«NOTES ON THE OLIVOCEREBELLAR CONNECTIONS* H. M. ZIMMERMAN AND BERNARD S. BRODY In a previous communication' evidence was adduced to indicate that the ...»
The remainder of the cerebellar cortex and the nuclei dentati and emboliformes were well preserved; the nuclei fastigii and globosi, unfortunately, could not be studied. Associated with the cerebellar lesions were an almost complete loss of nerve cells in the dorsal accessory olives and a partial loss of these cells in the ventral accessory olives. The main bodies of the inferior olives were normally preserved.
482 YALE JOURNAL OF BIOLOGY AND MEDICINECase III.
Clinical History (No. A7082). S. B., a white female 12 years of age, first became ill in January, 1932, at which time she developed severe frontal headache, vomited occasionally and became unsteady in gait. Vision began to fail one month later and resulted in blindness three months after the onset of her illness. Deafness soon followed and there appeared a marked change in personality, the patient becoming irascible and profane. On admission to the New Haven Hospital, June 23, 1932, neurologic examination revealed a bilateral papilloedema of about six diopters with considerable peripapillary edema extending into the macular regions. The eyes made wide excursive nystagmoid movements as is seen in total blindness. There was present a left facial weakness of peripheral type; the gag reflex was absent bilaterally.
There were no apparent sensory or motor defects. The deep reflexes were all depressed. Attempts to rotate the head to the left were met with considerable resistance and apparently produced pain. A diagnosis of cerebellar tumor was made and it was decided to relieve the intense hydrocephalus and cerebral edema before proceeding with an operative attack upon the tumor.
Consequently, a Frazier needle was inserted into the posterior horn of the right lateral ventricle and the galea and skin closed tightly over the needle.
Following this procedure the patient's mental condition improved considerably and the papilloedema began to subside. On July 1, 1932, a suboccipital exploration was performed by Dr. A. W. Oughterson, but nothing abnormal was apparent in either cerebellar hemisphere. The patient's postoperative course was a stormy one. Consciousness was never regained. On several occasions respirations ceased completely and it was necessary to tap the lateral ventricle each time in order to restore respiratory activity. Unfortunately, ventriculitis developed as a result of the repeated ventricular taps and the patient expired July 10, 1932.
Necropsy. Post-mortem examination was confined to the cranial contents.
There was clouding of the cerebral leptomeninges and flattening of the convolutions. Ventriculopuncture wounds were present in the right occipital lobe. Frank evidence of purulent meningitis was found in the interpeduncular fossa. The floor of the third ventricle was ballooned out into a cystlike structure behind the optic chiasm. A marked pressure cone was formed by the left, and in part also by the right, cerebellar tonsil. A superficial midline incision was present in the postero-inferior part of the vermis cerebelli, at the operative site. A spherical protuberance was found on the dorsal surface of the left cerebellar lobe which, when incised, revealed a thin-walled cyst filled with opalescent, yellow-green, semi-gelatinous fluid. The dorsum of the cyst was quite thin and was composed of cerebellar cortex. It almost completely replaced the left lobe of the cerebellum and extended medially also to involve the white matter of the vermis to a slight degree (Fig. 7).
On the anterior part of the floor of this cavity was found a mural nodule 483
OLIVOCEREBELLAR CONNECTIONSmeasuring 2 cm. in greatest diameter. Two gready dilated lateral ventricles whose walls were covered with a purulent exudate were exposed on frontal section of the cerebrum. This exudate also covered the choroid plexuses in all the cavities and involved the entire leptomeninges of the spinal cord.
Microscopic examination of the mural nodule in the cerebellar cyst proved it to be an astrocytoma composed chiefly of fibrillary cells. The cerebral and spinal meninges, the choroid plexuses, and the ventricular ependyma were all seats of an extensive suppurative reaction.
The medullary sheaths of both optic nerves showed complete degeneration by the various staining technics employed.
The cortex of the left cerebellar lobe was free of tumor cells, but its architecture was destroyed by a diffuse gliosis. There was also a generalized paucity of Purkinje cells in this part of the cerebellum. The left dentate nucleus was flattened as a result of the pressure and its cells were shrunken and ischemic. On the contrary, the right cerebellar lobe presented a normal picture both in its cortical and central medullary and nuclear portions. Likewise, no changes were to be noted in the cortex of the vermis cerebelli.
Unfortunately, the cerebellum was prepared for histologic study in such a manner as to preclude any investigation of the nuclei fastigii and globosi.
A few cells only were found in the dorsal half of the right inferior olive, and those present were pale and shrunken (Fig. 8). In the ventral half of this olive the nerve cells showed an "axonal" reaction, having swollen, hyalinlike cytoplasm and eccentrically placed nuclei. The accessory olives, both dorsal and ventral, on this side of the medulla showed no change whatever.
The main olive on the left side contained a diminished number of nerve cells in its dorsal portion, but showed no changes in the ventral portion. Both accessory olives on the left side were entirely normal.
The patient was a white female 12 years of age who had symptoms of cerebellar neoplasm for approximately six months. An unsuccessful cerebellar exploration was performed which, of course, failed to relieve the increased intracranial pressure. It was this, and a suppurative ventriculitis caused by repeated ventricular taps, which led to the fatal outcome. At necropsy a cystic fibrillary astrocytoma was found which almost completely destroyed the left cerebellar lobe and its dentate nucleus. This was the sole cerebellar lesion and was associated with degenerative changes involving the whole right inferior olive but sparing the accessory olives. The olivary structures on the left side were completely spared except for a decrease in the number of cells in the dorsal portion of the main olive. An
484 YALE JOURNAL OF BIOLOGY AND MEDICINEadditional finding irrelevant to the subject under discussion, but of prime importance as regards the fatal outcome, was a suppurative ventriculitis and cerebrospinal meningitis.
COMMENT The cases presented in this communication appear to indicate that the ventral (inferior) part of the vermis (folium, tuber, pyramis, uvula and nodulus) are connected with the ventromedian accessory olives and that the dorsal (superior) part of the paleocerebellum (lingula, lobus centralis, culmen and declive) are connected with the dorsal-accessory olives.
Case I, in which there was an aplasia of the ventral part of the vermis, also showed, in addition to an aplasia of the ventromedian accessory olives, a lack of development of the median parts of the inferior limbs of the inferior olives. Masuda6 had already postulated connections between the ventral halves of the inferior olives and the deep and caudal parts of the vermis, and the findings in Case I seem to substantiate his views.
In Case II the lesion in the vermis involved most of the dorsal part of this structure (the lingula alone being spared), and the folium and tuber of the ventral part. These cerebellar lesions were associated with an almost complete loss of nerve cells in the dorsal accessory olives and a partial loss of these cells in the ventral accessory olives. These findings are significant not only because they show the general regional relationship between the vermis and accessory olives but also because they demonstrate a quantitative relationship between these structures, i. e., the greater the involvement of the vermis the greater the changes in the accessory olives.
The findings in Case III are interesting from several viewpoints. They show that the lateral cerebellar lobes are not only connected with the contralateral inferior olives, but that the dorsal halves of the inferior olives also have homolateral connections with the cerebellar lobes. This is to be inferred from the fact that with the involvement of the left cerebellar lobe there was found a decrease in the number of nerve cells in the dorsal half of the left inferior olive besides, of course, a destruction of the whole right inferior olive. Reference has already been made to such a homolateral olivocerebellar relationship suggested by Bruns.
The findings in this case also indicate the direction which the
OLIVOCEREBELLAR CONNECTIONS 485fiber tract connections take between the cerebellum and olives, whether they are olivo- or cerebello-fugal. Inasmuch as the cells of the right inferior olive show the "axonal" type of reaction, which is a change in a neurone resulting from the interruption of its axon, the indication seems clear that the olivocerebellar tracts have an olivofugal direction. -
Lastly, this case demonstrates the complete independence that exists between the inferior and accessory olives by showing that the inferior olive may be almost completely destroyed at the same time that the accessory olives are completely spared.
REFERENCESZimmerman, H. M., and Finley, K. H.: Arch. Neurol. & Psychiat., 1932, 27, I 1402.
Holmes, G., and Stewart, T. G.: Brain, 1908, 31, 125.
2 3 Brouwer, B.: Arch. f. Psychiat., 1913, 51, 539.
4 Spiller, W. G.: Brain, 1896, 19, 588.
5 Pines, L., and Surabaschwili, A.: Arch. f. Psychiat., 1932, 96, 718.
Masuda, N.: Arb. a. d. hirnanat. Inst. in Zurich, 1914, 9/10, 1.