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Year: 2010

Cerebellum and source memory
Tamagni, C ; Mondadori, C R A ; Valko, P O ; Brugger, P ; Schuknecht, B ; Linnebank, M

Abstract: We report the case of a 40-year-old right-handed German-speaking man who presented with ischemic
stroke in the territories of the right superior cerebellar artery and posterior inferior cerebellar artery. The objective of the present study was to investigate the consequences of this cerebellar damage with regard to higher
cognitive functions. On admission to the stroke unit, the patient presented with dysarthria, right-sided appendicular ataxia, gait ataxia, and right-sided horizontal nystagmus (National Institutes of Health Stroke Scale, NIHSS,
score 4). When examined 10 days after his stroke using a set of neuropsychological tests, he showed a marked
deficit in the ability to remember when and in which context he had previously encountered verbal material. This
aspect of memory, so-called ’source memory’, is known to be mediated mainly by frontal and medial temporal
structures. The present case suggests the existence of a strong functional connectivity between cerebellum and
cortical regions underlying specific memory processes.
DOI: https://doi.org/10.1159/000282277

Posted at the Zurich Open Repository and Archive, University of Zurich
ZORA URL: https://doi.org/10.5167/uzh-34875
Journal Article
Published Version
Originally published at:
Tamagni, C; Mondadori, C R A; Valko, P O; Brugger, P; Schuknecht, B; Linnebank, M (2010). Cerebellum and
source memory. European Neurology, 63(4):234-236.
DOI: https://doi.org/10.1159/000282277

Original Paper
Eur Neurol 2010;63:234–236
DOI: 10.1159/000282277

Received: June 30, 2009
Accepted: January 30, 2010
Published online: March 19, 2010

Cerebellum and Source Memory
Corinne Tamagni a Christian R.A. Mondadori a Philipp O. Valko a Peter Brugger a
Bernhard Schuknecht b Michael Linnebank a
a
Unit of Neuropsychology, Department of Neurology, University Hospital Zürich, and b Diagnostic and
Vascular Neuroradiology, Medizinisch Radiologisches Institut Zürich, Klinik Bethanien, Zürich, Switzerland

Key Words
Cerebellar cognition ⴢ Cognitive impairment ⴢ Memory ⴢ
Magnetic resonance imaging ⴢ Neuropsychology ⴢ
Stroke unit

Abstract
We report the case of a 40-year-old right-handed Germanspeaking man who presented with ischemic stroke in the territories of the right superior cerebellar artery and posterior
inferior cerebellar artery. The objective of the present study
was to investigate the consequences of this cerebellar damage with regard to higher cognitive functions. On admission
to the stroke unit, the patient presented with dysarthria,
right-sided appendicular ataxia, gait ataxia, and right-sided
horizontal nystagmus (National Institutes of Health Stroke
Scale, NIHSS, score 4). When examined 10 days after his
stroke using a set of neuropsychological tests, he showed a
marked deficit in the ability to remember when and in which
context he had previously encountered verbal material. This
aspect of memory, so-called ‘source memory’, is known to be
mediated mainly by frontal and medial temporal structures.
The present case suggests the existence of a strong functional connectivity between cerebellum and cortical regions
underlying specific memory processes.
Copyright © 2010 S. Karger AG, Basel

© 2010 S. Karger AG, Basel
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Accessible online at:
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Introduction

Over the past two decades neuroimaging and clinical
studies have demonstrated cerebellar involvement in
higher cognitive functions.
Patients with cerebellar lesions may present with impairments of nonmotor functions such as language [1],
verbal fluency [2], visuospatial skills [3] and working
memory, in particular in the learning and in the recall
phase of verbal information [4]. Such observations suggest a functional connectivity between different parts of
the cerebellum and the cerebral cortex [5], in particular
with the frontal lobes, involved in social behavior, executive functions, planning, language control and working
memory. The frontal lobes also play a critical role in the
retrieval of source, the capacity to remember ‘when’,
‘where’ and ‘in which context’ a memory information has
been learned [6, 7]. Furthermore, besides frontal structures, many studies suggest the involvement of medial
temporal lobe subregions in recognition performance,
some of these mediating human source recollection ability [8].
Many studies documented a relationship between
frontal lobe functioning and source recall ability [9]. Patients with frontal lobe lesions often show a diminished
performance in tasks requiring the recall of the context
of an episodic memory [10]. Accordingly, functional
magnetic resonance imaging (MRI) studies emphasize
that source memory relies on the frontal lobe [11].
Corinne Tamagni
Neuropsychology Unit
Department of Neurology, University Hospital Zürich
CH–8091 Zürich (Switzerland)
Tel. +41 44 255 5579, Fax +41 44 255 4429, E-Mail corinne.tamagni @ usz.ch

b

a

Fig. 1. Diffusion-weighted imaging with
areas of restricted diffusion indicating
acute ischemia. Ischemia of the right caudal cerebellar hemisphere and dentate nucleus (territory of the posterior inferior
cerebellar artery; a, b) and the anterior
lobe of the superior right cerebellar hemisphere (right superior cerebellar artery; c,
d).

c

Patient and Methods
Patient
This 40-year-old right-handed man was admitted to our
stroke unit following a car accident. Neurological examination
revealed dysarthria, right-sided appendicular ataxia, gait ataxia,
and right-sided horizontal nystagmus (National Institutes of
Health Stroke Scale, NIHSS, score 4). After exclusion of intracerebral hemorrhage on initial computed tomography scan of the
brain, intravenous thrombolysis with recombinant tissue plasminogen activator was performed 144 min after symptom onset.
MRI of the brain was performed 24 h after admission and showed
acute ischemic lesions in the vascular territories of the right posterior inferior and right superior cerebellar arteries (fig. 1); there
were no extracerebellar lesions in the posterior circulation.
Stroke etiology remained unclear after extended diagnostic
workup, which revealed normal results: extra- and intracranial
duplex sonography, computed tomography and MR angiography
of the neck and brain, fat-suppressed MRI of the neck for exclusion of artery dissections, transesophageal echocardiography
and 48-hour Holter electrocardiography. Electroencephalography was normal suggesting that epileptiform discharges caused
by the ischemic lesions did not contribute to the patient’s symptoms.

d

For verbal learning and retrieval, a regularly applied and wellvalidated memory test (VLMT, revised German version) was used
[13]. In this test, a list of 15 words is presented in 5 consecutive
learning runs. An interference list of 15 new words is then read
and immediate recall is tested. Thereafter, the first list of words
must be recalled and again after 30 min. Since the patient unexpectedly showed signs of source memory deficit during the verbal
learning trials (i.e. an increased number of confabulations and
perseverations), we immediately modified the recognition part of
the VLMT during the neuropsychological examination. This part
of the test has therefore not been validated before.
To evaluate the patient’s verbal source and recognition memory capacity, selected words from those he had produced during
the verbal fluency tasks were mixed among the words of the
VLMT learning lists and were orally presented along with entirely novel distractor words. The patient was asked to decide whether a read word was new, from the original list, the interference list,
or whether it was a self-generated word.

Results

Methods
To investigate cognitive functions, we applied a set of various
neuropsychological tests. Results were compared to an age-matched
reference population and z-scores were calculated using normative
values. Left-hemisphere language dominance was ensured by a
standard lateralized tachistoscopic lexical decision task [12].

The patient achieved average performance in measures of information processing speed, divided attention,
visuoconstructive ability, concept finding, and category
fluency. A slight performance reduction was found in
verbal phonematic fluency (z = –1.26) and in verbal (digit span backward; z = –1.02) and visual (visual span back-

Cerebellum and Source Memory

Eur Neurol 2010;63:234–236

235

ward; z = –1.32) working memory. The results in the
VLMT task showed that verbal learning (z = –2.34), verbal delayed recall (z = –2.97) and verbal recognition
(z = –2.13) were severely impaired. The numbers of words
recovered during the 5 learning runs out of 15 words in
total were 7, 6, 7, 6 and 8. Four words were recovered after
30 min. Notably, the patient exhibited an especially
marked deficit in the recognition of previously self-generated words: only 4 of the 13 presented words were recognized as self-generated. Together with a low recognition rate for words from the interference list (7 recognized out of 11), this reflects a dramatic deficit in the
ability to remember when and in what context correctly
recognized items had been learned (source memory).
Conversely, figural learning and recall (Rey 15 Figures
Test) [14] were in the average lower range, although recognition performance was also impaired.

memory [15]. On top of these aspects of memory, in the
patient reported here, the right cerebellar lesion was also
accompanied by a marked impairment of source monitoring for verbal information while nonverbal learning
and recall remained nearly unaffected.
These observations clinically illustrate the functional
connectivity of the cerebellum with frontal and mediotemporal subregions mediating a specific aspect of human memory, the ‘source memory’. Although considering the absence of functional imagery we are not able to
establish which regions (more frontal or more medial
temporal lobe) are underactive in our patient, this case
makes a small but substantial contribution to the not yet
comprehensive understanding of cerebellar-cortical networks.
As knowing about the when and where of learning is
of considerable everyday relevance, careful neuropsychological assessment in cases with cerebellar lesions is important for medical and occupational rehabilitation.

Discussion

Cerebellar lesions are associated with dysfunctions of
the contralateral cortical hemisphere, with right cerebellum damage often affecting verbal working and episodic

Acknowledgment
C.T. was funded by the COGITO foundation.

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Tamagni /Mondadori /Valko /Brugger /
Schuknecht /Linnebank