Noon conference banta

1. Noon Conference
Wade Banta
05/01/2019

2. © 2016 Virginia Mason Medical Center 2
Objectives
Cerebellar infarct
• Cerebellar anatomy and circuitry
• Discuss clinical presentation
• Physical exam
• Review illness script
• Discuss treatment

3. © 2016 Virginia Mason Medical Center
Cerebellum vascular anatomy
3Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 36095

4. © 2016 Virginia Mason Medical Center
Cerebellum vascular anatomy
4UW Mind, Brain, and Behavior cerebellum syllabus

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Cerebellum functional anatomy
5Buckner, et. al.

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Clinical presentation
• Varies by distribution of infarct
• Limb ataxia more likely present when superior/lateral
areas are infarcted
• Truncal instability and gait imbalance more likely with
medial/vermial distribution
• Vestibular dysfunction (N/V, vertigo, and nystagmus)
are more prominent in medial/vermial lesions
• Accompanying dorsolateral medullary
infarct (PICA)
• Loss of ALS mod. in contralateral trunk and limbs,
and ipsilateral face
• Uvular deviation, dysarthria, dysphagia
• Respiratory dysfunction
• Ipsilateral Horners syndrome
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7. © 2016 Virginia Mason Medical Center
Physical exam
• HINTS
• Head impulse test: corrective saccade in peripheral
lesion, VOR maintained in central
• Nystagmus: unidirectional in peripheral, bidirectional
in central
• Test of skew: abnormal vertical correction is 98%
specific for central
• Dix-Hallpike maneuver:
• Immediate, non-fatigueable, bidirectional nystagmus
in central lesions.
• Latent, fatigueable, unidirectional nystagmus in
peripheral.
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Diagnostic tests
• Video nystagmography:
• Increased sensitivity
• Lasting record of results
• Imaging
• CT can identify hemorrhagic strokes (rare)
• MRI is the gold standard for ischemic strokes
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Changing clinical practice
• Double mortality risk of cerebral stroke
• 23% vs. 12.5%
• Time is tissue
• BE-FAST
• Balance
• Eyes
• Face
• Arm
• Speech
• Time
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Illness Scripts
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Cerebellar stroke Vestibular neuritis
Pathophysiology Hemorrhage/infarction
Viral/postviral inflammation of the vestibular
portion of the vestibulocochlear nerve
Epidemiology
10-16/100k
2% of all strokes, >80% ischemic
>70% over age 65, M>W
5.2% AI/AN, 4.1% non-Hispanic black
Smoking, HTN, DM, inactivity
3.5/100k
15% over age 55, peak 30-50
No known risk factors
Time course Acute Acute
Clinical
presentation
Vertigo, N/V, gait impairment, diplopia/oscillopsia
headache
Vertigo, N/V, gait impairment
Diagnostics
Labs: No useful lab testing
HINTS: Bidirectional nystagmus, intact VOR,
test of skew positive
Imaging: CT can identify hemorrhage (rare),
MRI is gold standard for infarct
Labs: No useful lab tests
HINTS: Unidirectional nystagmus, corrective
saccade, test of skew negative
Imaging: useful only for ruling out infarction
when there is any ambiguity
Therapeutics tPA
Acute: limit anti-emetics to first few days,
vestibular rehabilitation training. Limited
evidence for corticosteroids.

11. © 2016 Virginia Mason Medical Center
Acknowledgements
Gaillard, radiopaedia.org rID 36095
UWSOM curriculum, Mind, Brain, and Behavior cerebellum syllabus
Buckner et. al., “The organization of the human cerebellum estimated by intrinsic
functional connectivity”
Cargoud et. al., “Long-Lasting Visuo-Vestibular Mismatch in Freely-Behaving Mice
Reduces the Vestibulo-Ocular Reflex and Leads to Neural Changes in the Direct Vestibular
Pathway”
Ioannides et. al., “Cerebellar Infarct-StatPearls”
Seong-Hae, et. al., “Vestibular Neuritis”
Gleason, Kesser, “Dizziness and vertigo across the lifespan”
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