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Simon MV, Rutkove SB, Ngo L, Fehnel CR, Das AS, Sarge T, Bose S, Selim M, Kumar S. Understanding the variability of the electrophysiologic laryngeal adductor reflex. Clin Neurophysiol 2024; 162:141-150. [PMID: 38631074 DOI: 10.1016/j.clinph.2024.03.019] [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: 12/02/2023] [Revised: 03/11/2024] [Accepted: 03/16/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE The laryngeal adductor reflex (LAR) is vital for airway protection and can be electrophysiologically obtained under intravenous general anesthesia (IGA). This makes the electrophysiologic LAR (eLAR) an important tool for monitoring of the vagus nerves and relevant brainstem circuitry during high-risk surgeries. We investigated the intra-class variability of normal and expected abnormal eLAR. METHODS Repeated measures of contralateral R1 (cR1) were performed under IGA in 58 patients. Data on presence/absence of cR2 and potential confounders were also collected. Review of neuroimaging, pathology and clinical exam, allowed classification into normal and expected abnormal eLAR groups. Using univariate and multivariate analysis we studied the variability of cR1 parameters and their differences between the two groups. RESULTS In both groups, cR1 latencies had coefficients of variation of <2%. In the abnormal group, cR1 had longer latencies, required higher activation currents and was more frequently desynchronized and unsustained; cR2 was more frequently absent. CONCLUSIONS cR1 latencies show high analytical precision for measurements. Delayed onset, difficult to elicit, desynchronized and unsustained cR1, and absence of cR2 signal an abnormal eLAR. SIGNIFICANCE Understanding the variability and behavior of normal and abnormal eLAR under IGA can aid in the interpretation of its changes during monitoring.
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Affiliation(s)
- Mirela V Simon
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Seward B Rutkove
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Long Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Corey R Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Alvin S Das
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Todd Sarge
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Somnath Bose
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Sandeep Kumar
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Kameda-Smith MM, Ragulojan M, Elliott C, Bliss L, Moore H, Sader N, Alsuwaihel M, Tso MK, Dakson A, Ajani O, Yarascavitch B, Fleming A, Mehta V, Aminnejad M, Farrokhyar F, Singh SK. National multicentered retrospective review of clinical and intraoperative factors associated with the development of cerebellar mutism after pediatric posterior fossa tumor resection. Childs Nerv Syst 2024; 40:1339-1347. [PMID: 38279985 DOI: 10.1007/s00381-024-06292-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 01/14/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Cerebellar mutism (CM) is characterized by a significant loss of speech in children following posterior fossa (PF) surgery. The biological origin of CM remains unclear and is the subject of ongoing debate. Significant recovery from CM is less likely than previously described despite rigorous multidisciplinary neuro-rehabilitational efforts. METHODS A national multi-centered retrospective review of all children undergoing PF resection in four midsized Canadian academic pediatric institutions was undertaken. Patient, tumor and surgical factors associated with the post-operative development of CM were reviewed. Retrospective identification of PF surgery patients including those developing and those that did not (internal control). RESULTS The study identified 258 patients across the 4 centers between 2010 and 2020 (mean age 6.73 years; 42.2% female). Overall, CM was experienced in 19.5% of patients (N = 50). Amongst children who developed CM histopathology included medulloblastoma (35.7%), pilocytic astrocytoma (32.6%) and ependymoma (17.1%). Intraoperative impression of adherence to the floor of the 4th ventricle was positive in 36.8%. Intraoperative abrupt changes in blood pressure and/or heart rate were identified in 19.4% and 17.8% of cases. The clinical resolution of CM was rated to be complete, significant resolution, slight improvement, no improvement and deterioration in 56.0%, 8.0%, 20.0%, 14.0% and 2.0%, respectively. In the cohort of children who experienced post-operative CM as compared to their no-CM counterpart, proportionally more tumors were felt to be adherent to the floor of the 4th ventricle (56.0% vs 49.5%), intraoperative extent of resection was a GTR (74% vs 68.8%) and changes in heart rate were noted (≥ 20% from baseline) (26.0% vs 15.9%). However, a multiple regression analysis identified only abrupt changes in HR (OR 5.97, CI (1.53, 23.1), p = 0.01) to be significantly associated with the development of post-operative CM. CONCLUSION As a devastating surgical complication after posterior fossa tumor surgery with variable clinical course, identifying and understanding the operative cues and revising intraoperative plans that optimizes the child's neurooncological and clinical outcome are essential.
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Affiliation(s)
- Michelle M Kameda-Smith
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada.
- Great Ormond Street Hospital for Children, London, England.
- Canadian Neurosurgery Research Collaborative (CNRC), Hamilton, Canada.
- McMaster Pediatric Brain Tumor Study Group (PBTSG), Hamilton, ON, Canada.
| | - Malavan Ragulojan
- McMaster Pediatric Brain Tumor Study Group (PBTSG), Hamilton, ON, Canada
| | - Cameron Elliott
- Canadian Neurosurgery Research Collaborative (CNRC), Hamilton, Canada
- Division of Neurosurgery, University of Alberta, Edmonton, AB, Canada
| | - Lori Bliss
- Division of Neurosurgery, University of Alberta, Edmonton, AB, Canada
| | - Hanna Moore
- Division of Neurosurgery, University of Alberta, Edmonton, AB, Canada
| | - Nicholas Sader
- Division of Neurosurgery, University of Calgary, Calgary, AB, Canada
| | | | - Michael K Tso
- Canadian Neurosurgery Research Collaborative (CNRC), Hamilton, Canada
- Division of Neurosurgery, University of Calgary, Calgary, AB, Canada
| | - Ayoub Dakson
- Canadian Neurosurgery Research Collaborative (CNRC), Hamilton, Canada
- Division of Neurosurgery, Dalhousie University, Halifax, NS, Canada
| | - Olufemi Ajani
- Great Ormond Street Hospital for Children, London, England
- McMaster Pediatric Brain Tumor Study Group (PBTSG), Hamilton, ON, Canada
| | - Blake Yarascavitch
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
- McMaster Pediatric Brain Tumor Study Group (PBTSG), Hamilton, ON, Canada
| | - Adam Fleming
- McMaster Pediatric Brain Tumor Study Group (PBTSG), Hamilton, ON, Canada
| | - Vivek Mehta
- Division of Neurosurgery, University of Alberta, Edmonton, AB, Canada
| | - Minoo Aminnejad
- McMaster Pediatric Brain Tumor Study Group (PBTSG), Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
- McMaster Pediatric Brain Tumor Study Group (PBTSG), Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sheila K Singh
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
- McMaster Pediatric Brain Tumor Study Group (PBTSG), Hamilton, ON, Canada
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Feletti A, Vernile B, Testa M, Scarpelli M, Bonetti B, Sala F. Endoscopic trans-Magendie foramen biopsy of the superior medullary velum: Technical note. J Clin Neurosci 2023; 117:11-14. [PMID: 37717276 DOI: 10.1016/j.jocn.2023.09.002] [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: 05/14/2023] [Revised: 09/03/2023] [Accepted: 09/05/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Surgery of the fourth ventricle is challenging due to the presence of several surrounding delicate structures. Traditional approaches do not offer an easy visualization of these areas, especially those on the roof. Thanks to the most recent developments in neurosurgical endoscopy, it is possible to access the fourth ventricle via physiological pathways, avoiding unnecessary stress or damage to the nervous and vascular structures. METHODS We present the case of a patient with a lesion at the lingula-superior medullary velum, and an history of surgically resected lung and pancreatic adenocarcinomas. An endoscopic biopsy of the lesion through the foramen of Magendie was performed. The few reports on this endoscopic approach were also critically reviewed. RESULTS The retrograde endoscopic exploration through a suboccipital, trans-Magendie foramen approach using a flexible endoscope allowed the clear visualization of the superior medullary velum and the possibility to obtain diagnostic biopsies of the lesion with a minimally invasive technique. CONCLUSIONS The trans-Magendie navigation with a flexible endoscope is a safe and elegant technique to approach lesions located in any point of the fourth ventricle, particularly in its rostral portion.
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Affiliation(s)
- Alberto Feletti
- Department of Neurosciences, Biomedicine and Movement Sciences, Institute of Neurosurgery, University of Verona, Italy
| | - Bruno Vernile
- Department of Neurosciences, Biomedicine and Movement Sciences, Institute of Neurosurgery, University of Verona, Italy.
| | - Mattia Testa
- Department of Neurosciences, Biomedicine and Movement Sciences, Institute of Neurosurgery, University of Verona, Italy
| | - Mauro Scarpelli
- Institute of Neurology, Azienda Ospedaliera Universitaria Integrata di Verona, Italy
| | - Bruno Bonetti
- Institute of Neurology, Azienda Ospedaliera Universitaria Integrata di Verona, Italy
| | - Francesco Sala
- Department of Neurosciences, Biomedicine and Movement Sciences, Institute of Neurosurgery, University of Verona, Italy
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Anetsberger S, Mellal A, Garvayo M, Diezi M, Perez MH, Beck Popovic M, Renella R, Cossu G, Daniel RT, Starnoni D, Messerer M. Predictive Factors for the Occurrence of Perioperative Complications in Pediatric Posterior Fossa Tumors. World Neurosurg 2023; 172:e508-e516. [PMID: 36693620 DOI: 10.1016/j.wneu.2023.01.063] [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: 01/02/2023] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Central nervous system tumors are the most common solid neoplasm in children, 60%-70% occurring in the posterior fossa. Surgery is the mainstay of treatment but surgery in the pediatric population is associated with a high risk of perioperative complications. We aimed at analyzing the perioperative complications after posterior fossa surgery in a pediatric population and identifying the associated risk factors. METHODS Retrospective study of all pediatric patients undergoing surgery for resection of a posterior fossa tumor between 1999 and 2019, at the University Hospital of Lausanne. Data were collected including age, clinical presentation, tumor localization, presence of preoperative hydrocephalus, timing of surgery, surgical approach, surgical team, extent of surgical resection, perisurgical complications, and histopathological diagnosis. Statistical analysis was performed to correlate the data with the risk of complications. RESULTS Sixty-seven patients were included. Perisurgical complications were identified in 39 patients (58.2%), of which 14 (35.9%) required corrective interventions. The perioperative mortality rate was zero. In the univariate analysis, surgery performed under emergency conditions, transvermian and telovelar approaches were statistically correlated with an increased rate of complications. Extent of resection, hydrocephalus, and Lansky index at presentation were not predictive of perioperative complications. Midline tumor, tumor volume >25 cm3, and surgery performed by a nonspecialized pediatric onconeurosurgeon were found to be independent risk factors in the multivariate analysis. CONCLUSIONS Surgery in the posterior fossa in the pediatric population harbors a high risk of complications. Identifying the variables contributing to these complications is important in order to improve surgical management of these patients.
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Affiliation(s)
- Stephanie Anetsberger
- Department of Neurosurgery, Department of Neuroscience, Lausanne University Hospital and Lausanne, Lausanne, Switzerland
| | - Amine Mellal
- Department of Neurosurgery, Department of Neuroscience, Lausanne University Hospital and Lausanne, Lausanne, Switzerland
| | - Marta Garvayo
- Department of Neurosurgery, Department of Neuroscience, Lausanne University Hospital and Lausanne, Lausanne, Switzerland
| | - Manuel Diezi
- Pediatric Hematology-Oncology Unit, Division of Pediatrics, Lausanne University Hospital and Lausanne, Lausanne, Switzerland
| | - Marie-Helene Perez
- Pediatric Intensive and Intermediate care Unit, Service of Pediatrics, Women-Mother-Child Department, Lausanne University Hospital and Lausanne, Lausanne, Switzerland
| | - Maja Beck Popovic
- Pediatric Hematology-Oncology Unit, Division of Pediatrics, Lausanne University Hospital and Lausanne, Lausanne, Switzerland
| | - Raffaele Renella
- Pediatric Hematology-Oncology Unit, Division of Pediatrics, Lausanne University Hospital and Lausanne, Lausanne, Switzerland
| | - Giulia Cossu
- Department of Neurosurgery, Department of Neuroscience, Lausanne University Hospital and Lausanne, Lausanne, Switzerland
| | - Roy Thomas Daniel
- Department of Neurosurgery, Department of Neuroscience, Lausanne University Hospital and Lausanne, Lausanne, Switzerland
| | - Daniele Starnoni
- Department of Neurosurgery, Department of Neuroscience, Lausanne University Hospital and Lausanne, Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, Department of Neuroscience, Lausanne University Hospital and Lausanne, Lausanne, Switzerland.
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Wright SH, Blumenow W, Kumar R, Mallucci C, Felton A, McMahon S, Hennigan D, Avula S, Pizer B. Prevalence of dysphagia following posterior fossa tumour resection in children: the Alder Hey experience. Childs Nerv Syst 2023; 39:609-616. [PMID: 36512048 DOI: 10.1007/s00381-022-05774-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/23/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Surgery for posterior fossa tumours (PFTs) in children is associated with bulbar palsy and swallowing difficulties although this risk is not well defined in the literature and issues contributing to dysphagia following surgery are not fully understood. AIMS This study aims to study the eating, drinking and swallowing function of children following PFT resection in a specialist paediatric neurosurgery centre. This included the frequency and duration of dysphagia, the risk of aspiration and the link between tumour type and dysphagia. MATERIALS AND METHODS This is a retrospective review of children undergoing surgery for PFT between 2014 and 2019. Information was obtained from the patients' hospital and speech and language therapy (SLT) notes, oncology database and clinical letters. The International Dysphagia Diet Standardisation Initiative (IDDSI) Framework was used to describe food and fluid modifications. RESULTS Seventy children had surgery to resect a posterior fossa tumour at Alder Hey from 2014 to 2019. Thirty-one children were included in the study following referral to SLT. Videofluoroscopy (VF) was undertaken at our institution in 68% (21/31) of cases. Fifty-two percent (11/21) of children aspirated or were considered at risk, and 55% (6/11) of those who aspirated showed silent aspiration. After 3 months, 43% (13/30) still required modified food and/or fluid textures, with this proportion reducing as time progressed. By tumour type, VF was performed in 5/7 medulloblastoma patients with 3/5 showing aspiration and 3/3 silently aspirating; in 8/9 patients with ependymoma with 4/8 patients aspirating with 2/4 showing silent aspiration; and 6/12 glioma patients with 4/6 aspirating with 1/4 showing silent aspiration. CONCLUSION Swallowing difficulties, including silent aspiration, are an important complication of PFT resection. A proportion of children will need ongoing food and/or fluid modification. Further study into dysphagia following PFT resection is indicated.
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Affiliation(s)
- Samantha H Wright
- Department of Speech and Language Therapy, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
| | - Wendy Blumenow
- Department of Speech and Language Therapy, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Ram Kumar
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Conor Mallucci
- Department of Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Alison Felton
- Department of Speech and Language Therapy, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Siobhan McMahon
- Department of Speech and Language Therapy, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Dawn Hennigan
- Department of Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Shivaram Avula
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Barry Pizer
- Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Panagopoulos D, Stranjalis G, Gavra M, Boviatsis E, Korfias S, Karydakis P, Themistocleous M. The Entity of Cerebellar Mutism Syndrome: A Narrative Review Centered on the Etiology, Diagnostics, Prevention, and Therapeutic Options. CHILDREN (BASEL, SWITZERLAND) 2022; 10:children10010083. [PMID: 36670634 PMCID: PMC9856273 DOI: 10.3390/children10010083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 12/23/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023]
Abstract
Cerebellar mutism syndrome (CMS), also known as posterior fossa syndrome, is an entity that entails a constellation of signs and symptoms which are recorded in a limited number of pediatric patients who have been operated on mainly for tumors involving the posterior cranial fossa, and more precisely, the region of the vermis. Medulloblastoma seems to constitute the most commonly recognized pathological substrate, associated with this entity. The most prevalent constituents of this syndrome are noted to be a, often transient, although protracted, language impairment, emotional lability, along with cerebellar and brainstem dysfunction. Apart from that, a definite proportion of involved individuals are affected by irreversible neurological defects and long-lasting neurocognitive impairment. A bulk of literature and evidence based on clinical trials exist, which reflect the continuous effort of the scientific community to highlight all perspectives of this complex phenomenon. There are several circumstances that intervene in our effort to delineate the divergent parameters that constitute the spectrum of this syndrome. In summary, this is implicated by the fact that inconsistent nomenclature, poorly defined diagnostic criteria, and uncertainty regarding risk factors and etiology are all constituents of a non-well-investigated syndrome. Currently, a preliminary consensus exists about the identification of a group of diagnostic prerequisites that are managed as sine qua non, in our aim to document the diagnosis of CMS. These include language impairment and emotional lability, as proposed by the international Board of the Posterior Fossa Society in their consensus statement. It is common concept that midline tumor location, diagnosis of medulloblastoma, younger age at diagnosis, and preoperatively established language impairment should be accepted as the most determinant predisposing conditions for the establishment of this syndrome. A well-recognized pathophysiological explanation of CMS includes disruption of the cerebellar outflow tracts, the cerebellar nuclei, and their efferent projections through the superior cerebellar peduncle. Despite the relative advancement that is recorded regarding the diagnostic section of this disease, no corresponding encouraging results are reported, regarding the available treatment options. On the contrary, it is mainly targeted toward the symptomatic relief of the affected individuals. The basic tenet of our review is centered on the presentation of a report that is dedicated to the definition of CMS etiology, diagnosis, risk factors, clinical presentation, and clinical management. Apart from that, an effort is made that attempts to elucidate the paramount priorities of the scientific forum, which are directed toward the expansion our knowledge in the era of diagnostics, prevention, and therapeutic options for patients suffering from CM, or who are at risk for development of this syndrome.
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Affiliation(s)
- Dimitrios Panagopoulos
- Neurosurgical Department, Pediatric Hospital of Athens, ‘Agia Sophia’, 45701 Athens, Greece
- Correspondence: ; Tel.: +30-698-132-8628
| | - Georgios Stranjalis
- 1st University Neurosurgical Department, ‘Evangelismos’ Hospital, University of Athens, Neurosurgery, Medical School, 10676 Athens, Greece
| | - Maria Gavra
- Radiology Department, Pediatric Hospital of Athens, ‘Agia Sophia’, 45701 Athens, Greece
| | - Efstathios Boviatsis
- 2nd University Neurosurgical Department, ‘Attikon’ Hospital, University of Athens, Neurosurgery, Medical School, 12462 Athens, Greece
| | - Stefanos Korfias
- 1st University Neurosurgical Department, ‘Evangelismos’ Hospital, University of Athens, Neurosurgery, Medical School, 10676 Athens, Greece
| | - Ploutarchos Karydakis
- Neurosurgical Department, General Hospital of Athens ‘Gennimatas’, 11527 Athens, Greece
| | - Marios Themistocleous
- Neurosurgical Department, Pediatric Hospital of Athens, ‘Agia Sophia’, 45701 Athens, Greece
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Chami S, Hodges R, Campbell E, Knijnik SR, Docking K. Communication and swallowing management in childhood brain tumour or leukaemia: A survey of health professionals and consumers. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2022; 24:395-406. [PMID: 34651529 DOI: 10.1080/17549507.2021.1987520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Purpose: Brain tumour and leukaemia represent the most common childhood cancers and can result in communication and swallowing difficulties. The purpose of this study was to survey health professionals and consumers regarding the management of communication and swallowing difficulties in children with brain tumour or leukaemia (CBTL).Method: In this study participants completed a survey focussing on (1) communication and swallowing assessment and intervention, (2) multidisciplinary team (MDT) practices and (3) risk factors. Quantitative data were reported using descriptive statistics. Qualitative data were analysed using NVivo12 Qualitative Data Analysis Software.Result: Twenty-four participants were included (22 health professionals; two consumers). Most participants (≥80%) agreed that comprehensive and regular communication and swallowing assessments improved outcomes. Communication and swallowing interventions were reported to improve outcomes by 96% of participants. MDT care was considered essential in improving outcomes. Speech-language pathologists were the primary health professional identified in communication management; additional multidisciplinary health professionals were highlighted in swallowing management. Risk factors were identified across three categories: cancer-related, treatment-related and child-factors.Conclusion: This study collates the expertise and experience of multidisciplinary health professionals and consumers which can be used to guide assessment and intervention for communication and swallowing in CBTL. It also provides perspectives on MDT care and consideration of patient values and risk factors.
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Affiliation(s)
- Sara Chami
- Speech Pathology, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Rosemary Hodges
- Speech Pathology, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Western Sydney Speech Pathology, Sydney, Australia
| | - Emma Campbell
- Speech Pathology, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Integrated & Community Health, Western Sydney Local Health District Sydney, Australia
| | - Stefani R Knijnik
- Speech Pathology, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Kimberley Docking
- Speech Pathology, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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8
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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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9
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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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10
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Alighieri C, De Maere K, Poncelet G, Willekens L, Linden CV, Oostra K, Van Lierde K, D'haeseleer E. Occurrence of speech-language disorders in the acute phase following pediatric acquired brain injury: results from the Ghent University Hospital. Brain Inj 2021; 35:907-921. [PMID: 34056971 DOI: 10.1080/02699052.2021.1927185] [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] [Indexed: 10/21/2022]
Abstract
AIMS This study investigated the occurrence of speech-language disorders during the acute phase of recovery in children with acquired brain injury (ABI) with an age between 0 and 16 years. METHODS A retrospective chart analysis was performed including 228 children (n = 118 boys, n = 110 girls) who consecutively presented with ABI over a 10-year period (2006-2016) at the children's rehabilitation center at Ghent University Hospital. Descriptive statistical analyses were applied. RESULTS 71.1% (162/228) of the children who were admitted to the rehabilitation center presented with a speech-language disorder. Within this sample (n = 162), results demonstrated the occurrence of acquired disorders in language (48.9%), speech (35.1%), learning (33.3%), swallowing (21.5%), and early communicative functions (17.4%). The proportion of children presenting with disturbances in early communicative functions differed by ABI cause. More than half (10/18, 58.8%) of the children who presented with ABI following inflammatory processes demonstrated disorders in early communicative functions. CONCLUSIONS Especially in young children who present with inflammatory processes as the ABI cause, speech-language pathologists (SLPs) must be aware of disorders in early speech-language development. The present findings allow the SLP to appropriately plan research, education, and clinical management.
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Affiliation(s)
| | - Katrien De Maere
- Children's Rehabilitation Center, Ghent University Hospital, Gent, Belgium
| | - Gaby Poncelet
- Department of Rehabilitation Sciences, Ghent University, Gent, Belgium
| | - Lore Willekens
- Department of Rehabilitation Sciences, Ghent University, Gent, Belgium
| | | | - Kristine Oostra
- Department of Rehabilitation Sciences, Ghent University, Gent, Belgium
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11
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Chu JK, Chiarelli PA, Rea ND, Pimentel N, Flyer BE, McComb JG, Durham SR, Krieger MD. Postoperative facial palsy after pediatric posterior fossa tumor resection. J Neurosurg Pediatr 2021; 27:566-571. [PMID: 33711807 DOI: 10.3171/2020.9.peds20372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/29/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Facial palsy can be caused by masses within the posterior fossa and is a known risk of surgery for tumor resection. Although well documented in the adult literature, postoperative facial weakness after posterior fossa tumor resection in pediatric patients has not been well studied. The objective of this work was to determine the incidence of postoperative facial palsy after tumor surgery, and to investigate clinical and radiographic risk factors. METHODS A retrospective analysis was conducted at a single large pediatric hospital. Clinical, radiographic, and histological data were examined in children who were surgically treated for posterior fossa tumors between May 1, 1994, and June 1, 2011. The incidence of postoperative facial weakness was documented. A multivariate logistic regression model was used to analyze the predictive ability of clinicoradiological variables for facial weakness. RESULTS A total of 163 patients were included in this study. The average age at surgery was 7.4 ± 4.7 years, and tumor pathologies included astrocytoma (44%), medulloblastoma (36%), and ependymoma (20%). The lesions of 27 patients (17%) were considered high grade in nature. Thirteen patients (8%) exhibited preoperative symptoms of facial palsy. The overall incidence of postoperative facial palsy was 26% (43 patients), and the incidence of new postoperative facial palsy in patients without preoperative facial weakness was 20% (30 patients). The presence of a preoperative facial palsy had a large and significant effect in univariate analysis (OR 11.82, 95% CI 3.07-45.44, p < 0.01). Multivariate logistic regression identified recurrent operation (OR 4.45, 95% CI 1.49-13.30, p = 0.01) and other preoperative cranial nerve palsy (CNP; OR 3.01, 95% CI 1.24-7.29, p = 0.02) as significant risk factors for postoperative facial weakness. CONCLUSIONS Facial palsy is a risk during surgical resection of posterior fossa brain tumors in the pediatric population. The study results suggest that the incidence of new postoperative facial palsy can be as high as 20%. The presence of preoperative facial palsy, an operation for recurrent tumor, and the presence of other preoperative CNPs were found to be significant risk factors for postoperative facial weakness.
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Affiliation(s)
- Jason K Chu
- Divisions of1Neurosurgery and.,3Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Peter A Chiarelli
- Divisions of1Neurosurgery and.,3Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | | | | | - J Gordon McComb
- Divisions of1Neurosurgery and.,3Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Susan R Durham
- Divisions of1Neurosurgery and.,3Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mark D Krieger
- Divisions of1Neurosurgery and.,3Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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12
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Hodges R, Campbell L, Chami S, Knijnik SR, Docking K. Communication and swallowing outcomes of children diagnosed with childhood brain tumor or leukemia: A systematic review. Pediatr Blood Cancer 2021; 68:e28809. [PMID: 33219751 DOI: 10.1002/pbc.28809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/15/2020] [Accepted: 10/30/2020] [Indexed: 11/11/2022]
Abstract
The purpose of this systematic review was to appraise and synthesize evidence on communication and swallowing outcomes associated with childhood brain tumor or leukemia (CBTL). A comprehensive database and grey literature search was conducted. Studies included: (a) peer-reviewed research published between 1998 and 2019, (b) English language, (c) children aged 0-16 years diagnosed with CBTL, and (d) used outcome measures focused on communication and/or swallowing. Quality assessment was completed and certainty of evidence rated using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Fifty-seven studies met inclusion criteria: 46 examined communication, seven examined swallowing, and four considered both. Most studies were descriptive and prospective. Communication difficulties were frequently reported and apparent at one or more points from diagnosis to survivorship. Swallowing difficulties were frequently reported during oncology treatment. Despite quality assessment revealing methodological shortcomings, results have implications for clinical services and future research.
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Affiliation(s)
- Rosemary Hodges
- Discipline of Speech Pathology, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Lani Campbell
- Discipline of Speech Pathology, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Sara Chami
- Discipline of Speech Pathology, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Stefani Ribeiro Knijnik
- Discipline of Speech Pathology, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kimberley Docking
- Discipline of Speech Pathology, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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13
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Maloumeh EN, Khoshnoud RJ, Ebrahimzadeh K, Tavassol HH, Salari S, Mousavinejad A, Kargari A, Samadian M, Rezaei O. Surgical management of the fourth ventricular tumors using telovelar approach and the role of neuroendoscopy: Post-operative outcome and long-term results in a series of 52 cases. Clin Neurol Neurosurg 2020; 201:106419. [PMID: 33340840 DOI: 10.1016/j.clineuro.2020.106419] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/13/2020] [Accepted: 12/04/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The telovelar approach is a surgical method performed through natural corridors of the brain to access the fourth ventricle. The aim of this study is to assess the results of this approach as well as the role of neuroendoscopy in surgical management of fourth ventricle tumors. MATERIAL AND METHODS A retrospective study was designed, and a series of 52 consecutive patients (32 male, 20 female) with fourth ventricle tumor undergoing telovelar approach was undertaken. In 10 patients (19 %) with a tumor invading the rostral fourth ventricle, an adjustable angle endoscope was also used to ensure total resection of the tumor. RESULTS Complete resection was obtained in majority of patients (94 %). 30 patients (57 %) required insertion of an external ventricular drain which was discontinued in all patients after 72 h. 2 patients (4 %) underwent permanent ventriculoperitoneal shunt. The postoperative complications included meningitis (8 %), transient facial nerve paralysis (8 %), transient sixth cranial nerve paralysis (6 %) and transient unilateral absence of the gag reflex (4 %). No patient experienced mutism and there was a mortality rate of 2 % (1 case) in current study. CONCLUSION In our experience, a high rate of total resection of the fourth ventricle tumors could be achieved with the telovelar approach associated with a low risk of surgical morbidity and mortality. Moreover, the use of an adjustable angle endoscope could be useful in patients with a tumor involving the rostral fourth ventricle to ensure total resection of the tumor and also to minimize the extent of telovelar dissection.
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Affiliation(s)
- Ehsan Nazari Maloumeh
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Reza Jalili Khoshnoud
- Functional Neurosurgery Research Center, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Kaveh Ebrahimzadeh
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Hesameddin Hoseini Tavassol
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Sepideh Salari
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Ali Mousavinejad
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Atiye Kargari
- Tehran University of Medical Sciences, Pharmacy School, Tehran, Iran.
| | - Mohammad Samadian
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Omidvar Rezaei
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Dellatolas G, Câmara-Costa H. The role of cerebellum in the child neuropsychological functioning. HANDBOOK OF CLINICAL NEUROLOGY 2020; 173:265-304. [PMID: 32958180 DOI: 10.1016/b978-0-444-64150-2.00023-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Georges Dellatolas
- GRC 24, Handicap Moteur et Cognitif et Réadaptation, Sorbonne Université, Paris, France.
| | - Hugo Câmara-Costa
- GRC 24, Handicap Moteur et Cognitif et Réadaptation, Sorbonne Université, Paris, France; Centre d'Etudes en Santé des Populations, INSERM U1018, Paris, France
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15
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Lapa S, Quick-Weller J, Nasari C, Dziewas R, Gessler F, Wagner M, Warnecke T, Hattingen E, Seifert V, Konczalla J. Pre- and Post-Surgical Dysphagia in Adults with Tumors of the Posterior Fossa: A Prospective Blinded Study. Cancers (Basel) 2020; 12:E2561. [PMID: 32916787 PMCID: PMC7564918 DOI: 10.3390/cancers12092561] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/05/2020] [Accepted: 09/07/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND While swallowing disorders are frequent sequela following posterior fossa tumor (PFT) surgery in children, data on dysphagia frequency, severity, and outcome in adults are lacking. The aim of this study was to investigate dysphagia before and after surgical removal of PFT. Additionally, we tried to identify clinical predictors for postsurgical swallowing disorders. Furthermore, this study explored the three-month outcome of dysphagic patients. METHODS In a cohort of patients undergoing PFT surgery, dysphagia was prospectively assessed pre- and postoperatively using fiberoptic endoscopic evaluation of swallowing. Patients with severe dysphagia at discharge were re-evaluated after three months. Additionally, clinical and imaging data were collected to identify predictors for post-surgical dysphagia. RESULTS We included 26 patients of whom 15 had pre-operative swallowing disorders. After surgery, worsening of pre-existing dysphagia could be noticed in 7 patients whereas improvement was observed in 2 and full recovery in 3 subjects. New-onset dysphagia after surgery occurred in a minority of 3 cases. Postoperatively, 47% of dysphagic patients required nasogastric tube feeding. Re-evaluation after three months of follow-up revealed that all dysphagic patients had returned to full oral intake. CONCLUSION Dysphagia is a frequent finding in patients with PFT already before surgery. Surgical intervention can infer a deterioration of impaired swallowing function placing affected patients at temporary risk for aspiration. In contrast, surgery can also accomplish beneficial results resulting in both improvement and full recovery. Overall, our findings show the need of early dysphagia assessment to define the safest feeding route for the patient.
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Affiliation(s)
- Sriramya Lapa
- Department of Neurology, University Hospital Frankfurt, 60528 Frankfurt, Germany;
- Department of Neurosurgery, University Hospital Frankfurt, 60528 Frankfurt, Germany; (J.Q.-W.); (F.G.); (V.S.); (J.K.)
| | - Johanna Quick-Weller
- Department of Neurosurgery, University Hospital Frankfurt, 60528 Frankfurt, Germany; (J.Q.-W.); (F.G.); (V.S.); (J.K.)
| | - Christiane Nasari
- Department of Neurology, University Hospital Frankfurt, 60528 Frankfurt, Germany;
- Department of Neurosurgery, University Hospital Frankfurt, 60528 Frankfurt, Germany; (J.Q.-W.); (F.G.); (V.S.); (J.K.)
| | - Rainer Dziewas
- Department of Neurology, University Hospital Münster, 48149 Münster, Germany; (R.D.); (T.W.)
| | - Florian Gessler
- Department of Neurosurgery, University Hospital Frankfurt, 60528 Frankfurt, Germany; (J.Q.-W.); (F.G.); (V.S.); (J.K.)
| | - Marlies Wagner
- Department of Neuroradiology, University Hospital Frankfurt, 60528 Frankfurt, Germany; (M.W.); (E.H.)
| | - Tobias Warnecke
- Department of Neurology, University Hospital Münster, 48149 Münster, Germany; (R.D.); (T.W.)
| | - Elke Hattingen
- Department of Neuroradiology, University Hospital Frankfurt, 60528 Frankfurt, Germany; (M.W.); (E.H.)
| | - Volker Seifert
- Department of Neurosurgery, University Hospital Frankfurt, 60528 Frankfurt, Germany; (J.Q.-W.); (F.G.); (V.S.); (J.K.)
| | - Jürgen Konczalla
- Department of Neurosurgery, University Hospital Frankfurt, 60528 Frankfurt, Germany; (J.Q.-W.); (F.G.); (V.S.); (J.K.)
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16
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Du R, Tafreshi A, Donoho D, Rutkowski M, Zada G. Endoscopic assisted craniotomy for resection of fourth ventricular lesions and confirmation of aqueductal patency via a suboccipital median aperture approach. J Clin Neurosci 2020; 80:50-55. [PMID: 33099366 DOI: 10.1016/j.jocn.2020.07.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 07/26/2020] [Accepted: 07/30/2020] [Indexed: 11/15/2022]
Abstract
Adequate exposure to fourth ventricular (4V) lesions located adjacent to the cerebral aqueduct and superior medullary velum often mandates extensive telovelar dissection. We assessed the utility of endoscopic assistance via a median aperture approach during suboccipital resection of 4V lesions. We retrospectively reviewed a series of nine patients who underwent suboccipital resection of a 4V lesion via an endoscopic-assisted median aperture approach from 2011 to 2018. Our series included the following pathology: ependymoma (2), rosette-forming glioneuronal tumors (2), pilocytic astrocytoma (1), metastatic melanoma (1), epidermoid cyst (1), organized hematoma (1), and neurocysticercosis (1). Preoperative symptoms included headache (n = 8, 88.9%), nausea (n = 5, 55.6%), vomiting, dizziness, and gait disturbance (n = 4 each, 44.5%). In four cases, the endoscope was used for the majority of the resection or to resect additional tumor located rostrally in the 4V following maximal microscopic resection. In five patients, it was used to confirm extent of resection and patency of the cerebral aqueduct. Gross total resection was achieved in five patients (55.6%). No postoperative complications were attributed to use of the endoscope for additional resection. No patients required immediate CSF diversion, and one patient underwent ventriculoperitoneal (VP) shunt insertion over one year after initial biopsy/fenestration due to tumor progression. Our series is the first to demonstrate the utility of angled endoscopic assistance via a median aperture approach during microsurgical approaches for a variety of 4V lesions. Confirmation of patency of the cerebral aqueduct may help avoid requirements for CSF diversion.
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Affiliation(s)
- Robin Du
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, United States
| | - Ali Tafreshi
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, United States
| | - Daniel Donoho
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, United States
| | - Martin Rutkowski
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, United States
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, United States.
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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: 15] [Impact Index Per Article: 3.8] [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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Goethe EA, Gadgil N, Stormes K, Wassef A, LoPresti M, Lam S. Predicting dysphagia in children undergoing surgery for posterior fossa tumors. Childs Nerv Syst 2020; 36:925-931. [PMID: 31897637 DOI: 10.1007/s00381-019-04468-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 12/04/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Posterior fossa tumors (PFTs) are the most common type of brain tumor in children. Dysphagia is a known complication of PFT resection in children, but data regarding risk factors and clinical course are sparse. METHODS The records of all children who underwent resection of posterior fossa tumor between April 2007 and May 2017 at our institution were analyzed. Clinical, radiographic, histologic data were gathered. Swallowing function was assessed immediately postoperatively and at 1-year follow-up. RESULTS A total of 197 patients were included. Forty-three (21.8%) patients developed dysphagia after surgery. Patients who developed dysphagia were younger (4.5 vs. 7.2 years, p < 0.01), were more likely to have brainstem compression (74.4% vs. 57.8%, p < 0.03) or invasion (14.0 vs. 9.7%, p < 0.03), and were more likely to have ependymoma (27.9% vs. 13.6%, p < 0.01) or ATRT (atypical teratoid/rhabdoid tumor) (9.3% vs. 3.9%, p < 0.01). Patients with postoperative dysphagia also had a longer length of stay (33.7 vs. 12.7 days, p < 0.01) and were more likely to be discharged to inpatient rehabilitation (25.6% vs. 9.1%, p < 0.01). Ten patients (5.1%) were PEG-dependent by 1-year follow-up. These patients were younger (2.7 vs. 5.6 years, p < 0.01), had a longer length of stay (55.5 vs. 27.4 days, p < 0.01), and were more likely to have ATRT (30.0% vs. 0.0%, p < 0.01). Recovery was not associated with tumor grade or extent of resection. CONCLUSIONS Dysphagia after PFT resection is associated with younger age, aggressive tumor histology, and increased healthcare utilization. While most patients recover, a small percentage are still dependent on enteral feeding at 1-year follow-up. Further research is needed to identify factors associated with persistent deficits.
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Affiliation(s)
- Eric A Goethe
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St., Ste. 1230, Houston, TX, 77030, USA
| | - Nisha Gadgil
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St., Ste. 1230, Houston, TX, 77030, USA
| | - Katie Stormes
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St., Ste. 1230, Houston, TX, 77030, USA
| | - Audrey Wassef
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St., Ste. 1230, Houston, TX, 77030, USA
| | - Melissa LoPresti
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St., Ste. 1230, Houston, TX, 77030, USA
| | - Sandi Lam
- Division of Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital, Chicago, IL, 60611, USA.
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA.
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Tanner L, Keppner K, Lesmeister D, Lyons K, Rock K, Sparrow J. Cancer Rehabilitation in the Pediatric and Adolescent/Young Adult Population. Semin Oncol Nurs 2020; 36:150984. [DOI: 10.1016/j.soncn.2019.150984] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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20
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Coça KL, Bergmann A, de Angelis EC, Ferman S, Ribeiro MG. Incidence and risk factors of communication, swallowing, and orofacial myofunctional disorders in children and adolescents with cancer and benign neoplasms. J Pediatr Rehabil Med 2020; 13:25-35. [PMID: 32176665 DOI: 10.3233/prm-180576] [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] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To describe the incidence and risk factors of communication, swallowing, and orofacial myofunctional disorders in a cohort of children and adolescents with cancer and benign neoplasms. METHODS A prospective cohort study conducted with children aged ⩾ 2 years and adolescents of both genders admitted at the Pediatric Oncology Department of the Instituto Nacional de Câncer (INCA) between March 2014 and April 2015. Study participants were submitted to a Speech-Language Pathology (SLP) assessment at three different times: (T1) at hospital admission; (T2) six months after admission; (T3) one year after admission. RESULTS One hundred and sixty individuals were evaluated. At the time of hospital admission, 68 individuals (42.5%) presented with some type of SLP disorder. After one year of follow-up, 22.8% of the patients had developed new impairments. The occurrence of new speech-language disorders had a statistically significant association with the tumor site. In the risk analysis for the development of speech-language disorders with respect to the primary tumor site, compared to other sites, the central nervous system (CNS) tumor group was 8.29 times more likely to present some new alterations, while the head and neck (HN) tumor group had a 10.36-fold higher risk. CONCLUSION An incidence of 22.8% for communication, swallowing, and orofacial myofunctional disorders was observed. The development of these disorders was greater in individuals with tumors in the CNS and in the HN region.
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Affiliation(s)
- Kaliani Lima Coça
- Section of Speech-Language Pathology, Instituto Nacional do Câncer (INCA), Rio de Janeiro, Brazil
| | - Anke Bergmann
- Molecular Carcinogenesis Program, Instituto Nacional do Câncer, Rio de Janeiro, Brazil
| | | | - Sima Ferman
- Pediatric Oncology Service, Instituto Nacional do Câncer, Rio de Janeiro, Brazil
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Brignell A, St John M, Boys A, Bruce A, Dinale C, Pigdon L, Hildebrand MS, Amor DJ, Morgan AT. Characterization of speech and language phenotype in children with NRXN1 deletions. Am J Med Genet B Neuropsychiatr Genet 2018; 177:700-708. [PMID: 30358070 DOI: 10.1002/ajmg.b.32664] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/28/2018] [Accepted: 06/18/2018] [Indexed: 11/11/2022]
Abstract
Neurexin 1 gene (NRXN1) deletions are associated with several neurodevelopmental disorders. Communication difficulties have been reported, yet no study has examined specific speech and language features of individuals with NRXN1 deletions. Here, we characterized speech and language phenotypes in 21 children (14 families), aged 1.8-17 years, with NRXN1 deletions. Deletions ranged from 74 to 702 kb and consisted mostly of either exons 1-3 or 1-5. Speech sound disorders were frequent (69%), although few were severe. The majority (57%) of children had difficulty with receptive and/or expressive language, although no homogeneous profiles of deficit were seen across semantic, morphological, or grammatical systems. Social language difficulties were seen in over half the sample (53%). All but two individuals with language difficulties also had intellectual disability/developmental delay. Overall, while speech and language difficulties were common, there was substantial heterogeneity in the severity and type of difficulties observed and no striking communication phenotype was seen. Rather, the speech and language deficits are likely part of broader concomitant neurodevelopmental profiles (e.g., intellectual disability, social skill deficits). Nevertheless, given the high rate of affectedness, it is important speech/language development is assessed so interventions can be applied during childhood in a targeted and timely manner.
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Affiliation(s)
- Amanda Brignell
- Speech and Language, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Miya St John
- Speech and Language, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Amber Boys
- Victorian Clinical Genetics Services, Parkville, Victoria, Australia
| | - Amanda Bruce
- Department of Audiology and Speech Pathology, University of Melbourne, Parkville, Victoria, Australia
| | - Carla Dinale
- Department of Audiology and Speech Pathology, University of Melbourne, Parkville, Victoria, Australia
| | - Lauren Pigdon
- Speech and Language, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Michael S Hildebrand
- Department of Medicine, Austin Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - David J Amor
- Victorian Clinical Genetics Services, Parkville, Victoria, Australia.,Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Angela T Morgan
- Speech and Language, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Audiology and Speech Pathology, University of Melbourne, Parkville, Victoria, Australia
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Coça KL, Bergmann A, Ferman S, Angelis ECD, Ribeiro MG. Prevalence of communication, swallowing and orofacial myofunctional disorders in children and adolescents at the time of admission at a cancer hospital. Codas 2018. [PMID: 29513872 DOI: 10.1590/2317-1782/20182017123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Describe the prevalence of communication, swallowing and orofacial myofunctional disorders in a group of children and adolescents at the time of registration at a cancer hospital. METHODS A cross-sectional study conducted with children aged ≥2 and adolescents, of both genders, admitted to the Pediatric Oncology Section of the Instituto Nacional de Câncer José de Alencar Gomes da Silva (INCA) from March 2014 to April 2015 for investigation and/or treatment of solid tumors. A protocol was used to record the sociodemographic and clinical information and findings of the speech-language pathology clinical evaluation, which included aspects of the oral sensorimotor system, swallowing, speech, language, voice, and hearing. RESULTS Eighty-eight children/adolescents (41.3%) presented some type of speech-language disorder. The most frequent speech-language disorders were orofacial myofunctional disorder, dysphonia, and language impairments, whereas the less frequent ones were dysacusis, tongue paralysis, and trismus. Site of the lesion was the clinical variable that presented statistically significant correlation with presence of speech-language disorders. CONCLUSION High prevalence of speech-language disorders was observed in children and adolescents at the time of admission at a cancer hospital. Occurrence of speech-language disorders was higher in participants with lesions in the central nervous system and in the head and neck region.
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Affiliation(s)
- Kaliani Lima Coça
- Setor de Fonoaudiologia, Instituto Nacional de Câncer José de Alencar Gomes da Silva - INCA - Rio de Janeiro (RJ), Brasil.,Programa de Pós-graduação em Clínica Médica, Universidade Federal do Rio de Janeiro - UFRJ - Rio de Janeiro (RJ), Brasil
| | - Anke Bergmann
- Programa de Carcinogênese Molecular, Instituto Nacional de Câncer José de Alencar Gomes da Silva - INCA - Rio de Janeiro (RJ), Brasil
| | - Sima Ferman
- Serviço de Oncologia Pediátrica, Instituto Nacional de Câncer José de Alencar Gomes da Silva - INCA - Rio de Janeiro (RJ), Brasil
| | | | - Márcia Gonçalves Ribeiro
- Departamento de Pediatria, Universidade Federal do Rio de Janeiro - UFRJ - Rio de Janeiro (RJ), Brasil
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Abstract
Cerebellar mutism most commonly, but not exclusively, develops in children after surgery for midline cerebellar or intraventricular tumors in the posterior fossa, typically medulloblastoma. Cerebellar mutism syndrome (CMS) comprises a complex set of neurologic and neurocognitive signs and symptoms, the cardinal and central component of which is an initially profound but usually reversible speech disorder. As such, CMS is currently recognized as an extreme form of the so-called cerebellar cognitive affective syndrome (Schmahmann syndrome). The putative cause of CMS is a substantial surgical injury to the proximal components of the bilateral efferent cerebellar pathways, disrupting cerebellar input to the supratentorial brain. The resultant cerebellocerebral diaschisis may lead to supratentorial cortical perfusion depression with frontal predominance. The speech disorder is, therefore, likely an apraxia. As our understanding of the mechanism and the clinical spectrum of CMS evolves, clinically useful preoperative risk stratification schemes, adjustments to surgical strategies and techniques, and possible early therapeutic-rehabilitative measures are being sought and developed to reduce the burden of this severe and particularly handicapping chronic morbidity on affected individuals and their families.
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Austerman R, Lucas J, Kammen A, Zada G. Endoscopic-Assisted Median Aperture Approach for Resection of Fourth Ventricular Tumor and Confirmation of Patency of Cerebral Aqueduct Using an Adjustable-Angle Endoscope: Technical Case Report. Oper Neurosurg (Hagerstown) 2017; 13:293-296. [DOI: 10.1093/ons/opw007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 02/28/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE: Open microsurgical approaches to the roof of the fourth ventricle via a telovelar approach typically require cerebellar retraction and/or splitting of the vermis and may be associated with postoperative neurological morbidities. In this case report and technical note, we describe the use of an adjustable-angle endoscope inserted into the median aperture via suboccipital craniotomy, resulting in enhanced visualization of the roof of the fourth ventricle and cerebral aqueduct and maximal safe tumor resection.
CLINICAL PRESENTATION: A 49-yr-old woman with obstructive hydrocephalus and a fourth ventricular mass that was not fully visible with the use of an operative microscope.
CONCLUSION: Direct visualization of the roof of the fourth ventricle, including the superior medullary velum and cerebral aqueduct, can be facilitated with an adjustable angle endoscope inserted into the median aperture via suboccipital craniotomy to minimize the degree of telovelar dissection and vermis splitting.
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De Witte E, Wilssens I, De Surgeloose D, Dua G, Moens M, Verhoeven J, Manto M, Mariën P. Apraxia of speech and cerebellar mutism syndrome: a case report. CEREBELLUM & ATAXIAS 2017; 4:2. [PMID: 28074148 PMCID: PMC5217307 DOI: 10.1186/s40673-016-0059-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 12/12/2016] [Indexed: 11/10/2022]
Abstract
Background Cerebellar mutism syndrome (CMS) or posterior fossa syndrome (PFS) consists of a constellation of neuropsychiatric, neuropsychological and neurogenic speech and language deficits. It is most commonly observed in children after posterior fossa tumor surgery. The most prominent feature of CMS is mutism, which generally starts after a few days after the operation, has a limited duration and is typically followed by motor speech deficits. However, the core speech disorder subserving CMS is still unclear. Case presentation This study investigates the speech and language symptoms following posterior fossa medulloblastoma surgery in a 12-year-old right-handed boy. An extensive battery of formal speech (DIAS = Diagnostic Instrument Apraxia of Speech) and language tests were administered during a follow-up of 6 weeks after surgery. Although the neurological and neuropsychological (affective, cognitive) symptoms of this patient are consistent with Schmahmann’s syndrome, the speech and language symptoms were markedly different from what is typically described in the literature. In-depth analyses of speech production revealed features consistent with a diagnosis of apraxia of speech (AoS) while ataxic dysarthria was completely absent. In addition, language assessments showed genuine aphasic deficits as reflected by distorted language production and perception, wordfinding difficulties, grammatical disturbances and verbal fluency deficits. Conclusion To the best of our knowledge this case might be the first example that clearly demonstrates that a higher level motor planning disorder (apraxia) may be the origin of disrupted speech in CMS. In addition, identification of non-motor linguistic disturbances during follow-up add to the view that the cerebellum not only plays a crucial role in the planning and execution of speech but also in linguistic processing. Whether the cerebellum has a direct or indirect role in motor speech planning needs to be further investigated.
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Affiliation(s)
- E De Witte
- Clinical and Experimental Neurolinguistics, CLIN, Vrije Universiteit Brussel, Pleinlaan 2, B-1050 Brussels, Belgium
| | - I Wilssens
- Department of Speech and Language Therapy, ZNA Middelheim, Lindendreef 1, B-2020 Antwerp, Belgium
| | - D De Surgeloose
- Department of Radiology, ZNA Middelheim, Lindendreef 1, B-2020 Antwerp, Belgium
| | - G Dua
- Department of Neurosurgery, ZNA Middelheim, Lindendreef 1, B-2020 Antwerp, Belgium
| | - M Moens
- Department of Neurosurgery and Center for Neuroscience, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, B-1090 Brussels, Belgium
| | - J Verhoeven
- Department of Language and Communication Science, City University London, Northampton Square, London, EC1V 0HB UK
| | - M Manto
- Unité d'Etude du Mouvement, FNRS-ULB, Bruxelles, Belgium
| | - P Mariën
- Clinical and Experimental Neurolinguistics, CLIN, Vrije Universiteit Brussel, Pleinlaan 2, B-1050 Brussels, Belgium ; Department of Neurology & Memory Clinic, ZNA Middelheim Hospital, Lindendreef 1, B-2020 Antwerp, Belgium
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O'Hare A. Management of developmental speech and language disorders. Part 2: acquired conditions. Arch Dis Child 2016; 101:278-83. [PMID: 25990500 DOI: 10.1136/archdischild-2014-306153] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 04/01/2015] [Indexed: 11/03/2022]
Abstract
Many children who present with these acquired impairments of communication have a clear preceding event such as an acquired brain injury from a road traffic accident. Children often respond differently in this situation to adult presentations. They may have a period of mutism when the prognosis might look poor and yet they subsequently make rapid progress and recover speech. They have greater potential for neural plasticity and language recovery, although they often have persisting difficulties in oral and written language. Alternatively, there may be a presentation with a paroxysmal event such as a seizure or a period of depressed consciousness, and the unusual behaviour that may accompany dysphasia and dysarthria may be misinterpreted in the child, whereas for the adult with the more common 'stroke-like' presentation, it would be immediately considered. Rarely the aphasia/dysphasia may itself be the paroxysmal event where actually recognising that the child's disrupted communication is the basis of any observed behaviours can be the greater challenge.
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27
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One-year outcome of postoperative swallowing impairment in pediatric patients with posterior fossa brain tumor. J Neurooncol 2015; 127:73-81. [DOI: 10.1007/s11060-015-2010-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 11/22/2015] [Indexed: 10/22/2022]
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Tomasello F, Conti A, Cardali S, La Torre D, Angileri FF. Telovelar Approach to Fourth Ventricle Tumors: Highlights and Limitations. World Neurosurg 2015; 83:1141-7. [DOI: 10.1016/j.wneu.2015.01.039] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 01/16/2015] [Accepted: 01/19/2015] [Indexed: 11/25/2022]
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Telo-velar approach to fourth-ventricle tumours: how I do it. Acta Neurochir (Wien) 2015; 157:607-10. [PMID: 25652723 DOI: 10.1007/s00701-015-2358-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 01/19/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND The "telo-velar" approach is an alternative to cerebellar splitting to gain access to the fourth ventricle through the so-called cerebello-medullary fissure (CMF). METHOD In this approach, the CMF is exposed and access to the ventricle is obtained by incising the tela chorioidea and inferior medullary velum. This approach enables the exploration of the entire ventricle cavity from the obex to the aqueduct. CONCLUSIONS The exposure of the fourth ventricle is satisfactory and the floor of the fourth ventricle can be visualised early and protected. The extent of resection and outcome are satisfactory in most patients, including those with large tumours or lesions attached to the lateral or superolateral recesses of the ventricle. The deep rostral tumour attachment is the main limitation of the telo-velar approach. KEY POINTS • Early exposure of the interface lesion-floor of the fourth ventricle favours a safer tumour dissection. • We feel that resection of tonsils is not necessary in the surgical setting. • The posterior arch of C1 should be removed only if the tonsils are below the level of the foramen magnum. • The improved access to the lateral recess of the ventricle makes the telo-velar approach particularly effective in lesions attached to cerebellar peduncles. • The wide dissection of the cerebello-medullary fissure and gentle tonsils retraction may prevent from the occurrence of cerebellar mutism or other major cerebellar dysfunctions. • Even the bilateral opening of the CMF does not result in cerebellar mutism if wide and cautious dissection, avoiding retraction and vascular injuries, is obtained. • The exposure of the fourth ventricle was satisfactory also in patients harbouring lesions attached to the lateral or even the superolateral recesses of the ventricle. • A deep rostral tumour attachment seems to be, at least in our experience, the main specific limitation of the telo-velar approach. • The risk of hydrocephalus can be reduced by opening of the fissure bilaterally, exposing the aqueduct, and by cisterna magna-fourth ventricle communication augmentation. • The EVD is taken in place for 48-72 h to prevent possible abrupt increase of the intracranial pressure and to favour wound closure.
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30
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Wadhwa R, Toms J, Chittiboina P, Tawfik T, Glenn C, Caldito G, Guthikonda B, Nanda A. Dysphagia Following Posterior Fossa Surgery in Adults. World Neurosurg 2014; 82:822-7. [DOI: 10.1016/j.wneu.2013.01.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 09/15/2012] [Accepted: 01/08/2013] [Indexed: 10/27/2022]
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Reed-Berendt R, Phillips B, Picton S, Chumas P, Warren D, Livingston JH, Hughes E, Morrall MCHJ. Cause and outcome of cerebellar mutism: evidence from a systematic review. Childs Nerv Syst 2014; 30:375-85. [PMID: 24452481 DOI: 10.1007/s00381-014-2356-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 01/02/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE Cerebellar mutism is a serious neurosurgical complication after posterior fossa surgery, but the cause, incidence and outcome remain incompletely defined. The aim of this paper was to identify and review all reports of this phenomenon to better delineate and improve the evidence base. METHODS A systematic search and retrieval of databases was conducted using advanced search techniques. Review/outcomes criteria were developed, and study quality was determined. RESULTS The retrieval identified 2,281 papers of which 96 were relevant, identifying 650 children with cerebellar mutism. Causative factors, clinical features and outcomes were reported variably; papers focussed on multiple areas, the majority reporting incidence in single or series of case studies with little or no analysis further than description. CONCLUSIONS The complexity and variability of data reporting, likely contributing factors and outcomes make cerebellar mutism difficult to predict in incidence and the degree of impact that may ensue. A clear and accepted universal definition would help improve reporting, as would the application of agreed outcome measures. Clear and consistent reporting of surgical technique remains absent. Recommendations for practice are provided.
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Affiliation(s)
- Rosa Reed-Berendt
- Paediatric Neuropsychology, The Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK
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Piscione PJ, Bouffet E, Mabbott DJ, Shams I, Kulkarni AV. Physical functioning in pediatric survivors of childhood posterior fossa brain tumors. Neuro Oncol 2013; 16:147-55. [PMID: 24305707 DOI: 10.1093/neuonc/not138] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Survival rates for children diagnosed with posterior fossa brain tumors (PFBTs) have improved significantly over the past several decades, and long-term functioning assessments have become priorities. These evaluations have occurred frequently in adults but only rarely in children. This study describes a cross-sectional assessment of physical functioning in pediatric survivors of PFBTs using the Bruininks-Osteretsky Test of Motor Performance, Second Edition (BOT-2). METHODS Primary analyses compared BOT-2 scores to normative data using 1-sample t tests for each gross motor subscale (Bilateral Coordination, Balance, Running Speed/Agility, Strength) and motor-area composite (Body Coordination and Strength and Agility). Second, the cohort was stratified by diagnostic or treatment variables. Group differences and groups vs norms were evaluated using independent 2-sample and 1-sample t tests, respectively. Primary analyses compared BOT-2 scores with normative data using 1-sample t tests for each gross motor subscale (Bilateral Coordinationcoordination, Balance, Running Speed/Agility, Strength) and motor-area composite (Body Coordination and Strength and Agility). Second, the cohort was stratified by diagnostic or treatment variables. Group differences and groups vs norms were evaluated using independent 2-sample and 1-sample t tests, respectively. RESULTS Mean age of 30 participants was 11.4 years (range, 4.9y-18.2y), and mean time from diagnosis was 6.1 years (range, 1.1y-16.7y). Cerebellar astrocytoma (43.3%) and medulloblastoma (40%) were the most common diagnoses. As a group, significantly decreased functioning, compared with norms, was observed in Balance (P < .001) and Running Speed/Agility (P = .005). Specifically in Balance, 21 (70%) participants performed below or well-below average. Participants with a non-astrocytoma performed significantly lower than norms in all areas, independent of age at diagnosis. Survivors with tumors infiltrating the vermis demonstrated significantly lower Body Coordination than norms (P < .001). CONCLUSIONS Pediatric survivors of PFBTs demonstrated decreased physical functioning, most notably in Balance. These data underscore the need for further research and implementation of physical activity programs aimed specifically at approaches to minimize physical limitations.
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Affiliation(s)
- P Janine Piscione
- Corresponding author: P. Janine Piscione, MSc, BScPT, Department of Rehabilitation, Hospital for Sick Children, 555 University Avenue, S229, Toronto, Ontario, Canada M5G 1X8.
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Abstract
Mutism of cerebellar origin is a well-described clinical entity that complicates operations for posterior fossa tumors, especially in children. This review focuses on the current understanding of principal pathophysiological aspects and risk factors, epidemiology, clinical characteristics, treatment strategies, and outcome considerations. The PubMed database was searched using the term cerebellar mutism and relevant definitions to identify publications in the English-language literature. Pertinent publications were selected from the reference lists of the previously identified articles. Over the last few years an increasing number of prospective studies and reviews have provided valuable information regarding the cerebellar mutism syndrome. Importantly, the clarification of principal terminology that surrounds the wide clinical spectrum of the syndrome results in more focused research and more effective identification of this entity. In children who undergo surgery for medulloblastoma the incidence of cerebellar mutism syndrome was reported to be 24%, and significant risk factors so far are brainstem involvement and midline location of the tumor. The dentate-thalamo-cortical tracts and lesions that affect their integrity are considered significant pathophysiological issues, especially the tract that originates in the right cerebellar hemisphere. Moderate and severe forms of the cerebellar mutism syndrome are the most frequent types during the initial presentation, and the overall neurocognitive outcome is not as favorable as thought in the earlier publications. Advanced neuroimaging techniques could contribute to identification of high-risk patients preoperatively and allow for more effective surgical planning that should focus on maximal tumor resection with minimal risk to important neural structures. Properly designed multicenter trials are needed to provide stronger evidence regarding effective prevention of cerebellar mutism and the best therapeutic approaches for such patients with a combination of pharmacological agents and multidisciplinary speech and behavior augmentation.
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Affiliation(s)
- Marina Pitsika
- Department of Pediatric Neurosurgery, Mitera Children's Hospital, Athens, Greece
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Zakaria R, Ellenbogen J, Graham C, Pizer B, Mallucci C, Kumar R. A decision analysis tool for the assessment of posterior fossa tumour surgery outcomes in children--the "Liverpool Neurosurgical Complication Causality Assessment Tool". Childs Nerv Syst 2013; 29:1277-83. [PMID: 23494657 DOI: 10.1007/s00381-013-2065-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 02/26/2013] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Complications may occur following posterior fossa tumour surgery in children. Such complications are subjectively and inconsistently reported even though they may have significant long-term behavioural and cognitive consequences for the child. This makes comparison of surgeons, programmes and treatments problematic. MATERIALS AND METHODS We have devised a causality tool for assessing if an adverse event after surgery can be classified as a surgical complication using a series of simple questions, based on a tool used in assessing adverse drug reactions. This tool, which we have called the "Liverpool Neurosurgical Complication Causality Assessment Tool", was developed by reviewing a series of ten posterior fossa tumour cases with a panel of neurosurgery, neurology, oncology and neuropsychology specialists working in a multidisciplinary paediatric tumour treatment programme. DISCUSSION AND CONCLUSION We have demonstrated its use and hope that it may improve reliability between different assessors both in evaluating the outcomes of existing programmes and treatments as well as aiding in trials which may directly compare the effects of surgical and medical treatments.
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Affiliation(s)
- Rasheed Zakaria
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Lower Lane, Fazakerley, Liverpool L9 7LJ, UK.
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Transcerebellomedullary fissure approach to lesions of the fourth ventricle: less is more? Acta Neurochir (Wien) 2013; 155:1011-6. [PMID: 23563748 DOI: 10.1007/s00701-013-1689-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 03/21/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND The transcerebellomedullary fissure (trans-CMF) approach is safe and effective. Nevertheless, previous research documented a few differences in the use of this approach with regard to the opening portion of the fissure and roof of the ventricle. Here, we present a series of patients with fourth ventricular lesions and our experience using the trans-CMF approach. METHODS Fifty patients who underwent the trans-CMF approach were analyzed. The tela choroidea was simply incised in 32 patients: 27 unilaterally and 5 bilaterally. Both the tela and inferior medullary velum were cut in 18 patients: 16 unilaterally and 2 bilaterally. Unless the tumor extended below the C1 level, C1 was preserved intact. Brainstem mapping (BSM) and corticobulbar tract (CBT) motor-evoked potential (MEP) monitoring were used. RESULTS Gross total removal was achieved in 41 (82 %) cases, and sub-total removal was achieved in 9 (18 %) cases. Two deaths occurred 1-2 months postoperatively because of pulmonary complications. Four patients developed temporary mutism, all of whom underwent the bilateral trans-CMF approach (this rate is significantly higher than that of the unilateral approach, P < 0.05). No permanent neurological deficit occurred. CONCLUSION The trans-CMF approach provides excellent access to fourth ventricular lesions without splitting the vermis. The opening portion of the fissure and roof of the ventricle should be determined by the location, extension and size of the lesion. In most cases, the unilateral trans-CMF approach with only a tela choroidea incision is adequate; this procedure is mini-invasive and possibly prevents postoperative mutism.
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Ram Z, Grossman R. Dysphagia as a complication of posterior fossa surgery in adults. World Neurosurg 2013; 82:625-6. [PMID: 23454178 DOI: 10.1016/j.wneu.2013.02.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 02/08/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Zvi Ram
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.
| | - Rachel Grossman
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
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