer 5

• rebound phenomenon-ask them to keep their arms straight and close their eyes. Tell them you are going to be pushing down and ask them to keep their arms in the same position. Exaggeration-> spasticity-> lesion in cerebellum. Normal +ve. -ve with limb continuing to move in cerebellar lesion
• finger to nose test-looking out for intention tremor; past pointing if they cannot place finger at selected point
• dydiadochokinesia-incoordination; ask them to clap palm to palm then back of hand to palm; start off slow and ask them to lift hand and hear clap; then ask them to go as fast as they can
• tone-hypotonia in ipsilateral cerebellar lesion

Question 6

What are the things you want to be assessing for lower limb?

Answer 6

• assess tone-hypotonia in ipsilateral cerebellar lesion
• reflexes-pendular (continues to move several times after hitting knee)
• heel to shin test
• put your right heel to your left knee and run it down the length of your leg; lift up and repeat this again until I tell you to stop
• checking for incoordination in cerebellar disease