Final Project for "Understanding the Brain - The Neurobiology of Daily Life"

1. Cerebellum damage
caused by Arteriovenous malformation (AVM)
- an abnormal connection between arteries and veins,
bypassing the capillary system
A Case Study

2. Final Project Components
Here are the three components required for the peer
review:
The project is mainly about a real case of AVM hemorrhage
which affect the brain stem function temporarily and the
cerebellum permanently. The former was life threatening, the
latter permanently impair movements (of thought, speech and
thought)
The main functions of the cerebellum is motor coordination and
motor learning (thought/cognition is also implicated)
 Anatomy and functions of the cerebellum are covered in lecture
0 through 8 in Week 8

3. Legend
• The narrative of the case is in white
• Annotation for terms used in the narrative is
in yellow. Please skip the yellow pages if you
are familiar with the term.

4. Main Idea
The cerebellum contains more neurons than the
rest of the brain. But what does it do?

5. Modulation/regulation of movement

6. Background
• Last year, during a school reunion cruise trip, I met the wife of
one of my school mate, who suffered a life threatening stroke
10 years ago.
• I was taking the Coursera course, “Medical Neuroscience”
offered by Duke University at the time.
• The wife, Mrs X, has ataxic gait, a cardinal sign of a cerebellar
damage (week 8 lecture 1), apparently caused by the stroke.
• After the trip, the husband sent me her medical record.
• Since I am not a medical doctor, it took me some effort to
annotate and understand what happened.
• With knowledge gained from the Medi-Neuro course and this
course, I was able to have a overall understanding of the case
and the resulting disabilities Mrs X suffers.

7. Cerebellum Disorders
• Stanford Cerebellum Examination
Mrs. X exhibits symptoms of lesions to cerebellum
• Ataxic gait – characterized by a broad stance, with
wide staggering quality
• Decomposition of multi-joint movements
• Dysdiadochokinesia - Inability to perform rapid
alternate movements (confirmed by her husband)
• All these can be seen in the following link and
reviewing Week 8 lectures will help understanding
these disorders

8. Key points for the case study
• Stroke
– AVM hemorrhage and its consequences
– Brainstem damages
• Cerebellum as the modulator of movement
– Motor cortex
– Brain stem

9. How It Happened
• One evening 10 years ago, Mrs. X suffered
sudden onset of severe neck pain and
headache
• She soon fainted and lapsed into coma
• Her husband called the ambulance to rush her
to hospital

10. At the hospital
1. Intubated
• the insertion of a tube into an external or internal
orifice of the body for the purpose of adding or
removing fluids.
2. CT brain scan indicates
• cerebellar hemorrahage, and
• IVH - intraventricular hemorrhage

11. Diagnosis
1. GCS 4
• Glasgow Coma Scale
oSevere, GCS < 8-9
oModerate, GCS 9–12]
oMinor, GCS ≥ 13
2. Pupils equal but sluggish to light

12. Operation Procedures
1 Urgent craniotomy and ICP done
– a large AVM was found occupying the left cerebellum
2. A craniectomy procedure includes the removal of a bone
flap
– Craniectomy – the flap is not returned right after the procedure
– Craniotomy – the flap is returned after the procedure
3. Partial removal of a clot
– Partial because of profuse bleeding
4. posterior fossa decompression done
– The posterior cranial fossa is part of the intracranial cavity, located
between the foramen magnum and tentorium cerebelli. It contains
the brainstem and cerebellum

13. Posterior Cranial Fossa

14. Posterior Cranial Fossa
arteries and veins

15. Atriovenous Malformation

16. Atriovenous Malformation
An AVM is a tangled bundle of blood vessels where arteries
connect directly to veins with no capillary bed between.
AVM
Normal

17. Procedure Record (1)
1. 6 cm ventricular catheter inserted – blood-stained ventricular CSF
under high pressure
2. Patient was then turned to prone position – face down
3. Supine first with right frontal burr hole made
• Supine is lying down with face up
4. Midline suboccipital incision made to expose Post Cranial Fossa and C1
(first cervical vertebrae)
Sub-occipital

18. Procedure Record (2)
5. The underlying brain was quite tense
6. Suboccipital craniotomy and C1 laminectomy performed
• craniectomy procedure also includes the removal of a bone flap
• laminectomy is a surgical procedure that removes a portion of the vertebral bone called the lamina.
7. USG confirmed the hematoma was located at the left
cerebellum, with a diffuse AVM lying medial to the clot.
• USG - ultrasound-based diagnostic imaging
• AVM – Atrovenous Malformation
8. The hematoma was actually inside the AVM nidus, making removal of clot
hazardous and bleeding from AVM arterioles was difficult
9. Finally hemostasis was secured
• The cerebellum tension was fair
• ICP measured was about 10-12 mmHg

19. Procedure Record (3)
10. No further attempt of clot removal was tried
11. Duraplasty done with fascia graft
• A reconstructive operation on the open dura mater that involves a
primary closure or secondary closure with another soft tissue material
(muscle, fascia, allograft dura).
12. Dura was covered with gelfoam
13. Wound closed in layers with vicryl and nylon
14. 1 wound drain Inserted
15. Keep Systolic Blood Pressure < 110 mm Hg and control
Intracranial Pressure
16. Procedure completed
17. Haematunia (blood in urine) subsided after 18 days

20. Procedure Record (4)
• At 23rd day, pre-operative embolization of the Left PICA done
• Posterior inferior cerbellar artery (PICA) is the largest branch of the vertebral artery,
one of three main arterial blood supplies for the cerebellum
• Embolization – deliberately blocking a blood vessel
• At 30th day, pre-operative embolization of distal right superior cerebellar artery
• At 66th day, operation to remove AVM
• Condition improved to GCS 15 points (see slide 11)
• 2 times of pre-op embolization done
• Admit for removal of AVM
• Total removal done
• Confirmed by intra-op angiogram

21. Summary – Principal Diagnosis
Acute bilateral cerebellar haemorrhage
• underlying absormality, arteriovenous malformation
• cerebellar AVM bleeding
Hydrocephalus
• "water on the brain," is a medical condition in which
there is an abnormal accumulation of cerebrospinal
fluid (CSF) in the ventricles, or cavities, of the brain
Respiratory failure and loss of consciousness
• Temporary damages to the brain stem

22. Pathology
• The resulting tangle of blood vessels, often called
a nidus (Latin for "nest"), has no capillaries. It can be
extremely fragile and prone to bleeding

23. The Cause
• AVM in the cerebellum
• Hemorrhage caused damage to cerebellum and
brainstem
• Brainstem damage caused the cessation of normal
breathing and induced coma – loss of consciousness
• CO2 detection in the pons ; Breathing pattern generation in the
medulla (lecture 9.6)
• Lasting cerebellum disorders

24. Cerebellar Dysfunction
Mrs. X shows many effects of cerebellar damages (see Stanford
Video on slide 6)
1. Ataxic gait - walking
2. Decomposition of movements
– For example, touching one’s finger to one’s nose
requires the coordinated activity of shoulder, elbow,
and wrist joints. Cerebellar patients must first
perform the shoulder movement, then the elbow
movement, and finally the wrist movement in
sequence, rather than as one, uniform motion
3. Dysmetria
– Instability of a limb as it approaches a target, typically
overshooting or undershooting

25. Cerebellar Dysfunction (cont.)
4. Intention tremor
– When making a movement to a target, cerebellar
patients often produce an involuntary tremor that
increases as they approach closer to the target
5. Dysdiadochokinesia
– Impairment of rapid, alternate, repetitive movements
(see Stanford Video on slide 6)
6. Deficits in motor learning
– cerebellar damage causes deficits in motor learning
in both human patients

26. Non-motor effects
• “There are ways in which the processing that the
cerebellum does for motor output could also be
applied to non-motor output “
– thought and emotion
• In social situation, Mrs. X’s social interaction is not as
agile
– Slurred speech
– Following multi-facet arguments or narratives
• Similar to multi-joint movement, thought process
involves chunking that requires a normally
functioning cerebellum

27. Cerebellar Plasticity and Rehabilitation
• According to some recent research, after an injuries to the
cerebellum, there is a critical period of up to a few months
when the cerebellum becomes plastic and relearning is easier.
Many movement disorders can be reduced during this period.
• It appears that Mrs X did not receive adequate therapy and
her disorders was not significantly reduced.
• There are evidences that cerebellum modulate not just
movements, it also modulates thoughts and cognition. It is
apparent that Mrs. X suffer, to some degree, her mental
agility.

28. Observation
• The cerebellum is critical to all movements in our daily life;
Without a fully functioning cerebellum, our motions, motor-
learning and even thought agility will be all compromised.
• The brain is the most complex organ in our body. It is both very
fragile and plastic. A simple bleeding in the brain can cause
massive, even fatal damages. Our brain can also recover given
proper treatment and rehabilitation.

29. Purkinje cell sketch by Santiago Ramón j Cajal.
“I am very moved by the aesthetics of
neurons that look so gorgeous like
this.”
- Prof. Peggy Mason, U. of Chicago
Purkinje cells of the cerebellum

30. Additional images

31. Cerelbellum

32. Cerelbellum

33. Brain Stem

34. Cerebellum and Brain Stem

35. END OF PRESENTATION
THANK YOU!