J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.38.2.143 on 1 February 1975. Downloaded from Journal ofNeurology, Neurosurgery, and Psychiatry, 1975, 38, 143-148 Mechanism of production of gait unsteadiness by tumours in the posterior fossa R. S. MAURICE-WILLIAMS From the Department ofNeurosurgery, St Bartholomew's Hospital, London SYNOPSIS The hypothesis is put forward that the disturbance of gait seen with tumours of the posterior fossa is largely due to subacute dilatation of the ventricular system and not to the involve- ment of midline cerebellar structures concerned with balance or the coordination of truncal muscles, as is widely taught. This hypothesis is examined in the light of the clinical evidence provided by the symptomatology and treatment of 19 consecutive cases of intracranial mass lesions exhibiting truncal ataxia. It is well known that a disturbance of gait, often by focal signs are, in fact, situated in the mid- guest. Protected by copyright. termed 'truncal ataxia' or 'dysequilibrium' line of the cerebellum-the most striking being occurs with mass lesions situated in the cere- the medulloblastomas of childhood. bellar vermis, and it is widely held that its Truncal ataxia may be defined as a disturbance presence is ofvalue in localizing a tumour to that of gait or balance which cannot be attributed to region ofthe brain. The mechanism by which the motor weakness, sensory loss, incoordination of gait disorder is produced has long been believed the limbs tested individually, or to a lesion of the to be by involvement of those midline structures vestibular apparatus. It is sometimes referred to of the cerebellum thought to be concerned with as 'dysequilibrium', the presumption in that balance and with the coordination of truncal case apparently being that it is due to a defect of muscles. On the basis of clinical evidence, this the central mechanisms concerned with balanc- paper postulates an alternative theory. It sug- ing, as opposed to one ofthe central coordinating gests that the truncal ataxia of posterior fossa system for truncal muscles, if such a distinction tumours is largely the consequence of acute or can be made. subacute hydrocephalus-dilatation of the ven- When the possibility that the mechanism of tricular system. truncal ataxia might be hydrocephalus occurred The evidence for this alternative theory may be to the author, a search was made for clinical simply summarized as follows: cases of intra- material to confirm or refute the theory. Over http://jnnp.bmj.com/ cranial tumour where truncal ataxia occurs will the next two years, 19 consecutive cases of be found to have dilatation of the lateral truncal ataxia associated with intracranial ventricles, whether or not the tumour is situated tumours were personally observed, 17 at the in the cerebellar vermis. Operations which relieve Guy's-Maudsley Neurosurgical Unit and two at the hydrocephalus will relieve the gait disturb- St Bartholomew's Hospital. Brief summaries of ance, even if the tumour is left undisturbed or if these 19 cases are given and their relevant features its removal causes greater local damage to the analysed before the existing literature on the gait cerebellar vermis than that caused by the tumour disturbances of cerebellar lesions is discussed in on September 28, 2021 by before operation. It is suggested that the reason relation to them (Table). why vermis tumours have for so long been believed to cause a gait disturbance by a local ANALYSIS OF CASES effect is that the majority of tumours which give All the cases summarized had a disturbance of rise to an early hydrocephalus unaccompanied gait, varying in severity from a mild unsteadiness (Accepted 15 August 1974.) to a complete inability to sit or stand unaided. 143 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.38.2.143 on 1 February 1975. Downloaded from 144 R. S. Maurice- Williams TABLE CLINICAL DETAILS OF 19 PATIENTS Case Sex, Symptoms Signs Radiological Treatment Sequel age (a), investigations hosp. no. M 2 m-headaches Disorientated. Papil- Ventriculography: Metastasis removed 20 d postop.: no 65 1 m-unsteady gait, loedema. Nystagmus hydrocephalus and from R cerebellar longer confused and GM 9633 confusion, weight on lateral and up- mass in R cerebellar hemisphere walking unaided, loss ward gaze. Mild hemisphere though ataxia of cerebellar type R limbs unchanged ataxia of R limbs. Unable to sit up or stand 2 F 1 yr-worsening gait, Mental state normal. Angiography: sym- Total removal of Immediate relief of 47 unsteadiness. No papilloedema. metrical hydro- cystic haemangio- headaches and GM 9584 Vertigo produced Nystagmus on cephalus; haeman- blastoma deep in vertigo; 2 w post- by sudden head lateral gaze. Gait gioblastoma in superior vermis op. gait appeared movements. very unsteady, superior vermis normal and could 1 m-headaches broad-based walk heel to toe with minimal un- steadiness 3 M 8 m-worsening gait. Disorientated. Papil- Angiography: dilata- Total removal of solid 2 w later confusion 56 w-confusion loedema. Nystagmus tion of lateral ven- haemangioblastoma gone, gait greatly GM 9568 on lateral gaze. Mild tricles. Haemangio- of L cerebellar improved. Ataxia of cerebellar ataxia of blastoma of L hemisphere L limbs unchanged L limbs. Gait broad- cerebellar hemi- based, falls back- sphere guest. Protected by copyright. wards 4 M 3 m-headache, Gait unsteady, broad- Angiography: dilata- Subtotal removal of 10 d postop.: head- 4 vomiting based. Papilloedema tion of lateral ven- astrocytoma of aches gone, papil- GM 9500 tricles; avascular inferior vermis loedema resolving, mass in inferior gait improved vermis 5 M 3 w-headaches, fall- Lethargic, confused. Carotid angiography: Subtotal removal of 3 d later well-orien- 63 ing around. Papilloedema. symmetrical hydro- metastasis in upper tated, walking un- GM 9110 5 d-confusion and Nystagmus on cephalus. Ventriculo- midline cerebellum aided though now apathy lateral gaze. No gram: mass in ver- extending into L had moderate ataxia limb ataxia or mis cerebellar hemi- of L limbs weakness. Unable to sphere stand, falls back- wards 6 F 9 m-headache. Gait Well-orientated but Angiography: sym- Subtotal removal of 7 d later mental state 58 unsteadiness. Loss distractable. Mild metrical hydro- solid haemangio- normal, no head- GM 9408 of memory ataxia left limbs. cephalus and avascu- blastoma of L cere- ache and walking Completely unable lar tumour behind L bellar hemisphere unaided, though to stand unaided petrous bone extending into ataxia of L limbs vermis was worse 7 M 2 m-headache, Papilloedema. Bi- Carotid angiogram: ?Total removal of 8 d later walking heel 25 vomiting. lateral sixth nerve symmetrical hydro- medulloblastoma in to toe with minimal GM 8798 2 w-gait deteriora- palsies. Mild cere- cephalus. Ventriculo- outer part of R clumsiness. R limbs ting bellar ataxia of right graphy: mass in R cerebeUlar hemi- still slightly ataxic limbs. Gait very cerebellar hemi- sphere unsteady sphere 2 m 8 F 6 w-headache, Papilloedema. Un- Ventriculography: Subtotal removal of No signs post-op. http://jnnp.bmj.com/ 7 vomiting, malaise steady on heel to hydrocephalus and astrocytoma of GM 8972 toe walking mass on R of pos- inferior vermis and terior fossa R cerebellar hemi- sphere 9 M 2 m-headaches. Confused. Papil- Carotid angiography: Partial removal of At 14 d well orien- 61 Clumsy right hand. loedema. Mild limb hydrocephalus. vermis glioma ex- tated and gait vir- GM 9142 Worsening gait ataxia L > R. Un- Ventriculography: tending into both tually normal able to sit or stand mass in inferior cerebellar hemi- 1 yr later had re- unaided vermis spheres lapse of gait ataxia and confusion. Both only partially re- lieved by a ven- on September 28, 2021 by triculoatrial shunt 10 F 6 m-worsening gait. Disinhibited, confused. Angiography: hydro- Ventriculoatrial shunt 8 d later well-orien- 62 Mental deteriora- Nystagmus on cephalus and menin- tated and walking GM 9453 tion lateral and vertical gioma of R petrous with assistant gaze. Reduced R apex corneal reflex. Un- able to stand un- aided J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.38.2.143 on 1 February 1975. Downloaded from Mechanism ofproduction ofgait unsteadiness by tumours in the posterior fossa 145 TABLE-continued Case Sex, Symptoms Signs Radiological Treatment Sequel age (yr), investigations hosp. no. 11 F 9 m-worsening gait. Demented. Limitation Pneumoencephalo- Ventriculoatrial shunt 5 m later: gait and 68 Intellectual de- of conjugate up- graphy: hydro- (no radiotherapy) mental state normal GM 9352 terioration ward gaze. Sym- cephalus and pineal metrically brisk ten- mass don reflexes. Slight ataxia L arm. Un- able to stand un- aided 12 M 7 m-headache. Alert, well-orientated. Angiography: hydro- Preliminary ventricu- Gait returned vir- 25 Worsening gait Bilateral papil- cephalus, and mass lar drain. Removal tually to normal. GM 9376 loedema. Minimal in superior vermis of tuberculoma of L-sided ataxia ataxia L limbs. Gait superior vermis worse. Gait im- unsteady, broad provement main- based tained 13 M 9 m-headache, Intellect normal. Ventriculography: Ventriculoatrial shunt Gait returned to vir- 55 vomiting, drowsi- Papilloedema. Gross hydrocephalus tually normal. GM 8658 ness. gait unsteadiness. caused by anterior Spastic L hemi- 6 m-worsening gait Slight spasticity and third ventricle paresis unaltered. weakness left limbs (?thalamic) mass Relapse of head- aches and gait un- steadiness 6 m later relieved by revision of shunt guest. Protected by copyright. 14 F 1 yr-headaches. Confused. Papil- Angiography: hydro- Partial removal of 10 d later: well orien- 68 6 m-changed per- loedema. Impaired cephalus, and lymphoma on tated, no headaches, GM 9225 sonality. Worsening upward gaze. Slight avascular mass high underside of tentor- gait virtually normal gait ataxia R arm. Gross in midline of pos- ium gait unsteadiness terior fossa 15 F 2 yr-headache, Confused.