Long-term sequelae after acquired pediatric hemorrhagic cerebellar lesions

Looking beyond body structure and function: a scoping review of non-impairment impacts of stroke on adolescents

BACKGROUND

Much of the childhood stroke literature has not distinguished impacts for adolescents from those of younger children. Research has also focused on body impairments. With adolescence being a unique period, this scoping review aimed to identify the impacts of childhood stroke on activity, participation, and quality of life for adolescents 13-18 years, and identify how these impacts were determined.

METHOD

This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Data pertaining to non-impairment impacts of childhood stroke for adolescents, participant and study characteristics, and measurement instruments were extracted.

RESULTS

Following screening, 79 articles were included, and 33 measurement instruments identified. Only 6 studies reported separate data for adolescents, identifying difficulties with daily activities, social and academic impacts, and reduced quality of life. Impacts of post-stroke communication difficulties on daily activities and schooling were also noted. Measurement instruments developed specifically for adolescents with stroke are lacking.

INTERPRETATION

The review identified limited research reporting non-impairment impacts of childhood stroke for adolescents. Further research specific to this population and the development of measurement instruments for adolescents who have experienced childhood stroke is required to support future research and clinicians working with this population.

Neurocognitive outcomes following intracerebral hemorrhage in childhood

Neurocognitive deficits commonly occur following intracerebral hemorrhage (ICH) in childhood, yet this population remains understudied. The current study is a preliminary exploration of neurocognitive outcomes in this population. At the Hospital for Sick Children in Toronto, Canada, 17 patients (Mage = 14.2, SD = 4.6) with a history of childhood ICH completed a neuropsychological assessment evaluating perceptual reasoning, verbal reasoning, processing speed, working memory, verbal learning, verbal memory, visuomotor integration, selective attention, and executive functioning. Mean Full Scale IQ (FSIQ; M = 98.1, SD = 13.6) fell within the clinically average range compared to population norms, though it was skewed toward lower ranges. Furthermore, approximately 50-60% of the participants scored under the clinically average range on tests of verbal learning, verbal memory, processing speed, and visuomotor integration. Youth with childhood ICH may present with FSIQ within the average range, but as a group they skew toward lower ranges and are more likely to demonstrate deficits in distinct neurocognitive domains. Clinical evaluation of a wide range of neuropsychological skills is warranted. Clinical implications encompass informing of intake interviews, development of test batteries, and appraisal of prognosis. Findings contribute to the limited knowledge base about neurocognitive outcomes following childhood ICH.

Implications of age at lesion onset for neuropsychological outcomes: A systematic review focusing on focal brain lesions

Theories of the relation between age at lesion onset and outcomes posit different views of the young brain: resilient and plastic (i.e., the so-called "Kennard Principle"), or vulnerable (i.e., the Early Vulnerability Hypothesis). There is support for both perspectives in previous research and questions about the "best" or "worst" times to sustain brain injury remain. Here, we present a systematic review investigating the influence of age at focal brain lesion onset on cognitive functioning. This systematic review identifies and qualitatively synthesizes empirical studies from 1985 to 2021 that investigated age at lesion onset as a variable of interest associated with neuropsychological outcomes. A total of 45 studies were identified from PubMed, PsycINFO, and CINAHL databases. Almost all studies indicated that brain injury earlier in the developmental period predicts worse cognitive outcomes when compared to onset either later in the developmental period or in adulthood. More specifically, the overwhelming majority of studies support an "earlier is worse" model for domains of intellect, processing speed, attention and working memory, visuospatial and perceptual skills, and learning and memory. Relatively more variability in outcomes exists for domains of language and executive functioning. Outcomes for all domains are influenced by various other age and injury variables (e.g., lesion size, lesion laterality, chronicity, a history of epilepsy). Continued interdisciplinary understanding and communication about the influence of age at lesion onset on neuropsychological outcomes will aid in promoting the best possible outcomes for patients.

Emotional disorders and the cerebellum: Neurobiological substrates, neuropsychiatry, and therapeutic implications

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.

The role of cerebellum in the child neuropsychological functioning

This chapter proposes a review of neuropsychologic and behavior findings in pediatric pathologies of the cerebellum, including cerebellar malformations, pediatric ataxias, cerebellar tumors, and other acquired cerebellar injuries during childhood. The chapter also contains reviews of the cerebellar mutism/posterior fossa syndrome, reported cognitive associations with the development of the cerebellum in typically developing children and subjects born preterm, and the role of the cerebellum in neurodevelopmental disorders such as autism spectrum disorders and developmental dyslexia. Cognitive findings in pediatric cerebellar disorders are considered in the context of known cerebellocerebral connections, internal cellular organization of the cerebellum, the idea of a universal cerebellar transform and computational internal models, and the role of the cerebellum in specific cognitive and motor functions, such as working memory, language, timing, or control of eye movements. The chapter closes with a discussion of the strengths and weaknesses of the cognitive affective syndrome as it has been described in children and some conclusions and perspectives.

The Cerebellar Cognitive Affective/Schmahmann Syndrome: a Task Force Paper

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.

The Cerebellar Cognitive Affective/Schmahmann Syndrome: a Task Force Paper

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.

Successful neuropsychological rehabilitation in a patient with Cerebellar Cognitive Affective Syndrome

The objective of this case study was to describe the neuropsychological rehabilitation of a 16-year-old patient who presented a Cerebellar Cognitive Affective Syndrome (CCAS) following a bilateral cerebellar hemorrhage. The patient presented severe and diffuse cognitive deficits, massive behavioral disorders, and emotion regulation difficulties. The cognitive rehabilitation was performed in the chronic phase (one year after the onset of the hemorrhage) using a transdisciplinary neurobehavioral approach based on the patient's favorite interest (soccer). A significant behavioral and cognitive improvement was observed. The patient became progressively independent in all activities of daily living and was discharged home. The Functional Independence Measure at discharge was 124/126 (vs. 37/126 at entry). The patient was able to complete his schooling despite the mild cognitive and behavioral sequelae. This first description of the use of neurobehavioral therapy in a case of chronic CCAS suggests that (a) major clinical improvement can occur more than one year after the onset of the CCAS, showing the importance of long-term and intensive neurorehabilitation; and (b) when the cerebellum cannot properly play its regulator role in cognition, neuropsychological intervention through a behavioral and cognitive approach can be of great help by acting as an external modulator to help the patient regain control over himself.

White matter hyperintensities and cognitive dysfunction in patients with infratentorial stroke

Objective

To determine whether cognitive function is associated with white matter hyperintensities (WMH) in patients with infratentorial stroke.

Methods

This was a retrospective, cross-sectional study. Twenty-four first-ever infratentorial stroke patients between 18 and 60 years of age were enrolled. WMH was evaluated by the Fazekas scale and the Scheltens scale. Cognitive functions were assessed using the Korean Mini-Mental Status Examination (K-MMSE), Rey-Osterrieth Complex Figure Test, and the Seoul Computerized Neuropsychological Test Battery (SCNT) at one month after stroke. All participants were divided into two groups based on the presence of WMH (no-WMH group and WMH group). General characteristics and cognitive functions were compared between the groups.

Results

There were no significant differences in general characteristics, such as age, stroke type, hypertension history, and education level between the two groups. However, K-MMSE in the WMH group was significantly lower compared to the no-WMH group (p<0.05). The verbal learning test score in SCNT was significantly higher in the no-WMH group compared to the WMH group (p<0.05). Executive function in the no-WMH group tended to be higher compared to the WMH group.

Conclusion

Impairment of cognitive function in patients with infratentorial stroke appeared to be associated with WMH. WMH should be carefully evaluated during rehabilitation of infratentorial stroke patients.

Cognitive phenotype in ataxia-telangiectasia

BACKGROUND

Pediatric cerebrocerebellar neurodegenerative disorders such as ataxia-telangiectasia (AT) have not been examined in detail for neuropsychologic changes. Such studies may contribute to the further understanding of ataxia-telangiectasia and to the role of the cerebrocerebellar system in the development of cognitive function in childhood.

METHODS

Twenty-two patients with the classic phenotype of ataxia-telangiectasia were grouped into early stage cerebellar disease (group AT-I) versus late stage cerebrocerebellar disease (group AT-II) and examined for neurocognitive features. Results were compared with those of healthy control subjects and with standard norms.

RESULTS

Patients in AT-I group scored low average compared with standard norms on all tests and were impaired compared with healthy control subjects for verbal intelligence quotient (P < 0.001), vocabulary and comprehension (P = 0.007), processing speed (P = 0.005), visuospatial processing (P = 0.020), and working memory (P = 0.046). Patients in AT-II group scored below average compared with standard norms on all tests and were impaired compared with control subjects for attention (P < 0.001), working memory (P < 0.001), and abstract reasoning (P < 0.001). Comprehension scores were lower for patients in AT-II than in AT-I group (P = 0.002), whereas vocabulary scores showed no difference between groups (P = 0.480).

CONCLUSION

Cognitive impairments in ataxia-telangiectasia present early, coinciding with cerebellar pathology and are characteristic of the cerebellar cognitive affective syndrome. Widespread and deeper cognitive deficits manifest in later stages of ataxia-telangiectasia when additional noncerebellar pathology develops. These results are the first indications of distinct cerebellar and extracerebellar and/or subcortical contributions to the range of cognitive domains affected in ataxia-telangiectasia and need to be confirmed in future studies.