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Dekeyzer S, Vanden Bossche S, De Cocker L. Anything but Little: a Pictorial Review on Anatomy and Pathology of the Cerebellum. Clin Neuroradiol 2023; 33:907-929. [PMID: 37410171 DOI: 10.1007/s00062-023-01326-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/09/2023] [Indexed: 07/07/2023]
Abstract
Despite its small size the cerebellum is an anatomically complex and functionally important part of the brain. Traditionally the cerebellum is viewed as a motor control structure entirely devoted to motor control and learning, but recent functional magnetic resonance imaging (fMRI) studies demonstrated significant involvement of the cerebellum in higher order cognitive functions. The anatomical complexity of the cerebellum is reflected by the several nomenclature systems that exist for the description of cerebellar anatomy. The cerebellum can be affected by a variety of pathological processes, including congenital, infectious and inflammatory, neoplastic, vascular, degenerative and toxic metabolic diseases. The purpose of this pictorial review is to (1) provide a general overview of cerebellar anatomy and function, (2) demonstrate normal cerebellar anatomy on imaging studies, and (3) illustrate both common as well as rare pathological conditions affecting the cerebellum.
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Affiliation(s)
- Sven Dekeyzer
- Department of Radiology and Medical Imaging, Ghent University Hospital (UZG), Corneel Heymanslaan 10, 9000, Gent, Belgium.
- Department of Radiology, Antwerp University Hospital (UZA), Drie Eikenstraat 655, 2650, Edegem, Belgium.
| | - Stephanie Vanden Bossche
- Department of Radiology, Antwerp University Hospital (UZA), Drie Eikenstraat 655, 2650, Edegem, Belgium
- Department of Radiology, AZ Sint Jan Bruges, Ruddershove 10, 8000, Bruges, Belgium
| | - Laurens De Cocker
- Department of Radiology, AZ Maria Middelares Gent, Buitenring-Sint-Denijs 30, 9000, Gent, Belgium
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Altiparmak T, Nazliel B, Caglayan HB, Tokgoz N, Gurses AA, Ucar M. Baseline Factors Affecting the Prognosis of Ischemic Cerebellar Stroke Patients in Turkey: A Cross-Sectional Study. Niger J Clin Pract 2023; 26:1677-1684. [PMID: 38044773 DOI: 10.4103/njcp.njcp_302_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 10/01/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Cerebellar infarcts are encountered commonly in clinical practice; however, they are likely to be misinterpreted. They cannot be adequately evaluated on scales such as the National Institute of Health Stroke Scale (NIHSS), which can have fatal consequences. AIM To evaluate the baseline features, prognosis, and 6-month survival in patients with cerebellar stroke. METHODS A total of 200 patients with cerebellar ischemia were included in the study. Patients were analyzed retrospectively from 10 years of data. Both univariate and multivariate analyses were evaluated. RESULTS Mean age was 68 years old, and men were more frequently affected. The most common symptoms were dysarthria and vertiginous sensations. Ischemic lesions were usually cortical/juxtacortical, multiple, hemispheric, and small (below 1.5 cm). The most commonly affected artery was the medial branch of the posterior inferior cerebellar artery. Cardioembolism was the more frequent etiology. Gait ataxia was associated with a more favorable prognosis and 6-month modified Rankin Scale (mRS) scores (OR: 0.15, 95% CI, P = 0.03). Older age (OR: 1.75, 95%, P = 0.02), female gender (OR: 6.72, 95%, P = 0.02), multiple (OR: 10.92, 95%, P = 0.01) and large lesions (OR: 6.56, 95% CI, P = 0.01), posterior circulation ischemic lesions extra-cerebellum (OR: 8.33, 95% CI, P = 0.01), left ventricular apical hypokinesia or AF (OR: 5.58, 95% CI, P = 0.02), and a high mRS score on admission (OR: 5.21, 95% CI, P < 0.001) was correlated with higher 6-month mRS and a lower survival rates. CONCLUSION The study found that some baseline clinical, neurovascular imaging findings, and the mRS score on admission are useful predictors of cerebellar stroke prognosis and outcome.
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Affiliation(s)
- T Altiparmak
- Department of Neurology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - B Nazliel
- Department of Neurology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - H B Caglayan
- Department of Neurology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - N Tokgoz
- Department of Radiology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - A A Gurses
- Department of Neurology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - M Ucar
- Department of Radiology, Gazi University Faculty of Medicine, Ankara, Turkey
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Yu L, Li X, Hou Y, Hu H, Bai M, Yang L, Hu W. Incidence and clinical features of acute multiple small cerebellar infarction. J Stroke Cerebrovasc Dis 2022; 31:106777. [PMID: 36174324 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106777] [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: 04/22/2022] [Revised: 08/18/2022] [Accepted: 09/07/2022] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To investigate the clinical and imaging features and to identify possible etiology of acute multiple small cerebellar infarction (MSCI). METHODS We retrospectively enrolled 220 patients with acute cerebellar infarction, divided them into MSCI and large cerebellar infarction (LCI) groups, according to the quantity and size of lesions confirmed by MRI analysis. Clinical and imaging features were compared between the two groups to explore the possible etiology and pathogenesis. RESULTS Among 220 patients, 90 patients presented MSCI symptoms. The proportions of extracerebellar lesions (P = 0.001) and bilateral infarction (P = 0.001) in the MSCI group were higher than those in the LCI group. No significant differences were found in terms of age, gender, and common vascular risk factors between the two groups. The proportions of vertigo and headache in the MSCI group were significantly lower than those in the LCI group (P < 0.000 and 0.034, respectively), and limb weakness was significantly higher (P = 0.039) in the MSCI patients. Moreover, the proportions of nystagmus and ataxia in the MSCI group were significantly lower than those in the LCI group (P < 0.043 and 0.003, respectively). The MSCI group had higher proportions of ACA and MCA stenosis, while the proportion of posterior circulation stenosis was similar between the two groups. Infarctions involving the posterior inferior cerebellar (PICA) region and mixed territories were far more frequent than those involving the anterior inferior cerebellar artery (AICA) region and superior cerebellar artery (SCA) territory (P < 0.05). Large-artery atherosclerosis and multiple plus undetermined etiology were the main etiological factors of MSCI. CONCLUSION In patients with acute cerebellar infarction, 30% of patients presented with MSCI. MSCI and LCI showed similar vascular risk factors and vascular stenosis in the posterior circulation system. Patients with MSCI should pay more attention to evaluating anterior circulation vessels' anatomy. Large-artery atherosclerosis was the main pathogenesis of acute MSCI. Assessment of cerebral vessels might be critically required in patients with MSCI complicated atrial fibrillation.
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Affiliation(s)
- Ling Yu
- Department of Endocrinology, Beijing Chaoyang Hospital, Capital Medical University, PR China
| | - Xuanting Li
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8, South Gongti Road, Beijing 100020, PR China
| | - Yutong Hou
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8, South Gongti Road, Beijing 100020, PR China
| | - Hongmei Hu
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8, South Gongti Road, Beijing 100020, PR China
| | - Mingyue Bai
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8, South Gongti Road, Beijing 100020, PR China
| | - Lei Yang
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8, South Gongti Road, Beijing 100020, PR China.
| | - Wenli Hu
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8, South Gongti Road, Beijing 100020, PR China
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De Cocker LJL, Hendrikse J. Depth-of-Fissure Cerebellar Infarcts in Adults. AJNR Am J Neuroradiol 2020; 41:E60. [PMID: 32586962 DOI: 10.3174/ajnr.a6626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
| | - J Hendrikse
- Department of RadiologyUniversity Medical Center UtrechtUtrecht, the Netherlands
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Ter Schiphorst A, Tatu L, Thijs V, Demattei C, Thouvenot E, Renard D. Small obliquely oriented cortical cerebellar infarctions are associated with cardioembolic stroke. BMC Neurol 2019; 19:100. [PMID: 31103038 PMCID: PMC6525367 DOI: 10.1186/s12883-019-1328-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 05/08/2019] [Indexed: 11/17/2022] Open
Abstract
Background A revised classification of cerebellar infarctions (CI) may uncover unrecognized associations with etiologic stroke subtypes. We hypothesized that obliquely oriented small cortical cerebellar infarction (SCCI) representing end zone infarctions on MRI would be associated with cardiac embolism. Methods We retrospectively analyzed consecutive stroke patients recruited between January–December 2016 in our center. Analyzed baseline characteristics: sex, age, cardiovascular risk factors, history of stroke or atrial fibrillation (AF). TOAST classification was used for determining stroke subtype. Acute infarction location (anterior/posterior/mixed anterior-posterior circulation), acute uni- or multiterritorial infarction, and acute or chronic CI/SCCI/non-SCCI were assessed by MRI, and vertebrobasilar stenosis/occlusion by vessel imaging. Pre-specified analysis was also performed in patients without known high cardioembolic risk (known AF history or acute multiterritorial infarction). Results We included 452 patients (CI in 154, isolated SCCI in 55, isolated non-SCCI in 50, and mixed SCCI/non-SCCI in 49). Both SCCI and non-SCCI were associated with AF history (SCCI, p = 0.021; non-SCCI, p = 0.004), additional acute posterior circulation infarction (p < 0.001 both CI-subtypes), multiterritorial infarctions (SCCI, p = 0.003; non-SCCI, p < 0.001) and cardioembolic more frequent than large-artery atherosclerosis origin (p < 0.001 for both CI-subtypes). SCCI was associated with older age (p < 0.001), whereas non-SCCI was associated with stroke history (p = 0.036) and vertebrobasilar stenosis/occlusion (p = 0.002). SCCI were older (p = 0.046) than non-SCCI patients, had less frequently prior stroke (p < 0.001), and more frequent cardioembolic infarction (p = 0.025). In patients without known high cardioembolic risk (n = 348), SCCI was strongly associated with subsequent cardioembolism diagnosis (OR 3.00 [CI 1.58–5.73, p < 0.001]). No such association was present in non-SCCI. Conclusions Acute or chronic SCCI are strongly associated with a cardioembolic origin.
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Affiliation(s)
- Adrien Ter Schiphorst
- Department of Neurology, Nîmes University Hospital, Hôpital Carémeau, 4, Rue du Pr Debré, 30029, Nîmes, Cedex 4, France
| | - Lavinia Tatu
- Department of Neurology, Nîmes University Hospital, Hôpital Carémeau, 4, Rue du Pr Debré, 30029, Nîmes, Cedex 4, France
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Vic, Australia.,Department of Neurology, Austin Health, Heidelberg, Vic, Australia
| | - Christophe Demattei
- Service de Biostatistique, Epidémiologie Clinique, Santé Publique et Innovation en Méthodologie (BESPIM), Nîmes University Hospital, Nîmes, France
| | - Eric Thouvenot
- Department of Neurology, Nîmes University Hospital, Hôpital Carémeau, 4, Rue du Pr Debré, 30029, Nîmes, Cedex 4, France.,Institut de Génomique Fonctionnelle, UMR5203, INSERM 1191, Université Montpellier, Montpellier, France
| | - Dimitri Renard
- Department of Neurology, Nîmes University Hospital, Hôpital Carémeau, 4, Rue du Pr Debré, 30029, Nîmes, Cedex 4, France.
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De Cocker LJ, Lindenholz A, Zwanenburg JJ, van der Kolk AG, Zwartbol M, Luijten PR, Hendrikse J. Clinical vascular imaging in the brain at 7T. Neuroimage 2018; 168:452-458. [PMID: 27867089 PMCID: PMC5862656 DOI: 10.1016/j.neuroimage.2016.11.044] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 09/30/2016] [Accepted: 11/16/2016] [Indexed: 01/23/2023] Open
Abstract
Stroke and related cerebrovascular diseases are a major cause of mortality and disability. Even at standard-field-strengths (1.5T), MRI is by far the most sensitive imaging technique to detect acute brain infarctions and to characterize incidental cerebrovascular lesions, such as white matter hyperintensities, lacunes and microbleeds. Arterial time-of-flight (TOF) MR angiography (MRA) can depict luminal narrowing or occlusion of the major brain feeding arteries, and this without the need for contrast administration. Compared to 1.5T MRA, the use of high-field strength (3T) and even more so ultra-high-field strengths (7T), enables the visualization of the lumen of much smaller intracranial vessels, while adding a contrast agent to TOF MRA at 7T may enable the visualization of even more distal arteries in addition to veins and venules. Moreover, with 3T and 7T, the arterial vessel walls beyond the circle of Willis become visible with high-resolution vessel wall imaging. In addition, with 7T MRI, the brain parenchyma can now be visualized on a submillimeter scale. As a result, high-resolution imaging studies of the brain and its blood supply at 7T have generated new concepts of different cerebrovascular diseases. In the current article, we will discuss emerging clinical applications and future directions of vascular imaging in the brain at 7T MRI.
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Affiliation(s)
- Laurens Jl De Cocker
- Department of Radiology, University Medical Center Utrecht, The Netherlands; Department of Radiology, Kliniek Sint-Jan, Brussels, Belgium.
| | - Arjen Lindenholz
- Department of Radiology, University Medical Center Utrecht, The Netherlands
| | - Jaco Jm Zwanenburg
- Department of Radiology, University Medical Center Utrecht, The Netherlands
| | | | - Maarten Zwartbol
- Department of Radiology, University Medical Center Utrecht, The Netherlands
| | - Peter R Luijten
- Department of Radiology, University Medical Center Utrecht, The Netherlands
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, The Netherlands
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Calic Z, Cappelen-Smith C, Cuganesan R, Anderson CS, Welgampola M, Cordato DJ. Frequency, Aetiology, and Outcome of Small Cerebellar Infarction. Cerebrovasc Dis Extra 2017; 7:173-180. [PMID: 29130973 PMCID: PMC5731170 DOI: 10.1159/000481459] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 09/07/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Strokes due to small (<2 cm) cerebellar infarction are under-recognised, and their profile and aetiology have not been well characterised. We aimed to determine the frequency, clinical features, aetiology, and outcome of small as compared to large cerebellar infarction. METHODS This study is a retrospective analysis of clinical and imaging features of a prospectively assessed series of 108 consecutive patients with acute cerebellar infarction admitted to Liverpool Hospital, Sydney, NSW, Australia, during 2011-2015. RESULTS The mean age of the patients was 67 years, and 33 (31%) had small cerebellar infarction. Compared to large cerebellar infarction, those with small cerebellar infarction had a comparable distribution of vascular risk factors but significantly less nausea and vomiting, gait disturbance, limb ataxia, and dysarthria. The posterior (n = 22, 67%) lobe was most commonly affected, followed by the anterior (n = 9, 27%) and flocculonodular (n = 2) lobes. Dizziness, limb ataxia, and nystagmus were significantly more common in patients with anterior lobe infarction. Vertebrobasilar disease was the presumed aetiology in 40 patients (37%), and was less commonly seen in small as compared to large cerebellar infarction. Cardioembolism affected 37% of the patients, irrespective of the size or topography of the cerebellar infarction, and there was no relation of supratentorial white matter lucencies (WMLs) to the size of cerebellar infarction. At 3 months, 65% of the patients were functionally independent (according to modified Rankin Scale scores of 0-2), and having a poor outcome was significantly related to moderate-to-severe supratentorial WML and large cerebellar infarction. CONCLUSIONS Small cerebellar infarction accounted for one-third of the ischaemic strokes in this location, most often involved the posterior lobe, causing fewer clinical features, and had a better clinical outcome than large cerebellar infarction. Patients with small cerebellar infarction require appropriate vascular management including investigation for a cardioembolic source.
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Affiliation(s)
- Zeljka Calic
- Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Cecilia Cappelen-Smith
- Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Ramesh Cuganesan
- Department of Radiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Miriam Welgampola
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Dennis J Cordato
- Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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De Cocker LJL, Lövblad KO, Hendrikse J. MRI of Cerebellar Infarction. Eur Neurol 2017; 77:137-146. [PMID: 28095387 DOI: 10.1159/000455229] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 12/17/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND MRI is the imaging modality of choice for diagnosing brain infarction. Because of few or atypical clinical symptoms and a relatively low sensitivity of CT scans, many cerebellar infarctions may be detected only with MRI. With adequate recognition of cerebellar infarction on MRI and prompt initiation or optimisation of preventive therapeutic measures, more dramatic strokes may be avoided in selected cases. SUMMARY We first briefly review the clinical presentation of cerebellar infarctions, followed by a short refresher on cerebellar anatomy and pathophysiological mechanisms of cerebellar infarcts. Then, we review the arterial cerebellar perfusion territories recently made visible with territorial arterial spin labeling (ASL), followed by a discussion and illustration of the MRI appearance of cerebellar infarcts in different stages. Similar to large cerebellar infarcts, recent studies investigating volumetric MRI datasets have now shown that small cerebellar infarcts occur in typical spatial patterns, knowledge of which may help in the diagnosis of even the smallest of cerebellar infarcts on MRI. Key Messages: MRI is the modality of choice for diagnosing cerebellar infarction. The posterior inferior cerebellar artery (PICA)-territories can be visualised with super-selective territorial ASL MRI. The PICA supplies at least the medial part of the posterior cerebellar surface. Anterior inferior cerebellar artery-infarcts can be mistaken for lateral PICA-infarcts. Small infarcts typically affect the cortex and often present as incidental cavities. Subacute cerebellar infarcts may be missed on imaging due to a phenomenon called "fogging."
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Affiliation(s)
- Laurens J L De Cocker
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
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Abstract
The goal of this thesis was to elucidate the details of cerebellovascular diseases with advanced magnetic resonance (MR) imaging (MRI) and to translate the findings to routine clinical MRI. The first aim was to image cerebellar arterial perfusion territories, which was achieved by applying super-selective arterial spin labelling (ASL) MRI with labelling of both vertebral arteries in addition to the carotid arteries. The second aim was to unravel the imaging patterns of cerebellar infarctions with 7T post-mortem MRI in addition to volume (3D) clinical MRI. This research led to the description of “cerebellar cortical infarct cavities”, an incidental imaging finding that proved to be the most frequent manifestation of cerebellar ischemia as well as a marker of atherosclerotic and thromboembolic cerebrovascular disease. Finally, we found that almost all patients with such cavities lack a clinical history of vertebrobasilar transient ischemic attack (TIA) or stroke, disclosing the still very high incidence of clinically occult ischemia in the posterior fossa.
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