You are on page 1of 4

Module No.

Neurosciences Lecture

Examination of the Cerebellar System and the Meninges

October 3, 2016

Katherine Ann San Diego, MD, FPNA

1.

2.

1.
2.
3.
4.

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
1.
2.

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

Page 1 of 4

[Neurology Lecture]
2.
3.

4.

[Examination of the Cerebellar Systems and Meninges]

Module 3

Slower smooth pursuit movements with catchup saccades


Nystagmus usually gaze-evoked, upbeat,
rebound with abnormal kinetic nystagmus if with
midline cerebellar lesions; periodic alternating
nystagmus with lesions of the uvula, nodulus;
downbeat nystagmus with posterior midline
lesions
Other cerebellar eye signs ocular flutter,
opsoclonus, ocular bobbing, square wave jerks at
rest, skew deviation, failure to suppress the
vestibulo-ocular reflex

INTENTION or ATAXIC TREMOR

Hypermetria overshooting the target

When the finger approaches the target, there is a


side-to-side movement of the finger before
reaching the target.

Titubation - 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, the patients 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.

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.

Pancerebellar Syndrome
> Bilateral signs of cerebellar dysfunction
affecting
the
trunk,
limbs,
and
cranial
musculature
>Some etiologies:

infectious and parainfectious processes

hypoglycemia

hyperthermia

paraneoplastic cerebellar degeneration


associated with small cell lung cancer (antiHu antibodies), breast and ovarian
carcinomas (anti-Yo antibodies), or Hodgkin's
lymphoma Tr antibodies)

Toxic processes

The 4 Cerebellar Syndromes


1.

2.

Hemispheric Syndrome
> Incoordination of ipsilateral appendicular
movements
> Usual etiologies: Infarcts, neoplasms,
abscesses

Rostral Vermis Syndrome


> A wide-based stance and titubating gait
> Ataxia of gait, 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, nystagmus,
and dysarthria

[Transcribed by Trinidad, Virtusio]

Page 2 of 4

[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, Speech

Check smooth pursuit

Listen to patients 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. Meninges
Anatomy
1.

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, 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 patients 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 - rich in blood vessels and


nerves and adherent to the cranium

Inner meningeal layer closely attached to


underlying arachnoid
2. Arachnoid mater DELICATE
3.

Pia mater THIN


Leptomeninges

Dura
mater
+
Arachnoid mater

Pachymeninges Arachnoid mater + Pia


mater

Projections of the Dura Mater


Falx cerebri
Sickle- shaped double layer of the dura matter,
lying in between the cerebral hemisphere
Falx cerebelli

Small sickle shaped projection between the


cerebellar hemispheres
Tentorium cerebelli

Page 3 of 4

[Neurology Lecture]

[Examination of the Cerebellar Systems and Meninges]

Module 3

Crescentic fold that supports the occipital lobes


and covers the cerebellum, 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,
the pia and arachnoid are often widely separated,
creating subarachnoid cisterns (spaces).
1.
2.
3.
4.
5.
6.

Cisterna magna

Cerebellomedullary
Pontine cisterns
Interpeduncular cisterns
Chiasmatic cisterns
Superior cisterns
Lumbar cistern

From the conus medullaris to about the 2nd


sacral vertebra; contains the filum terminale
and nerve roots of cauda equina

Examination of the Meninges


A.

Kernigs Sign
a. Use for diagnosis of meningitis
b. Inability of the knee to be flexed to 90
degrees because of severe stiffness of
hamstrings
c. Protective reaction to prevent pain and
spasm of hamstring muscles due to stretch
of inflamed nerve roots

B.

Brudzinkis sign- 4 maneuvers for the diagnosis


of meningitis:
a. Obscure cheek sign pressure on the
cheek elicits reflex rise and flexion of
forearm
b. Symphyseal sign pressure on pubic
symphysis elicits reflex flexion of hip and
knee and abduction of leg
c. Brudzinkis reflex
d. Brudzinkis neck sign forced flexion of
neck elicits reflex flexion of hips

Flexion of both the hips and knees is a


positive Brudzinkis sign.

[Transcribed by Trinidad, Virtusio]

Page 4 of 4