Cerebellar Examination Flashcards
What are the 6 important things to cover in a cerebellar examination?
Remember DANISH!
- Dysdiadochokinesia
- Ataxia (gait and posture)
- Nystagmus
- Intention tremor
- Slurred, staccato speech
- Hypotonia/heel-shin test
What may an abnormal posture indicate in a cerebellar exam?
Truncal ataxia
What does a slurred staccato speech indicate?
Cerebellar disease
What is ataxia?
A neurological sign consisting of involuntary movements with an irregular oscillatory quality which interferes with normal smooth movement
What is truncal ataxia and what causes it?
- Affects proximal musculature that is involved in gait stability
- Caused by damage to cerebellar vermis and associated pathways
What is appendicular ataxia and what causes it?
- Affects musculature of the arms and legs involved in the control of limb movement
- Caused by damage to cerebellar hemispheres
What does a broad-based ataxic gait indicate?
Midline cerebellar pathology (MS lesion or secondary to alcohol excess)
What does a staggering, slow and unsteady gait indicate?
Cerebellar pathology
Which side will the patient veer to in unilateral cerebellar disease?
The side of the lesion
How will those with cerebellar disease find turning?
Difficult
What does a tandem (‘heel-to-toe’) gait show?
- Makes it easier to recognise subtle ataxia
- Good at identifying dysfunction of the cerebellar vermis (alcohol-induced).
What is the pathophysiology of cerebellar disease?
Progressive loss of Purkinje cells
Name 4 causes of cerebellar degeneration
- Chronic alcohol abuse
- Nutritional deficiency
- Paraneoplastic disorders
- Neurological diseases e.g. MS
Name 4 clinical features of cerebellar degeneration
- Broad-based ataxic gait
- Trunca ataxia
- Dysmetria (incoordination)
- Nsytagmus (abnormal eye movements)
What is Romberg’s test used for?
- To assess for loss of proprioceptive or vestibular function
- Screen for non-cerebellar causes of balance issues
What are the premises that Romberg’s test is based off?
A patient requires at least 2 out of 3 to maintain balance while standing:
- Proprioception
- Vestibular function
- Vision
What is proprioception?
The awareness of one’s body position in space
What is vestibular function?
The ability to know one’s head position in space
What is a positive Romberg’s sign?
When a patient falls with their eyes closed
What may swaying during a Romberg’s test indicate?
Truncal ataxia
What may cause a positive Romberg’s test?
- Sensory ataxia
- Proprioceptive dysfunction e.g. Ehlers-Danlos, B12 def., Parkinsons
- Vestibular dysfunction e.g. vestibular neuronitis
How can ataxic dysarthria present?
- Scanning speech
- Slurred speech
What is scanning speech?
Words are broken down into separate syllables, often separated by pauses and spoken with varying volume
How do you assess for nystagmus?
Do the ‘H-test’
How is the direction of nystagmus relevant?
- Has a fast phase and a slow phase
- Direction is defined from fast phase
- In a lesion, the direction is towards the lesion side
What is dysmetric saccades?
- Do the ‘finger movement’ test
- The overshoot and subsequent correction in cerebellar pathologies dysmetric saccades
What is impaired smooth pursuit?
- Do the ‘finger movement’ test
- Movement may be jerky
What may be found in the finger-to-nose test?
- Dysmetria
- Intention tremor
How does dysmetria present in cerebellar disease?
- Lack of coordination of movement
- Missing the target by over/undershooting
How does an intention tremor present in cerebellar disease?
- A broad, coarse low-frequency tremor that develops as a limb reaches the end point of a deliberate movement
What does dysmetria and intention tremor indicate during the finger-to-nose test?
Ipsilateral cerebellar pathology
What is rebound phenomenon?
A reflex that occurs when a patient attempts to move a limb against resistance that has been suddenly removed
What does an exaggerated version of rebound phenomenon indicate?
Suggestive of spasticity
What does complete absence of the rebound phenomenon indicate?
Suggestive of cerebellar disease
What may cause hypotonia in a cerebellar exam?
An ipsilateral cerebellar lesion
What is dysdiadochokinesia?
The inability to perform rapid, alternating movements, which is a feature of ipsilateral cerebellar pathology
What does the presence of dysdiadochkinesia indicate?
Ipsilateral cerebellar pathology
How are reflexes described in cerebellar disease?
Pendular - less brisk and slower in their rise and fall
What should be completed after a cerebellar exam?
- Full neurological examination
- Neuroimaging
- Formal hearing assessment
