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Hoffmann-Lamplmair D, Leiss U, Peyrl A, Slavc I, Czech T, Gram A, Pletschko T. Evaluating the diagnostic validity of the Cerebellar Cognitive Affective Syndrome (CCAS) in pediatric posterior fossa tumour patients. Neurooncol Adv 2022; 4:vdac065. [PMID: 35694105 PMCID: PMC9175301 DOI: 10.1093/noajnl/vdac065] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background The aim of this case-control study was to investigate the severity of the cerebellar cognitive affective syndrome (CCAS) in patients treated for pediatric posterior fossa tumors (PFT) and evaluate its diagnostic validity and predictive value for long-term effects. Methods Using neuropsychological test data from 56 patients with PFT (average age: 14 years), the severity of deficits in the CCAS core areas (executive functions, verbal functions, visuospatial abilities and emotions/behaviour) was examined. Neuropsychological and academic long-term outcomes of patients with CCAS were compared to two control groups of PFT patients (treated with either surgery or surgery followed by radio-/chemotherapy) without the syndrome. Risk factors associated with various deficits were considered. Results All but one PFT patient suffered from slight to severe impairments in at least one CCAS domain, while complete CCAS occurred in 35.7%. Seven years after tumor diagnosis CCAS patients performed worse in information processing, logical reasoning, verbal functions, visuospatial skills, and executive functioning and required more special educational support compared to the control groups. CCAS patients performed equally poor as patients treated with chemo-/radiotherapy in tasks measuring information processing speed. Risk factors were significantly associated with deficits in information processing speed but not CCAS emergence. Conclusions Deficits in the core CCAS domains are commonly found in PFT patients, but varying in severity, which suggests the syndrome to be continuous rather than dichotomous. However, the validity of CCAS diagnosis was low and unspecific. The exclusion of relevant functions typically impaired in PFT patients (eg, information processing) resulted in difficulties being overlooked.
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Affiliation(s)
- Doris Hoffmann-Lamplmair
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center Pediatrics Vienna, Medical University of Vienna, Vienna, Austria
| | - Ulrike Leiss
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center Pediatrics Vienna, Medical University of Vienna, Vienna, Austria
| | - Andreas Peyrl
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center Pediatrics Vienna, Medical University of Vienna, Vienna, Austria
| | - Irene Slavc
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center Pediatrics Vienna, Medical University of Vienna, Vienna, Austria
| | - Thomas Czech
- Comprehensive Center Pediatrics Vienna, Medical University of Vienna, Vienna, Austria
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Alexandra Gram
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center Pediatrics Vienna, Medical University of Vienna, Vienna, Austria
| | - Thomas Pletschko
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center Pediatrics Vienna, Medical University of Vienna, Vienna, Austria
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Structural damage burden and hypertrophic olivary degeneration in pediatric postoperative cerebellar mutism syndrome. Neurosurg Rev 2022; 45:2757-2765. [PMID: 35441993 PMCID: PMC9349162 DOI: 10.1007/s10143-022-01791-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/18/2022] [Accepted: 04/12/2022] [Indexed: 11/25/2022]
Abstract
Cerebellar mutism syndrome (CMS) occurs in one out of four children after posterior fossa tumor surgery, with open questions regarding risk factors, pathophysiology, and prevention strategies. Because of similarities between several cerebellar syndromes, a common pathophysiology with damage to the dentato-thalamo-cortical and dentato-rubro-olivary pathways has been proposed. Hypertrophic olivary degeneration (HOD) is an imaging correlate of cerebellar injury observed for instance in stroke patients. Aim of this study was to investigate whether the occurrence and severity of CMS correlates with the extent of damage to the relevant anatomical structures and whether HOD is a time-dependent postoperative neuroimaging correlate of CMS. We performed a retrospective single center study of CMS patients compared with matched non-CMS controls. CMS occurred in 10 children (13% of the overall cohort) with a median age of 8 years. Dentate nucleus (DN) injury significantly correlated with CMS, and superior cerebellar peduncle (SCP) injury was associated by tendency. HOD was observed as a dynamic neuroimaging phenomenon in the postoperative course and its presence significantly correlated with CMS and DN injury. Children who later developed HOD had an earlier onset and tended to have longer persistence of CMS. These findings can guide surgical measures to protect the DN and SCP during posterior fossa tumor resections and to avoid a high damage burden (i.e., bilateral damage). Development of intraoperative neuromonitoring of the cerebellar efferent pathways as well as improved preoperative risk stratification could help to establish a patient-specific strategy with optimal balance between degree of resection and functional integrity.
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Wickenhauser ME, Khan RB, Raches D, Ashford JM, Russell KMW, Lyons K, Robinson GW, Gajjar A, Klimo P, Conklin HM. The posterior fossa syndrome questionnaire: using science to inform practice. J Neurooncol 2022; 157:465-473. [PMID: 35380295 PMCID: PMC10146631 DOI: 10.1007/s11060-022-03990-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/17/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Up to 34% of patients with medulloblastoma develop posterior fossa syndrome (PFS) following brain tumor resection and have increased risk of long-term neurocognitive impairments. Lack of agreement in conceptualization and diagnosis of PFS calls for improvements in diagnostic methods. The current study aimed to describe psychometric properties of a new posterior fossa syndrome questionnaire (PFSQ). METHODS The PFSQ was informed by prior research and developed by a multidisciplinary team with subject matter expertise. Participants (N = 164; 63.4% Male; 78.7% White; Mage at diagnosis = 10.38 years, SD = 5.09, range 3-31 years) included patients with newly diagnosed medulloblastoma enrolled in the SJMB12 clinical trial. Forty-four patients (26.8%) were classified as having PFS based on attending physician's post-surgical yes/no report. A PFSQ was completed by a neurologist within 2 weeks of coming to St. Jude Children's Research Hospital for adjuvant treatment, irrespective of suspicion for PFS. RESULTS PFSQ items ataxia (100.00%), dysmetria (95.45%), and speech/language changes (79.55%) were most sensitive. However, ataxia (26.50%) and dysmetria (46.61%) demonstrated low specificity. Speech/language changes (81.36%), mutism (95.76%), orofacial apraxia (98.29%) and irritability (96.61%) had high specificity. A principal component analysis found four components: (1) speech/language changes, (2) apraxias (including mutism), (3) motor/oromotor, and (4) emotional lability. CONCLUSIONS The PFSQ is a dimensional diagnostic approach that can be used to improve diagnostic consistency across clinical and research groups to help accelerate understanding of PFS etiology, identify surgical correlates of risk, predict long-term impairments, and develop targeted interventions. Additional measure validation, including correlation with symptom resolution, is required.
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Affiliation(s)
| | - Raja B Khan
- Division of Neurology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Darcy Raches
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jason M Ashford
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kathryn M W Russell
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kristin Lyons
- Rehabilitation Services, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Giles W Robinson
- Division of Neuro-Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Amar Gajjar
- Division of Neuro-Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee, Memphis, TN, USA
| | - Heather M Conklin
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA.
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54
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Cerebellar mutism syndrome in pediatric head trauma with cerebellar injury. Childs Nerv Syst 2022; 38:759-766. [PMID: 34993606 DOI: 10.1007/s00381-021-05422-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 11/24/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE Cerebellar mutism syndrome (CMS) after cerebellar injury in pediatric head trauma is a poorly recognized condition that is not properly diagnosed or treated in our daily practice. We aimed to clinically identify this syndrome after isolated posttraumatic cerebellar injury and to propose pathophysiological explanation. METHODS We retrospectively analyzed 8 consecutive children presenting with isolated cerebellar injury over 16 years. Clinical presentation, radiological type and localization of injury, clinical initial CMS symptoms, and long-term neurocognitive outcome were reviewed. RESULTS Out of 8 patients presenting with isolated traumatic cerebellar injury, we diagnosed 2 cases with initial clinical symptoms of CMS. Both patients had an injury damaging median structures of the posterior fossa, especially the fourth ventricle and dentate nuclei. Initial symptoms lasted more than 1 month for one patient, who still presented concentration difficulties almost 1 year after the head injury. CONCLUSION CMS after traumatic cerebellar injury does exist, even if it seems to be a very rare entity. It has to be better detected and studied in order to enrich pathophysiological knowledge about CMS of all etiologies and to bring our concerned patients the suitable follow-up and rehabilitative care that they could benefit from.
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Onorini N, Spennato P, Orlando V, Savoia F, Calì C, Russo C, De Martino L, de Santi MS, Mirone G, Ruggiero C, Quaglietta L, Cinalli G. The Clinical and Prognostic Impact of the Choice of Surgical Approach to Fourth Ventricular Tumors in a Single-Center, Single-Surgeon Cohort of 92 Consecutive Pediatric Patients. Front Oncol 2022; 12:821738. [PMID: 35280797 PMCID: PMC8912940 DOI: 10.3389/fonc.2022.821738] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Objective A single-institution cohort of 92 consecutive pediatric patients harboring tumors involving the fourth ventricle, surgically treated via the telovelar or transvermian approach, was retrospectively reviewed in order to analyze the impact of surgical route on surgery-related outcomes and cumulative survival. Methods Clinical, radiological, surgical, and pathology details were retrospectively analyzed. We selected n = 6 surgery-related clinical and radiological outcomes: transient and permanent neurological deficits, duration of assisted ventilation, postoperative new onset medical events, postoperative cerebellar mutism, and extent of resection. We built univariate and multivariate logistic models to analyze the significance of relationships between the surgical routes and the outcomes. Cumulative survival (CS) was estimated by the cohort approach. Results There were 53 girls and 39 boys (mean age, 83 months). Telovelar approach was performed in 51 cases and transvermian approach in 41 cases. Early postoperative MRI studies showed complete removal in 57 cases (62%) and measurable residual tumor in 35 cases (38%). The average tumor residual volume was 1,316 cm3 (range, 0.016-4.231 cm3; median value, 0.9875 cm3). Residual disease was more often detected on immediate postop MRI after telovelar approach, but the difference was not significant. Cerebellar mutism was observed in 10 cases (11%). No significant difference in the onset of cerebellar mutism was detected between telovelar and transvermian approach. The choice of surgical approach did not significantly modify any other postoperative outcome and 1-/3-year CS of high-grade surgically treated tumors. Conclusions With the limitation of a single-center, single-surgeon retrospective series, our findings offer significant data to reconsider the real impact of the choice of the surgical route to the fourth ventricle on the incidence of cerebellar mutism and surgery-related morbidity. This seems to be in line with some recent reports in the literature. Surgical approach to the fourth ventricle should be individualized according to the location of the tumor, degree of vermian infiltration, and lateral and upward extension. Telovelar and transvermian approaches should not be considered alternative but complementary. Pediatric neurosurgeons should fully master both approaches and choose the one that they consider the best for the patient based on a thorough and careful evaluation of pre-operative imaging.
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Affiliation(s)
- Nicola Onorini
- Department of Pediatric Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Pietro Spennato
- Department of Pediatric Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Valentina Orlando
- Department of Pediatric Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy.,Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Fabio Savoia
- Evaluative Epidemiology-Childhood Cancer Registry of Campania, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Camilla Calì
- Evaluative Epidemiology-Childhood Cancer Registry of Campania, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Carmela Russo
- Department of Pediatric Neurosciences, Pediatric Neuroradiology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Lucia De Martino
- Department of Pediatric Neurosciences, Pediatric Neuro-Oncology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Maria Serena de Santi
- Department of Pediatric Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Giuseppe Mirone
- Department of Pediatric Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Claudio Ruggiero
- Department of Pediatric Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Lucia Quaglietta
- Department of Pediatric Neurosciences, Pediatric Neuro-Oncology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Giuseppe Cinalli
- Department of Pediatric Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
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Aarsen FK, van Veelen-Vincent MLC, Partanen M, Catsman-Berrevoets CE. Perioperative risk factors for long-term intelligence in children with postoperative cerebellar mutism syndrome after medulloblastoma surgery. Pediatr Blood Cancer 2022; 69:e29536. [PMID: 34971023 DOI: 10.1002/pbc.29536] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/29/2021] [Accepted: 11/17/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Approximately 7%-50% of children with medulloblastoma (MB) develop postoperative cerebellar mutism syndrome (pCMS). pCMS has a short-term negative impact on intelligence, but effects on long-term outcomes are contradictory. The aim of this study was to assess long-term effects of pCMS in MB patients on aspects of intelligence quotient (IQ) and its perioperative risk factors. METHODS In this single-center retrospective cohort study, 31 children were included (14 pCMS). Perioperative risk factors included brainstem invasion, vermis incision, hydrocephalus, tumor size, severity of pCMS, neurological symptoms, mean body temperature (BT) on days 1-4 post surgery, and age at resection. Age-appropriate Wechsler Intelligence tests were assessed at least 2 years after tumor resection. RESULTS Mean interval between tumor resection and neuropsychological evaluation was 3.9 years in pCMS and 4 years and 11 months in the no-pCMS group. No significant differences in IQ scores were found between groups. The pCMS group had a clinically relevant difference of 10 points when compared to age norms on verbal IQ (VIQ). Bilateral pyramidal and swallowing problems were risk factors for lower performance. In the overall group, tumor size, younger age at surgery, and raised mean BT were negatively correlated with aspects of IQ. CONCLUSIONS We found a clinically significant reduction of VIQ in the pCMS patient group. pCMS patients with a larger tumor size, younger age at surgery, a higher mean BT in the first days after surgery, bilateral pyramidal symptoms, and swallowing problems 10 days post surgery are more at risk for VIQ deficits at long-term.
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Affiliation(s)
- Femke K Aarsen
- Pediatric Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Marita Partanen
- Pediatric Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Coriene E Catsman-Berrevoets
- Department of Paediatric Neurology, Erasmus MC/Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Paediatric Neurosurgery, Erasmus MC/Sophia Children's Hospital, Rotterdam, The Netherlands
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Basilar Artery Vasospasm as a Cause of Post-Operative Cerebellar Mutism Syndrome. Case Rep Pediatr 2022; 2022:9148100. [PMID: 35186341 PMCID: PMC8853815 DOI: 10.1155/2022/9148100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 12/20/2021] [Accepted: 01/18/2022] [Indexed: 11/17/2022] Open
Abstract
Post-operative cerebellar mutism syndrome (CMS), also known as posterior fossa syndrome (PFS), is a well-recognized and frequent complication of surgery for posterior fossa tumours in children and young people. Its incidence varies between 8 and 31%, and the pathophysiological mechanisms of delayed onset and resolution of cerebellar mutism are not clear, but axonal damage, oedema, and perfusion defects may be involved. Magnetic resonance imaging has failed to reveal a universal anatomical substrate or a single definite mechanism of injury. We present a case of 16-year-old boy who developed CMS three days after resection of a medulloblastoma, a primary fourth ventricular tumour. Early post-operative imaging showed bleeding in the posterior fossa which required evacuation. CT angiography seven days after surgery demonstrated basilar artery vasospasm. Magnetic resonance brain angiography confirmed persistent narrowing of a segment of the basilar artery closely related to a left cerebellopontine (CP) angle peri-operative haematoma. The patient was treated with nimodipine and hypervolemia. The patient started vocalisation without speech five days later with reversal of radiological lesions. Further recovery of post-operative neurological deficits occurred over a protracted period of several months. This case represents a rare cause of post-operative CMS, with rapid initial recovery that occurred after specific treatment directed at the cause. To our knowledge, this is the first reported case showing mutism associated with basilar artery vasospasm with imaging evidence. This case may suggest the need to undertake urgent vascular imaging in selected cases of post-operative CMS.
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58
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Sidpra J, Marcus AP, Löbel U, Toescu SM, Yecies D, Grant G, Yeom K, Mirsky DM, Marcus HJ, Aquilina K, Mankad K. Improved prediction of postoperative paediatric cerebellar mutism syndrome using an artificial neural network. Neurooncol Adv 2022; 4:vdac003. [PMID: 35233531 PMCID: PMC8882257 DOI: 10.1093/noajnl/vdac003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Postoperative paediatric cerebellar mutism syndrome (pCMS) is a common but severe complication which may arise following the resection of posterior fossa tumours in children. Two previous studies have aimed to preoperatively predict pCMS, with varying results. In this work, we examine the generalisation of these models and determine if pCMS can be predicted more accurately using an artificial neural network (ANN).
Methods
An overview of reviews was performed to identify risk factors for pCMS, and a retrospective dataset collected as per these defined risk factors from children undergoing resection of primary posterior fossa tumours. The ANN was trained on this dataset and its performance evaluated in comparison to logistic regression and other predictive indices via analysis of receiver operator characteristic curves. Area under the curve (AUC) and accuracy were calculated and compared using a Wilcoxon signed rank test, with p<0.05 considered statistically significant.
Results
204 children were included, of whom 80 developed pCMS. The performance of the ANN (AUC 0.949; accuracy 90.9%) exceeded that of logistic regression (p<0.05) and both external models (p<0.001).
Conclusion
Using an ANN, we show improved prediction of pCMS in comparison to previous models and conventional methods.
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Affiliation(s)
- Jai Sidpra
- University College London Medical School, London, WC1E 6DE, UK
- Developmental Biology and Cancer Section, University College London Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Adam P Marcus
- Department of Brain Sciences and Computing, Imperial College London, London, SW7 2BU, UK
| | - Ulrike Löbel
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Sebastian M Toescu
- Department of Neurosurgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
- Developmental Imaging and Biophysics Section, University College London Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Derek Yecies
- Department of Neurosurgery, Lucile Packard Children’s Hospital, Stanford, CA 94304, USA
| | - Gerald Grant
- Department of Neurosurgery, Lucile Packard Children’s Hospital, Stanford, CA 94304, USA
| | - Kristen Yeom
- Department of Neuroradiology, Lucile Packard Children’s Hospital, Stanford, CA 94304, USA
| | - David M Mirsky
- Department of Radiology, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Hani J Marcus
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, WC1N 3BG, UK
- Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, London, WC1E 6BT, UK
| | - Kristian Aquilina
- Developmental Biology and Cancer Section, University College London Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Neurosurgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Kshitij Mankad
- Developmental Biology and Cancer Section, University College London Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
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Chen KT, Ho TY, Siow TY, Yeh YC, Huang SY. OUP accepted manuscript. Cereb Cortex Commun 2022; 3:tgac008. [PMID: 35281215 PMCID: PMC8914218 DOI: 10.1093/texcom/tgac008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/08/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ko-Ting Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan
- School of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Neuroscience Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan
| | - Tsung-Ying Ho
- Department of Nuclear Medicine and Molecular Imaging Center, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan 333, Taiwan
| | - Tiing-Yee Siow
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan
| | - Yu-Chiang Yeh
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan
| | - Sheng-Yao Huang
- Corresponding author: Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan.
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Acharya S, Guo Y, Patni T, Li Y, Wang C, Gargone M, Ashford JM, Wilson L, Faught A, Reddick WE, Patay Z, Gajjar A, Conklin HM, Merchant TE. Association Between Brain Substructure Dose and Cognitive Outcomes in Children With Medulloblastoma Treated on SJMB03: A Step Toward Substructure-Informed Planning. J Clin Oncol 2022; 40:83-95. [PMID: 34714708 PMCID: PMC8683226 DOI: 10.1200/jco.21.01480] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/31/2021] [Accepted: 09/29/2021] [Indexed: 01/03/2023] Open
Abstract
PURPOSE To characterize the association between neurocognitive outcomes (memory and processing speed) and radiation (RT) dose to the hippocampus, corpus callosum (CC), and frontal white matter (WM) in children with medulloblastoma treated on a prospective study, SJMB03. PATIENTS AND METHODS Patients age 3-21 years with medulloblastoma were treated at a single institution on a phase III study. The craniospinal RT dose was 23.4 Gy for average-risk patients and 36-39.6 Gy for high-risk patients. The boost dose was 55.8 Gy to the tumor bed. Patients underwent cognitive testing at baseline and once yearly for 5 years. Performance on tests of memory (associative memory and working memory) and processing speed (composite processing speed and perceptual speed) was analyzed. Mixed-effects models were used to estimate longitudinal trends in neurocognitive outcomes. Reliable change index and logistic regression were used to define clinically meaningful neurocognitive decline and identify variables associated with decline. RESULTS One hundred and twenty-four patients were eligible for inclusion, with a median neurocognitive follow-up of 5 years. Mean right and left hippocampal doses were significantly associated with decline in associative memory in patients without posterior fossa syndrome (all P < .05). Mean CC and frontal WM doses were significantly associated with decline in both measures of processing speed (all P < .05). Median brain substructure dose-volume histograms were shifted to the right for patients with a decline in associative memory or processing speed. The odds of decline in associative memory and composite processing speed increased by 23%-26% and by 10%-15% for every 1-Gy increase in mean hippocampal dose and mean CC or frontal WM dose, respectively. CONCLUSION Increasing RT dose to the CC or frontal WM and hippocampus is associated with worse performance on tests of processing speed and associative memory, respectively. Brain substructure-informed RT planning may mitigate neurocognitive impairment.
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Affiliation(s)
- Sahaja Acharya
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, TN
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medicine, Baltimore, MD
| | - Yian Guo
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - Tushar Patni
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - Yimei Li
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - Chuang Wang
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Melissa Gargone
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Jason M. Ashford
- Department of Psychology, St Jude Children's Research Hospital, Memphis, TN
| | - Lydia Wilson
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Austin Faught
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Wilburn E. Reddick
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, Memphis, TN
| | - Zoltan Patay
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, Memphis, TN
| | - Amar Gajjar
- Division of Neuro-Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Heather M. Conklin
- Department of Psychology, St Jude Children's Research Hospital, Memphis, TN
| | - Thomas E. Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, TN
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Ricci FS, D’Alessandro R, Somà A, Salvalaggio A, Rossi F, Rampone S, Gamberini G, Davico C, Peretta P, Cacciacarne M, Gaglini P, Pacca P, Pilloni G, Ragazzi P, Bertin D, Vallero SG, Fagioli F, Vitiello B. Development and application of a diagnostic and severity scale to grade post-operative pediatric cerebellar mutism syndrome. Eur J Pediatr 2022; 181:941-950. [PMID: 34651204 PMCID: PMC8897365 DOI: 10.1007/s00431-021-04290-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/03/2021] [Accepted: 10/04/2021] [Indexed: 11/24/2022]
Abstract
The post-operative pediatric cerebellar mutism syndrome (CMS) affects about one-third of children and adolescents following surgical removal of a posterior fossa tumor (PFT). According to the Posterior Fossa Society consensus working definition, CMS is characterized by delayed-onset mutism/reduced speech and emotional lability after cerebellar or 4th ventricle tumor surgery in children, and is frequently accompanied by additional features such as hypotonia and oropharyngeal dysfunction/dysphagia. The main objective of this work was to develop a diagnostic scale to grade CMS duration and severity. Thirty consecutively referred subjects, aged 1-17 years (median 8 years, IQR 3-10), were evaluated with the proposed Post-Operative Pediatric CMS Survey after surgical resection of a PFT and, in case of CMS, for 30 days after the onset (T0) or until symptom remission. At day 30 (T1), CMS was classified into mild, moderate, or severe according to the proposed scale. CMS occurred in 13 patients (43%, 95% C.I.: 25.5-62.6%), with mild severity in 4 cases (31%), moderate in 4 (31%), and severe in 5 (38%). At T1, longer symptom persistence was associated with greater severity (p = 0.01). Greater severity at T0 predicted greater severity at T1 (p = 0.0001). Children with a midline tumor location and those aged under 5 years at diagnosis were at higher risk of CMS (p = 0.025 and p = 0.008, respectively). In conclusion, the proposed scale is a simple and applicable tool for estimating the severity of CMS at its onset, monitoring its course over time, and providing an early prognostic stratification to guide treatment decisions.
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Affiliation(s)
- Federica S. Ricci
- grid.7605.40000 0001 2336 6580Section of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy ,Section of Child and Adolescent Neuropsychiatry, Children’s Hospital “Regina Margherita”, Piazza Polonia 94, 10126 Torino, Italy
| | - Rossella D’Alessandro
- grid.7605.40000 0001 2336 6580Section of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Alessandra Somà
- grid.7605.40000 0001 2336 6580Section of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Anna Salvalaggio
- grid.7605.40000 0001 2336 6580Section of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Francesca Rossi
- grid.7605.40000 0001 2336 6580Section of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Sara Rampone
- Child and Adolescent Neuropsychiatry Unit, Arrigo Hospital, Alessandria, Italy
| | - Giorgia Gamberini
- grid.7605.40000 0001 2336 6580Section of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Chiara Davico
- grid.7605.40000 0001 2336 6580Section of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Paola Peretta
- Section of Pediatric Neurosurgery, Children’s Hospital “Regina Margherita”, Torino, Italy
| | - Mario Cacciacarne
- Section of Pediatric Neurosurgery, Children’s Hospital “Regina Margherita”, Torino, Italy
| | - Pierpaolo Gaglini
- Section of Pediatric Neurosurgery, Children’s Hospital “Regina Margherita”, Torino, Italy
| | - Paolo Pacca
- Section of Pediatric Neurosurgery, Children’s Hospital “Regina Margherita”, Torino, Italy
| | - Giulia Pilloni
- Section of Pediatric Neurosurgery, Children’s Hospital “Regina Margherita”, Torino, Italy
| | - Paola Ragazzi
- Section of Pediatric Neurosurgery, Children’s Hospital “Regina Margherita”, Torino, Italy
| | - Daniele Bertin
- grid.7605.40000 0001 2336 6580Section of Pediatric Onco-Hematology, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Stefano G. Vallero
- grid.7605.40000 0001 2336 6580Section of Pediatric Onco-Hematology, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Franca Fagioli
- grid.7605.40000 0001 2336 6580Section of Pediatric Onco-Hematology, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Benedetto Vitiello
- grid.7605.40000 0001 2336 6580Section of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
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Bhaisora K, Datta A, Kumar A, Singh S, Srivastava A, Sardhara J, Das K, Mehrotra A, Jaiswal A, Behari S. Factors predicting “postoperative cerebellar mutism syndrome’’ after posterior fossa tumor excision in pediatric patients. J Pediatr Neurosci 2022. [DOI: 10.4103/jpn.jpn_38_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Boisgontier J, Fillon L, Rutten C, Saitovitch A, Dufour C, Lemaître H, Beccaria K, Blauwblomme T, Levy R, Dangouloff-Ros V, Grévent D, Roux CJ, Grill J, Vinçon-Leite A, Saidoun L, Bourdeaut F, Zilbovicius M, Boddaert N, Puget S. A CBF decrease in the left supplementary motor areas: New insight into postoperative pediatric cerebellar mutism syndrome using arterial spin labeling perfusion MRI. J Cereb Blood Flow Metab 2021; 41:3339-3349. [PMID: 34259072 PMCID: PMC8669281 DOI: 10.1177/0271678x211031321] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Postoperative pediatric cerebellar mutism syndrome (pCMS), characterized mainly by delayed onset transient mutism is a poorly understood complication that may occur after pediatric medulloblastoma (MB) resection. Our aim was to investigate postoperative changes in whole-brain cerebral blood flow (CBF) at rest in pCMS patients using arterial spin labeling (ASL) perfusion imaging. This study compared preoperative and postoperative T2-weighted signal abnormalities and CBF using a voxel-wise, whole-brain analysis in 27 children undergoing MB resection, including 11 patients who developed mutism and 16 who did not. Comparison of postoperative T2 signal abnormalities between patients who developed pCMS (mean age 7.0 years) and those who did not showed that pCMS (mean age 8.9 years) patients were significantly more likely to present with T2-weighted hyperintensities in the right dentate nucleus (DN) (p = 0.02). Comparison of preoperative and postoperative CBF in patients with pCMS showed a significant postoperative CBF decrease in the left pre-supplementary motor area (pre-SMA) (p = 0.007) and SMA (p = 0.009). In patients who did not develop pCMS, no significant differences were observed. Findings provide evidence of an association between pCMS, injury to the right DN, and left pre-SMA/SMA hypoperfusion, areas responsible for speech. This supports the relevance of CBF investigations in pCMS.
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Affiliation(s)
- Jennifer Boisgontier
- Paediatric Radiology Department, AP-HP, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France.,Université de Paris, Institut Imagine INSERM U1163, Paris, France
| | - Ludovic Fillon
- Université de Paris, Institut Imagine INSERM U1163, Paris, France
| | - Caroline Rutten
- Paediatric Radiology Department, AP-HP, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France
| | - Ana Saitovitch
- Université de Paris, Institut Imagine INSERM U1163, Paris, France
| | - Christelle Dufour
- Peadiatric and Adolescent Oncology, Institut Gustave Roussy, Villejuif, France
| | - Hervé Lemaître
- Neurofunctional Imaging Group (GIN), Neurodegenerative Diseases Institute, UMR 5293, Bordeaux University, Bordeaux, France
| | - Kévin Beccaria
- Paediatric Neurosurgery Department, AP-HP, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France
| | - Thomas Blauwblomme
- Paediatric Neurosurgery Department, AP-HP, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France
| | - Raphaël Levy
- Paediatric Radiology Department, AP-HP, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France
| | - Volodia Dangouloff-Ros
- Paediatric Radiology Department, AP-HP, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France.,Université de Paris, Institut Imagine INSERM U1163, Paris, France
| | - David Grévent
- Paediatric Radiology Department, AP-HP, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France.,Université de Paris, Institut Imagine INSERM U1163, Paris, France
| | - Charles-Joris Roux
- Paediatric Radiology Department, AP-HP, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France
| | - Jacques Grill
- Peadiatric and Adolescent Oncology, Institut Gustave Roussy, Villejuif, France
| | | | - Lila Saidoun
- Peadiatric and Adolescent Oncology, Institut Gustave Roussy, Villejuif, France
| | - Franck Bourdeaut
- SIREDO Pediatric Oncology Center, Institut Curie, Paris-Science Lettres University, Paris, France
| | - Monica Zilbovicius
- Université de Paris, Institut Imagine INSERM U1163, Paris, France.,INSERM ERL "Developmental Trajectories & Psychiatry": Université Paris Saclay, Ecole Normale Supérieure Paris-Saclay, Université de Paris, CNRS, Centre Borelli, Paris, France
| | - Nathalie Boddaert
- Paediatric Radiology Department, AP-HP, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France.,Université de Paris, Institut Imagine INSERM U1163, Paris, France.,INSERM ERL "Developmental Trajectories & Psychiatry": Université Paris Saclay, Ecole Normale Supérieure Paris-Saclay, Université de Paris, CNRS, Centre Borelli, Paris, France
| | - Stéphanie Puget
- Paediatric Neurosurgery Department, AP-HP, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France
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Grønbæk JK, Wibroe M, Toescu S, Frič R, Thomsen BL, Møller LN, Grillner P, Gustavsson B, Mallucci C, Aquilina K, Fellows GA, Molinari E, Hjort MA, Westerholm-Ormio M, Kiudeliene R, Mudra K, Hauser P, van Baarsen K, Hoving E, Zipfel J, Nysom K, Schmiegelow K, Sehested A, Juhler M, Mathiasen R. Postoperative speech impairment and surgical approach to posterior fossa tumours in children: a prospective European multicentre cohort study. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 5:814-824. [PMID: 34624241 DOI: 10.1016/s2352-4642(21)00274-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/16/2021] [Accepted: 08/17/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Brain tumours are the most common solid tumours in childhood. Half of these tumours occur in the posterior fossa, where surgical removal is complicated by the risk of cerebellar mutism syndrome, of which postoperative speech impairment (POSI) is a cardinal symptom, in up to 25% of patients. The surgical approach to midline tumours, mostly undertaken by transvermian or telovelar routes, has been proposed to influence the risk of POSI. We aimed to investigate the risk of developing POSI, the time course of its resolution, and its association with surgical approach and other clinical factors. METHODS In this observational prospective multicentre cohort study, we included children (aged <18 years) undergoing primary surgery for a posterior fossa tumour at 26 centres in nine European countries. Within 72 h of surgery, the operating neurosurgeon reported details on the tumour location, surgical approach used, duration of surgery, use of traction, and other predetermined factors, using a standardised surgical report form. At 2 weeks, 2 months, and 1 year after surgery, a follow-up questionnaire was filled out by a paediatrician or neurosurgeon, including neurological examination and assessment of speech. Speech was classified as mutism, reduced speech, or habitual speech. POSI was defined as either mutism or severely reduced speech. Ordinal logistic regression was used to analyse the risk of POSI. FINDINGS Between Aug 11, 2014, and Aug 24, 2020, we recruited 500 children. 426 (85%) patients underwent primary tumour surgery and had data available for further analysis. 192 (45%) patients were female, 234 (55%) patients were male, 81 (19%) patients were aged 0-2 years, 129 (30%) were aged 3-6 years, and 216 (51%) were aged 7-17 years. 0f 376 with known postoperative speech status, 112 (30%) developed POSI, 53 (14%) developed mutism (median 1 day [IQR 0-2]; range 0-10 days), and 59 (16%) developed reduced speech after surgery (0 days [0-1]; 0-4 days). Mutually adjusted analyses indicated that the independent risk factors for development of POSI were younger age (linear spline, p=0·0087), tumour location (four levels, p=0·0010), and tumour histology (five levels, p=0·0030); surgical approach (six levels) was not a significant risk factor (p=0·091). Tumour location outside the fourth ventricle and brainstem had a lower risk of POSI (with fourth ventricle as reference, odds ratio (OR) for cerebellar vermis 0·34 [95% CI 0·14-0·77] and OR for cerebellar hemispheres 0·23 [0·07-0·70]). Compared with pilocytic or pilomyxoid astrocytoma, a higher risk of POSI was seen for medulloblastoma (OR 2·85 [1·47-5·60]) and atypical teratoid rhabdoid tumour (10·30 [2·10-54·45]). We did not find an increased risk of POSI for transvermian surgical approach compared with telovelar (0·89 [0·46-1·73]). Probability of speech improvement from mutism reached 50% around 16 days after mutism onset. INTERPRETATION Our data suggest that a midline tumour location, younger age, and high-grade tumour histology all increase the risk of speech impairment after posterior fossa tumour surgery. We found no evidence to recommend a preference for telovelar over transvermian surgical approach in the management of posterior fossa tumours in children in relation to the risk of developing POSI. FUNDING The Danish Childhood Cancer Foundation, the Swedish Childhood Cancer Foundation, the UK Brain Tumour Charity, the Danish Cancer Society, Det Kgl Kjøbenhavnske Skydeselskab og Danske Broderskab, the Danish Capitol Regions Research Fund, Dagmar Marshall Foundation, Rigshospitalet's Research Fund, and Brainstrust.
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Affiliation(s)
- Jonathan Kjær Grønbæk
- Department of Neurosurgery, The University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Morten Wibroe
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Sebastian Toescu
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK; Developmental Imaging and Biophysics Section, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Radek Frič
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | | | - Lisbeth Nørgaard Møller
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Pernilla Grillner
- Pediatric Oncology Unit, Astrid Lindgrens Childrens Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Bengt Gustavsson
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Conor Mallucci
- Department of Paediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
| | - Greg Adam Fellows
- Department of Paediatric Neurosurgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Emanuela Molinari
- Department of Neurology, The Queen Elizabeth University Hospital, University of Glasgow, Glasgow, UK
| | - Magnus Aasved Hjort
- Department of Pediatric Hematology and Oncology, St Olavs Hospital, Trondheim, Norway
| | | | - Rosita Kiudeliene
- Center of Pediatric Oncology and Hematology at Pediatric Department and Hospital of Kauno Klinikos, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Katalin Mudra
- 2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Peter Hauser
- 2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary; Pediatric Oncology and Transplantation Unit, Velkey László Child's Health Center, Borsod-Abaúj-Zemplén County University Teaching Hospital, Miskolc, Hungary
| | | | - Eelco Hoving
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Julian Zipfel
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany
| | - Karsten Nysom
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Astrid Sehested
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, The University Hospital Rigshospitalet, Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
| | - René Mathiasen
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark.
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Docking KM, Knijnik SR. Prospective longitudinal decline in cognitive-communication skills following treatment for childhood brain tumor. Brain Inj 2021; 35:1472-1479. [PMID: 34495783 DOI: 10.1080/02699052.2021.1970806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The effect of childhood brain tumor and its treatments on the developing brain are recognized to cause late-occurring structural and functional changes, inclusive of neurocognitive and communication disturbances. AIMS The aim of the present study was to investigate changes in function in the prospective cognitive-communication and language abilities of two children surviving childhood brain tumor (CBT) over a 12-month period post-treatment. METHODS The comprehensive language and cognitive-communication abilities of two cases (male aged 7;8-8;8, female aged 10;9-11;9) were assessed at two timepoints over a 12-month period: six months and 18 months following completion of CBT cancer treatment. RESULTS Findings revealed a sharp decline in problem solving abilities over a 12-month period in the early stages of recovery from CBT in both cases examined, despite no or mild-moderate deficits in cognitive-communication or language function at initial assessment. Pre-literacy skills were noted to deteriorate on one task for one child, despite intact abilities at first assessment. CONCLUSIONS The findings of progressive deterioration of cognitive-communication skills in both children treated for CBT highlights a clear need for ongoing surveillance and full comprehensive assessment across development. The critical need for ongoing management after discharge and implementation of early intervention throughout development is highlighted.
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Affiliation(s)
- Kimberley M Docking
- Speech Pathology, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Stefani R Knijnik
- Speech Pathology, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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The medical therapy for cerebellar mutism syndrome: a case report and literature review. Childs Nerv Syst 2021; 37:2727-2734. [PMID: 34128119 DOI: 10.1007/s00381-021-05233-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/26/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE Cerebellar mutism syndrome (CMS) represents a major complication affecting many children that undergo surgery for posterior fossa lesions. Etiology and pathophysiology are still not fully understood. CMS deeply influences quality of life and recovery of these patients. An effective treatment has not been defined yet. This case-based review aims at analyzing the available evidence and knowledge to better delineate this phenomenon and to determine whether CMS can be successfully treated with pharmacological therapy. METHODS Systematic research and retrieval of databases were conducted analyzing all papers where medical treatment of CMS was reported. A summary of the latest understanding and reports regarding definition, clinical manifestations, pathophysiology, management, and outcome of CMS has been conducted. RESULTS Consensus on definition of this syndrome is lacking. CMS is the term accepted by the Posterior Fossa Society in 2016. Pathophysiology is still poorly understood but the most likely mechanism is injury along proximal components of the efferent cerebellar pathway. Nine papers describing positive effects of pharmacological therapy for CMS have been identified. Fluoxetine, zolpidem, bromocriptine, and midazolam are the drugs that seem to alleviate symptoms of CMS and improve recovery. To date, cognitive rehabilitation and physiotherapy are the only treatment options available. CONCLUSION CMS has deep impact on affected children and their families. Despite attempts to identify preventive measures and treatment, cases still occur on a regular basis. Pharmacological treatments have been proposed to help reduce the symptoms of CMS with some promising results, but reports are limited; therefore, further studies are needed.
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Kristiansen I, Eklund C, Strinnholm M, Strömberg B, Törnhage M, Frisk P. Cognitive, language, and school performance in children and young adults treated for low-grade astrocytoma in the posterior fossa in childhood. Cancer Rep (Hoboken) 2021; 5:e1494. [PMID: 34231973 PMCID: PMC8955056 DOI: 10.1002/cnr2.1494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/19/2021] [Accepted: 06/24/2021] [Indexed: 11/24/2022] Open
Abstract
Background Pilocytic astrocytoma is the most common brain tumour type in childhood located in the posterior fossa, and treated mainly with surgery. These tumours have low mortality, but knowledge concerning its long‐term outcome is sparse. Aim The aim of this study was to investigate whether children treated for pilocytic astrocytoma in the posterior fossa had late complications affecting cognition, language and learning. Methods This descriptive single‐centre study includes eight children and 12 adults treated as children for pilocytic astrocytoma in the posterior fossa, with a mean follow‐up time of 12.4 (range 5–19) years. Well‐established tests of intelligence, executive, language and academic function were used. Results Intelligence tests showed average results compared with norms. Five patients scored <−1 SD (70–84) and 3 low average (85–92) on full scale IQ. The patients scored average on subtests regarding executive function, except for significantly lower results in inhibition/switching (p = .004). In Rey complex figure test half of the patients scored below −1 SD. Language tests were normal except for significantly lower results in naming ability (p = .049) and in inference (p = .046). In academic tests, results were average, except for significantly lower results in reading speed (p = .024). Patients with learning difficulties performed worse in the tests. Conclusions The patients' functional outcome was favourable but, a not‐negligible part of the patients displayed neurocognitive difficulties as revealed by extensive neuro‐cognitive and academic testing. Thus, it is important to identify those in need of more thorough cognitive and pedagogic follow‐up programmes, including school interventions.
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Affiliation(s)
- Ingela Kristiansen
- Department of Women's and Children's Health, Uppsala University and Uppsala University Children's Hospital, Uppsala, Sweden
| | - Cristina Eklund
- Department of Women's and Children's Health, Uppsala University and Uppsala University Children's Hospital, Uppsala, Sweden
| | - Margareta Strinnholm
- Department of Women's and Children's Health, Uppsala University and Uppsala University Children's Hospital, Uppsala, Sweden
| | - Bo Strömberg
- Department of Women's and Children's Health, Uppsala University and Uppsala University Children's Hospital, Uppsala, Sweden
| | - Maria Törnhage
- Department of Women's and Children's Health, Uppsala University and Uppsala University Children's Hospital, Uppsala, Sweden
| | - Per Frisk
- Department of Women's and Children's Health, Uppsala University and Uppsala University Children's Hospital, Uppsala, Sweden
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Ashida R, Nazar N, Edwards R, Teo M. Cerebellar Mutism Syndrome: An Overview of the Pathophysiology in Relation to the Cerebrocerebellar Anatomy, Risk Factors, Potential Treatments, and Outcomes. World Neurosurg 2021; 153:63-74. [PMID: 34157457 DOI: 10.1016/j.wneu.2021.06.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/11/2021] [Accepted: 06/12/2021] [Indexed: 10/21/2022]
Abstract
Cerebellar mutism syndrome (CMS) is one the most disabling postoperative neurological complications after posterior fossa surgery in children. CMS is characterized by a transient mutism with a typical onset demonstrated within 2 days postoperatively accompanied by associated ataxia, hypotonia, and irritability. Several hypotheses for the anatomical basis of pathophysiology and risk factors have been suggested. However, a definitive theory and treatment protocols have not yet been determined. Animal histological and electrophysiological studies and more recent human imaging studies have demonstrated the existence of a compartmentalized representation of cerebellar function, the understanding of which might provide more information on the pathophysiology. Damage to the dentatothalamocortical pathway and cerebrocerebellar diaschisis have been described as the anatomical substrate to the CMS. The risk factors, which include tumor type, brainstem invasion, tumor localization, tumor size, and vermal splitting technique, have not yet been clearly elucidated. The efficacy of potential pharmacological and speech therapies has been studied in small trials. Long-term motor speech deficits and associated cognitive and behavioral disturbances have now been found to be common among CMS survivors, affecting their development and requiring rehabilitation, leading to significant financial effects on the healthcare system and distress to the family. The aim of the present review was to outline the cerebellar anatomy and function and its connections in relationship to the pathophysiology and to refine the risk factors and treatment strategies for CMS.
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Affiliation(s)
- Reiko Ashida
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Naadir Nazar
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Richard Edwards
- Department of Paediatric Neurosurgery, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Mario Teo
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom.
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Difficulties encountered by physicians and mental health professionals in evaluating and caring for affective and behavioral problems in pediatric brain tumor survivors. Support Care Cancer 2021; 29:6771-6780. [PMID: 33990882 DOI: 10.1007/s00520-021-06250-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pediatric brain tumor survivors (PBTS) present a high risk for emotional and behavioral disorders. When addressing these difficulties, differences in study designs; variety of and disagreement about diagnoses; and intricate links of emotional, behavioral, and cognitive issues may complicate the interpretation of studies and probably also the work of clinicians. We aimed to survey the difficulties perceived by physicians and mental health professionals in their practice and their interest in developing a new evaluative tool. METHODOLOGY We surveyed 29 health professionals involved in the follow-up of this population. They completed questionnaires about their clinical practice (difficulties, needs, activities) and indicated diagnosis hypotheses and treatment plans on a clinical case developed for this study. RESULTS Emotional and behavioral disorders were reported as difficult to assess for 93% of participants. The overlap of symptoms (90%) and the lack of an adapted diagnostic framework (90%) were the main reasons mentioned. Respectively 93%, 90%, and 65% of participants would at least "often" make referrals to psychological (93%), neuropsychological (90%), and psychiatric (65%) assessments and care. Family and group therapy were less common as was drug management. All participants were in favor of creating a tool to help with diagnosis and treatment. When responding to a clinical case, the heterogeneity of participants' responses highlighted their issues in diagnosing and managing these patients. CONCLUSION This survey exemplifies the difficulties of health professionals related to the evaluation and management of affective and behavioral disorders experienced by PBTS. It underlines the need to help professionals by initiating systematic assessment strategies with this vulnerable population.
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Giampiccolo D, Basaldella F, Badari A, Squintani GM, Cattaneo L, Sala F. Feasibility of cerebello-cortical stimulation for intraoperative neurophysiological monitoring of cerebellar mutism. Childs Nerv Syst 2021; 37:1505-1514. [PMID: 33835202 PMCID: PMC8084839 DOI: 10.1007/s00381-021-05126-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 03/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cerebellar mutism can occur in a third of children undergoing cerebellar resections. Recent evidence proposes it may arise from uni- or bilateral damage of cerebellar efferents to the cortex along the cerebello-dento-thalamo-cortical pathway. At present, no neurophysiological procedure is available to monitor this pathway intraoperatively. Here, we specifically aimed at filling this gap. METHODS We assessed 10 patients undergoing posterior fossa surgery using a conditioning-test stimulus paradigm. Electrical conditioning stimuli (cStim) were delivered to the exposed cerebellar cortex at interstimulus intervals (ISIs) of 8-24 ms prior to transcranial electric stimulation of the motor cortex, which served as test stimulus (tStim). The variation of motor-evoked potentials (MEP) to cStim + tStim compared with tStim alone was taken as a measure of cerebello-cortical connectivity. RESULTS cStim alone did not produce any MEP. cStim preceding tStim produced a significant inhibition at 8 ms (p < 0.0001) compared with other ISIs when applied to the lobules IV-V-VI in the anterior cerebellum and the lobule VIIB in the posterior cerebellum. Mixed effects of decrease and increase in MEP amplitude were observed in these areas for longer ISIs. CONCLUSIONS The inhibition exerted by cStim at 8 ms on the motor cortex excitability is likely to be the product of activity along the cerebello-dento-thalamo-cortical pathway. We show that monitoring efferent cerebellar pathways to the motor cortex is feasible in intraoperative settings. This study has promising implications for pediatric posterior fossa surgery with the aim to preserve the cerebello-cortical pathways and thus prevent cerebellar mutism.
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Affiliation(s)
- Davide Giampiccolo
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Neurosurgery, University Hospital, Piazzale Stefani 1, 37124, Verona, Italy
| | - Federica Basaldella
- Intraoperative Neurophysiology Unit, Division of Neurology, University Hospital, Verona, Italy
| | - Andrea Badari
- Intraoperative Neurophysiology Unit, Division of Neurology, University Hospital, Verona, Italy
| | | | - Luigi Cattaneo
- CIMeC-Center for Mind/Brain Sciences, University of Trento, Trento, Italy
| | - Francesco Sala
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Neurosurgery, University Hospital, Piazzale Stefani 1, 37124, Verona, Italy.
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71
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Khan RB, Patay Z, Klimo P, Huang J, Kumar R, Boop FA, Raches D, Conklin HM, Sharma R, Simmons A, Sadighi ZS, Onar-Thomas A, Gajjar A, Robinson GW. Clinical features, neurologic recovery, and risk factors of postoperative posterior fossa syndrome and delayed recovery: a prospective study. Neuro Oncol 2021; 23:1586-1596. [PMID: 33823018 DOI: 10.1093/neuonc/noab030] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Posterior fossa syndrome (PFS) is a known consequence of medulloblastoma resection. Our aim was to clinically define PFS, its evolution over time, and ascertain risk factors for its development and poor recovery. METHODS Children with medulloblastoma treated at St Jude Children's Research Hospital from 6/2013 to 7/2019 received standardized neurological examinations, before and periodically after radiation therapy. Most (98.3%) were enrolled on the ongoing multi-institutional protocol (SJMB12; NCT01878617). RESULTS Sixty (34%) of 178 evaluated children had PFS. Forty (23%) had complete mutism (PFS1) and 20 (11%) had diminished speech (PFS2). All children with PFS had severe ataxia and 42.5% of PFS1 had movement disorders. By multivariable analysis, younger age (P = .0005) and surgery in a low-volume surgery center (P = .0146) increased PFS risk, while Sonic Hedgehog tumors had reduced risk (P = .0025). Speech and gait returned in PFS1/PFS2 children at a median of 2.3/0.7 and 2.1/1.5 months, respectively, however, 12 (44.4%) of 27 PFS1 children with 12 months of follow-up were nonambulatory at 1 year. Movement disorder (P = .037) and high ataxia score (P < .0001) were associated with delayed speech recovery. Older age (P = .0147) and high ataxia score (P < .0001) were associated with delayed gait return. Symptoms improved in all children but no child with PFS had normal neurologic examination at a median of 23 months after surgery. CONCLUSIONS Categorizing PFS into types 1 and 2 has prognostic relevance. Almost half of the children with PFS1 with 12-month follow-up were nonambulatory. Surgical experience was a major modifiable contributor to the development of PFS.
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Affiliation(s)
- Raja B Khan
- Division of Neurology, Department of Pediatrics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Zoltan Patay
- Department of Radiology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Paul Klimo
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, USA
| | - Jie Huang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Rahul Kumar
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Frederick A Boop
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, USA
| | - Darcy Raches
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Heather M Conklin
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Richa Sharma
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Andrea Simmons
- Division of Neurology, Department of Pediatrics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Zsila S Sadighi
- Department of Oncology, MD Anderson Center, Houston, Texas, USA
| | - Arzu Onar-Thomas
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Amar Gajjar
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Giles W Robinson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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72
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Jabarkheel R, Amayiri N, Yecies D, Huang Y, Toescu S, Nobre L, Mabbott DJ, Sudhakar SV, Malik P, Laughlin S, Swaidan M, Al Hussaini M, Musharbash A, Chacko G, Mathew LG, Fisher PG, Hargrave D, Bartels U, Tabori U, Pfister SM, Aquilina K, Taylor MD, Grant GA, Bouffet E, Mankad K, Yeom KW, Ramaswamy V. Molecular correlates of cerebellar mutism syndrome in medulloblastoma. Neuro Oncol 2021; 22:290-297. [PMID: 31504816 DOI: 10.1093/neuonc/noz158] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Cerebellar mutism syndrome (CMS) is a common complication following resection of posterior fossa tumors, most commonly after surgery for medulloblastoma. Medulloblastoma subgroups have historically been treated as a single entity when assessing CMS risk; however, recent studies highlighting their clinical heterogeneity suggest the need for subgroup-specific analysis. Here, we examine a large international multicenter cohort of molecularly characterized medulloblastoma patients to assess predictors of CMS. METHODS We assembled a cohort of 370 molecularly characterized medulloblastoma subjects with available neuroimaging from 5 sites globally, including Great Ormond Street Hospital, Christian Medical College and Hospital, the Hospital for Sick Children, King Hussein Cancer Center, and Lucile Packard Children's Hospital. Age at diagnosis, sex, tumor volume, and CMS development were assessed in addition to molecular subgroup. RESULTS Overall, 23.8% of patients developed CMS. CMS patients were younger (mean difference -2.05 years ± 0.50, P = 0.0218) and had larger tumors (mean difference 10.25 cm3 ± 4.60, P = 0.0010) that were more often midline (odds ratio [OR] = 5.72, P < 0.0001). In a multivariable analysis adjusting for age, sex, midline location, and tumor volume, Wingless (adjusted OR = 4.91, P = 0.0063), Group 3 (adjusted OR = 5.56, P = 0.0022), and Group 4 (adjusted OR = 8.57 P = 9.1 × 10-5) tumors were found to be independently associated with higher risk of CMS compared with sonic hedgehog tumors. CONCLUSIONS Medulloblastoma subgroup is a very strong predictor of CMS development, independent of tumor volume and midline location. These findings have significant implications for management of both the tumor and CMS.
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Affiliation(s)
- Rashad Jabarkheel
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Nisreen Amayiri
- Department of Oncology, King Hussein Cancer Center, Amman, Jordan.,Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Derek Yecies
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Yuhao Huang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Sebastian Toescu
- University College London, Great Ormond Street Institute of Child Health, London, UK
| | - Liana Nobre
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Donald J Mabbott
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Psychology, University of Toronto, Toronto, Ontario, Canada.,Programme in Neuroscience and Mental Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sniya V Sudhakar
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Prateek Malik
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Suzanne Laughlin
- Division of Neuroradiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maisa Swaidan
- Department of Diagnostic Radiology, King Hussein Cancer Center, Amman, Jordan
| | | | - Awni Musharbash
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Geeta Chacko
- Department of Pathology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Leni G Mathew
- Department of Pediatrics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Paul G Fisher
- Departments of Neurology & Pediatrics, Stanford University, Palo Alto, California, USA
| | - Darren Hargrave
- University College London, Great Ormond Street Institute of Child Health, London, UK
| | - Ute Bartels
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Uri Tabori
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Stefan M Pfister
- Hopp Children's Cancer Center Heidelberg, Division of Pediatric Neurooncology, German Cancer Research Center, German Cancer Consortium, and Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kristian Aquilina
- Neurosurgery Department, Great Ormond Street Hospital for Children, London, UK
| | - Michael D Taylor
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Programme in Developmental and Stem Cell Biology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Eric Bouffet
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital for Children, London, UK
| | - Kristen W Yeom
- Department of Radiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Programme in Developmental and Stem Cell Biology, Hospital for Sick Children, Toronto, Ontario, Canada
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Beez T, Munoz-Bendix C, Steiger HJ, Hänggi D. Functional tracts of the cerebellum-essentials for the neurosurgeon. Neurosurg Rev 2021; 44:273-278. [PMID: 32056026 PMCID: PMC7851031 DOI: 10.1007/s10143-020-01242-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/01/2020] [Accepted: 01/09/2020] [Indexed: 02/07/2023]
Abstract
The cerebellum is historically implicated in motor coordination, but accumulating modern evidence indicates involvement in non-motor domains, including cognition, emotion, and language. This correlates with the symptoms observed in postoperative cerebellar mutism syndrome (CMS). Profound knowledge of cerebellar functional topography and tractography is important when approaching cerebellar tumors, as surgical trauma to relevant structures of cerebellar pathways plays a role in the pathogenesis of CMS. The aim of this systematic review is to provide a concise overview of relevant modern neuroimaging data and cerebellar functional tracts with regard to neurosurgical procedures.
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Affiliation(s)
- Thomas Beez
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - Christopher Munoz-Bendix
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
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74
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Grassiot B, Beuriat PA, Di Rocco F, Leblond P, Faure-Conter C, Szathmari A, Mottolese C. Surgical management of posterior fossa medulloblastoma in children: The Lyon experience. Neurochirurgie 2021; 67:52-60. [PMID: 33482236 DOI: 10.1016/j.neuchi.2021.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 11/22/2020] [Accepted: 01/06/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Modern approach for the treatment of posterior fossa medulloblastomas remains a challenge for pediatric neurosurgeons and pediatric oncologists and requires a multidisciplinary approach to optimize survival and clinical results. MATERIAL AND METHODS We report the surgical principles of the treatment of posterior fossa medulloblastomas in children and how to avoid technical mistakes especially in very young patients. We also report our experience in a series of 64 patients operated from a medulloblastoma between 2000 and 2018 in Lyon. RESULTS All patients had a craniospinal MRI. Eighty-one percent of the patients (n=50) had strictly midline tumor while 19% (n=14) had lateralized one. Eleven percent (n=7) had metastasis at diagnosis on the initial MRI. Forty-one percent (n=29) had an emergency ETV to treat hydrocephaly and the intracranial hypertension. All patient underwent a direct approach and a complete removal was achieved in 78% (n=58) of the cases on the postoperative MRI realized within 48h postsurgery. Histological findings revealed classical medulloblastoma in 73% (n=46), desmoplastic medulloblastoma in 17% (n=11) and anaplastic/large cell medulloblastoma in 10% (n=7). Patients were classified as low risk in 7 cases, standard risk in 30 cases and high risk in 27 cases. Ninety-six percent (n=61) of the patient received radiotherapy. Seventy-six percent (n=48) received pre-irradiation or adjuvant chemotherapy. At last follow-up in December 2018, 65% (n=41) of the patient were in complete remission, 12% (n=8) were in relapse and 27% (n=15) had died from their disease. The overall survival at five , ten and fifteen years for all the series was of 76%, 73% and 65.7% respectively. CONCLUSIONS Medulloblastomas remain a chimiosensible and radiosensible disease and the complete surgical removal represents a favorable prognostic factor. The extension of surgery has also to be weighted in consideration of the new biomolecular and genetic knowledge that have to be integrated by surgeons to improve quality of life of patients.
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Affiliation(s)
- B Grassiot
- Department of Pediatric Neurosurgery, hôpital Femme-Mère-Enfant, 32, avenue du Doyen Jean-Lépine, 69677 Lyon Cedex, France
| | - P A Beuriat
- Department of Pediatric Neurosurgery, hôpital Femme-Mère-Enfant, 32, avenue du Doyen Jean-Lépine, 69677 Lyon Cedex, France
| | - F Di Rocco
- Department of Pediatric Neurosurgery, hôpital Femme-Mère-Enfant, 32, avenue du Doyen Jean-Lépine, 69677 Lyon Cedex, France
| | - P Leblond
- Department of Pediatric Hematology and Oncology, Institut d'hématologie et d'oncologie pédiatrique, 69008 Lyon, France
| | - C Faure-Conter
- Department of Pediatric Hematology and Oncology, Institut d'hématologie et d'oncologie pédiatrique, 69008 Lyon, France
| | - A Szathmari
- Department of Pediatric Neurosurgery, hôpital Femme-Mère-Enfant, 32, avenue du Doyen Jean-Lépine, 69677 Lyon Cedex, France
| | - C Mottolese
- Department of Pediatric Neurosurgery, hôpital Femme-Mère-Enfant, 32, avenue du Doyen Jean-Lépine, 69677 Lyon Cedex, France.
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75
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A Paravermal Trans-Cerebellar Approach to the Posterior Fossa Tumor Causes Hypertrophic Olivary Degeneration by Dentate Nucleus Injury. Cancers (Basel) 2021; 13:cancers13020258. [PMID: 33445527 PMCID: PMC7826586 DOI: 10.3390/cancers13020258] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/07/2021] [Accepted: 01/07/2021] [Indexed: 11/30/2022] Open
Abstract
Simple Summary Posterior fossa tumor surgery is challenging due to the proximity and exposure of cerebellar structures. A favorable operative approach is unknown. Following lesions to the dentato–rubro–olivary-pathway, a neurodegenerative disease called hypertrophic olivary degeneration (HOD) can occur. This study for the first time demonstrates that paravermal trans-cerebellar approaches are associated with a significantly higher likelihood of HOD on MRI when compared to other approaches. This finding can well be attributed to dentate nucleus (DN) injury. Furthermore, cerebellar mutism syndrome (CMS) was discussed in the literature to be correlated with HOD due to a functional overlap of pathways involved. We found no such correlation in this study, but HOD was shown to be a reliable indicator for surgical disruption of efferent cerebellar pathways involving the DN. Henceforth, neurosurgeons should consider more midline or lateral approaches in posterior fossa surgery to spare the DN whenever feasible, and focus on cerebellar functional anatomy in their preoperative planning. Abstract Background: In brain tumor surgery, injury to cerebellar connectivity pathways can induce a neurodegenerative disease called hypertrophic olivary degeneration (HOD), along with a disabling clinical syndrome. In children, cerebellar mutism syndrome (CMS) is another consequence of damage to cerebello–thalamo–cortical networks. The goal of this study was to compare paravermal trans-cerebellar to other more midline or lateral operative approaches in their risk of causing HOD on MR-imaging and CMS. Methods: We scanned our neurosurgical database for patients with surgical removal of pilocytic astrocytoma, ependymoma and medulloblastoma in the posterior fossa. Fifty patients with a mean age of 22.7 (±16.9) years were identified and analyzed. Results: HOD occurred in n = 10/50 (20%) patients within four months (median), always associated with contralateral dentate nucleus (DN)-lesions (p < 0.001). Patients with paravermal trans-cerebellar approach significantly more often developed HOD (7/11; 63.6%) when compared to other approaches (3/39; 7.7%; p < 0.001). Injury to the DN occurred more frequently after a paravermal approach (8/11 vs. 13/39 patients; p < 0.05). CMS was described for n = 12/50 patients (24%). Data indicated no correlation of radiological HOD and CMS development. Conclusions: A paravermal trans-cerebellar approach more likely causes HOD due to DN-injury when compared to more midline or lateral approaches. HOD is a radiological indicator for surgical disruption of cerebellar pathways involving the DN. Neurosurgeons should consider trajectories and approaches in the planning of posterior fossa surgery that spare the DN, whenever feasible.
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76
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Severo Bem L, Gemir J, Cysneiros RRM, Azevedo HC. The Understanding of Pediatric Akinetic Mutism. Cureus 2021; 13:e12593. [PMID: 33542880 PMCID: PMC7849921 DOI: 10.7759/cureus.12593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Pediatric akinetic mutism syndrome is a clinical disease resulting from cerebellar injury and characterized by the absence of speech or reduced speech, emotional lability, there may also be hypotonia, oropharyngeal dysfunction/dysphagia, bladder and intestinal incontinence, or other behavioral disorders and neurological signals. It is described as the most recurrent complication in children, after posterior fossa tumor surgery, mainly related to cerebellar midline injuries. An increasing number of research and prospective reviews have provided valuable information on cerebellar mutism syndrome in recent years. The purpose of this review was to elucidate the pathophysiological basis and the predictive factors for this syndrome. Most cases of mutism are due to injury cerebellar tracts and cerebellar-cerebral circuits, involving particularly distinct points of the dentate-thalamus-cortical and dentato-rubro-thalamus-cortical. Advanced neuroimaging techniques, such as tractography and perfusion studies, have contributed to demonstrating changes in these pathways in patients with pediatric cerebellar mutism.
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Affiliation(s)
- Luiz Severo Bem
- Neurological Surgery, Hospital da Restauração, Recife, BRA.,Neuroscience Post-Graduate Program, Federal University of Pernambuco, Recife, BRA
| | - Júlia Gemir
- Neurological Surgery, University of Pernambuco, Recife, BRA
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77
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Schmahmann JD. Emotional disorders and the cerebellum: Neurobiological substrates, neuropsychiatry, and therapeutic implications. HANDBOOK OF CLINICAL NEUROLOGY 2021; 183:109-154. [PMID: 34389114 DOI: 10.1016/b978-0-12-822290-4.00016-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The notion that the cerebellum is devoted exclusively to motor control has been replaced by a more sophisticated understanding of its role in neurological function, one that includes cognition and emotion. Early clinical reports, as well as physiological and behavioral studies in animal models, raised the possibility of a nonmotor role for the cerebellum. Anatomical studies demonstrate cerebellar connectivity with the distributed neural circuits linked with autonomic, sensorimotor, vestibular, associative, and limbic/paralimbic brain areas. Identification of the cerebellar cognitive affective syndrome in adults and children underscored the clinical relevance of the role of the cerebellum in cognition and emotion. It opened new avenues of investigation into higher-order deficits that accompany the ataxias and other cerebellar diseases, as well as the contribution of cerebellar dysfunction to neuropsychiatric and neurocognitive disorders. Brain imaging studies have demonstrated the complexity of cerebellar functional topography, revealing a double representation of the sensorimotor cerebellum in the anterior lobe and lobule VIII and a triple cognitive representation in the cerebellar posterior lobe, as well as representation in the cerebellum of the intrinsic connectivity networks identified in the cerebral hemispheres. This paradigm shift in thinking about the cerebellum has been advanced by the theories of dysmetria of thought and the universal cerebellar transform, harmonizing the dual anatomic realities of homogeneously repeating cerebellar cortical microcircuitry set against the heterogeneous and topographically arranged cerebellar connections with extracerebellar structures. This new appreciation of cerebellar incorporation into circuits that subserve cognition and emotion mandates a deeper understanding of the cerebellum by practitioners in behavioral neurology and neuropsychiatry because it impacts the understanding and diagnosis of disorders of emotion and intellect and has potential for novel cerebellar-based approaches to therapy.
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Affiliation(s)
- Jeremy D Schmahmann
- Ataxia Center, Cognitive Behavioral Neurology Unit, Laboratory for Neuroanatomy and Cerebellar Neurobiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
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78
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Grosse F, Rueckriegel SM, Thomale UW, Hernáiz Driever P. Mapping of long-term cognitive and motor deficits in pediatric cerebellar brain tumor survivors into a cerebellar white matter atlas. Childs Nerv Syst 2021; 37:2787-2797. [PMID: 34355257 PMCID: PMC8423645 DOI: 10.1007/s00381-021-05244-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 06/01/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Diaschisis of cerebrocerebellar loops contributes to cognitive and motor deficits in pediatric cerebellar brain tumor survivors. We used a cerebellar white matter atlas and hypothesized that lesion symptom mapping may reveal the critical lesions of cerebellar tracts. METHODS We examined 31 long-term survivors of pediatric posterior fossa tumors (13 pilocytic astrocytoma, 18 medulloblastoma). Patients underwent neuronal imaging, examination for ataxia, fine motor and cognitive function, planning abilities, and executive function. Individual consolidated cerebellar lesions were drawn manually onto patients' individual MRI and normalized into Montreal Neurologic Institute (MNI) space for further analysis with voxel-based lesion symptom mapping. RESULTS Lesion symptom mapping linked deficits of motor function to the superior cerebellar peduncle (SCP), deep cerebellar nuclei (interposed nucleus (IN), fastigial nucleus (FN), ventromedial dentate nucleus (DN)), and inferior vermis (VIIIa, VIIIb, IX, X). Statistical maps of deficits of intelligence and executive function mapped with minor variations to the same cerebellar structures. CONCLUSION We identified lesions to the SCP next to deep cerebellar nuclei as critical for limiting both motor and cognitive function in pediatric cerebellar tumor survivors. Future strategies safeguarding motor and cognitive function will have to identify patients preoperatively at risk for damage to these critical structures and adapt multimodal therapeutic options accordingly.
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Affiliation(s)
- Frederik Grosse
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Pediatric Oncology and Hematology, Berlin, Germany
| | | | - Ulrich-Wilhelm Thomale
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Pediatric Neurosurgery, Berlin, Germany
| | - Pablo Hernáiz Driever
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Pediatric Oncology and Hematology, Berlin, Germany.
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79
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Ahmadian N, van Baarsen KM, Robe PAJT, Hoving EW. Association between cerebral perfusion and paediatric postoperative cerebellar mutism syndrome after posterior fossa surgery-a systematic review. Childs Nerv Syst 2021; 37:2743-2751. [PMID: 34155533 PMCID: PMC8423702 DOI: 10.1007/s00381-021-05225-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/21/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Paediatric postoperative cerebellar mutism syndrome (ppCMS) is a common complication following the resection of a cerebellar tumour in children. It is hypothesized that loss of integrity of the cerebellar output tracts results in a cerebello-cerebral "diaschisis" and reduced function of supratentorial areas of the brain. METHODS We performed a systematic review of the literature according to the PRISMA guidelines, in order to evaluate the evidence for hypoperfusion or hypofunction in the cerebral hemispheres in patients with ppCMS. Articles were selected based on the predefined eligibility criteria and quality assessment. RESULTS Five studies were included, consisting of three prospective cohort studies, one retrospective cohort study and one retrospective case control study. Arterial spin labelling (ASL) perfusion MRI, dynamic susceptibility contrast (DSC) perfusion MRI and single photon emission computed tomography (SPECT) were used to measure the cerebral and cerebellar tissue perfusion or metabolic activity. Reduced cerebral perfusion was predominantly demonstrated in the frontal lobe. CONCLUSIONS This systematic review shows that, after posterior fossa tumour resection, cerebral perfusion is reduced in ppCMS patients compared to patients without ppCMS. Well-powered prospective studies, including preoperative imaging, are needed to ascertain the cause and role of hypoperfusion in the pathophysiology of the syndrome.
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Affiliation(s)
- Narjes Ahmadian
- Department of Neurology and Neurosurgery, Rudolf Magnus Brain Institute, University Medical Center of Utrecht, 100 Heidelberglaan, G03.126, 3584 CX, Utrecht, The Netherlands.
| | - K. M. van Baarsen
- grid.487647.eDepartment of Neurology and Neurosurgery, Princess Maxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, The Netherlands
| | - P. A. J. T. Robe
- grid.7692.a0000000090126352Department of Neurology and Neurosurgery, Rudolf Magnus Brain Institute, University Medical Center of Utrecht, 100 Heidelberglaan, G03.126, 3584 CX Utrecht, The Netherlands
| | - E. W. Hoving
- grid.487647.eDepartment of Pediatric Neurosurgery, Princess Maxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, The Netherlands
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Amor-García MÁ, Fernández-Llamazares CM, Manrique-Rodríguez S, Narrillos-Moraza Á, García-Morín M, Huerta-Aragonés J, Sanjurjo-Sáez M. Bromocriptine for the treatment of postoperative cerebellar mutism syndrome in pediatric patients: Three case reports. J Oncol Pharm Pract 2020; 27:1753-1757. [PMID: 33356885 DOI: 10.1177/1078155220982046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Cerebellar mutism syndrome (CMS) is a common complication after posterior fossa tumor resection. It is characterized by a significant lack or loss of speech. Its biological origin remains unclear and there are no standardized treatments. However, bromocriptine seems to be a possible treatment for this condition. CASE REPORT In this paper, we present three cases of pediatric patients (4, 5, and 17-year old) who developed CMS after posterior fossa tumor surgery. They were treated with bromocriptine to improve neurological symptoms.Management and outcome: Bromocriptine was started at a low dose and was progressively increased to reach the minimum effective dose. After four months of treatment, a normal and fluid speech was observed in the three patients. No discontinuation due to adverse events were reported. DISCUSSION Bromocriptine has shown to be an effective and safe treatment for CMS in pediatric patients after posterior fossa tumor resection.
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Affiliation(s)
- Miguel Á Amor-García
- Pharmacy Service, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Cecilia M Fernández-Llamazares
- Pharmacy Service, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Silvia Manrique-Rodríguez
- Pharmacy Service, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Álvaro Narrillos-Moraza
- Pharmacy Service, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Marina García-Morín
- Section of Pediatric Hematology and Oncology, Department of Pediatrics, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jorge Huerta-Aragonés
- Section of Pediatric Hematology and Oncology, Department of Pediatrics, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Sanjurjo-Sáez
- Pharmacy Service, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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81
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Nayak R, Menon G, Rathod S. Cerebellar mutism following the posterior fossa tumour excision. BMJ Case Rep 2020; 13:13/12/e239969. [PMID: 33370958 DOI: 10.1136/bcr-2020-239969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Raghavendra Nayak
- Neurosurgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education (MAHE), Manipal, Udupi, Karanataka, India
| | - Girish Menon
- Neurosurgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education (MAHE), Manipal, Udupi, Karanataka, India
| | - Sanjeev Rathod
- Neurosurgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education (MAHE), Manipal, Udupi, Karanataka, India
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82
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Neuropsychological Profile in Children with Posterior Fossa Tumors with or Without Postoperative Cerebellar Mutism Syndrome (CMS). THE CEREBELLUM 2020; 19:78-88. [PMID: 31832994 DOI: 10.1007/s12311-019-01088-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cerebellar mutism syndrome (CMS) is a common surgical sequela in children following posterior fossa tumor (PFT) resection. Here, we analyze the neuropsychological features associated with PFT in children, focusing particularly on the differential profiles associated with the presence or absence of CMS after surgery. We further examine the effect of post-resection treatments, tumor type, and presence/absence of hydrocephalus on surgical outcome. Thirty-six patients diagnosed with PFT (19 with and 17 without CMS) and 34 age- and gender-matched healthy controls (HCs) were recruited. A comprehensive neuropsychological evaluation was conducted in all patients postoperatively and in HCs, including an assessment of general cognitive ability, motor skills, perception, language, memory, attention, executive functions, and academic competence. CMS was found to be a clinical marker of lower neuropsychological profile scores across all cognitive domains except auditory-verbal processing and visual memory tasks. PFT patients not presenting CMS exhibited milder impairment in intellectual functioning, motor tasks, reasoning, language, verbal learning and recall, attention, cognitive executive functions, and academic competence. High-grade tumors were associated with slower processing speed and verbal delayed recall as well as alterations in selective and sustained attention. Hydrocephalus was detrimental to motor functioning and nonverbal reasoning. Patients who had undergone surgery, chemotherapy, and radiotherapy presented impaired processing speed, verbal learning, and reading. In addition to the deleterious effects of PFT, post-resection PFT treatments have a negative cognitive impact. These undesired consequences and the associated tumor-related damage can be assessed using standardized, long-term neuropsychological evaluation when planning rehabilitation.
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83
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Cerebellar mutism after embolization of vermian arteriovenous malformation. Childs Nerv Syst 2020; 36:1301-1305. [PMID: 31897635 DOI: 10.1007/s00381-019-04483-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 12/17/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cerebellar mutism is usually associated with posterior fossa tumor surgery. CASE REPORT We report a case of a 17-year-old female, presented with headache and tremor after hemorrhage from a vermian arteriovenous malformation. She was successfully treated by embolization; however, on immediate postoperative, she developed persistent mutism. To the best authors' knowledge, this is the first case of cerebellar mutism after endovascular treatment reported in the medical literature. CONCLUSION The endovascular approach may have the same potential of complication of conventional surgery; therefore, more study is necessary to clarify the role and limits of this technique to treat cerebellar arteriovenous malformation.
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84
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Grønbæk J, Molinari E, Avula S, Wibroe M, Oettingen G, Juhler M. The supplementary motor area syndrome and the cerebellar mutism syndrome: a pathoanatomical relationship? Childs Nerv Syst 2020; 36:1197-1204. [PMID: 31127340 DOI: 10.1007/s00381-019-04202-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/09/2019] [Indexed: 01/25/2023]
Abstract
PURPOSE The supplementary motor area (SMA) syndrome affects adults after tumour resection in SMA neighbouring motor cortex. Cerebellar mutism syndrome (CMS) affects children after tumour resection in the posterior fossa. Both syndromes include disturbances in speech and motor function. The causes of the syndromes are unknown; however, surgical damage to the dentato-thalamo-cortical pathway (DTCP) has been associated with CMS. Thus, an anatomical link between the areas associated with the syndromes is possible. We discuss the syndromes and their possible relationship through the DTCP. METHODS We identified 61 articles (cohort studies, case reports and reviews) in MEDLINE and Embase searching for CMS, SMA syndrome or DTCP or synonyms and reviewed for evidence linking CMS and SMA. RESULTS We found that SMA syndrome and CMS are similar regarding (1) surgical causation; (2) symptoms including speech impairment, disturbance in motor function and facial dysfunction; (3) delayed onset; (4) the courses of the syndromes are transient; and (5) long-term sequelae are seen in both. Relevant differences include age predominance of adults in SMA syndrome versus children in CMS. CONCLUSIONS The similarities of the two syndromes could be traced back to their mutual connection through the DTCP and their membership to a cerebro-cerebellar circuit. The connectivity network could explain the emotional changes and speech reduction in CMS. The difference in time of post-surgical onset may be related to the anatomical distance between the surgical damage to the cerebellum and the SMA, respectively, and the effector neural loop underpinning symptoms.
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Affiliation(s)
- Jonathan Grønbæk
- Department of Neurosurgery, The University Hospital Rigshospitalet, Copenhagen, Denmark.
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark.
| | - Emanuela Molinari
- Department of Neurology, The Queen Elizabeth University Hospital, University of Glasgow, Glasgow, UK
| | - Shivaram Avula
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Morten Wibroe
- Department of Neurosurgery, The University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Gorm Oettingen
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, The University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Paquier PF, Walsh KS, Docking KM, Hartley H, Kumar R, Catsman-Berrevoets CE. Post-operative cerebellar mutism syndrome: rehabilitation issues. Childs Nerv Syst 2020; 36:1215-1222. [PMID: 31222445 PMCID: PMC7250945 DOI: 10.1007/s00381-019-04229-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 05/24/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Tumors of the cerebellum are the most common brain tumors in children. Modern treatment and aggressive surgery have improved the overall survival. Consequently, growing numbers of survivors are at high risk for developing adverse and long-term neurological deficits including deficits of cognition, behavior, speech, and language. Post-operative cerebellar mutism syndrome (pCMS) is a well-known and frequently occurring complication of cerebellar tumor surgery in children. In the acute stage, children with pCMS may show deterioration of cerebellar motor function as well as pyramidal and cranial neuropathies. Most debilitating is the mutism or the severe reduction of speech and a range of neurobehavioral symptoms that may occur. In the long term, children that recover from pCMS continue to have more motor, behavioral, and cognitive problems than children who did not develop pCMS after cerebellar tumor surgery. The severity of these long-term sequelae seems to be related to the length of the mute phase. AIM OF THIS NARRATIVE REVIEW The impact of pCMS on patients and families cannot be overstated. This contribution aims to discuss the present knowledge on the natural course, recovery, and rehabilitation of children with pCMS. We suggest future priorities in developing rehabilitation programs in order to improve the long-term quality of life and participation of children after cerebellar tumor surgery and after pCMS in particular.
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Affiliation(s)
- Philippe F Paquier
- Department of Neuropsychology, University Hospital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Clinical and Experimental Neurolinguistics, Center for Linguistics (CLIN), Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Unit of Translational Neurosciences, School of Medicine and Health Sciences, Universiteit Antwerpen (UA), Antwerp, Belgium
| | - Karin S Walsh
- Division of Pediatric Neuropsychology, Children's National Health System, Departments of Pediatrics and Psychiatry, The George Washington University Medical Center, Washington DC, USA
| | - Kimberley M Docking
- Discipline of Speech Pathology, University of Sydney, and Sydney Children's Hospital Network, Sydney, Australia
| | - Helen Hartley
- Department of Physiotherapy, Alder Hey Children's Hospital, Liverpool, UK
| | - Ram Kumar
- Department of Paediatric Neurology, Alder Hey Children's Hospital, Liverpool, UK
| | - Coriene E Catsman-Berrevoets
- Department of Pediatric Neurology, Erasmus University Hospital/ Sophia Children's Hospital, Postbox 2040, 3000 CA, Rotterdam, The Netherlands.
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86
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Avula S. Radiology of post-operative paediatric cerebellar mutism syndrome. Childs Nerv Syst 2020; 36:1187-1195. [PMID: 31183530 DOI: 10.1007/s00381-019-04224-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 05/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Post-operative paediatric cerebellar mutism syndrome is a well-recognized complication following posterior fossa tumour resection in children. Over the past few decades, imaging has played an important role in understanding this disorder. AIM This review article aims to focus on the disorder from a radiological perspective, summarizing the salient radiological evidence related to the anatomical structures, pathophysiology, and risk factors related to this disorder. CONCLUSION Radiological studies have been integral to the improved understanding of this condition. Future large multicentre studies and quantitative analysis techniques will be vital in further refinement of our understanding of this complex condition.
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Affiliation(s)
- Shivaram Avula
- Alder Hey Children's NHS Foundation Trust, East Prescot Road, Liverpool, L14 5AB, UK.
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87
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Schmahmann JD. Pediatric post-operative cerebellar mutism syndrome, cerebellar cognitive affective syndrome, and posterior fossa syndrome: historical review and proposed resolution to guide future study. Childs Nerv Syst 2020; 36:1205-1214. [PMID: 31240391 PMCID: PMC7020253 DOI: 10.1007/s00381-019-04253-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 06/05/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cerebellar mutism (CM), pseudobulbar palsy, posterior fossa syndrome (PFS), and cerebellar cognitive affective syndrome (CCAS) are terms that have been used, sometimes interchangeably, to refer to the complex neurological constellation that occurs following surgical removal of cerebellar and fourth ventricular tumors, mostly in children, but also sometimes in adults. METHODS This paper reviews the origins of what is now regarded as pediatric post-operative cerebellar mutism, the cerebellar cognitive affective syndrome, and the neurological manifestations of injury to or disruption of brainstem and cerebellar structures. It examines the specific components of each of these phenomena in the context of the evolving understanding of the role of the cerebellum in nervous system function. RESULTS Children undergoing surgical management of tumors in the posterior cranial fossa are at risk of experiencing cranial neuropathies, corticospinal damage, cerebellar ataxia and related motor disorders, neuropsychiatric and cognitive changes, and in some patients, mutism. These clinical presentations are differentiated from each other and examined in the context of the relevant anatomical structures and distributed neural circuits. The term posterior fossa syndrome is not sufficiently helpful in distinguishing the different elements of the clinical phenomena from each other, and because of this lack of precision and specificity, there is consensus among investigators in the international Posterior Fossa Society that the designation be retired. CONCLUSIONS Using contemporary brain imaging methods and guided by careful clinical observation and meticulous definition of clinical phenomenology, it is now feasible to perform detailed structure function correlation analyses to achieve two critical goals in the care of children with tumors in the posterior cranial fossa. The first goal is to identify and understand the neural circuits responsible for the different manifestations-arousal, cranial neuropathies, long tract signs, cerebellar motor syndrome, cerebellar vestibular syndrome, cerebellar cognitive affective syndrome including emotional dyscontrol, and mutism. The second goal is to transform this knowledge into practical clinical intervention, preventing the complications inherent in the necessary surgery whenever possible, and develop new approaches to treatment with methods including brain modulation targeting interconnected nodes of the damaged neural circuits.
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Affiliation(s)
- Jeremy D Schmahmann
- Ataxia Unit, Cognitive Behavioral Neurology Unit, Laboratory for Neuroanatomy and Cerebellar Neurobiology, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, Suite 2000, Boston, MA, 02114, USA.
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88
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Posterior Fossa Society Consensus Meeting 2018: a synopsis. Childs Nerv Syst 2020; 36:1145-1151. [PMID: 31177321 DOI: 10.1007/s00381-019-04220-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/23/2019] [Indexed: 01/08/2023]
Abstract
PURPOSE The Posterior Fossa Society (PFS) was founded 4 years ago to systematically gather and exchange information on the post-operative (CMS) and cerebellar cognitive affective syndrome (CCAS). With its consensus meetings, the PFS orchestrates research studies in the field of cerebellar injury and progresses the knowledge of post-operative pediatric cerebellar mutism syndrome (CMS). In this article, we captured the 3-day program of presentations, group discussions, interactive workshops, and dialogue, highlighting the key topic areas of CMS and its research advances. METHODS This synopsis is based on the third consensus meeting which was held in Reykjavik, Iceland, in August 2018. RESULTS Three working groups have been defined to drive the future research priorities on post-surgical CMS: (i) refining definition and symptoms scoring of CMS; (ii) understanding the pathogenesis and enhancing risk-stratification strategies; and (iii) developing rehabilitation approaches and protocols. CONCLUSIONS The third consensus meeting highlighted a unanimous desire for data-driven information to advance the knowledge and guide future research efforts. The PFS constitutes an established and expanding network of multi-disciplinary expertise that can facilitate the development of collaborative studies and produce official guidelines on the topic.
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89
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Cobourn K, Marayati F, Tsering D, Ayers O, Myseros JS, Magge SN, Oluigbo CO, Keating RF. Cerebellar mutism syndrome: current approaches to minimize risk for CMS. Childs Nerv Syst 2020; 36:1171-1179. [PMID: 31273496 DOI: 10.1007/s00381-019-04240-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 05/28/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Cerebellar mutism syndrome (CMS) is a serious source of morbidity following posterior fossa surgery in the pediatric population. However, methods for effectively decreasing its incidence and impact remain unclear. It is our aim to examine the impact of adjusting surgical factors, namely the use of a telovelar approach and avoidance of cavitronic ultrasonic aspirator, on the incidence of CMS in our population as well as outlining potential pre-, intra-, and postoperative factors that may contribute to its development. METHODS Retrospective review was performed to identify patients undergoing posterior fossa surgery for resection of a medulloblastoma. Demographic, surgical, and postoperative data were collected. These data were analyzed for possible correlations to the risk of developing CMS via univariate analysis. For factors found to be significant, a multivariate analysis was performed to assess their independence. RESULTS Seven of 65 patients (10.8%) developed CMS postoperatively. Factors found to be significantly associated with a higher risk of CMS were the degree of retraction utilized during the procedure (p = 0.0000) and incision of the vermis (p = 0.0294). Although they did not reach the threshold of statistical significance, tumor vascularity (p = 0.19), adoption of a transvermian approach (p = 0.19), and lack of intraoperative imaging (p = 0.17) exhibited strongly suggestive trends towards a correlation with CMS. DISCUSSION In an effort to reduce the incidence and severity of CMS in our population, our institution adopted surgical practices that minimize tissue trauma and mitigate postoperative edema. This included the use of a telovelar over a transvermian approach to obviate the need for vermian incision, avoidance of the CUSA, and minimization of heavy retraction during surgery. This was successful in reducing the incidence of CMS from 39% in our medulloblastoma patients to 10.8%. The development of CMS after posterior fossa surgery appears to be a "two-hit" phenomenon requiring a combination of existing predisposition, surgical injury, and postoperative exacerbation. Therefore, it is critical to identify the factors involved at each stage and investigate treatments to target them appropriately.
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Affiliation(s)
- Kelsey Cobourn
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,Georgetown University School of Medicine, Washington, DC, USA
| | - Fares Marayati
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,Princeton University, Princeton, NJ, USA
| | - Deki Tsering
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Owen Ayers
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,Princeton University, Princeton, NJ, USA
| | - John S Myseros
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,George Washington University School of Medicine, Washington, DC, USA
| | - Suresh N Magge
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,George Washington University School of Medicine, Washington, DC, USA
| | - Chima O Oluigbo
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,George Washington University School of Medicine, Washington, DC, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA. .,George Washington University School of Medicine, Washington, DC, USA.
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90
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Renne B, Radic J, Agrawal D, Albrecht B, Bonfield CM, Cohrs G, Davis T, Gupta A, Hebb ALO, Lamberti-Pasculli M, Knerlich-Lukoschus F, Lindsay S, McNeely PD, Pillai S, Rai HIS, Sborov KD, Vitali A, Walling S, Woerdeman P, Suryaningtyas W, Cochrane D, Singhal A, Steinbok P. Cerebellar mutism after posterior fossa tumor resection in children: a multicenter international retrospective study to determine possible modifiable factors. Childs Nerv Syst 2020; 36:1159-1169. [PMID: 30659354 DOI: 10.1007/s00381-019-04058-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 01/08/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE A preliminary survey of pediatric neurosurgeons working at different centers around the world suggested differences in clinical practice resulting in variation in the risk of pediatric cerebellar mutism (CM) and cerebellar mutism syndrome (CMS) after posterior fossa (PF) tumor resection. The purposes of this study were (1) to determine the incidence and severity of CM and CMS after midline PF tumor resection in children treated at these centers and (2) to identify potentially modifiable factors related to surgical management (rather than tumor biology) that correlate with the incidence of CM/CMS. METHODS Attending pediatric neurosurgeons at British Columbia's Children's Hospital (BCCH) and neurosurgeons who completed a pediatric neurosurgery fellowship at BCCH were invited to provide data from the center where they currently practiced. Children aged from birth to less than 18 years who underwent initial midline PF tumor resection within a contemporary, center-selected 2-year period were included. Data was obtained by retrospective chart and imaging review. Modifiable surgical factors that were assessed included pre-resection surgical hydrocephalus treatment, surgical positioning, ultrasonic aspirator use, intraoperative external ventricular drain (EVD) use, surgical access route to the tumor, and extent of resection. CM was defined as decreased or absent speech output postoperatively and CMS as CM plus new or worsened irritability. RESULTS There were 263 patients from 11 centers in 6 countries (Canada, Germany, the Netherlands, India, Indonesia, and the USA). Median age at surgery was 6 years (range < 1 to 17 years). The overall incidence of postoperative CM was 23.5% (range 14.7-47.6% for centers with data on ≥ 20 patients). The overall incidence of CMS was 6.5% (range 0-10.3% for centers contributing data on ≥ 20 patients). A multivariate logistic regression on the full data set showed no significant association between pre-resection surgical hydrocephalus treatment, prone position, ultrasonic aspirator use, EVD use, telovelar approach, complete or near total resection, or treating center and either postoperative CM or CMS. CONCLUSIONS While there was variation in surgical management of midline PF tumors among centers participating in this study, the factors in management that were examined did not predict postoperative CM or CMS.
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Affiliation(s)
- Bryan Renne
- Faculty of Medicine, University of British Columbia, Vancouver, Canada.
| | - Julia Radic
- Division of Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Canada
| | - Deepak Agrawal
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Gesa Cohrs
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Taylor Davis
- University of Saskatchewan College of Medicine, Saskatoon, Canada
| | - Ashok Gupta
- Department of Neurosurgery, SMS Medical College, Jaipur, Rajasthan, India
| | - Andrea L O Hebb
- Division of Neurosurgery, IWK Health Centre, Halifax, Canada
| | | | | | - Spencer Lindsay
- University of Saskatchewan College of Medicine, Saskatoon, Canada
| | | | - Shibu Pillai
- Department of Neurosurgery, Mazumdar Shaw Medical Center, Narayana Health, Bangalore, India
| | - Hitesh Inder Singh Rai
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Katherine D Sborov
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aleksander Vitali
- Division of Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Canada
| | - Simon Walling
- Division of Neurosurgery, IWK Health Centre, Halifax, Canada
| | - Peter Woerdeman
- Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wihasto Suryaningtyas
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga and Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Douglas Cochrane
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Canada
| | - Ash Singhal
- Division of Neurosurgery, Department of Surgery, British Columbia Children's Hospital and University of British Columbia, Vancouver, Canada
| | - Paul Steinbok
- Division of Neurosurgery, Department of Surgery, British Columbia Children's Hospital and University of British Columbia, Vancouver, Canada
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Russ JB, Weiss WA. Conversations on mutism: risk stratification for cerebellar mutism based on medulloblastoma subtype. Neuro Oncol 2020; 22:175-176. [PMID: 31792531 DOI: 10.1093/neuonc/noz228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jeffrey B Russ
- Department of Neurology, University of California San Francisco, San Francisco, California
| | - William A Weiss
- Departments of Neurology, Pediatrics and Neurosurgery, Brain Tumor Research Center, University of California San Francisco, San Francisco, California.,Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
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92
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Schepke E, Tisell M, Kennedy C, Puget S, Ferroli P, Chevignard M, Doz F, Pizer B, Rutkowski S, Massimino M, Navajas A, Schwalbe E, Hicks D, Clifford SC, Pietsch T, Lannering B. Effects of the growth pattern of medulloblastoma on short-term neurological impairments after surgery: results from the prospective multicenter HIT-SIOP PNET 4 study. J Neurosurg Pediatr 2020; 25:425-433. [PMID: 31952041 DOI: 10.3171/2019.11.peds19349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 11/01/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Extensive resection of a tumor in the posterior fossa in children is associated with the risk of neurological deficits. The objective of this study was to prospectively evaluate the short-term neurological morbidity in children after medulloblastoma surgery and relate this to the tumor's growth pattern and to the extent of resection. METHODS In 160 patients taking part in the HIT-SIOP PNET 4 (Hyperfractionated Versus Conventionally Fractionated Radiotherapy in Standard Risk Medulloblastoma) trial, neurosurgeons prospectively responded to questions concerning the growth pattern of the tumor they had resected. The extent of resection (gross, near, or subtotal) was evaluated using MRI. The patients' neurological status before resection and around 30 days after resection was recorded. RESULTS Invasive tumor growth, defined as local invasion in the brain or meninges, cranial nerve, or major vessel, was reported in 58% of the patients. After surgery almost 70% of all patients were affected by one or several neurological impairments (e.g., impaired vision, impaired extraocular movements, and ataxia). However, this figure was very similar to the preoperative findings. Invasive tumor growth implied a significantly higher number of impairments after surgery (p = 0.03) and greater deterioration regarding extraocular movements (p = 0.012), facial weakness (p = 0.048), and ataxia in the arms (p = 0.014) and trunk (p = 0.025) compared with noninvasive tumor growth. This deterioration was not dependent on the extent of resection performed. Progression-free survival (PFS) at 5 years was 80% ± 4% and 76% ± 5% for patients with invasive and noninvasive tumor growth, respectively, with no difference in the 5-year PFS for extent of resection. CONCLUSIONS Preoperative neurological impairments and invasive tumor growth were strong predictors of deterioration in short-term neurological outcome after medulloblastoma neurosurgery, whereas the extent of resection was not. Neither tumor invasiveness nor extent of resection influenced PFS. These findings support the continuation of maximal safe resection in medulloblastoma surgery where functional risks are not taken in areas with tumor invasion.
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Affiliation(s)
- Elizabeth Schepke
- 1Sahlgrenska Cancer Center, Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg
- 2Department of Pediatrics, Sahlgrenska University Hospital, Gothenburg
| | - Magnus Tisell
- 3Department of Neurosurgery, Sahlgrenska University Hospital and
- 4Institute of Neuroscience and Physiology, Department of Neuroscience, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Colin Kennedy
- 5University of Southampton Faculty of Medicine and University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - Stephanie Puget
- 6Département de Neurochirurgie Pédiatrique, Hôpital Necker-Enfants Malades, Université, Paris, France
| | - Paolo Ferroli
- 7Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Mathilde Chevignard
- 8Rehabilitation Department for Children with Acquired Neurological Injury, Saint Maurice Hospitals, Saint Maurice
- 9Laboratoire d'Imagerie Biomédicale and
- 10GRC 24 HaMCRe, Sorbonne Université, Paris
| | - François Doz
- 11SIREDO Cancer Center (Care, Innovation & Research, in Childhood, Adolescent and Young-Adult Oncology), Institut Curie Paris
- 12Department of Pediatrics, University Paris Descartes, Paris, France
| | - Barry Pizer
- 13Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Stefan Rutkowski
- 14Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maura Massimino
- 15Fondazione Istituto di Ricovero e Cura a Carattere Scientifico IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Edward Schwalbe
- 17Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle-upon-Tyne
- 18Department of Applied Sciences, Northumbria University, Newcastle-upon-Tyne, United Kingdom
| | - Debbie Hicks
- 17Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle-upon-Tyne
| | - Steven C Clifford
- 17Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle-upon-Tyne
| | - Torsten Pietsch
- 19Institute of Neuropathology, DGNN Brain Tumour Reference Center, University of Bonn, Germany; and
| | - Birgitta Lannering
- 20Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Germany
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Abstract
The cerebellar cognitive affective syndrome (CCAS) was first described by Schmahmann and Sherman in 1998. Despite their clear depiction of the syndrome, it is our experience that the CCAS has not yet found solid ground as a disease entity in routine clinical practice. This made us question the dimension of the CCAS in cerebellar patients. We performed a systematic review of the literature according to the PRISMA guidelines, in order to answer the question whether patients with acquired isolated cerebellar lesions perform significantly worse on neuropsychological testing compared to healthy controls. Studies were selected based on the predefined eligibility criteria and quality assessment. The systematic search resulted in ten studies, mainly observational cohorts consecutively including adult patients with isolated cerebellar lesions. Patients were compared to healthy controls, and neuropsychological investigation was done within one year of diagnosis. Meta-analysis of the twelve tests that were done in two or more studies showed that cerebellar patients perform significantly worse on Phonemic Fluency, Semantic Fluency, Stroop Test (naming, reading and interference), Block Design test and WMS-R visual memory. Cerebellar patients have significant and relevant deficits in the visuospatial, language and executive function domain. This meta-analysis therefore emphasizes the importance of the cerebellar cognitive affective syndrome as described by Schmahmann and Sherman.
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94
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Wickenhauser ME, Khan RB, Raches D, Ashford JM, Robinson GW, Russell KMW, Conklin HM. Characterizing Posterior Fossa Syndrome: A Survey of Experts. Pediatr Neurol 2020; 104:19-22. [PMID: 31911026 PMCID: PMC7010537 DOI: 10.1016/j.pediatrneurol.2019.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/17/2019] [Accepted: 11/03/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite recent efforts, disagreement remains among frontline clinicians regarding the operational definition of a syndrome commonly referred to as posterior fossa syndrome or cerebellar mutism syndrome. METHODS We surveyed experts in the clinical care of children with posterior fossa tumors to identify trends and discrepancies in diagnosing posterior fossa syndrome. RESULTS All surveyed professionals conceptualized posterior fossa syndrome as a spectrum diagnosis. The majority agreed that mutism is the most important symptom for diagnosis. However, results highlighted ongoing discrepancies related to important features of posterior fossa syndrome. CONCLUSIONS Greater posterior fossa syndrome conceptual alignment among providers is needed to formulate specific diagnostic criteria that would further research and clinical care. The authors propose preliminary diagnostic criteria for posterior fossa syndrome that require refinement through careful clinical characterization and targeted empirical investigation.
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Affiliation(s)
| | - Raja B. Khan
- Division of Neurology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Darcy Raches
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Jason M. Ashford
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Giles W. Robinson
- Division of Neuro-Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | | | - Heather M. Conklin
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN, USA
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95
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Grieco JA, Abrams AN, Evans CL, Yock TI, Pulsifer MB. A comparison study assessing neuropsychological outcome of patients with post-operative pediatric cerebellar mutism syndrome and matched controls after proton radiation therapy. Childs Nerv Syst 2020; 36:305-313. [PMID: 31325031 PMCID: PMC7067447 DOI: 10.1007/s00381-019-04299-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/02/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Post-operative pediatric cerebellar mutism syndrome (CMS), characterized by mutism, ataxia/hypotonia, and emotional lability, can result in long-term deficits following resection of posterior fossa (PF) tumors. This longitudinal study compared neuropsychological outcomes of pediatric patients with post-operative CMS to a matched control patient group without CMS. METHODS Fifty-eight PF tumor patients received post-surgical proton radiation therapy (PRT) and testing at baseline and at ≥ 1-year post-PRT over a 10-year period. Of these, 18 (31%) had post-operative CMS with baseline and follow-up neuropsychological test data. Those participants were matched to 18 controls by tumor location, age, gender, and handedness; no significant group differences were found at baseline for clinical/demographic variables. Total mean age at baseline was 7.26 years (SD = 4.42); mean follow-up interval was 3.26 years (SD = 2.24). Areas assessed: overall intelligence, expressive and receptive vocabulary, visuomotor integration, fine motor speed, inhibition, emotional control, depression, and anxiety. RESULTS Patients were 52% male; 86% medulloblastoma/14% ependymoma; 86% craniospinal irradiation/14% focal radiation; and 86% chemotherapy. No group differences were found between most mean baseline scores; expressive vocabulary and fine motor speed were significantly lower in the post-operative CMS group (p < 0.05). Mean change scores revealed no significant differences for the sample; scores were within the normal range except fine motor skills were impaired for both groups. CONCLUSIONS Longitudinal neuropsychological outcomes for post-operative pediatric CMS patients did not differ significantly from matched controls without this condition. Patients were in the normal range in all areas except fine motor speed, which was impaired for both groups independent of CMS diagnosis.
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Affiliation(s)
- Julie A. Grieco
- Department of Psychiatry, Massachusetts General Hospital,Harvard Medical School
| | - Annah N. Abrams
- Department of Psychiatry, Massachusetts General Hospital,Harvard Medical School
| | - Casey L. Evans
- Department of Psychiatry, Massachusetts General Hospital
| | - Torunn I. Yock
- Department of Radiation Oncology, Massachusetts General Hospital,Harvard Medical School
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96
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Argyropoulos GPD, van Dun K, Adamaszek M, Leggio M, Manto M, Masciullo M, Molinari M, Stoodley CJ, Van Overwalle F, Ivry RB, Schmahmann JD. The Cerebellar Cognitive Affective/Schmahmann Syndrome: a Task Force Paper. CEREBELLUM (LONDON, ENGLAND) 2020; 19:102-125. [PMID: 31522332 PMCID: PMC6978293 DOI: 10.1007/s12311-019-01068-8] [Citation(s) in RCA: 139] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Sporadically advocated over the last two centuries, a cerebellar role in cognition and affect has been rigorously established in the past few decades. In the clinical domain, such progress is epitomized by the "cerebellar cognitive affective syndrome" ("CCAS") or "Schmahmann syndrome." Introduced in the late 1990s, CCAS reflects a constellation of cerebellar-induced sequelae, comprising deficits in executive function, visuospatial cognition, emotion-affect, and language, over and above speech. The CCAS thus offers excellent grounds to investigate the functional topography of the cerebellum, and, ultimately, illustrate the precise mechanisms by which the cerebellum modulates cognition and affect. The primary objective of this task force paper is thus to stimulate further research in this area. After providing an up-to-date overview of the fundamental findings on cerebellar neurocognition, the paper substantiates the concept of CCAS with recent evidence from different scientific angles, promotes awareness of the CCAS as a clinical entity, and examines our current insight into the therapeutic options available. The paper finally identifies topics of divergence and outstanding questions for further research.
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Affiliation(s)
| | - Kim van Dun
- Rehabilitation Research Center REVAL, UHasselt, Hasselt, Belgium
| | - Michael Adamaszek
- Clinical and Cognitive Neurorehabilitation, Center of Neurology and Neurorehabilitation, Klinik Bavaria Kreischa, An der Wolfsschlucht 1-2, 01703 Kreischa, Germany
| | - Maria Leggio
- Department of Psychology, Sapienza University of Rome, Rome, Italy
- Ataxia Laboratory, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - Mario Manto
- Department of Neurology, CHU-Charleroi, 6000 Charleroi, Belgium
- Department of Neurosciences, University of Mons, 7000 Mons, Belgium
| | - Marcella Masciullo
- SPInal REhabilitation Lab (SPIRE), IRCCS Fondazione Santa Lucia, Via Ardeatina 306, 00179 Rome, Italy
| | - Marco Molinari
- Neuro-Robot Rehabilitation Lab, IRCCS Fondazione Santa Lucia, Via Ardeatina 306, 00179 Rome, Italy
| | | | | | - Richard B. Ivry
- Department of Psychology, University of California, Berkeley, CA USA
| | - Jeremy D. Schmahmann
- Ataxia Unit, Cognitive Behavioral Neurology Unit, Laboratory for Neuroanatomy and Cerebellar Neurobiology, Department of Neurology Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
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97
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Meoded A, Jacobson L, Liu A, Bauza C, Huisman TAGM, Goldenberg N, Weiner H, Jallo G, Jackson E. Diffusion Tensor Imaging Connectomics Reveals Preoperative Neural Connectivity Changes in Children with Postsurgical Posterior Fossa Syndrome. J Neuroimaging 2020; 30:192-197. [PMID: 31908091 DOI: 10.1111/jon.12686] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/13/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Posterior fossa syndrome (PFS), characterized by loss of language and other neurological impairments within the immediate postoperative period, occurs in approximately 25% of children who undergo surgical resection of posterior fossa tumors. Diffusion tensor imaging connectomics offer promise for elucidation of pathway-level disruption in neural connectivity of patients with this disorder. We aim to determine differences in pre- and postoperative connectomics between children with PFS and children with mild or no language deficit after surgery. METHODS Pre- and postoperative diffusion tensor imaging connectomics were applied and compared among patients with PFS, mild deficits, and intact language. RESULTS A total of 35 patients were included in the study. Twenty-three patients with preoperative data and 24 patients with postoperative data were included in the analysis. Mean ages: PFS-8.5 years, mild-3.1 years, intact language-9.4 years (P = .02). Diagnoses included medulloblastoma (44.1%), pilocytic astrocytoma (28.6%), ependymoma (8.6%), other (11.4%), and unknown (8.6%). Five (21.7%) patients had PFS, 4 (17.4%) had mild deficits, and 14 (60.9%) had intact language. The assortativity coefficient was significantly higher in patients with PFS when compared to patients with mild deficits (P = .023). In the connectometry analyses, decreased connectivity was found involving the corpus callosum, right corticothalamic pathway, and right corticostriatal pathway in patients with PFS when compared to patients with intact language. CONCLUSIONS Our findings revealed significant differences in preoperative neural connectivity involving the corticothalamic and other pathways among children who did, versus who did not, develop PFS postoperatively. Diffusion tensor imaging connectomics offers a unique opportunity to study the effect of the posterior fossa tumors on cerebello-cerebral networks and provide new insights into the mechanism of the structural plasticity/reorganization after surgery.
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Affiliation(s)
- Avner Meoded
- Edward B. Singleton Department of Radiology, Section of Pediatric Neuroradiology, Texas Children's Hospital, Houston, TX
| | - Lisa Jacobson
- Department of Neuropsychology, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ann Liu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Colleen Bauza
- Health Informatics, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Thierry A G M Huisman
- Edward B. Singleton Department of Radiology, Section of Pediatric Neuroradiology, Texas Children's Hospital, Houston, TX
| | - Neil Goldenberg
- Department of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.,All Children's Research Institute, and Johns Hopkins Cancer and Blood Disorders Institute, St. Petersburg, FL
| | - Howard Weiner
- Department of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - George Jallo
- Johns Hopkins All Children's Institute for Brain Protection Sciences, St. Petersburg, FL
| | - Eric Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
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98
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Bae D, Mlc VV, Catsman-Berrevoets CE. Preoperative prediction of postoperative cerebellar mutism syndrome. Validation of existing MRI models and proposal of the new Rotterdam pCMS prediction model. Childs Nerv Syst 2020; 36:1471-1480. [PMID: 32072230 PMCID: PMC7299925 DOI: 10.1007/s00381-020-04535-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 02/08/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Postoperative cerebellar mutism syndrome (pCMS) is a complication that may occur after pediatric fossa posterior tumor surgery. Liu et al. developed an MRI-based prediction model to estimate pCMS risk preoperatively. The goal of this study was to validate the model of Liu et al. and if validation was not as sensitive in our group as previously described to develop an easy to use, reliable, and sensitive preoperative risk prediction model for pCMS. METHODS In this study, 121children with a fossa posterior tumor who underwent surgery at ErasmusMC/Sophia Children's Hospital, the Netherlands between 2004 and 2018 could be included. Twenty-six percent of them developed pCMS. Preoperative MRI were scored using the Liu et al. model. RESULTS The Liu et al. model reached an accuracy of 78%, a sensitivity of 58%, and a specificity of 84% in our cohort. In a new risk model some of the variables of Liu et al. were included as well as some of the recently described preoperative MRI characteristics in pCMS patients by Zhang et al. The new model reached an accuracy of 87%, a sensitivity of 97%, and a specificity of 84% in our patient group. CONCLUSION Because the Liu et al. model did not provide an as accurate risk prediction in our cohort as was expected, we created a new risk prediction model that reached high model accuracy in our cohort that could assist neurosurgeons in determining their surgical tactics and help prepare high risk patients and their parents for this severe complication.
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Affiliation(s)
- Dhaenens Bae
- Department of Pediatric Neurology, Erasmus Medical Center/ Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Van Veelen Mlc
- Department of Pediatric Neurosurgery, Erasmus Medical Center/Sophia Children's Hospital, Dr Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - C E Catsman-Berrevoets
- Department of Pediatric Neurology, Erasmus Medical Center/ Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
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99
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Yecies D, Jabarkheel R, Han M, Kim YH, Bruckert L, Shpanskaya K, Perez A, Edwards MSB, Grant GA, Yeom KW. Posterior fossa syndrome and increased mean diffusivity in the olivary bodies. J Neurosurg Pediatr 2019; 24:376-381. [PMID: 31349230 DOI: 10.3171/2019.5.peds1964] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 05/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Posterior fossa syndrome (PFS) is a common postoperative complication following resection of posterior fossa tumors in children. It typically presents 1 to 2 days after surgery with mutism, ataxia, emotional lability, and other behavioral symptoms. Recent structural MRI studies have found an association between PFS and hypertrophic olivary degeneration, which is detectable as T2 hyperintensity in the inferior olivary nuclei (IONs) months after surgery. In this study, the authors investigated whether immediate postoperative diffusion tensor imaging (DTI) of the ION can serve as an early imaging marker of PFS. METHODS The authors retrospectively reviewed pediatric brain tumor patients treated at their institution, Lucile Packard Children's Hospital at Stanford, from 2004 to 2016. They compared the immediate postoperative DTI studies obtained in 6 medulloblastoma patients who developed PFS to those of 6 age-matched controls. RESULTS Patients with PFS had statistically significant increased mean diffusivity (MD) in the left ION (1085.17 ± 215.51 vs 860.17 ± 102.64, p = 0.044) and variably increased MD in the right ION (923.17 ± 119.2 vs 873.67 ± 60.16, p = 0.385) compared with age-matched controls. Patients with PFS had downward trending fractional anisotropy (FA) in both the left (0.28 ± 0.06 vs 0.23 ± 0.03, p = 0.085) and right (0.29 ± 0.06 vs 0.25 ± 0.02, p = 0.164) IONs compared with age-matched controls, although neither of these values reached statistical significance. CONCLUSIONS Increased MD in the ION is associated with development of PFS. ION MD changes may represent an early imaging marker of PFS.
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100
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Yecies D, Shpanskaya K, Jabarkheel R, Maleki M, Bruckert L, Cheshier SH, Hong D, Edwards MSB, Grant GA, Yeom KW. Arterial spin labeling perfusion changes of the frontal lobes in children with posterior fossa syndrome. J Neurosurg Pediatr 2019; 24:382-388. [PMID: 31374541 DOI: 10.3171/2019.5.peds18452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 05/15/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Posterior fossa syndrome (PFS) is a common complication following the resection of posterior fossa tumors in children. The pathophysiology of PFS remains incompletely elucidated; however, the wide-ranging symptoms of PFS suggest the possibility of widespread cortical dysfunction. In this study, the authors utilized arterial spin labeling (ASL), an MR perfusion modality that provides quantitative measurements of cerebral blood flow without the use of intravenous contrast, to assess cortical blood flow in patients with PFS. METHODS A database of medulloblastoma treated at the authors' institution from 2004 to 2016 was retrospectively reviewed, and 14 patients with PFS were identified. Immediate postoperative ASL for patients with PFS and medulloblastoma patients who did not develop PFS were compared. Additionally, in patients with PFS, ASL following the return of speech was compared with immediate postoperative ASL. RESULTS On immediate postoperative ASL, patients who subsequently developed PFS had statistically significant decreases in right frontal lobe perfusion and a trend toward decreased perfusion in the left frontal lobe compared with controls. Patients with PFS had statistically significant increases in bilateral frontal lobe perfusion after the resolution of symptoms compared with their immediate postoperative imaging findings. CONCLUSIONS ASL perfusion imaging identifies decreased frontal lobe blood flow as a strong physiological correlate of PFS that is consistent with the symptomatology of PFS. This is the first study to demonstrate that decreases in frontal lobe perfusion are present in the immediate postoperative period and resolve with the resolution of symptoms, suggesting a physiological explanation for the transient symptoms of PFS.
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Affiliation(s)
| | | | | | | | - Lisa Bruckert
- 4Division of Developmental-Behavioral Pediatrics, Stanford University School of Medicine, Stanford, California; and
| | - Samuel H Cheshier
- 3Department of Neurosurgery, University of Utah Primary Children's Hospital, Salt Lake City, Utah
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