Neuroscience

Module 4.4
Neuroscience 4.3
Examination of the Cerebellum and Meninges
Examination of the Cerebellar Systems and the Meninges
Katherine
Diego
Dr.Dra.
Katherine
SanSan
Diego

O UTLINE
A.

B.
C.
D.
E.

Review of the Cerebellar System

a) Anatomy of the Cerebellum
b) Cerebellar Signs
c) The 4 Cerebellar Syndromes
Examination of the Cerebellum and Cerebellar Pathways
Summary of clinical tests for cerebellar dysfunction
Review of the Meninges
Examination of the Meninges

EXAMINATION OF THE CEREBELLAR SYSTEM

AND THE MENINGES

A. R EVIEW OF THE CEREBELLAR SYSTEM

Cerebellum

Located behind the dorsal aspect of pons and medulla

Separated from occipital lobe by tentorium

Fills most of the posterior fossa

Parts of the Cerebellum

Vermis - midline portion

- separates two lateral lobes or hemispheres

Folia - narrow, ridge-like folds

- oriented transversely on external surface
th

Adjacent to 4 ventricle
Functions
1. Coordinate skilled voluntary movements
2. Receive collateral input from sensory and special sensory
systems
Cerebellum processes sensory information
Does not influence motor neurons directly
Cerebellar Pathway
What is unique about the Cerebellar Pathway?
Double decussation. Therefore, lesions are ipsilateral.
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 (most common)

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

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.

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November 23

Disturbances of Ocular Movement

Inability to hold eccentric gaze

Slower smooth pursuit movements with catch-up

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 sideto-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

The 4 Cerebellar Syndromes

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
Caudal vermis syndrome

Axial disequilibrium (truncal ataxia) and staggering

gait

Little or no limb ataxia

Sometimes spontaneous nystagmus and rotated

postures of the head
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 (anti-Hu antibodies), breast
and ovarian carcinomas (anti-Yo antibodies), or
Hodgkin's lymphoma (Tr antibodies)

Toxic processes

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Neuroscience 4.3
B. EXAMINATION OF CEREBELLUM AND CEREBELLAR PATHWAYS

Tools? None. Just plain observation of the patient

CLINICAL TEST FOR ARM DYSTAXIA
1. Postural tremor and tremor of the arms during the finger-tonose test
Ask patient to extend the arms straight out in the front
(Inspect the arms for wavering and frank, rhythmic postural
tremor). Then, have the patient do the finger-to-nose test
(Inspect for dystaxia of the movement in progress or tremor as
finger approaches the tip of the nose).
If uncertain of the result, have the Pt alternately touch his nose,
your finger, and his nose several times.

A tremor of the outstretched hands is called a POSTURAL

TREMOR

A tremor that increases as the finger approaches the nose

or is reaching a target is called POSITIONAL INTENTION
TYPE OF KINETIC TREMOR
2. The rapid-alternating movements tests for dystaxia and
dysmetria (dysdiadochokinesia)
Rapid-pronation supination
The Pt holds out the hands and pronates and supinates them
as rapidly as possible.Test the hands separately and
together.The dystaxic hand overshoots one time,undershoots
the next,and is slower than normal.

Figure 1. Pronation and supination test for dystaxia and

dysmetria of the hands. Notice the even excursions of the normal
right hand and the uneven excursions of the ataxic left hand.
A subtler, superior method is the thigh-patting test. Test each
hand separately and together. First demonstrate the action to the
Pt by lightly slapping your own thigh,alternating first by slapping
the palm and then the back of the hand, as rapidly and
rhythmically as possible.Be sure to make an audible sound with
each pat. Instruct the Pt to make actions that sound exactly like
yours. You can detect the irregular rhythm of the alternating
movements much better by sound than by sight.

CLINICAL TEST FOR LEG DYSTAXIA

The heel-to-shin test for dystaxia supplements gait testing.
Have the Pt supine or sitting.Instruct the Pt to place one heel
precisely on the opposite knee.Have the Pt hold the heel to the
knee for a few seconds and observe for a positional
tremor.Then direct the Pt to run the heel in a straight line
precisely down the shin.Again emphasize the importance of
accuracy in the heel placement and movement.

Figure 3. Heel-to-shin test

For the heel-tapping test, ask the Pt to place one heel over the
other shin and to tap the shin with the heel as rapidly as
possible on one spot.The cerebellar Pt misses the spot
(dysmetria) and taps dysrhythmically (dysdiadochokinesia).
CLINICAL TEST FOR DYSTAXIA OF STATION AND GAIT
Symptomatic cerebellar lesions universally impair the gait
and stance (the standing posture)
Inspect the Pt for swaying when standing,which involves
volitional posture, and for dystaxia of gait, which involves
volitional foot placement.The unsteady stance and reeling gait of
the drunken person need no wordy description.
To compensate for unsteadiness of stance and gait,the
cerebellar Pt assumes a broad-based stance and a broad-based
gait, just as a toddler does before gaining coordination,or an
elderly Pt does after losing some.
To challenge the Pts coordination and overcome the
compensatory broad-base, the Ex asks the Pt to stand with the
feet together.Similarly,to expose gait incoordination, use a test
known to every policeman: ask the Pt to step along a straight
line,placing the heel of one foot directly in front of the toe of the
other, the so-called tandem walking. It is the most sensitive
clinical test for gait ataxia (Manto,2001;Stolze et al.,2002).

Figure 4. Tandem walking

To judge broad-based gaits, the medial margin of the heels
must fall exactly on the line.
CLINICAL DEMONSTRATION OF HYPOTONIA
Muscle tone is operationally defined as the muscular
resistance the Ex feels when moving the Pts resting extremity

Figure 2. Thigh-patting test for dystaxia and dysmetria. The

cerebellar patient slaps irregularly and turns the hand too much
or too little in alternately slapping the front and the back of his
hand on his thigh.

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Inspection for hypotonia

At rest,the hypotonic Pt assumes floppy postures and joint
positions uncomfortable for a normal subjectrag-doll or
dumped-in-a-heap postures. In a normal person,muscle tone
helps to limit joint excursions.

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Neuroscience 4.3
When walking,the hypotonic Pt presents a floppy,sagging,loosejointed appearance. The arms fail to swing properly, the knees
may bend backward slightly (genu recurvatum), and the head
and trunk boba rag-doll gait, as seen in drunkenness.

Cerebellar lesions result in nystagmus, dysmetria of saccades,

jerky rather than smooth pursuit,slowness in initiating eye
movements,and skew deviation (Bogousslavsky and
Meienberg,1987;Glaser,1999;Pierrot-Deseilligny et al.,1990)

Pendulous or hypotonic muscle stretch reflexes (MSRs)

The Pt sits with the legs swinging freely over a table edge.After
the quadriceps MSR is elicited, the leg normally stops swinging
after one or two excursions.The cerebellar Pts leg swings to and
fro several times,like a pendulum,without the normal checking of
the excursions by muscle tone.

To test for saccadic dysmetria,have the Pt look straight ahead

and place your index fingers in the temporal fields.Ask the Pt to
look first at one finger and then the other and then direct the Pt
to look rapidly from one to the other several times.

How to detect hypotonia in the cerebellar Pt?

Passively move the Pts extremities, inspect for rag-doll postures
and a rag-doll gait,and look for pendulous MSRs.
OVERSHOOTING AND CHECKING TESTS OF ARMS
The cerebellar Pt has difficulty in maintaining a posture or
position against a sudden,unexpected displacement.Have the Pt
stand with eyes closed and arms outstretched.
Tell the Pt,I am going to tap your arms.Hold them still.Dont let
me budge them. The Ex strikes the back of the Pts wrist a sharp
blow,strong enough to displace the arm.The normal subjects
arm returns quickly to its initial position.The cerebellar Pts arm
oscillates back and forth:it overshoots several times

Figure 5. Wrist-tapping test for abnormal overshooting

oscillation after sudden displacement of a part that is
maintaining a volitional posture. The thin arrow shows the
direction of the examiners blow, which displaces the part.
The arm-pulling test also demonstrates overshooting.
The Ex pulls hard against the Pts flexed arm.When the Ex
suddenly releases the Pts arm,the cerebellar Pt fails to check
the arms flight.

Figure 7. Cerebellar examination for eye movement (saccadic

dysmetria)
Dysarthria in cerebellar Pts consists of slowness, slurring of
words, and scanning speech. In scanning speech,the Pts
voice varies from a low volume to a high volume as if scanning
from peak to peak.The Pt fails to meter and modulate the
strength of the muscular contractions that produce the speech
sounds, thus accentuating the wrong syllables or words, or the
Pt may speak too loudly and garrulously.

HEMISPHERIC

ROSTRAL

CAUDAL

PANCEREB ELLAR

Table 1. Summary of Cerebellar syndromes

Figure 6. The arm-pulling test for overshooting. It tests how well
the cerebellum functions to check movement and to maintain a
given posture after a sudden release of tension on a muscle
that is voluntarily contracting.
Precaution:Notice in Fig.6 how the Ex places an arm to protect
the Pts face in case the Pts arm fails to check and overshoots
CLINICAL TEST FOR EYE MOVEMENTS, SPEECH

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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

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Neuroscience 4.3

C.

SUMMARY OF CLINICAL TESTS FOR CEREBELLAR

DYSFUNCTION

E.

EXAMINATION OF THE MENINGES

A.

Kernigs sign
a. Use for diagnosis of meningitis
b. Inability of to be flexed to 90 degrees because of
severe stiffness of harmstrings
c. Protective reaction to prevent pain and spasm of
hamstring muscles due to the 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

FREEDOM SPACE
D. REVIEW OF THE MENINGES
Meninges

The brain and spinal cord are protected by connective

tissue layers known as meninges:
1. Dura mater

Contains 2 layers: outer periosteal layer and inner

meningeal layer

Also has projections: falx cerebri, falx cerbelli, tentorium

cerebella and diaphragma sellae
2. Arachnoid mater
3. Pia mater

Leptomeninges collective term for Dura mater and

Arachnoid mater

Pachymeninges collective term for Arachnoid mater and

Pia mater
Spaces (Cisterns)
1. Cisterna magna cerebellomedullary
2. Pontine cisterns
3. Interpeduncular cisterns
4. Chiasmatic cisterns
5. Superior cisterns

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O BJECTIVES

To be familiar with the anatomy of the cerebellum

To get acquainted with the clinically significant cerebellar
pathways
To study the functions of the cerebellum
To discuss the manifestations of cerebellar dysfunction
To be familiar with conditions/diseases affecting the
cerebellum
To learn how to assess the integrity of the cerebellar
pathways
To know the basic neuroanatomy of the meninges
To know and understand the function and role of the
meninges
To learn the techniques in the examination of the meninges

R EFERENCES

th

Demyers The Neurologic Examination, 6 edition

Netters Atlas of Human Anatomy
Neuroscience Powerpoint slides (San Diego, 2015)

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