Cerebellar Examination

Question 1

What are the 6 important things to cover in a cerebellar examination?

Answer 1

Remember DANISH!

• Dysdiadochokinesia
• Ataxia (gait and posture)
• Nystagmus
• Intention tremor
• Slurred, staccato speech
• Hypotonia/heel-shin test

Question 2

What may an abnormal posture indicate in a cerebellar exam?

Answer 2

Truncal ataxia

Question 3

What does a slurred staccato speech indicate?

Answer 3

Cerebellar disease

Question 4

What is ataxia?

Answer 4

A neurological sign consisting of involuntary movements with an irregular oscillatory quality which interferes with normal smooth movement

Question 5

What is truncal ataxia and what causes it?

Answer 5

• Affects proximal musculature that is involved in gait stability
• Caused by damage to cerebellar vermis and associated pathways

Question 6

What is appendicular ataxia and what causes it?

Answer 6

• Affects musculature of the arms and legs involved in the control of limb movement
• Caused by damage to cerebellar hemispheres

Question 7

What does a broad-based ataxic gait indicate?

Answer 7

Midline cerebellar pathology (MS lesion or secondary to alcohol excess)

Question 8

What does a staggering, slow and unsteady gait indicate?

Answer 8

Cerebellar pathology

Question 9

Which side will the patient veer to in unilateral cerebellar disease?

Answer 9

The side of the lesion

Question 10

How will those with cerebellar disease find turning?

Answer 10

Difficult

Question 11

What does a tandem (‘heel-to-toe’) gait show?

Answer 11

• Makes it easier to recognise subtle ataxia

- Good at identifying dysfunction of the cerebellar vermis (alcohol-induced).

Question 12

What is the pathophysiology of cerebellar disease?

Answer 12

Progressive loss of Purkinje cells

Question 13

Name 4 causes of cerebellar degeneration

Answer 13

• Chronic alcohol abuse
• Nutritional deficiency
• Paraneoplastic disorders
• Neurological diseases e.g. MS

Question 14

Name 4 clinical features of cerebellar degeneration

Answer 14

• Broad-based ataxic gait
• Trunca ataxia
• Dysmetria (incoordination)
• Nsytagmus (abnormal eye movements)

Question 15

What is Romberg’s test used for?

Answer 15

• To assess for loss of proprioceptive or vestibular function
• Screen for non-cerebellar causes of balance issues

Question 16

What are the premises that Romberg’s test is based off?

Answer 16

A patient requires at least 2 out of 3 to maintain balance while standing:

• Proprioception
• Vestibular function
• Vision

Question 17

What is proprioception?

Answer 17

The awareness of one’s body position in space

Question 18

What is vestibular function?

Answer 18

The ability to know one’s head position in space

Question 19

What is a positive Romberg’s sign?

Answer 19

When a patient falls with their eyes closed

Question 20

What may swaying during a Romberg’s test indicate?

Answer 20

Truncal ataxia

Question 21

What may cause a positive Romberg’s test?

Answer 21

• Sensory ataxia
• Proprioceptive dysfunction e.g. Ehlers-Danlos, B12 def., Parkinsons
• Vestibular dysfunction e.g. vestibular neuronitis

Question 22

How can ataxic dysarthria present?

Answer 22

• Scanning speech

- Slurred speech

Question 23

What is scanning speech?

Answer 23

Words are broken down into separate syllables, often separated by pauses and spoken with varying volume

Question 24

How do you assess for nystagmus?

Answer 24

Do the ‘H-test’

Question 25

How is the direction of nystagmus relevant?

Answer 25

- Has a fast phase and a slow phase - Direction is defined from fast phase - In a lesion, the direction is towards the lesion side

Question 26

What is dysmetric saccades?

Answer 26

- Do the 'finger movement' test | - The overshoot and subsequent correction in cerebellar pathologies dysmetric saccades

Question 27

What is impaired smooth pursuit?

Answer 27

- Do the 'finger movement' test | - Movement may be jerky

Question 28

What may be found in the finger-to-nose test?

Answer 28

- Dysmetria | - Intention tremor

Question 29

How does dysmetria present in cerebellar disease?

Answer 29

- Lack of coordination of movement | - Missing the target by over/undershooting

Question 30

How does an intention tremor present in cerebellar disease?

Answer 30

- A broad, coarse low-frequency tremor that develops as a limb reaches the end point of a deliberate movement

Question 31

What does dysmetria and intention tremor indicate during the finger-to-nose test?

Answer 31

Ipsilateral cerebellar pathology

Question 32

What is rebound phenomenon?

Answer 32

A reflex that occurs when a patient attempts to move a limb against resistance that has been suddenly removed

Question 33

What does an exaggerated version of rebound phenomenon indicate?

Answer 33

Suggestive of spasticity

Question 34

What does complete absence of the rebound phenomenon indicate?

Answer 34

Suggestive of cerebellar disease

Question 35

What may cause hypotonia in a cerebellar exam?

Answer 35

An ipsilateral cerebellar lesion

Question 36

What is dysdiadochokinesia?

Answer 36

The inability to perform rapid, alternating movements, which is a feature of ipsilateral cerebellar pathology

Question 37

What does the presence of dysdiadochkinesia indicate?

Answer 37

Ipsilateral cerebellar pathology

Question 38

How are reflexes described in cerebellar disease?

Answer 38

Pendular - less brisk and slower in their rise and fall

Question 39

What should be completed after a cerebellar exam?

Answer 39

- Full neurological examination - Neuroimaging - Formal hearing assessment