Cerebellar activation in lobules IV, V, and VI has been reported in conditions associated with happiness or sadness (Lane et al.,1997). Morphologic differences in the cerebellum of patients with depression have been suspected. In particular, unipolar depression and bipo- lar disorder have been associated with smaller size of the cerebellum (Soares & Mann,1997). Moreover, decreased size of the vermis has been reported in major depression (Shah et al.,1992). A reduction of the size of vermal lobules VIII to X has been found in patients with multiple episodes of depression (DelBello et al., 1999). Further studies are required to confirm these findings and provide a definite link between cerebel- lar operations and control of mood.
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Chapter
3 Symptoms of cerebellar disorders
Cerebellar function is usually affected through sev- eral mechanisms, which often combine (Gilman et al., 1981): reduced bloodflow, edema, mechanical com- pression, invasion of cerebellar parenchyma, inflam- matory response, immune process, cytotoxic effect, and neurodegeneration. Brainstem and meninges are commonly affected also.
Five general principles apply (Manto,2002):
1. Lateral focal cerebellar lesions induce ipsilateral signs, although expanding lesions may produce a false localization of clinical signs.
2. Diffuse cerebellar disorders, such as degenerative ataxias, are usually responsible for relatively symmetric deficits.
3. Cerebellar deficits due to non-progressive disease tend to undergo attenuation with time.
4. Lesions involving the afferent or efferent cerebellar pathways outside the cerebellum may generate cerebellar-like deficits.
5. Cerebellar symptoms are influenced more by the location and rate of progression of the disease than by the pathological characteristics (Gilman et al.,1981; Lechtenberg,1993). Slowly progressive lesions may be remarkably asymptomatic for a long time, while rapidly expanding lesions are associated with severe symptoms in most cases (Dow & Moruzzi,1958; Gilman et al.,1981).
Table 3.1 lists the symptoms commonly encoun- tered in patients exhibiting a cerebellar ataxia, with lesions affecting mainly the cerebellum itself. Cogni- tive and emotional deficits are discussed in the sec- tionClassification of clinical signs, under “Cognitive abnormalities” and emotional disorders. Gait diffi- culties, headache, nausea/vomiting, and dizziness are the most common symptoms. In patients presenting lesions restricted to the cerebellum, the main symp- toms are gait difficulties, headache, dizziness, limb clumsiness, speech difficulties, blurred vision, feeble- ness, and fatigability.
Table 3.1 Symptoms associated with cerebellar disordersa Symptom
Gait difficulties Headache Nausea/vomiting Dizziness
Clumsiness in limbs Speech difficulties Tremor
Blurred vision, impaired visual acuity Diplopia
Feebleness Sensory complaints Fatigability Memory difficulties Impotence
Swallowing difficulties
Illusion of movement in environment Hearing loss
Tinnitus
Limb or facial weakness Urinary incontinence
aCognitive and emotional symptoms are discussed in section
“Cognitive abnormalities” and emotional disorders.
Headaches are reported very early in many patients.They can be influenced by postural changes.
Headaches may be the sole symptom in cases of tumor, abscess, or stroke. Pain may be restricted to a region around or behind the eye(s) or to the parietal or occipital region. Occipital pain may be associated with sensations of neck stiffness (Gilman et al.,1981). A cerebellar tumor must be ruled out in all children complaining of headache in the morning in association or not with nausea, vomiting, clumsiness, or gait difficulties. Vomiting may be projectile with
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Table 3.2 Clinical signs as a function of the sagittal zone affected
Vermal zone Paravermal
zone Lateral zone Oculomotor
deficits Dysarthria Oculomotor deficits
Dysarthria Dysarthria
Head tilt Head tilt
Ataxia of stance Dysmetria
Ataxic gait Kinetic tremor
Titubation Action tremor
Hypotonia Dysdiadochokinesia Decomposition of
movements Dysrhythmokinesia Impaired check/rebound Ataxia of stance Ataxic gait
no warning. Severe abrupt dull headache associated with gait ataxia and vomiting in a hypertensive patient suggests an intracerebellar hemorrhage.