Cerebellum

2020년 4월 21일 화요일 오후 3:41

the maintenance of posture and balance, the maintenance of muscle tone, and the coordination of voluntary motor activity

MAJOR DIVISIONS OF THE CEREBELLUM

consists of a midline vermis and two lateral hemispheres.

covered by a three-layered cortex, formed into folia and fissures.
contains a central medullary core, which is the white matter that contains myelinated axons and the four cerebellar nuclei (dentate,
emboliform, globose, and fastigial). The emboliform and globose nuclei are collectively the interposed nucleus.

1. Anterior lobe (spinocerebellum)

lies anterior to the primary fissure. receives input from stretch receptors (muscle spindles) and Golgi tendon organs via the
spinocerebellar tracts. plays a role in the regulation of muscle tone.

2. Posterior lobe (neocerebellum)

lies between the primary fissure and the posterolateral fissure. receives input from the neocorteX via the corticopontocerebellar fibers.
plays a role in the coordination of voluntary motor activity.

3. Flocculonodular lobe (vestibulocerebellum)

consists of the nodulus (of the vermis) and the flocculus. receives input from the vestibular system.
plays a role in the maintenance of posture and balance.

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1. Inferior cerebellar peduncle
connects the cerebellum to the rostral medulla and caudal pons.
consists of two divisions:

a. Restiform body an afferent fiber system containing

(1) Posterior spinocerebellartract
(2) Cuneocerebellartract
(3) Olivocerebellartract

b. Juxtarestiform body
contains afferent and efferent fibers:
(1) Vestibulocerebellarfibers (afferent)

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 (1) Vestibulocerebellarfibers (afferent)
(2) Cerebellovestibular fibers (efferent)

2. Middle cerebellar peduncle

• the largest cerebellar peduncle.
• connects the cerebellum to the pons.
• an afferent fiber system containing pontocerebellar fibers to the neocerebellum.

3. Superior cerebellar peduncle

• connects the cerebellum to the rostral pons and caudal midbrain.
• the major output pathway from the cerebellum.
a. Efferent pathways
○ Dentatorubrothalamic tract
○ lnterpositorubrothalamic tract
○ Fastigiothalamic tract
○ Fastigiovestibular tract

b. Afferent pathways
○ Anterior spinocerebellar tract
○ Trigeminocerebellar fibers
○ Ceruleocerebellar fibers

MAJOR CEREBELLAR PATHWAYS

VESTIBULOCEREBELLAR
• plays a role in the maintenance of posture, balance, and the coordination of eye movements.
• receives its major input from the vestibular receptors of the kinetic and static labyrinths.
1. Semicircular ducts and otolith organs
▪ project to the flocculonodular lobe and the vestibular nuclei.
2. Flocculonodular lobe
▪ receives visual input from the superior colliculus and the striate cortex.
▪ projects to the vestibular nuclei.
3. Vestibular nuclei

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 3. Vestibular nuclei
▪ project via the medial longitudinal fasciculi to the ocular motor nuclei of CN 111, CN IV,
and CN VI to coordinate eye movements.
▪ project via the medial and lateral vestibulospinal tracts to the spinal cord to regulate neck
and antigravity muscles, respectively.

VERMALSPINOCEREBELLAR
• maintains muscle tone and postural control over truncal (axial) and proximal (limb girdle) muscles.
1. Vermis
▪ receives spinocerebellar and labyrinthine input.
▪ projects to the fastigial nucleus.
2. Fastigial nucleus
▪ has excitatory output.
▪ projects via the vestibular nuclei to the spinal cord.
▪ projects to the ventral lateral nucleus of the thalamus.
3. Ventral lateral nucleus of the thalamus
▪ receives input from the fastigial nucleus.
▪ projects to the trunk area of the precentral gyrus.
4. Precentral gyrus
▪ gives rise to the anterior corticospinal tract, which regulates muscle tone of the truncal
and proximal muscles.

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PARAVERMAL - SPINOCEREBELLAR
• maintains muscle tone and postural control over distal muscle groups.
1. Paravermis
▪ receives spinocerebellar input from distal muscles.
▪ projects to the interposed nuclei.
2. lnterposed nuclei (emboliform and globose)
▪ have excitatory output.
▪ project to:
□ a. Ventral lateral nucleus
 projects to the extremities area of the precentral gyrus. The precentral gyrus gives
rise to the lateral corticospinal tract, which regulates distal muscle groups.
□ b. Red nucleus
 gives rise to the crossed rubrospinal tract, which mediates control over distal muscles.
 receives input from the contralateral nucleus interpositus and bilateral input from
the motor and premotor cortices.

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LATERAL HEMISPHERIC CEREBELLAR PATHWAY
• also called the neocerebellar or pontocerebellar pathway.
• regulates the initiation, planning, and timing of volitional motor activity.

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Cerebellar lesion
Hemispheric
Lesions that include the hemisphere produce a number of dysfunctions, mostly involving distal musculature.

○ intention tremor is seen when voluntary movements are performed. For

example, if a patient with a cerebellar lesion is asked to pick up a penny, a slight
tremor of the fingers is evident and increases as the penny is approached. The
tremor is barely noticeable or is absent at rest.

○ Dysmetria (past pointing) is the inability to stop a movement at the proper

place. The patient has difficulty performing the finger-to-nose test.

○ Dysdiadochokinesia (adiadochokinesia) is the reduced ability to perform alternating

movements, such as pronation and supination of the forearm, at amoderately quick pace.

○ Scanning dysarthria is caused by asynergy of the muscles responsible for speech.

In scanning dysarthria, patients divide words into syllables, thereby disrupting
the melody of speech.

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 the melody of speech.

○ Gaze dysfunction occurs when the eyes try to fix on a point: They may pass it
or stop too soon and then oscillate a few times before they settle on the target.

○ nystagmus may be present, particularly with acute cerebellar damage. The

nystagmus is often coarse, with the fast component usually directed toward the
involved cerebellar hemisphere.

○ Hypotonia usually occurs with an acute cerebellar insult that includes the deep
cerebellar nuclei. The muscles feel flabby on palpation, and deep tendon reflexes
are usually diminished.

Vermal
Vermal lesions result in difficulty maintaining posture, gait, or balance (an ataxic gait).
Patients with vermal damage may be differentiated from those with a lesion of the dorsal
columns by the Romberg sign. In cerebellar lesions, patients will sway or lose their balance
with their eyes open; in dorsal column lesions, patients sway with their eyes closed.

Cerebellar dysfunction examination

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 • Cerebellar ataxia: veers towards side of lesion. Common causes: drugs (e.g. phenytoin), alcohol, multiple sclerosis, cerebrovascular
disease.
• Reduced reflexes (more difficult to judge): occurs in a peripheral neuropathy, muscle disease and cerebellar syndrome.
• Pendular reflex: this is usually best seen in the knee jerk where the reflex continues to swing for several beats. This is associated
with cerebellar disease.
• Cerebellar dysarthria: slurred as if drunk, disjointed rhythm sometimes with scanning speech (equal emphasis on each syllable).

Finger–nose test
Hold your finger out about an arm's length in front of the patient.
Ask the patient to touch your finger with his index finger and then touch his nose (Fig. 23.1).
When he has done this correctly, ask him to repeat the movement faster. Watch for accuracy and smoothness of movement.

• The patient is able to complete the task quickly and accurately: normal.
• The patient develops a tremor as his finger approaches its target: intention tremor; finger overshoots its target: past pointing or
dysmetria.

Repeated movements
• Ask the patient to pat one hand on the back of the other quickly and regularly
• Ask the patient to twist his hand as if opening a door or unscrewing a light bulb

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 • Ask the patient to twist his hand as if opening a door or unscrewing a light bulb
• Ask the patient to tap the back of his right hand alternately with the palm, and then the back of his left hand. Repeat with the right
hand

• Disorganisation of the movement of the hands and the elbows take wider excursions than expected; irregularity of the movement s
which are performed without rhythm. Compare the two sides; these changes indicate cerebellar incoordination.
Often the abnormality is heard as a slapping sound rather than the normal tapping noise.
• When there is disorganisation of tapping the hand and then turning it over, this is referred to as dysdiadochokinesia.

Heel–shin test
The patient is lying down. Ask him to lift his leg and place the point of his
heel on his knee, and then run it down the sharp part of his shin ( Fig. 23.2 )
Watch for accuracy and smoothness of movement.

• Disorganisation of movement with the heel falling off the anterior part of the shin, and the knee falling from side to side.

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