Cerebellar - General Script

 

Thank you for asking me for Harry, who presented with difficulty walking / poor coordination.

 

On inspection, there is a broad-based ataxic gait with staggering to the left/right. The patient could/could not walk heel to toe, suggesting the presence/absence of a cerebellar pathology. The patient could/could not walk on their toes (S1), and the heels (foot drop, L4 or L5). Romberg’s sign was negative/positive. (eyes closed - posterior columns, eyes open - cerebellar).

 

On inspection of the legs, there were/were not scars. There was/was not pes cavus. There was/was not evidence of muscle wasting, and fasciculations. There was/was not muscle tenderness.

 

Tone was reduced/increased/normal in the knee and ankle, and there was/was not clonus.

 

Power was normal/reduced symmetrical/asymmetrically with __/5 power on the left leg, and __/5 power on the right. Note, could potentially skip this.

 

Reflexes were normal in the knee and ankle. Plantar response was upgoing/downgoing/inadequately assessed due to withdrawal.

 

Coordination was impaired on heel-shin, toe-finger and foot tapping assessment. (Ask them to lift the leg in an arc to make it more difficult if deficit is subtle).

 

On examination of the face, there was horizontal nystagmus with the fast component towards left/right (fast towards the side of the lesion). There was/was not broken pursuit, and normal/hypometric/hypermetric saccades (hypo- is undershoot, hyper- is overshoot).

The speech was slurred and a jerky, explosive, staccato character (ask to say Hippopotamus, Constitution, West Register Street).

 

In the arms, there was/was not arm drift.

 

Tone was normal/reduced (hypotonia sometimes in acute cerebellar disease).

 

There was/was not impaired finger-nose testing with dysmetria and an intention tremor on the right/left side. There was/was not dysdiadochokinesis.

 

There was/was not rebound phenomenon in the arms (ask the patient to lift his or her arms quickly from the sides and then stop. Hypotonia causes the patient to be unable to stop the arms.)

 

On sitting up over the edge of the bed, there was/was not evidence of truncal ataxia (by asking the patient to fold the arms, sit up and then, while sitting, to put the legs over the side of the bed; then test for pendular knee jerks.)

 

Pendular knee jerks were present/absent.

 

I would like to complete examination by:

• If unilateral - assessing cranial nerves for evidence of a cerebellopontine syndrome (5, 7 and 8) and lateral medullary syndrome

  • Lateral medullary syndrome:

    • Nystagmus to side of the lesion

    • Ipsilateral fifth nerve (pain and temperature), ninth and tenth nerve lesions

    • Ipsilateral cerebellar signs

    • Ipsilateral sensory loss in face, and contralateral pain and temperature loss over the trunk and limbs

    • Horner’s syndrome

• If midline (gait, truncal) - look for signs of cancer

• If bilateral = look for signs of MS, or FA (pes cavus)

• Fundoscopy for optic neuritis

 

In summary, my findings are consistent with a right/left/bilateral/midline cerebellar syndrome.

 

Differentials include:

• Unilateral:

  • A space-occupying lesion

  • Previous infarcts

  • Multiple sclerosis

  • Trauma

  • Paraneoplastic

• Bilateral

  • Toxic and drugs

    • Alcohol

    • Drugs (e.g. phenytoin)

  • MS

  • Congenital

    • Friedreich’s ataxia + other congenital or degenerative conditions

  • Space-occupying (large)

  • Trauma

  • Paraneoplastic

  • Hypothyroid

  • MSA-cerebellar

• Midline

  • Tumour

  • Paraneoplastic

​

I would like to proceed from here by:

• Assessing for aetiology with an MRI

 

What is the difference between spasticity and rigidity?

In spasticity, the resistance during flexion and extension is not equal. Hence it produces characteristic postures. It is also velocity dependent— the quicker you move the patient’s limbs, the stronger the resistance will be. Meanwhile, in rigidity, the resistance is the same in any direction you move the patient’s limb, and resistance is not velocity dependent. Cogwheel deformity is rigidity plus tremor