This document provides information about the cerebellum and cerebellar disorders. It discusses examination of ataxia, symptoms of cerebellar ataxia including limb ataxia, truncal ataxia, dysarthria, and visual symptoms. It also covers different types of cerebellar disorders like tumors, infections, metabolic disorders, and case scenarios of patients presenting with ataxia. Imaging findings are described that can help identify the cause of ataxia.

1. CEREBELLUM & ITS
CONNECTIONS (applied)
Dr. Md. Saiduzzaman (Munna)
MD Resident (Neurology, Phase B)
Department of Neurology
MMCH.

2. contents
 Examination
 Ataxia
 Cerebellar disorders
 Case scenarios

3. Examination
 Speech
 Nystagmus
 Finger nose test
 Dysdiadocokinesia
 Rebound phenomenon
 Muscle tone
 Knee jerk
 Stance and gait.

4. Ataxia
It is a group of disorders that affect co-ordination,
balance and speech and may result from a disorder
of the cerebellum and/or its connections, vestibular
or sensory disorders.

7. Symptoms in Patients with Ataxia
 Patients with cerebellar and sensory ataxia often
present with abnormalities of gait.
 The initial symptoms may be a sense of insecurity
while walking, especially when performing acts
that require a bit more skill, such as turning or
balancing on a narrow ledge. Even before gait
becomes abnormal, patients may note problems
with specialized skills such as bicycling or
climbing.
 Sensation is more like being on a boat.

8. Symptoms…
 Limb Ataxia
Clumsiness with activities such as writing, picking up objects,
and buttoning. Movements tend to become slower.
These symptoms are one-sided with lateralized lesions of the
cerebellum.
 Truncal Ataxia
Midline cerebellar lesions cause truncal ataxia. Patients may
experience head tremor and truncal instability leading to
oscillatory movements of the head and trunk while sitting or
standing (titubation). They may need back support while
sitting.

9. Symptoms…
 Dysarthria and Bulbar Symptoms
Ataxic diseases of cerebellar origin result in
slurred speech and abnormalities of pitch and
volume control (scanning speech).
 Dysphagia can result from incoordination of
swallowing muscles, and patients report
strangling and choking. Ineffectiveness of cough
may also be a symptom.

10. Symptoms…..
 Visual Symptoms
Patients may experience blurriness or a sense of
environmental movements as a result of cerebellar ocular
oscillations associated with cerebellar disease.
 Symptoms in Sensory Ataxia
Patients with a sensory basis for ataxia usually do not
experience dysarthria or visual symptoms. They may report
other symptoms of sensory pathway disease such as
paresthesias and numbness.

12. Midline…
 Lesion in cerebellar vermis.
 Causes “truncal ataxia” where the affected person is unable to
sit on their bed without steadying themselves.
 Often affects eye movements; there may be nystagmus, ocular
dysmetria and poor pursuit.

16. Differences between cerebellar and
sensory ataxia
Cerebellar ataxia Sensory ataxia
Sensory symptoms absent Present
Other cerebellar signs present Absent
Objective sensory loss absent Present
Broad based, staggering gait High stepping gait
Romberg’s sign absent Present
Vertigo may be present Absent
MRI is the investigation of choice NCS, biochemical parameters and
infection screen.

17. Neuro-imaging abnormalities pointing to
diagnosis of ataxia

18. Cerebellar disorders
 Mass in the cerebellum/ posterior fossa
Gliomas, meningiomas,Medulloblastoma
abscess
 Abnormal craniovertebral junction
Arnold-Chiari malformation,
 Infarcts, vascular malformations
Ischemic lesions, Haematoma, AVM

19. Cerebellar disorders……
 Signal density change in the cerebellum
MS, acute cerebellitis
 Cerebellar atrophy
- SCAs
- idiopathic cortical cerebellar atrophy
- drugs and toxin,
- Vitamin E deficiency
- Autoimmune ataxias
- Dandy-Walker syndrome

21. Cerebellar abscess

22. Arnold-Chiari malformation

23. Cerebellar infarction

24. Cerebellar haematoma

25. Multiple sclerosis

26. Acute cerebellitis

27. Dandy-Walker malformation

28. Case scenario 1

29. • A 51 years old diabetic, hypertensive male
with sudden onset difficulty walking and
tendency to fall to left side 03 days
• Intention tremor on left side

32. Case scenario 2

33. A 40 yrs old Diabetic male presented
to an ENT specialist with
complaints of
▪vertigo– for 15 days.
▪ discharge from left ear—
for3 months.
O/E : ▪ Pt is pyretic.
▪ scanning speech.
▪cerebellar ataxia

34. Infections affecting cerebellum
•Bacterial- cerebellar abscess,
tuberculoma
•Viral – acute- varicella.
chronic- HIV.
•Parasite- Toxoplasma, F. malaria,
•Prions- CJD, Kuru.

35. Case scenario 3

36. A 16 year old boy with
Progressive Gait ataxia for
02 years
Bilaterally symmetrical
intention tremor
Ankle reflex lost
Plantar bilateral extensor

39. Case scenario 4

40. • A 30 years old lady
• Recurrent ataxia and Recurrent visual
blurring for 03 episodes in the last 02
years

41. • INO
• Bilateral plantar
extensor

43. Case scenario 5

44. A 35 yrs old epileptic male pt.
on AED for 5 yrs with
complaint:
- Difficulty in walking – 5
months.
- Dysarthria for - 4 months.
O/E :
- Mildly anaemic,
- Scanning speech +
- truncal ataxia +
Investigation: PBF----
pancytopenia.

45. DRUGS & TOXIN AFFECTING
CEREBELLUM
 Alcohol
 Anticonvulsant drugs- Phenytoin
 Chemotherapy- 5-flurouracil , cytosine
arabinose
 Heavy metals-mercury , manganese , bismuth
 Chronic solvent abuse

46. Dandy Walker Malformation
Clinical presentation:
Infancy: symptoms and signs of hydrocephalus with prominent occiput.
Childhood: signs of cerebellar dysfunction with or without signs of
hydrocephalus.
Investigation: CT scan or MRI
Management: Cysto peritoneal shunt.

47. Arnold-Chiari malformation
 There is displacement of cerebellar tonsils and vermis through the
foramen magnum
 There is compression of spino-medullary junction
 Often associated with syringomyelia and hydrocephalus

48. CHIARI MALFORMATION
• Type I: No meningomyelocoele
• Type II: With meningomyeocoele (lumber)
• Type III: With occipitocervical meningomyelocoele
• Type IV: Only cerebellar hypoplasia
• Headache (raised ICP)
• Progressive ataxia
• Spastic quadriparesis
• Lower cranial nerve involvement
• Downbeat nystagmus
• Features of syringomyelia

49. Case scenario 6

50. A 10 year old boy presents with
vomiting, unsteady gait, slurred
speech, headache and diplopia

52. TUMOURS OF CEREBELLUM
Cerebellar tumors may be –
Primary-
Common in children
secondary-
Common in adults
Clinical features-
-ataxia
-brainstem dysfunction
-features of raised ICP.

53. Primary tumors of cerebellum
Medulloblastoma
Astrocytoma
Hemangioblastoma
Ependymoma
Oliogodendroglioma
Medulloblastoma, astrocytoma- common in
children
Hemangioblastoma- common in adults

54. Case scenario 7

55. • 50 years old male
patient
• Gait ataxia for 08
weeks
• Bilaterally
symmetrical
intention tremor
• Smoker for 20
years
• Clubbing

56. PARANEOPLASTIC CEREBELLAR
DEGENERATION
Common neoplasms associated-
SCLC, Ca Breast, Ca Ovary,
Hodgkin’s lymphoma
Immune associations-
Anti-Yo ab Ca breast
Anti Ri ab SCLC
Anti VGCC SCLC
Very few responds to therapy.

57. Metabolic disorders affecting
cerebellum
 Hypothyroidism
 Hypoxia
 Hypoglycemia
 Hyponatremia
 Deficiency disorders (vitamin B1, B12, E)
 Inborn errors of metabolism( lipid /amino acid
metabolism)