[Remote cerebellar hemorrhage after single burr hole drainage of chronic subdural hematoma of the elderly]

Remote cerebellar hemorrhage is a usual complication after supratentorial craniotomy. Especially, only several cases have been reported regarding the occurrence of remote cerebellar hemorrhage after burr hole drainage for the treatment of chronic subdural hematoma (CSDH). In this paper, we present an elder patient with this rare postoperative complication. A 73-year-old man presented with dysarthria and right hemiparesis. Computed tomography (CT) demonstrated a left chronic subdural hematoma. Hematoma drainage through a single burr hole was perfomed. About 3 hours after the surgery, the patient became restless and presented nausea and dizziness with a relatively large amount of drainage of hematoma. CT revealed resolution of the subdural hematoma and bilateral cerebellar hemorrhage appearing as "zebra sign". Magnetic resonance angiography and 3D-CT angiography showed the normal structure of posterior circulation in both the arterial and venous phases. The remote cerebellar hemorrhage was suspected to have happened as a result of overdrainage of hematoma. Finally, he was discharged without any neurological deficits. Although remote cerebellar hemorrhage after drainage through a burr hole for the treatment of chronic subdural hematoma is a rare complication, it is necessary to be aware of the possibility of such a complication after supratentorial surgery.

Clinical outcome following surgical treatment for bilateral cerebellar infarction

OBJECTIVES

To analyze the initial clinical and radiological findings, the surgical treatment, and the clinical outcome following surgical decompression in patients with space-occupying bilateral cerebellar infarction.

MATERIALS AND METHODS

Ten patients with expansive bilateral cerebellar infarction and decreased level of consciousness were operated with suboccipital craniectomy, removal of the infarcted tissue, and placement of external ventricular drainage. Long-term outcome was assessed using the modified Rankin scale (mRS).

RESULTS

Mean Glasgow coma scale (GCS) score before surgery was 8.9 ± 3.3 and improved to 12.6 ± 3.6 at discharge. At the long-term follow-up (median 57.6 months), six patients had a favorable outcome (mRS 1.3 ± 0.8). Four patients, all with an associated brain stem infarct, had a poor outcome.

CONCLUSIONS

In the absence of brain stem infarcts, surgical treatment resulted in a favorable clinical outcome and should be considered a treatment option for patients with expansive bilateral cerebellar infarction.

Radiation therapy-related ataxia associated with FDG-PET cerebellar hypometabolism

Brain FDG-PET after radiation therapy is classically used to differentiate between tumor recurrence and radiation-related tumor necrosis. Little is known about FDG-PET in patients with radiation-induced leukoencephalopathy without radiological aspect of necrosis. We present a 69-year-old woman who had preventive whole brain radiation after a diagnosis of paraneoplastic Lambert-Eaton syndrome related to small cell lung cancer Five months after radiation therapy, she developed radiation-induced leukoencephalopathy manifested by ataxia. Profound cerebellar hypometabolism on FDG-PET was in contrast with the presence of only discrete cerebellar white matter changes on MRI. FDG-PET abnormalities seem to correlate better with clinical signs related to radiation-associated brain toxicity than MRI.

The clinical presentation of preterm cerebellar haemorrhage

The objective of this study was to evaluate clinical symptoms and findings on cranial ultrasound (CUS) in preterm infants with cerebellar haemorrhage through retrospective analysis of all preterm infants with a postnatal CUS or MRI diagnosis of cerebellar haemorrhage admitted in a tertiary care centre between January 2002 and June 2009. Fifteen infants were identified; median gestational age was 25 2/7 weeks and median birth weight 730 g. We discerned six types of haemorrhage: subarachnoid (n = 3), folial (n = 1), lobar (n = 9, of which 4 bilateral), giant lobar (n = 1, including vermis) and contusional (n = 1). Especially in infants with lobar cerebellar haemorrhage, CUS showed preceding or concurrent lateral ventricle dilatation, mostly without intraventricular haemorrhage (IVH). Thirteen infants suffered from notable, otherwise unexplained motor agitation in the days preceding the diagnosis. In conclusion, motor agitation may be a presenting symptom of cerebellar haemorrhage in preterm infants. Unexplained ventriculomegaly can be a first sign of cerebellar haemorrhage and should instigate sonographic exploration of the cerebellum.

Classification of cerebellar atrophy using voxel-based morphometry and SPECT with an easy Z-score imaging system

OBJECTIVE

With conventional MRI and single-photon emission computed tomography (SPECT), accurate diagnosis and precise classification of cerebellar atrophy are often difficult. The objective was to verify the utility of MRI voxel-based morphometry (VBM) in combination with SPECT using easy Z-score imaging (eZIS) for diagnosing and classifying cerebellar atrophy.

PATIENTS AND METHODS

We assessed gray matter atrophy using VBM and blood perfusion using SPECT with eZIS in fifteen patients with different types of cerebellar atrophy, such as the cerebellar variant of multiple system atrophy (MSA-C), spinocerebellar ataxia type 3 (SCA3), SCA6, and autoimmune cerebellar ataxia (AICA).

RESULTS

In all five MSA-C patients, VBM imaging showed atrophy of the brainstem, the entire cerebellar vermis, and the cerebellar hemispheres, while SPECT using eZIS showed reduced perfusion in the same regions. Regarding SCA3, brainstem atrophy and reduced perfusion were recognized in two of the four patients, but none exhibited abnormal findings in the posterior lobe of the cerebellar vermis. SPECT showed that all four patients had obviously reduced perfusion in the anterior lobe of the vermis, but VBM demonstrated that there was no obvious atrophy of gray matter in any patient, meaning that the results of SPECT and VBM contradicted each other completely. All SCA6 and AICA patients exhibited atrophy and reduced perfusion in the cerebellar hemispheres but not in the brainstem. Only one AICA patient exhibited atrophy and reduced perfusion of the entire cerebellar vermis.

CONCLUSION

VBM clearly showed characteristic gray matter atrophy in the cerebellum and brainstem in different pathological conditions, thus indicating its high degree of utility in diagnosing and classifying cerebellar atrophy in combination with SPECT using eZIS.

Otogenic cerebellar abscess: a case report

This case report describes the gradual deterioration of a healthy, highly functioning man who initially presented with a draining right ear. The patient's indolent neurologic decline and referral to an otologist ultimately led to the diagnosis and treatment of an otogenic cerebellar abscess, an increasingly rare intracranial complication of otitis media. We report this case to illustrate that severe complications of chronic otitis media still occur in the United States, to stress the importance of clinical suspicion in the postantibiotic era, and to review the literature regarding the most appropriate time to perform the otologic portion of the surgery.

Inadvertent hyponatremia leading to acute cerebral edema and early evidence of herniation

INTRODUCTION

For years, the maintenance of normal or supranormal serum sodium (Na) concentrations has been believed to be beneficial in brain injuries. Recently published guidelines for cerebral trauma recommend the use of hypertonic saline to achieve hypernatremia for the management of increased intracranial pressure and these standards are generally practiced across most diseases in neurocritical care including stroke, hemorrhage and tumors. Severe hyponatremia has long been known to be detrimental, but objective evidence for the harm of mild hyponatremia as a secondary injury has been scarce.

DESCRIPTION OF CASE

In this case report, we describe a child with aneurysmal subarachnoid hemorrhage who had a sudden, inadvertent decrease in serum Na (128 meq/l) that was associated with a deterioration of her neurological examination and evidence of early transtentorial herniation on emergent brain CT scan. These findings were quickly reversed after the serum Na was corrected.

DISCUSSION

This report emphasizes that close monitoring of serum Na and osmolarity in acute head injured children is important, and provides evidence that alterations of these parameters is a substantial risk for cerebral edema in children with evolving brain injuries and briefly reviews the literature regarding the risks of hyponatremia in children.

A case of cerebellar infarction caused by vertebral artery injury from a stab wound to the neck

Vertebral artery injuries are the least common arterial injuries because of the deep location of the vessel in a bony canal. Injury of this vessel has not been associated with neurological deficits, and it is thought that many of these injuries are not recognized. The incidence of vertebral artery injury occurring after a penetration wound to the neck varies from 1.0% in gunshot wounds to 7.4% in stab wounds. However, even with vertebral artery injury in penetration wounds of the neck the association with cerebellar infarction is a rare occurrence. We describe a case of cerebellar infarction caused by vertebral artery injury from a stab wound that severed the vessel between the transverse processes of C3 and C4 with a hypoplastic contralateral vertebral artery. The patient ultimately suffered infarction of the cerebellum due to the lack of preservation of the posterior inferior cerebellar artery blood flow. Management is discussed and the medical literature is reviewed.

Clinical and imaging characterization of a patient with idiopathic progressive ataxia and palatal tremor

We describe clinical and imaging features of a patient with sporadic progressive ataxia and palatal tremor (PAPT) of unknown etiology. There was hypertrophy of bilateral inferior olivary nuclei with hyperintense T2-weighted signal and mild cerebellar atrophy at brain magnetic resonance imaging. 18F-fluoro-2-desoxy-d-glucose positron emission tomography scanning (FDG-PET) showed hypometabolism in the red nucleus, external globus pallidus and precuneus while FP-CIT-SPECT imaging revealed mild and progressive loss of striatal dopaminergic terminals. Our findings suggest that in idiopathic PAPT involvement of the dentato-rubro-olivary pathway occurs along with some dopaminergic dysfunction.

Cerebellar developmental venous anomalies with associated vascular pathology

Cerebellar developmental venous anomalies (CDVA) are benign conditions, although sometimes they are associated with haemorrhages and reported to be symptomatic. This is the largest follow-up study to investigate the symptomatology of CDVAs and their association with other malformations. Thirty-two patients were followed for 2 - 9 years. Twenty-eight had isolated asymptomatic CDVA without any neurological condition during follow-up, which might be linked to the CDVA. Four patients had CDVA and an associated vascular pathology: two pontine cavernomas, one asymptomatic arteriovenous malformation (this is the first published case in the literature) and one cerebellar infarct with a developmental variation of the posterior fossa venous circulation. One patient had two CDVAs, while another had a unique draining vein from the upper part of the brainstem too. In conclusion, CDVAs are benign, asymptomatic conditions, but they are sometimes associated with pathogenic malformations requiring detailed neuroradiological investigations.

Cervical vertebral artery variations: an anatomic study

In this article, we present 5 cases of uncommon anomalous vertebral arteries and discuss the possible embryologic etiologies. These cases include a left vertebral artery as the 2nd branch off the left subclavian, a left vertebral artery with 2 origins, a right vertebral artery arising as the last branch off the aorta, a right vertebral artery arising as the 2nd branch off the right subclavian artery, and right vertebral artery with proximal duplication as the 2nd branch off the right subclavian artery.

Pseudo-subarachnoid hemorrhage in cerebellar infarction

INTRODUCTION

The computed tomography (CT) appearance of subarachnoid hemorrhage (SAH) without subarachnoid blood has been labeled "pseudo-subarachnoid hemorrhage" (pseudo-SAH) and has been reported with several diffuse intracerebral insults including intrathecal contrast agents, meningitis, generalized cerebral edema, anoxic encephalopathy, and intracranial hypotension.

METHODS

Single case report.

RESULTS

We present a 43-year-old female who presented with vertigo and severe headache. Initial CT brain suggested SAH with hydrocephalus. Subsequent cerebral angiography was negative. Cerebrospinal fluid from an external ventricular drain (EVD) was negative for blood, and MRI brain revealed an acute stroke in the posterior inferior cerebellar artery (PICA) territory.

CONCLUSION

Our case suggests that PICA infarction can be associated with the CT finding of pseudo-SAH, thereby mimicking the clinical and radiographic presentation of SAH.

Intracerebellar hemorrhage in premature infants: sonographic detection and outcome

AIMS

Intracerebellar hemorrhage is a rarely confirmed diagnosis in preterm infants in comparison to peri-/intraventricular hemorrhage. This study evaluates the incidence of intracerebellar hemorrhage and neurological outcome in preterm infants.

METHODS

260 infants with gestational age of 22-32 weeks were studied prospectively by cranial ultrasound. Neurodevelopmental outcome was examined in the first three years of life.

RESULTS

15 infants had intracranial hemorrhage grade II-IV (10 intraventricular, 6 intracerebellar hemorrhage). Neurodevelopmental follow-up showed that one infant with intracerebellar hemorrhage is severely handicapped, two have moderate and two mild impairments and one has no sequelae.

CONCLUSION

Cerebellar hemorrhage is not rare if ultrasound examination is specifically focused on cerebellar lesions.

Two cases further delineating the Sakoda complex

Sakoda complex consists of sphenoethmoidal encephalomeningocele, agenesis of the corpus callosum, and cleft lip and/or palate. Associated abnormalities include optic disc dysplasia, microphthalmia, cortical dysgenesis, mental retardation and epilepsy. The etiology remains unknown. We describe two patients with anomalies consistent with the Sakoda complex including the cardinal features of sphenoethmoidal encephalomeningocele and cleft palate. The first patient also has right microphthalmia, optic nerve hypoplasia, diffuse pachygyria, asymmetric ventricles, atrial septal defect, hemivertebrae, and renal abnormalities. The second patient has right microphthalmia, absence of the right hemisphere, and a right bifid thumb. The features of Sakoda complex present in these patients may also overlap with frontonasal dysplasia and morning glory syndrome suggesting shared pathogenic relationships. We propose that the primary malformation of the Sakoda complex is probably genetic. The right hemispheric defect in Patient 2 suggests that at least some cases of Sakoda complex may also be associated with vascular disruption. Thus, more than one pathogenetic process contributes to the phenotypic spectrum of Sakoda complex.

Crossed cerebellar diaschisis: a positron emission tomography study withl-[methyl-11C]methionine and 2-deoxy-2-[18F]fluoro-d-glucose

OBJECTIVE

Crossed cerebellar diaschisis (CCD) is defined as a depression of blood flow and oxidative metabolism of glucose in the cerebellum contralateral to a supratentorial brain lesion, as detected with positron emission tomography (PET) and single photon emission computed tomography. We examined whether L-[methyl-11C]methionine (MET) uptake is affected in CCD.

METHODS

In 12 patients with a unilateral supratentorial brain tumor, we evaluated the uptake of 2-deoxy-2-[18F]fluoro-D-glucose (FDG) and MET in the cerebellar hemispheres by means of PET. Asymmetry index (AI) was defined as a difference in the average count between the ipsilateral and contralateral cerebellar hemispheres divided by the average count in both cerebellar hemispheres. Patients with AI of FDG PET more than 0.1 and those with AI equal to 0.1 or less than 0.1 were classified as CCD-positive and CCD-negative, respectively.

RESULTS

Six patients were CCD-positive and others were CCD-negative in the FDG PET study. Between CCD-positive and CCD-negative patients, mean AI of MET was not significantly different (0.017 +/- 0.023 and 0.014 +/- 0.039, respectively).

CONCLUSIONS

Different from glucose metabolism, cerebellar MET uptake was not affected in CCD. The present study may indicate that cerebellar MET uptake is independent of suppression of cerebellar neuronal activity.

[Otogenic cerebellar abscess - two case histories]

OBJECTIVE

The otogenic brain abscess remains a serious intracranial complication of otitis media despite advantages in diagnostics and antibiotic treatment during the last decades. We discuss the clinical picture and the possible ways of treatment by the example of two case histories.

CASE HISTORIES

Case 1: We report about a 38-year-old man, who was suffering in cholsteatoma since 30 years. The surgical revision was restricted by the patient since this time. The acute symptoms of meningitis were caused by intracranial involvement and cerebellar abscess due to cholesteatoma. After surgical revision we observed a period of clinical improvement. A repeated surgery became necessary because of renewed brain abscess at the cerebellar region five weeks after primary operation. Case 2: A 6-year-old girl was already treated with antibiotics because of subacute mastoiditis since three weeks. She was entering the ENT department because of headache and otorrhoea. During mastoidectomy the bone destruction leads to a cerebellar abscess. The neurological symptoms were regredient immediately after the surgical revision.

CONCLUSION

Both case histories underline the importance of cerebellar abscess as an intracranial complication of chronic otitis media. The neurologic symptoms and the CT-scan were essential for the exact diagnosis. The following treatment includes the surgical revision of the middle ear, the abscess-drainage as well as the lavage of the cavity with antibiotics.

[Pathology of the cerebellopontine angle]

The pathology of the cistern of the cerebellopontine angle is primarily that of the nervous and vascular structures that it contains and of the meninges that line it. Knowledge of its anatomy makes it possible to understand and search for a rare pathology, the hemifacial spasm, due to a conflict between the facial nerve and the vertebral artery and the posterior inferior cerbellerar artery. However, the pathology of the cerebellopontine angle remains especially tumoral. Imaging should not only make the diagnosis but also make an exhaustive, pretherapy, and accurate assessment of the three main tumours found in this area: the vestibular schwannoma, the meningioma, and the epidermoid cyst.

The cerebellum and emotional experience

While the role of the cerebellum in motor coordination is widely accepted, the notion that it is involved in emotion has only recently gained popularity. To date, functional neuroimaging has not been used in combination with lesion studies to elucidate the role of the cerebellum in the processing of emotional material. We examined six participants with cerebellar stroke and nine age and education matched healthy volunteers. In addition to a complete neuropsychological, neurologic, and psychiatric examination, participants underwent [15O]water positron emission tomography (PET) while responding to emotion-evoking visual stimuli. Cerebellar lesions were associated with reduced pleasant experience in response to happiness-evoking stimuli. Stroke patients reported an unpleasant experience to frightening stimuli similar to healthy controls, yet showed significantly lower activity in the right ventral lateral and left dorsolateral prefrontal cortex, amygdala, thalamus, and retrosplenial cingulate gyrus. Frightening stimuli led to increased activity in the ventral medial prefrontal, anterior cingulate, pulvinar, and insular cortex. This suggests that alternate neural circuitry became responsible for maintaining the evolutionarily critical fear response after cerebellar damage.

Pediatric infratentorial subdural empyema: analysis of 14 cases

OBJECT

Pediatric cases of infratentorial subdural empyema (SDE) are both rare and associated with high rates of morbidity and mortality. The goal of this study was to report patient characteristics, treatment, and outcome in an exclusively pediatric series of SDE cases.

METHODS

A series of 14 pediatric cases of infratentorial SDE was retrospectively analyzed. All patients were treated between 1994 and 2004. Sixty-four percent of the patients were boys; the majority of cases occurred during the summer months. Clinical features included headache, fever, vomiting, meningism, and otorrhea. Cerebellar signs were found only in 21% of patients. In 85.7% of the cases, the patients presented with a depressed level of consciousness (Glasgow Coma Scale Scores 11-15). In 79.6%, pus collection was seen over the cerebellar convexity; interhemispheric and tentorial collections were also observed in some cases. Hydrocephalus was present in 92.9% of patients. Five patients required external ventricular drainage during surgery or postoperatively. Shunt placement was required in 21% of cases. All patients were treated with antibiotic therapy and surgery (bur holes in 21% of the cases, craniectomy in 79%). Pus cultures demonstrated microbial infection in 71.4%, and polymicrobial infection in 21%. Four patients required repeated surgery for reaccumulation of pus. Minor postoperative complications developed in three patients. All 14 patients survived. At follow up, the Glasgow Outcome Scale scores were 4 or 5 in all cases.

CONCLUSIONS

Early diagnosis and prompt surgical treatment are crucial in cases of SDE. With appropriate surgery, antibiotic therapy, and management of hydrocephalus, good outcome can be expected.