Module No.

3

Neurosciences Lecture

Examination of the Cerebellar System and the Meninges

October 3, 2016

Katherine Ann San Diego, MD, FPNA

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Outline
Cerebellum
1. Anatomy
2. Function
3. Cerebellar Pathways
4. Cerebellar Signs
5. 4 Cerebellar Syndromes
6. Examination of the Cerebellum and Cerebellar
Pathways
Meninges
Anatomy
Projections of the Dura Mater
Meninges and Spaces
Examination of the Meninges

I. Cerebellum
Anatomy


Located behind the dorsal aspect of the Pons and
Medulla
Separated from the Occipital lobe by the Tentorium
Cerebelli
Fills most of the posterior fossa

Vermis
>midline portion
>separates two lateral lobes or hemispheres

Folia
>narrow, ridge-like folds
>oriented transversely on external surface

Adjacent to 4th ventricle

Cerebellar Signs
HYPOTONIA

It is related to a depression of gamma and alpha
motor neuron activity

The least evident of the cerebellar abnormalities

More apparent with acute than with chronic lesions

Failure to check a movement- a closely related
phenomenon (impairment of the check reflex)
ATAXIA or DYSTAXIA

“Cerebellar sign par excellence”

May affect the limbs, trunk or gait

Asynergia – lack of synergy of the various muscle
components in performing more complex movements
so that movements are disjointed and clumsy and
broken up into isolated successive parts

Dysmetria - Abnormalities in the rate, range and
force of movement

Adiodochokinesis; Dysdiadochokinesis –
abnormality in the rhythm of rapid alternating
movements

Functions
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Coordinate skilled voluntary movements
Receive collateral input from sensory and special
sensory systems
*** Cerebellum processes sensory information
*** Does not influence motor neurons directly

Cerebellar Pathways
[Transcribed by Trinidad, Virtusio]

CEREBELLAR DYSARTHRIA

Slurring dysarthria – similar to dysarthria from
corticospinal disorders

Scanning dysarthria – variable intonation (prosody)
and abnormalities in articulation; described also as
staccato, explosive, hesitant, slow altered accent, and
garbled speech.

Speech production is often labored with excessive
facial grimacing.

Thought to be a result of generalized hypotonia.

DISTURBANCES OF OCULAR MOVEMENT
1. Inability to hold eccentric gaze

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periodic alternating nystagmus with lesions of the uvula. failure to suppress the vestibulo-ocular reflex INTENTION or ATAXIC TREMOR • Hypermetria – overshooting the target • When the finger approaches the target. opsoclonus. Hemispheric Syndrome > Incoordination of ipsilateral appendicular movements > Usual etiologies: Infarcts. Virtusio] Page 2 of 4 . nodulus. 4.[Neurology Lecture] 2. [Examination of the Cerebellar Systems and Meninges] Module 3 Slower smooth pursuit movements with “catchup” saccades Nystagmus – usually gaze-evoked. nystagmus. downbeat nystagmus with posterior midline lesions Other “cerebellar” eye signs – ocular flutter. and cranial musculature >Some etiologies:  infectious and parainfectious processes  hypoglycemia  hyperthermia  paraneoplastic cerebellar degeneration associated with small cell lung cancer (antiHu antibodies). ocular bobbing. breast and ovarian carcinomas (anti-Yo antibodies). with proportionally little ataxia on the heel-to-shin maneuver with the patient lying down > Normal or only slightly impaired arm coordination > Infrequent presence of hypotonia. Caudal Vermis Syndrome > Axial disequilibrium (truncal ataxia) and staggering gait >Little or no limb ataxia >Sometimes spontaneous nystagmus and rotated postures of the head 4.A rhythmic tremor of the head or upper trunk (three to four per second) DISORDERS OF EQUILIBRIUM AND GAIT • Standing with feet together may be impossible • In walking. skew deviation. 2. the patient’s steps may be uneven and placement of the foot may be misaligned • Wide-based stance with increased trunk sway. irregular stepping with a tendency to stagger as if intoxicated • Impaired tandem walking 3. abscesses Rostral Vermis Syndrome > A wide-based stance and titubating gait > Ataxia of gait. or Hodgkin's lymphoma Tr antibodies)  Toxic processes The 4 Cerebellar Syndromes 1. limbs. rebound with abnormal kinetic nystagmus if with midline cerebellar lesions. and dysarthria [Transcribed by Trinidad. square wave jerks at rest. there is a side-to-side movement of the finger before reaching the target. 3. Pancerebellar Syndrome > Bilateral signs of cerebellar dysfunction affecting the trunk. neoplasms. • Titubation . upbeat.

Arachnoid mater – “DELICATE” 3.[Neurology Lecture] [Examination of the Cerebellar Systems and Meninges] Clinical • • • Module 3 demonstration of Hypotonia Inspect for hypotonia – rag doll postures Checking for hypotonia Pendulous or hypotonic muscle stretch reflexes Overshooting and checking tests of arms • Wrist-slapping test • Arm-pulling test Eye movements. Meninges Anatomy 1.shaped double layer of the dura matter. Speech • Check smooth pursuit • Listen to patient’s speech Cerebellar System Pancerebellar syndrome – occurs usually from ethanol or drug intoxication Cerebellar Hemisphere syndrome – occurs from tumors or strokes Caudal Vermis syndrome – often occurs from tumors or strokes Rostral Vermis syndrome – often occurs from tumors or strokes • • • • II. lying in between the cerebral hemisphere Falx cerebelli  Small sickle shaped projection between the cerebellar hemispheres Tentorium cerebelli  Page 3 of 4 . thigh-slapping test Clinical tests for Leg Dystaxia • Heel-to-shin test • Heel-tapping test Clinical • • • tests for Dystaxia of Station and Gait Observe the patient’s stance Ask the patient to walk Tandem-walk [Transcribed by Trinidad. Virtusio] The brain and spinal cord are protected by connective tissue layers known as meninges: Dura mater – “THICK” Contains 2 layers:  Outer periosteal layer . Examination of the Cerebellum and Cerebellar Pathways Clinical tests for Arm Dystaxia • Ask the patient to extend the arms straight out front • Do the finger to nose test. • Rapid pronation-supination test.rich in blood vessels and nerves and adherent to the cranium  Inner meningeal layer – closely attached to underlying arachnoid 2. Pia mater – “THIN” Leptomeninges – Dura mater + Arachnoid mater  Pachymeninges – Arachnoid mater + Pia mater  Projections of the Dura Mater Falx cerebri Sickle.

6. Kernig’s Sign a. Cisterna magna  Cerebellomedullary Pontine cisterns Interpeduncular cisterns Chiasmatic cisterns Superior cisterns Lumbar cistern  From the conus medullaris to about the 2nd sacral vertebra. Brudzinki’s sign. 3. the pia and arachnoid are often widely separated. Use for diagnosis of meningitis b. Brudzinki’s reflex d. 1. 4. creating subarachnoid cisterns (spaces). Protective reaction to prevent pain and spasm of hamstring muscles due to stretch of inflamed nerve roots B. Brudzinki’s neck sign – forced flexion of neck elicits reflex flexion of hips  Flexion of both the hips and knees is a positive Brudzinki’s sign. Inability of the knee to be flexed to 90 degrees because of severe stiffness of hamstrings c. divides the cranial cavity in supratentorial and infratentorial compartments Diaphragma sella Circular fold which covers the sella turcica separating the pituitary gland from the hypothalamus Meninges and Spaces At the base of the brain and around the brainstem. [Transcribed by Trinidad. Symphyseal sign – pressure on pubic symphysis elicits reflex flexion of hip and knee and abduction of leg c. contains the filum terminale and nerve roots of cauda equina Examination of the Meninges A. 2. 5.[Neurology Lecture]  [Examination of the Cerebellar Systems and Meninges] Module 3 Crescentic fold that supports the occipital lobes and covers the cerebellum. Virtusio] Page 4 of 4 .4 maneuvers for the diagnosis of meningitis: a. Obscure cheek sign – pressure on the cheek elicits reflex rise and flexion of forearm b.