46 Cerebellar syndrome
Salient features
History
• History of falls, wide-based gait, clumsiness and difficulty with fine coordinated movements
• Waxing and waning of symptoms (multiple sclerosis)
• Stroke (brainstem vascular lesion)
• Drug toxicity: phenytoin, alcohol abuse, lead poisoning and solvent abuse
• History of intracranial tumours (posterior fossa including cerebellopontine angle tumour)
• History of hypothyroidism (a reversible cause)
• Lung cancer (paraneoplastic manifestation)
• Family history (Friedreich’s ataxia and other hereditary ataxias)
• Birth defects (congenital malformations at the level of the foramen magnum).
Examination
• Ask the patient a few questions to assess speech
• Ask the patient to keep his arms outstretched; then give them a small push downward and look for rebound phenomenon
• Examine for rapid alternating movements with the hand
• Do the finger–nose test: look for past-pointing and intention tremor
• Examine the gait, in particular tandem walking. If ataxia is not marked, the patient’s gait may be tested with eyes closed; patients will often progresses to the side of the lesion.
• Tell the examiner that you would like to examine the fundus for optic atrophy as demyelination is the commonest cause of cerebellar signs.
Diagnosis
This patient has a cerebellar syndrome with optic atrophy (lesion) caused by multiple sclerosis (aetiology) and he is markedly ataxic (functional status).
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