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Zedde M, Grisendi I, Assenza F, Napoli M, Moratti C, Di Cecco G, Pavone C, Bonacini L, D'Aniello S, Pezzella FR, Romano A, Pavesi G, Valzania F, Pascarella R. Cerebellar mutism syndrome caused by bilateral cerebellar hemorrhage in adults: a case report and review of the literature. Neurol Sci 2024; 45:4161-4171. [PMID: 38724752 DOI: 10.1007/s10072-024-07571-z] [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: 02/26/2024] [Accepted: 04/29/2024] [Indexed: 08/09/2024]
Abstract
Cerebellar mutism syndrome (CMS) is a frequent complication of surgical intervention on posterior fossa in children. It has been only occasionally reported in adults and its features have not been fully characterized. In children and in young adults, medulloblastoma is the main reason for neurosurgery. A single case of postsurgical CMS is presented in an adult patient with a cerebellar hemorrhage and a systematic review of the published individual cases of CMS in adults was done. Literature review of individual cases found 30 patients, 18/30 (60%) males, from 20 to 71 years at diagnosis. All but one case was post-surgical, but in one of the post-surgical cases iatrogenic basilar artery occlusion was proposed as cause for CMS. The causes were: primary tumors of the posterior fossa in 16/22 (72.7%) metastasis in 3/30 (10%), ischemia in 3/30 (10%) cerebellar hemorrhage in 3/30 (10%), and benign lesions in 2/30 (6.7%) patients. 8/30 patients (26.7%) were reported as having persistent or incomplete resolution of CMS within 12 months. CMS is a rare occurrence in adults and spontaneous cerebellar hemorrhage has been reported in 3/30 (10%) adult patients. The generally accepted hypothesis is that CMS results from bilateral damage to the dentate nucleus or the dentate-rubro-thalamic tract, leading to cerebro-cerebellar diaschisis. Several causes might contribute in adults. The prognosis of CMS is slightly worse in adults than in children, but two thirds of cases show a complete resolution within 6 months.
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Affiliation(s)
- Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy.
| | - Ilaria Grisendi
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Federica Assenza
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Manuela Napoli
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Claudio Moratti
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Giovanna Di Cecco
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Claudio Pavone
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Lara Bonacini
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Serena D'Aniello
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | | | - Antonio Romano
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Giacomo Pavesi
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Franco Valzania
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Rosario Pascarella
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
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Samargia-Grivette S, Hartley H, Walsh K, Lemiere J, Payne AD, Litke E, Knight A. REhabilitation Approaches in CHildren with cerebellar mutism syndrome (REACH): An international cross-disciplinary survey study. J Pediatr Rehabil Med 2024; 17:185-197. [PMID: 38393929 PMCID: PMC11307050 DOI: 10.3233/prm-230006] [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: 03/17/2023] [Accepted: 11/27/2023] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVE Pediatric cerebellar mutism syndrome (pCMS) can occur following resection of a posterior fossa tumor and, although some symptoms are transient, many result in long-lasting neurological deficits. A multi-disciplinary rehabilitation approach is often used in cases of pCMS; however, there have been no clinical trials to determine gold standards in rehabilitation practice in this population, which remains a research priority. The purpose of this study was to identify and compare intervention practices used in pCMS throughout the disciplines of occupational and physical therapy, speech-language pathology, and neuropsychology across geographic regions. METHODS A 55-question e-survey was created by an international multidisciplinary research group made up of members of the Posterior Fossa Society and sent to rehabilitation professionals in pediatric neuro-oncology centers in the US, Canada, and Europe. RESULTS Although some differences in the type of intervention used in pCMS were identified within each discipline, many of the targeted interventions including dose, frequency, and intensity were similar within disciplines across geographic regions. In addition, there were common themes identified across disciplines regarding challenges in the rehabilitation of this population. CONCLUSION These results provide a foundation of current practices on which to build future intervention-based clinical trials.
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Affiliation(s)
- Sharyl Samargia-Grivette
- Department of Communication Sciences and Disorders, University of Minnesota Duluth, Duluth, MN, USA
| | - Helen Hartley
- Department of Physical Therapy, Alder Hey Children’s Hospital, Liverpool, UK
| | - Karin Walsh
- Department of Neuropsychology, National Children’s Medical Center, Washington, DC, USA
| | - Jurgen Lemiere
- Department Oncology, Pediatric Oncology, KU Leuven, Leuven, Belgium
- Pediatric Hemato-Oncology, Universitair Ziekenhuis Leuven (UZ Leven), Leuven, Belgium
| | - Allison D. Payne
- Department of Neuropsychology, National Children’s Medical Center, Washington, DC, USA
| | - Emma Litke
- Department of Communication Sciences and Disorders, University of Minnesota Duluth, Duluth, MN, USA
| | - Ashley Knight
- Department of Communication Sciences and Disorders, University of Minnesota Duluth, Duluth, MN, USA
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3
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Fabozzi F, Margoni S, Andreozzi B, Musci MS, Del Baldo G, Boccuto L, Mastronuzzi A, Carai A. Cerebellar mutism syndrome: From pathophysiology to rehabilitation. Front Cell Dev Biol 2022; 10:1082947. [PMID: 36531947 PMCID: PMC9755514 DOI: 10.3389/fcell.2022.1082947] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 11/24/2022] [Indexed: 07/25/2023] Open
Abstract
Cerebellar mutism syndrome (CMS) is a common complication following surgical resection of childhood tumors arising in the posterior fossa. Alteration of linguistic production, up to muteness and emotional lability, generally reported at least 24 h after the intervention, is the hallmark of post-operative CMS. Other associated traits include hypotonia and other cerebellar motor signs, cerebellar cognitive-affective syndrome, motor deficits from the involvement of the long pathways, and cranial neuropathies. Recovery usually takes 6 months, but most children are burdened with long-term residual deficits. The pathogenic mechanism is likely due to the damage occurring to the proximal efferent cerebellar pathway, including the dentate nucleus, the superior cerebellar peduncle, and its decussation in the mesencephalic tegmentum. Proven risk factors include brain stem invasion, diagnosis of medulloblastoma, midline localization, tumor size, invasion of the fourth ventricle, invasion of the superior cerebellar peduncle, left-handedness, and incision of the vermis. Currently, rehabilitation is the cornerstone of the treatment of patients with cerebellar mutism syndrome, and it must consider the three main impaired domains, namely speech, cognition/behavior, and movement.
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Affiliation(s)
- Francesco Fabozzi
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
- Department of Pediatrics, Università degli Studi di Roma Tor Vergata, Rome, Italy
| | - Stella Margoni
- School of Medicine, Sapienza Università di Roma, Rome, Italy
| | - Bianca Andreozzi
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Maria Simona Musci
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Giada Del Baldo
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Luigi Boccuto
- School of Nursing, College of Behavioral, Social and Health Science, Clemson University, Clemson, SC, United States
| | - Angela Mastronuzzi
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
- Faculty of Medicine and Surgery, Saint Camillus International University of Health Sciences, Rome, Italy
| | - Andrea Carai
- Department of Neurosciences, Neurosurgery Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
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4
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Toescu SM, Hales PW, Cooper J, Dyson EW, Mankad K, Clayden JD, Aquilina K, Clark CA. Arterial Spin-Labeling Perfusion Metrics in Pediatric Posterior Fossa Tumor Surgery. AJNR Am J Neuroradiol 2022; 43:1508-1515. [PMID: 36137658 PMCID: PMC9575521 DOI: 10.3174/ajnr.a7637] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 07/27/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Pediatric posterior fossa tumors often present with hydrocephalus; postoperatively, up to 25% of patients develop cerebellar mutism syndrome. Arterial spin-labeling is a noninvasive means of quantifying CBF and bolus arrival time. The aim of this study was to investigate how changes in perfusion metrics in children with posterior fossa tumors are modulated by cerebellar mutism syndrome and hydrocephalus requiring pre-resection CSF diversion. MATERIALS AND METHODS Forty-four patients were prospectively scanned at 3 time points (preoperatively, postoperatively, and at 3-month follow-up) with single- and multi-inflow time arterial spin-labeling sequences. Regional analyses of CBF and bolus arrival time were conducted using coregistered anatomic parcellations. ANOVA and multivariable, linear mixed-effects modeling analysis approaches were used. The study was registered at clinicaltrials.gov (NCT03471026). RESULTS CBF increased after tumor resection and at follow-up scanning (P = .045). Bolus arrival time decreased after tumor resection and at follow-up scanning (P = .018). Bolus arrival time was prolonged (P = .058) following the midline approach, compared with cerebellar hemispheric surgical approaches to posterior fossa tumors. Multivariable linear mixed-effects modeling showed that regional perfusion changes were more pronounced in the 6 children who presented with symptomatic obstructive hydrocephalus requiring pre-resection CSF diversion, with hydrocephalus lowering the baseline mean CBF by 20.5 (standard error, 6.27) mL/100g/min. Children diagnosed with cerebellar mutism syndrome (8/44, 18.2%) had significantly higher CBF at follow-up imaging than those who were not (P = .040), but no differences in pre- or postoperative perfusion parameters were seen. CONCLUSIONS Multi-inflow time arterial spin-labeling shows promise as a noninvasive tool to evaluate cerebral perfusion in the setting of pediatric obstructive hydrocephalus and demonstrates increased CBF following resolution of cerebellar mutism syndrome.
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Affiliation(s)
- S M Toescu
- From the Departments of Neurosurgery (S.M.T., E.W.D., K.A.)
- Developmental Imaging and Biophysics Section (S.M.T., P.W.H., J.D.C.), University College London Great Ormond Street Institute of Child Health, London, UK
| | - P W Hales
- Developmental Imaging and Biophysics Section (S.M.T., P.W.H., J.D.C.), University College London Great Ormond Street Institute of Child Health, London, UK
| | - J Cooper
- Neuroradiology (J.C., K.M., C.A.C.), Great Ormond Street Hospital, London, UK
| | - E W Dyson
- From the Departments of Neurosurgery (S.M.T., E.W.D., K.A.)
| | - K Mankad
- Neuroradiology (J.C., K.M., C.A.C.), Great Ormond Street Hospital, London, UK
| | - J D Clayden
- Developmental Imaging and Biophysics Section (S.M.T., P.W.H., J.D.C.), University College London Great Ormond Street Institute of Child Health, London, UK
| | - K Aquilina
- From the Departments of Neurosurgery (S.M.T., E.W.D., K.A.)
| | - C A Clark
- Neuroradiology (J.C., K.M., C.A.C.), Great Ormond Street Hospital, London, UK
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de Laurentis C, Cristaldi PMF, Rebora P, Valsecchi MG, Biassoni V, Schiavello E, Carrabba GG, Trezza A, DiMeco F, Ferroli P, Cinalli G, Locatelli M, Cenzato M, Talamonti G, Fontanella MM, Spena G, Stefini R, Bernucci C, Bellocchi S, Locatelli D, Massimino M, Giussani C. Posterior fossa syndrome in a population of children and young adults with medulloblastoma: a retrospective, multicenter Italian study on incidence and pathophysiology in a histologically homogeneous and consecutive series of 136 patients. J Neurooncol 2022; 159:377-387. [PMID: 35767101 DOI: 10.1007/s11060-022-04072-x] [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: 05/22/2022] [Accepted: 06/16/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Posterior fossa syndrome (PFS) is a set of debilitating complications that can occur after surgery for posterior fossa tumors. This study aimed to assess the preoperative radiological and surgical risk factors for the onset of PFS in a histologically homogeneous population of children with medulloblastoma and compare it to a similar population of young adults. METHODS Included patients underwent posterior fossa surgery for medulloblastoma at 11 Italian neurosurgical wards (2003-2019) and were referred to Fondazione IRCCS Istituto Nazionale dei Tumori in Milan (INT) for postoperative treatments. We collected patients' pre- and post-operative clinical, surgical and radiological data from the INT charts. To compare the distribution of variables, we used the Mann-Whitney and Fisher tests for continuous and categorical variables, respectively. RESULTS 136 patients (109 children and 27 young adults) were included in the study. Among children, 29 (27%) developed PFS, and all of them had tumors at midline site with invasion of the fourth ventricle. Radiological evidence of involvement of the right superior (39% versus 12%; p = 0.011) or middle cerebellar peduncles (52% versus 18%; p = 0.002) seemed more common in children who developed PFS. Young adults showed an expected lower incidence of PFS (4 out of 27; 15%), that may be due to anatomical, physiological and oncological elements. CONCLUSIONS This study confirmed some factors known to be associated with PFS onset and shed light on other debated issues. Our findings enhance an already hypothesized role of cerebellar language lateralization. The analysis of a population of young adults may shed more light on the often-neglected existence of PFS in non-pediatric patients.
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Affiliation(s)
- Camilla de Laurentis
- Department of Medicine and Surgery, School of Medicine, University of Milano-Bicocca, Milan, Italy.,Neurosurgery Unit, Ospedale San Gerardo, Monza, Italy
| | - Paola M F Cristaldi
- Department of Medicine and Surgery, School of Medicine, University of Milano-Bicocca, Milan, Italy.,Neurosurgery Unit, Ospedale San Gerardo, Monza, Italy
| | - Paola Rebora
- Bicocca Bioinformatics, Biostatistics and Bioimaging Centre - B4, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Maria Grazia Valsecchi
- Bicocca Bioinformatics, Biostatistics and Bioimaging Centre - B4, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Veronica Biassoni
- Pediatrics Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | | | - Giorgio G Carrabba
- Department of Medicine and Surgery, School of Medicine, University of Milano-Bicocca, Milan, Italy.,Neurosurgery Unit, Ospedale San Gerardo, Monza, Italy
| | - Andrea Trezza
- Neurosurgery Unit, Ospedale San Gerardo, Monza, Italy
| | - Francesco DiMeco
- Neurosurgery Unit 1, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Neurological Surgery, John Hopkins Medical School, Baltimore, MD, USA
| | - Paolo Ferroli
- Neurosurgery Unit 2, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giuseppe Cinalli
- Pediatric Neurosurgery Unit, Santobono-Pausilipon Children's Hospital, AORN, Naples, Italy
| | - Marco Locatelli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Neurosurgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Cenzato
- Neurosurgery Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuseppe Talamonti
- Neurosurgery Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco M Fontanella
- Neurosurgery Unit, ASST Spedali Civili di Brescia, Brescia, Italy.,Department of Medicine and Surgery, Università degli Studi di Brescia, Brescia, Italy
| | - Giannatonio Spena
- Neurosurgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roberto Stefini
- Neurosurgery Unit, Ospedale Civile di Legnano, Legnano, Italy
| | | | - Silvio Bellocchi
- Neurosurgery Unit, Ospedale Sant'Anna, San Fermo della Battaglia, Italy
| | - Davide Locatelli
- Neurosurgery Unit, Ospedale di Circolo, Varese, Italy.,Department of Medicine and Surgery, Università dell'Insubria, Varese, Italy
| | - Maura Massimino
- Pediatrics Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy.
| | - Carlo Giussani
- Department of Medicine and Surgery, School of Medicine, University of Milano-Bicocca, Milan, Italy.,Neurosurgery Unit, Ospedale San Gerardo, Monza, Italy
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Hoffmann-Lamplmair D, Leiss U, Peyrl A, Slavc I, Czech T, Gram A, Pletschko T. Evaluating the diagnostic validity of the Cerebellar Cognitive Affective Syndrome (CCAS) in pediatric posterior fossa tumour patients. Neurooncol Adv 2022; 4:vdac065. [PMID: 35694105 PMCID: PMC9175301 DOI: 10.1093/noajnl/vdac065] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background The aim of this case-control study was to investigate the severity of the cerebellar cognitive affective syndrome (CCAS) in patients treated for pediatric posterior fossa tumors (PFT) and evaluate its diagnostic validity and predictive value for long-term effects. Methods Using neuropsychological test data from 56 patients with PFT (average age: 14 years), the severity of deficits in the CCAS core areas (executive functions, verbal functions, visuospatial abilities and emotions/behaviour) was examined. Neuropsychological and academic long-term outcomes of patients with CCAS were compared to two control groups of PFT patients (treated with either surgery or surgery followed by radio-/chemotherapy) without the syndrome. Risk factors associated with various deficits were considered. Results All but one PFT patient suffered from slight to severe impairments in at least one CCAS domain, while complete CCAS occurred in 35.7%. Seven years after tumor diagnosis CCAS patients performed worse in information processing, logical reasoning, verbal functions, visuospatial skills, and executive functioning and required more special educational support compared to the control groups. CCAS patients performed equally poor as patients treated with chemo-/radiotherapy in tasks measuring information processing speed. Risk factors were significantly associated with deficits in information processing speed but not CCAS emergence. Conclusions Deficits in the core CCAS domains are commonly found in PFT patients, but varying in severity, which suggests the syndrome to be continuous rather than dichotomous. However, the validity of CCAS diagnosis was low and unspecific. The exclusion of relevant functions typically impaired in PFT patients (eg, information processing) resulted in difficulties being overlooked.
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Affiliation(s)
- Doris Hoffmann-Lamplmair
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center Pediatrics Vienna, Medical University of Vienna, Vienna, Austria
| | - Ulrike Leiss
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center Pediatrics Vienna, Medical University of Vienna, Vienna, Austria
| | - Andreas Peyrl
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center Pediatrics Vienna, Medical University of Vienna, Vienna, Austria
| | - Irene Slavc
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center Pediatrics Vienna, Medical University of Vienna, Vienna, Austria
| | - Thomas Czech
- Comprehensive Center Pediatrics Vienna, Medical University of Vienna, Vienna, Austria
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Alexandra Gram
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center Pediatrics Vienna, Medical University of Vienna, Vienna, Austria
| | - Thomas Pletschko
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center Pediatrics Vienna, Medical University of Vienna, Vienna, Austria
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Structural damage burden and hypertrophic olivary degeneration in pediatric postoperative cerebellar mutism syndrome. Neurosurg Rev 2022; 45:2757-2765. [PMID: 35441993 PMCID: PMC9349162 DOI: 10.1007/s10143-022-01791-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/18/2022] [Accepted: 04/12/2022] [Indexed: 11/25/2022]
Abstract
Cerebellar mutism syndrome (CMS) occurs in one out of four children after posterior fossa tumor surgery, with open questions regarding risk factors, pathophysiology, and prevention strategies. Because of similarities between several cerebellar syndromes, a common pathophysiology with damage to the dentato-thalamo-cortical and dentato-rubro-olivary pathways has been proposed. Hypertrophic olivary degeneration (HOD) is an imaging correlate of cerebellar injury observed for instance in stroke patients. Aim of this study was to investigate whether the occurrence and severity of CMS correlates with the extent of damage to the relevant anatomical structures and whether HOD is a time-dependent postoperative neuroimaging correlate of CMS. We performed a retrospective single center study of CMS patients compared with matched non-CMS controls. CMS occurred in 10 children (13% of the overall cohort) with a median age of 8 years. Dentate nucleus (DN) injury significantly correlated with CMS, and superior cerebellar peduncle (SCP) injury was associated by tendency. HOD was observed as a dynamic neuroimaging phenomenon in the postoperative course and its presence significantly correlated with CMS and DN injury. Children who later developed HOD had an earlier onset and tended to have longer persistence of CMS. These findings can guide surgical measures to protect the DN and SCP during posterior fossa tumor resections and to avoid a high damage burden (i.e., bilateral damage). Development of intraoperative neuromonitoring of the cerebellar efferent pathways as well as improved preoperative risk stratification could help to establish a patient-specific strategy with optimal balance between degree of resection and functional integrity.
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8
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Toescu SM, Bruckert L, Jabarkheel R, Yecies D, Zhang M, Clark CA, Mankad K, Aquilina K, Grant GA, Feldman HM, Travis KE, Yeom KW. Spatiotemporal changes in along-tract profilometry of cerebellar peduncles in cerebellar mutism syndrome. Neuroimage Clin 2022; 35:103000. [PMID: 35370121 PMCID: PMC9421471 DOI: 10.1016/j.nicl.2022.103000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 01/16/2022] [Accepted: 03/28/2022] [Indexed: 10/29/2022]
Abstract
Cerebellar mutism syndrome, characterised by mutism, emotional lability and cerebellar motor signs, occurs in up to 39% of children following resection of medulloblastoma, the most common malignant posterior fossa tumour of childhood. Its pathophysiology remains unclear, but prior studies have implicated damage to the superior cerebellar peduncles. In this study, the objective was to conduct high-resolution spatial profilometry of the cerebellar peduncles and identify anatomic biomarkers of cerebellar mutism syndrome. In this retrospective study, twenty-eight children with medulloblastoma (mean age 8.8 ± 3.8 years) underwent diffusion MRI at four timepoints over one year. Forty-nine healthy children (9.0 ± 4.2 years), scanned at a single timepoint, served as age- and sex-matched controls. Automated Fibre Quantification was used to segment cerebellar peduncles and compute fractional anisotropy (FA) at 30 nodes along each tract. Thirteen patients developed cerebellar mutism syndrome. FA was significantly lower in the distal third of the left superior cerebellar peduncle pre-operatively in all patients compared to controls (FA in proximal third 0.228, middle and distal thirds 0.270, p = 0.01, Cohen's d = 0.927). Pre-operative differences in FA did not predict cerebellar mutism syndrome. However, post-operative reductions in FA were highly specific to the distal left superior cerebellar peduncle, and were most pronounced in children with cerebellar mutism syndrome compared to those without at the 1-4 month follow up (0.325 vs 0.512, p = 0.042, d = 1.36) and at the 1-year follow up (0.342, vs 0.484, p = 0.038, d = 1.12). High spatial resolution cerebellar profilometry indicated a site-specific alteration of the distal segment of the superior cerebellar peduncle seen in cerebellar mutism syndrome which may have important surgical implications in the treatment of these devastating tumours of childhood.
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Affiliation(s)
- Sebastian M Toescu
- Division of Developmental-Behavioural Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA; Department of Radiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, CA 94305, USA; Developmental Imaging and Biophysics Section, UCL-GOS Institute of Child Health, 30 Guilford St, London WC1N 1EH, UK; Department of Neurosurgery, Great Ormond Street Hospital, London WC1N 3JH, UK.
| | - Lisa Bruckert
- Division of Developmental-Behavioural Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Rashad Jabarkheel
- Department of Neurosurgery, Lucille Packard Children's Hospital, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Derek Yecies
- Department of Neurosurgery, Lucille Packard Children's Hospital, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Michael Zhang
- Department of Neurosurgery, Lucille Packard Children's Hospital, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Christopher A Clark
- Developmental Imaging and Biophysics Section, UCL-GOS Institute of Child Health, 30 Guilford St, London WC1N 1EH, UK
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, London WC1N 3JH, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital, London WC1N 3JH, UK
| | - Gerald A Grant
- Department of Neurosurgery, Lucille Packard Children's Hospital, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Heidi M Feldman
- Division of Developmental-Behavioural Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Katherine E Travis
- Division of Developmental-Behavioural Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Kristen W Yeom
- Department of Radiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, CA 94305, USA
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9
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De Benedictis A, Rossi-Espagnet MC, de Palma L, Carai A, Marras CE. Networking of the Human Cerebellum: From Anatomo-Functional Development to Neurosurgical Implications. Front Neurol 2022; 13:806298. [PMID: 35185765 PMCID: PMC8854219 DOI: 10.3389/fneur.2022.806298] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
In the past, the cerebellum was considered to be substantially involved in sensory-motor coordination. However, a growing number of neuroanatomical, neuroimaging, clinical and lesion studies have now provided converging evidence on the implication of the cerebellum in a variety of cognitive, affective, social, and behavioral processes as well. These findings suggest a complex anatomo-functional organization of the cerebellum, involving a dense network of cortical territories and reciprocal connections with many supra-tentorial association areas. The final architecture of cerebellar networks results from a complex, highly protracted, and continuous development from childhood to adulthood, leading to integration between short-distance connections and long-range extra-cerebellar circuits. In this review, we summarize the current evidence on the anatomo-functional organization of the cerebellar connectome. We will focus on the maturation process of afferent and efferent neuronal circuitry, and the involvement of these networks in different aspects of neurocognitive processing. The final section will be devoted to identifying possible implications of this knowledge in neurosurgical practice, especially in the case of posterior fossa tumor resection, and to discuss reliable strategies to improve the quality of approaches while reducing postsurgical morbidity.
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Affiliation(s)
- Alessandro De Benedictis
- Neurosurgery Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Maria Camilla Rossi-Espagnet
- Neuroradiology Unit, Imaging Department, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Luca de Palma
- Neurology Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Andrea Carai
- Neurosurgery Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Carlo Efisio Marras
- Neurosurgery Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
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10
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Chen KT, Ho TY, Siow TY, Yeh YC, Huang SY. OUP accepted manuscript. Cereb Cortex Commun 2022; 3:tgac008. [PMID: 35281215 PMCID: PMC8914218 DOI: 10.1093/texcom/tgac008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/08/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ko-Ting Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan
- School of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Neuroscience Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan
| | - Tsung-Ying Ho
- Department of Nuclear Medicine and Molecular Imaging Center, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan 333, Taiwan
| | - Tiing-Yee Siow
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan
| | - Yu-Chiang Yeh
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan
| | - Sheng-Yao Huang
- Corresponding author: Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan.
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11
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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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12
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Clark SV, Semmel ES, Aleksonis HA, Steinberg SN, King TZ. Cerebellar-Subcortical-Cortical Systems as Modulators of Cognitive Functions. Neuropsychol Rev 2021; 31:422-446. [PMID: 33515170 DOI: 10.1007/s11065-020-09465-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 11/10/2020] [Indexed: 02/07/2023]
Abstract
Over the past few decades, research has established that the cerebellum is involved in executive functions; however, its specific role remains unclear. There are numerous theories of cerebellar function and numerous cognitive processes falling under the umbrella of executive function, making investigations of the cerebellum's role in executive functioning challenging. In this review, we explored the role of the cerebellum in executive functioning through clinical and cognitive neuroscience frameworks. We reviewed the neuroanatomical systems and theoretical models of cerebellar functions and the multifaceted nature of executive functions. Using attention deficit hyperactivity disorder and cerebellar tumor as clinical developmental models of cerebellar dysfunction, and the functional magnetic resonance imaging literature, we reviewed evidence for cerebellar involvement in specific components of executive function in childhood, adolescence, and adulthood. There is evidence for posterior cerebellar contributions to working memory, planning, inhibition, and flexibility, but the heterogeneous literature that largely was not designed to study the cerebellum makes it difficult to determine specific functions of the cerebellum or cerebellar regions. In addition, while it is clear that cerebellar insult in childhood affects executive function performance later in life, more work is needed to elucidate the mechanisms by which executive dysfunction occurs and its developmental course. The limitations of the current literature are discussed and potential directions for future research are provided.
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Affiliation(s)
- Sarah V Clark
- Department of Psychology, Georgia State University, GA, 30303, Atlanta, USA
| | - Eric S Semmel
- Department of Psychology, Georgia State University, GA, 30303, Atlanta, USA
| | - Holly A Aleksonis
- Department of Psychology, Georgia State University, GA, 30303, Atlanta, USA
| | | | - Tricia Z King
- Department of Psychology, Georgia State University, GA, 30303, Atlanta, USA. .,Neuroscience Institute, Georgia State University, GA, 30303, Atlanta, USA.
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13
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Panzeri D, Bettinelli MS, Biffi E, Rossi F, Pellegrini C, Orsini N, Recchiuti V, Massimino M, Poggi G. Application of the Scale for the Assessment and Rating of Ataxia (SARA) in pediatric oncology patients: A multicenter study. Pediatr Hematol Oncol 2020; 37:687-695. [PMID: 32705928 DOI: 10.1080/08880018.2020.1785600] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Posterior cranial fossa (PCF) tumors in childhood are often associated with ataxia as well as other motor, neurobehavioral and linguistic impairment. The use of a reliable outcome measure is mandatory to evaluate the severity of impairment and monitor rehabilitation effectiveness. The aim of this work is to explore the validity of the Scale for the Assessment and Rating of Ataxia (SARA) in pediatric subjects with ataxia secondary to PCF tumor resection and evaluate the influence of age and comorbidities. Seventy eight patients (3-18 years) were recruited in 5 centers from 2016 to 2018. The age effect on SARA was analyzed by correlating total SARA scores and item scores with age and gradually excluding youngest subjects. The comorbidity effect was evaluated by comparing the ataxia-only group vs a group of subjects with ataxia + dysfunction of cranial nerves or cerebellar mutism (CM) and a group of patients with ataxia + hemiparesis. Several negative correlations between SARA scores and age were found under age 9. Differences between ataxia-only group and the other two groups were closely associated with specific comorbidities (e.g. speech disturbance in cranial nerves or CM group (p value < 0.001) and gait, stance, sitting and finger chase in the hemiparetic group (mean p value 0.022)).
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Affiliation(s)
- Daniele Panzeri
- Unità Operativa Riabilitazione Neuroncologica, Scientific Institute, IRCCS E. Medea, Lecco, Italy
| | - Micol Sara Bettinelli
- Unità Operativa Riabilitazione Neuroncologica, Scientific Institute, IRCCS E. Medea, Lecco, Italy
| | - Emilia Biffi
- Bioengineering lab, Scientific Institute IRCCS Eugenio Medea, Lecco, Italy
| | - Francesca Rossi
- Public Health and Paediatric Sciences Department, A.O.U. Città della Salute e della Scienza - Regina Margherita Children Hospital, Rehabilitation Service, Torino, Italy
| | - Chiara Pellegrini
- Fondazione IRCCS Istituto Nazionale dei Tumori, S.C. Terapia del Dolore, Cure Palliative e Riabilitazione, Milano, Italy
| | - Nicoletta Orsini
- Dipartimento Testa-Collo e Neuroscienze, U.O.C. Medicina fisica e Riabilitazione, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Veronica Recchiuti
- Servizio di Riabilitazione Funzionale, Dipartimento Neuroscienze - Neuroriabilitazione, IRCCS Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Maura Massimino
- Fondazione IRCCS Istituto Nazionale dei Tumori, S.C. Terapia del Dolore, Cure Palliative e Riabilitazione, Milano, Italy
| | - Geraldina Poggi
- Unità Operativa Riabilitazione Neuroncologica, Scientific Institute, IRCCS E. Medea, Lecco, Italy
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14
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Reddy N, Ellison DW, Soares BP, Carson KA, Huisman TAGM, Patay Z. Pediatric Posterior Fossa Medulloblastoma: The Role of Diffusion Imaging in Identifying Molecular Groups. J Neuroimaging 2020; 30:503-511. [PMID: 32529709 DOI: 10.1111/jon.12704] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 02/13/2020] [Accepted: 03/05/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND PURPOSE The molecular groups WNT activated (WNT), Sonic hedgehog activated (SHH), group 3, and group 4 are biologically and clinically distinct forms of medulloblastoma. We evaluated apparent diffusion coefficient (ADC) values' utility in differentiating/predicting medulloblastoma groups at the initial diagnostic imaging evaluation and prior to surgery. METHODS We retrospectively measured the ADC values of the enhancing, solid portion of the tumor (EST) and of the whole tumor (WT) and performed Kruskal-Wallis testing to compare the absolute tumor ADC values and cerebellar and thalamic ratios of three medulloblastoma groups (WNT, SHH, and group 3/group 4 combined). RESULTS Ninety-three children (65 males) were included. Fifty-seven children had group 3/group 4, 27 had SHH, and 9 had WNT medulloblastomas. The median absolute ADC values in the EST and WT were .719 × 10-3 and .864 × 10-3 mm2 /s for group 3/group 4; .660 × 10-3 and .965 × 10-3 mm2 /s for SHH; and .594 × 10-3 and .728 × 10-3 mm2 /s for WNT medulloblastomas (P = .02 and .13). The median ratio of ADC values in the EST or the WT to normal cerebellar tissue was highest for group 3/group 4 and lowest for WNT medulloblastomas (P = .03 and .09), with similar results in pairwise comparisons of the corresponding thalamic ADC values (P = .02 and .06). CONCLUSION ADC analysis of a tumor's contrast-enhancing solid portion may aid preoperative molecular classification/prediction of pediatric medulloblastomas and may facilitate optimal surgical treatment planning, reducing surgery-induced morbidity.
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Affiliation(s)
- Nihaal Reddy
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David W Ellison
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN
| | - Bruno P Soares
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD.,Division of Neuroradiology, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Kathryn A Carson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Thierry A G M Huisman
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Zoltan Patay
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN
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15
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D'Amico A, Sala F. Intraoperative neurophysiology of the cerebellum: a tabula rasa. Childs Nerv Syst 2020; 36:1181-1186. [PMID: 32246192 DOI: 10.1007/s00381-020-04565-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 02/27/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Cerebellar mutism (CM) is a condition that occurs predominantly in children, after posterior fossa surgery (PFS). It is characterized by motor, speech, and behavioral disorders. Despite widespread use of intraoperative neurophysiological monitoring (IONM), little is known about the neurophysiological aspects involved in the pathophysiology of CM. We reviewed the IONM literature to identify working hypotheses aimed to investigate intraoperatively the circuits involved in CM. METHODS A systematic review of the literature was conducted using PubMed central database. Papers describing the use of IONM techniques in the cerebellum were selected, thoroughly reviewed, and discussed. RESULTS AND DISCUSSION Only two studies reported the use of intraoperative neurophysiology of the cerebellum, suggesting a possible somatotopic motor organization of the cerebellar cortex. In addition, extra-operative studies using transcranial magnetic stimulation showed the possibility to modulate-possibly through the dentato-thalamic-cortical (DTC) pathway-primary motor cortex output using an appropriate cerebellar stimulus. In theory, the preservation of this either inhibitory or facilitatory modulation may predict the preservation of this pathway, while a loss of the effect may indicate an injury to the pathway, and predict a CM. Analogously, in the extra-operative setting, the comparison of pre-operative and post-operative transcranial magnetic stimulation of the cerebellum may predict the onset of CM whenever a pre-existing modulatory effect is lost as a result of surgery. CONCLUSION Virtually, no data exist on the intraoperative neurophysiology of the cerebellum. This limited knowledge, nevertheless, offers a unique opportunity to pediatric neurosurgeons to develop and test working hypotheses on the pathophysiology of CM, through the use of IONM.
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Affiliation(s)
- Alberto D'Amico
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Piazzale Stefani 1, 37124, Verona, Italy
| | - Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Piazzale Stefani 1, 37124, Verona, Italy.
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16
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Doger de Spéville E, Kieffer V, Dufour C, Grill J, Noulhiane M, Hertz-Pannier L, Chevignard M. Neuropsychological consequences of childhood medulloblastoma and possible interventions: A review. Neurochirurgie 2018; 67:90-98. [PMID: 29716738 DOI: 10.1016/j.neuchi.2018.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/11/2018] [Accepted: 03/03/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Children who have been treated for a medulloblastoma often suffer long-term cognitive impairments that often negatively affect their academic performance and quality of life. In this article, we will review the neuropsychological consequences of childhood medulloblastoma and discuss the risk factors known to influence the presence and severity of these cognitive impairments and possible interventions to improve their quality of life. METHODS This narrative review was based on electronic searches of PubMed to identify all relevant studies. RESULTS Although many types of cognitive impairments often emerge during a child's subsequent development, the core cognitive domains that are most often affected in children treated for a medulloblastoma are processing speed, attention and working memory. The emergence and magnitude of these deficits varies greatly among patients. They are influenced by demographic (age at diagnosis, parental education), medical and treatment-related factors (perioperative complications, including posterior fossa syndrome, radiation therapy dose, etc.), and the quality of interventions such as school adaptations provided to the child or rehabilitation programs that focus on cognitive skills, behavior and psychosocial functioning. CONCLUSION These patients require specialized and coordinated multidisciplinary rehabilitation follow-up that provides timely and adapted assessments and culminates in personalized intervention goals being set with the patient and the family. Follow-up should be continued until referral to adult services.
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Affiliation(s)
- E Doger de Spéville
- Inserm U1129, CEA, Paris Descartes university, 75005 Paris, France; UNIACT, institut Joliot, DRF, Neurospin, CEA, Paris Saclay university, 91190 Gif-sur-Yvette, France; Department of pediatric and adolescent oncology, Gustave-Roussy, 94800 Villejuif, France
| | - V Kieffer
- Department of pediatric and adolescent oncology, Gustave-Roussy, 94800 Villejuif, France; CSI (Outreach team for children and adolescents with acquired brain injury), department for children with acquired brain injury, hôpitaux de Saint-Maurice, 94410 Saint-Maurice, France
| | - C Dufour
- Department of pediatric and adolescent oncology, Gustave-Roussy, 94800 Villejuif, France
| | - J Grill
- Department of pediatric and adolescent oncology, Gustave-Roussy, 94800 Villejuif, France
| | - M Noulhiane
- Inserm U1129, CEA, Paris Descartes university, 75005 Paris, France; UNIACT, institut Joliot, DRF, Neurospin, CEA, Paris Saclay university, 91190 Gif-sur-Yvette, France
| | - L Hertz-Pannier
- Inserm U1129, CEA, Paris Descartes university, 75005 Paris, France; UNIACT, institut Joliot, DRF, Neurospin, CEA, Paris Saclay university, 91190 Gif-sur-Yvette, France
| | - M Chevignard
- CSI (Outreach team for children and adolescents with acquired brain injury), department for children with acquired brain injury, hôpitaux de Saint-Maurice, 94410 Saint-Maurice, France; Rehabilitation department for children with acquired neurological injury, and outreach team for children and adolescents with acquired brain injury, Saint-Maurice hospitals, 14, rue du Val-d'Osne, 94410 Saint-Maurice, France; Sorbonne université, laboratoire d'imagerie biomédicale, LIB, 75006 Paris, France; GRC n(o) 18, handicap cognitif et réadaptation (HanCRe)- Sorbonne université, 75013 Paris, France.
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17
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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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18
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Wibroe M, Cappelen J, Castor C, Clausen N, Grillner P, Gudrunardottir T, Gupta R, Gustavsson B, Heyman M, Holm S, Karppinen A, Klausen C, Lönnqvist T, Mathiasen R, Nilsson P, Nysom K, Persson K, Rask O, Schmiegelow K, Sehested A, Thomassen H, Tonning-Olsson I, Zetterqvist B, Juhler M. Cerebellar mutism syndrome in children with brain tumours of the posterior fossa. BMC Cancer 2017. [PMID: 28637445 PMCID: PMC5480181 DOI: 10.1186/s12885-017-3416-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Central nervous system tumours constitute 25% of all childhood cancers; more than half are located in the posterior fossa and surgery is usually part of therapy. One of the most disabling late effects of posterior fossa tumour surgery is the cerebellar mutism syndrome (CMS) which has been reported in up to 39% of the patients but the exact incidence is uncertain since milder cases may be unrecognized. Recovery is usually incomplete. Reported risk factors are tumour type, midline location and brainstem involvement, but the exact aetiology, surgical and other risk factors, the clinical course and strategies for prevention and treatment are yet to be determined. Methods This observational, prospective, multicentre study will include 500 children with posterior fossa tumours. It opened late 2014 with participation from 20 Nordic and Baltic centres. From 2016, five British centres and four Dutch centres will join with a total annual accrual of 130 patients. Three other major European centres are invited to join from 2016/17. Follow-up will run for 12 months after inclusion of the last patient. All patients are treated according to local practice. Clinical data are collected through standardized online registration at pre-determined time points pre- and postoperatively. Neurological status and speech functions are examined pre-operatively and postoperatively at 1–4 weeks, 2 and 12 months. Pre- and postoperative speech samples are recorded and analysed. Imaging will be reviewed centrally. Pathology is classified according to the 2007 WHO system. Germline DNA will be collected from all patients for associations between CMS characteristics and host genome variants including pathway profiles. Discussion Through prospective and detailed collection of information on 1) differences in incidence and clinical course of CMS for different patient and tumour characteristics, 2) standardized surgical data and their association with CMS, 3) diversities and results of other therapeutic interventions, and 4) the role of host genome variants, we aim to achieve a better understanding of risk factors for and the clinical course of CMS - with the ultimate goal of defining strategies for prevention and treatment of this severely disabling condition. Trial registration Clinicaltrials.gov: NCT02300766, date of registration: November 21, 2014.
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Affiliation(s)
- Morten Wibroe
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark.,Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Johan Cappelen
- Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
| | - Charlotte Castor
- Department of Paediatrics Lund Skåne University Hospital, Lund, Sweden
| | - Niels Clausen
- Department of Pediatrics, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - Pernilla Grillner
- Department of Women's and Children's Health, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Thora Gudrunardottir
- Posterior Fossa Society.,Department of Oncology and Palliation, North Zealand Hospital, Hillerød, Denmark
| | - Ramneek Gupta
- Center for Biological Sequence Analysis, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Bengt Gustavsson
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Heyman
- Department of Women's and Children's Health, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Stefan Holm
- Department of Women's and Children's Health, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Atte Karppinen
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Camilla Klausen
- Department of Neuroradiology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Tuula Lönnqvist
- Department of Child Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - René Mathiasen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Pelle Nilsson
- Department of Neuroscience, Neurosurgery, Akademiska sjukhuset, Uppsala, Sweden
| | - Karsten Nysom
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Karin Persson
- Child and Youth Rehabilitation Centre, Habilitation and Technical Aid, Lund, Sweden
| | - Olof Rask
- Department of Paediatrics Lund Skåne University Hospital, Lund, Sweden
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Division of Pediatric Hematology/Oncology, Perlmutter Cancer Center, Univesity Langone Medical Center, New York, USA
| | - Astrid Sehested
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | | | | | - Barbara Zetterqvist
- Department of Clinical Intervention and Technique, Karolinska Institute, Stockholm, Sweden
| | - Marianne Juhler
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark. .,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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19
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Post-operative diffusion weighted imaging as a predictor of posterior fossa syndrome permanence in paediatric medulloblastoma. Childs Nerv Syst 2017; 33:457-465. [PMID: 28190209 DOI: 10.1007/s00381-017-3356-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 01/31/2017] [Indexed: 01/06/2023]
Abstract
PURPOSE Posterior fossa syndrome (PFS) is a serious complication faced by neurosurgeons and their patients, especially in paediatric medulloblastoma patients. The uncertain aetiology of PFS, myriad of cited risk factors and therapeutic challenges make this phenomenon an elusive entity. The primary objective of this study was to identify associative factors related to the development of PFS in medulloblastoma patient post-tumour resection. METHODS This is a retrospective study based at a single institution. Patient data and all related information were collected from the hospital records, in accordance to a list of possible risk factors associated with PFS. These included pre-operative tumour volume, hydrocephalus, age, gender, extent of resection, metastasis, ventriculoperitoneal shunt insertion, post-operative meningitis and radiological changes in MRI. Additional variables included molecular and histological subtypes of each patient's medulloblastoma tumour. Statistical analysis was employed to determine evidence of each variable's significance in PFS permanence. RESULTS A total of 19 patients with appropriately complete data was identified. Initial univariate analysis did not show any statistical significance. However, multivariate analysis for MRI-specific changes reported bilateral DWI restricted diffusion changes involving both right and left sides of the surgical cavity was of statistical significance for PFS permanence. CONCLUSION The authors performed a clinical study that evaluated possible risk factors for permanent PFS in paediatric medulloblastoma patients. Analysis of collated results found that post-operative DWI restriction in bilateral regions within the surgical cavity demonstrated statistical significance as a predictor of PFS permanence-a novel finding in the current literature.
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20
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Wahab SS, Hettige S, Mankad K, Aquilina K. Posterior fossa syndrome-a narrative review. Quant Imaging Med Surg 2016; 6:582-590. [PMID: 27942479 DOI: 10.21037/qims.2016.10.12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Posterior fossa syndrome (PFS), or cerebellar mutism syndrome (CMS), is a collection of neurological symptoms that occur following surgical resection of a posterior fossa tumour, and is characterised by either a reduction or an absence of speech. Some authors suggest that CM is only one symptom of the CMS complex that also includes ataxia, hypotonia and irritability as well as cranial nerve deficits, neurobehavioral changes and urinary retention or incontinence. It is seen almost exclusively in children. In 1985 Rekate et al. published the first work describing CM as a clinical entity, occurring as a consequence of bilateral cerebellar injury. Other associated symptoms include visual impairment, altered mood, impaired swallowing and significant gross and fine motor deficits. The effects of this can have a devastating impact on both the patient and their carers, posing a significant clinical challenge to neurorehabilitation services. The reported incidence was between 8% and 31% of children undergoing surgery for posterior fossa tumour. The underlying pathologies include vasospasm, oedema, and axonal/neuronal injury. Neuroimaging has contributed to a better understanding of the anatomical location of postoperative injury. There have been a number of suggestions for treatment interventions for PFS. However, apart from some individual reports, there have been no clinical trials indicating possible benefit. Occupational therapy, speech and language therapy, as well as neurocognitive support, contribute to the recovery of these patients.
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Affiliation(s)
- Salima S Wahab
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Samantha Hettige
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Kshtij Mankad
- Department of Neuroradiology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
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McEvoy SD, Lee A, Poliakov A, Friedman S, Shaw D, Browd SR, Ellenbogen RG, Ojemann JG, Mac Donald CL. Longitudinal cerebellar diffusion tensor imaging changes in posterior fossa syndrome. NEUROIMAGE-CLINICAL 2016; 12:582-590. [PMID: 27689022 PMCID: PMC5031477 DOI: 10.1016/j.nicl.2016.09.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 09/06/2016] [Accepted: 09/07/2016] [Indexed: 11/30/2022]
Abstract
Posterior fossa syndrome is a severe transient loss of language that frequently complicates resection of tumors of the cerebellum. The associated pathophysiology and relevant anatomy to this language deficit remains controversial. We performed a retrospective analysis of all cerebellar tumor resections at Seattle Children's Hospital from 2010 to 2015. Diffusion tensor imaging was performed on each of the patients as part of their clinical scan. Patients included in the study were divided into groups based on language functioning following resection: intact (N = 19), mild deficit (N = 19), and posterior fossa syndrome (N = 9). Patients with posterior fossa syndrome showed white matter changes evidenced by reductions in fractional anisotropy in the left and right superior cerebellar peduncle following resection, and these changes were still evident 1-year after surgery. These changes were greater in the superior cerebellar peduncle than elsewhere in the cerebellum. Prior to surgery, posterior fossa patients did not show changes in fractional anisotropy however differences were observed in mean and radial diffusivity measures in comparison to other groups which may provide a radiographic marker of those at greatest risk of developing post-operative language loss.
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Key Words
- AD, axial diffusivity
- AP, anterior-posterior
- CBW, cerebellar white matter
- CTC, cerebellar-thalamic-cortical
- Cerebellar mutism syndrome (CMS)
- Diffusion tensor imaging
- FA, fractional anisotropy
- KW, kruskal-wallis
- MCP, middle cerebellar peduncle
- MD, mean diffusivity
- MPRAGE, Magnetization Prepared Rapid Acquisition Gradient Echo
- PFS, posterior fossa syndrome
- Posterior fossa syndrome (PFS)
- RD, radial diffusivity
- RESTORE, Robust Estimation of Tensors by Outlier Rejection
- SCP, superior cerebellar peduncle
- SWI, Susceptibility weighted imaging
- TE, echo time
- TORTOISE, Tolerably Obsessive Registration and Tensor Optimization Indolent Software Ensemble
- TR, relaxation time
- Tumor
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Affiliation(s)
- Sean D McEvoy
- University of Washington, Department of Neurological Surgery, 325 Ninth Avenue, Seattle, WA 98104-2499, USA
| | - Amy Lee
- University of Washington, Department of Neurological Surgery, 325 Ninth Avenue, Seattle, WA 98104-2499, USA; Seattle Children's Hospital, Division of Neurosurgery, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Andrew Poliakov
- Seattle Children's Hospital, Division of Radiology, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Seth Friedman
- Seattle Children's Hospital, Division of Radiology, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Dennis Shaw
- Seattle Children's Hospital, Division of Radiology, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Samuel R Browd
- University of Washington, Department of Neurological Surgery, 325 Ninth Avenue, Seattle, WA 98104-2499, USA; Seattle Children's Hospital, Division of Neurosurgery, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Richard G Ellenbogen
- University of Washington, Department of Neurological Surgery, 325 Ninth Avenue, Seattle, WA 98104-2499, USA; Seattle Children's Hospital, Division of Neurosurgery, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Jeffrey G Ojemann
- University of Washington, Department of Neurological Surgery, 325 Ninth Avenue, Seattle, WA 98104-2499, USA; Seattle Children's Hospital, Division of Neurosurgery, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Christine L Mac Donald
- University of Washington, Department of Neurological Surgery, 325 Ninth Avenue, Seattle, WA 98104-2499, USA
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The use of 5-ALA to assist complete removal of residual non-enhancing part of childhood medulloblastoma: a case report. Childs Nerv Syst 2015; 31:2173-7. [PMID: 26070965 DOI: 10.1007/s00381-015-2762-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 05/22/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Medulloblastoma is the most common malignant brain tumor in childhood. Radical surgery in the non-metastatic stage is an important factor with respect to overall survival. In this case, 5-aminolevulinic acid (5-ALA) was used at second-look surgery in order to improve surgical results. METHODS The child was pretreated with 3 × 4 mg dexamethasone for 4 days prior to the second surgery. At 5 a.m. on the day of surgery, a freshly prepared solution of 5-ALA (20 mg/kg body weight; Medac, Germany) was given orally. RESULTS At surgery, through the original opening, the vague red fluorescence of the tumor was clearly distinctive from the cerebellum with no tumor infiltration. All fluorescent tissue was removed. Postoperative MRI gave suspicion of yet at small tumor residue, but this structure is less than 1.5 ml in calculated volume, and consequently the recommended adjuvant therapy of the child changed from the high-risk medulloblastoma regimen to the standard-risk regimen. CONCLUSIONS In this particular difficult case of non-contrast-enhancing tumor, 5-ALA was of vital importance to improve rate of resection and change the aggressiveness needed in postsurgery radiation therapy.
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Abstract
INTRODUCTION Cerebellar mutism (CM) is defined as a peculiar form of mutism that may complicate the surgical excision of posterior cranial fossa tumor. The incidence is variable in the literature, occurring in up to one third of cases in some series. Commonly occurring peculiar features of CM are delayed onset following surgery, limited duration, and spontaneous recovery usually associated with dysarthria. METHODS A review has been performed concerning anatomical substrates and circuits actually considered to be involved in the development of cerebellar mutism, as well as risk factors for its development that have been documented in the literature. Attention has also been given to the long-term prognosis and the possibilities of rehabilitation that can be considered in these children, which has been compared with the authors' institutional experience. RESULTS AND CONCLUSIONS Tumor infiltration of the brainstem seems to represent the most relevant feature related to the development of CM, along with the histological diagnosis of medulloblastoma. On the other hand, hydrocephalus does not represent an independent risk factor. The higher rate of CM in children seems to be related to the higher incidence in children of tumors with malignant histology and brain stem involvement. Surgical technique does not seem to have a definite role; in particular, the use of a telovelar approach as compared to vermian split to reach the fourth ventricle extension of the tumor has not been demonstrated to prevent the development of cerebellar mutism. Concerning long-term prognosis, around one third of the children who develop cerebellar mutism after surgery have a persistent dysarthria, the remaining ones showing a residual phonological impairment. Long-term dysarthric features tend to be more severe and less prone to recovery in children presenting at diagnosis with associated combined procedural memory and defective neurocognitive functions.
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van Baarsen KM, Grotenhuis JA. The anatomical substrate of cerebellar mutism. Med Hypotheses 2014; 82:774-80. [DOI: 10.1016/j.mehy.2014.03.023] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Revised: 03/17/2014] [Accepted: 03/21/2014] [Indexed: 10/25/2022]
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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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Hansberry DR, Agarwal N, Tomei KL, Goldstein IM. Posterior reversible encephalopathy syndrome in a patient with a Chiari I malformation. Surg Neurol Int 2013; 4:130. [PMID: 24232171 PMCID: PMC3814995 DOI: 10.4103/2152-7806.119076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 08/07/2013] [Indexed: 11/13/2022] Open
Abstract
Background: The authors describe a unique case of a patient who developed posterior reversible encephalopathy syndrome (PRES) following postoperative treatment of a Chiari I malformation. Case Decsription: A 25-year-old female presented with complaints of left upper and lower extremity paresthesias and gait disturbances. A magnetic resonance imaging (MRI) of the brain and cervical spine showed a Chiari I malformation with tonsillar descent beyond the level of the C1 lamina. She underwent a suboccipital craniectomy and C1 laminectomy with cerebellar tonsillar cauterization and duraplasty. Postoperatively, an MRI showed bilateral acute infarcts of the cerebellar vermis. She was initially treated for cerebellar ischemia with hypertensive therapy with a subsequent decline in her neurologic status and generalized tonic–clonic seizure. Further workup showed evidence of PRES. After weaning pressors, the patient had a significant progressive improvement in her mental status. Conclusion: Although the mechanism of PRES remains controversial given its diverse clinical presentation, several theories implicate hypertension and steroid use as causative agents.
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Affiliation(s)
- David R Hansberry
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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Patay Z, Enterkin J, Harreld JH, Yuan Y, Löbel U, Rumboldt Z, Khan R, Boop F. MR imaging evaluation of inferior olivary nuclei: comparison of postoperative subjects with and without posterior fossa syndrome. AJNR Am J Neuroradiol 2013; 35:797-802. [PMID: 24184519 DOI: 10.3174/ajnr.a3762] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Posterior fossa syndrome is a severe postoperative complication occurring in up to 29% of children undergoing posterior fossa tumor resection; it is most likely caused by bilateral damage to the proximal efferent cerebellar pathways, whose fibers contribute to the Guillain-Mollaret triangle. When the triangle is disrupted, hypertrophic olivary degeneration develops. We hypothesized that MR imaging patterns of inferior olivary nucleus changes reflect patterns of damage to the proximal efferent cerebellar pathways and show association with clinical findings, in particular the presence or absence of posterior fossa syndrome. MATERIALS AND METHODS We performed blinded, randomized longitudinal MR imaging analyses of the inferior olivary nuclei of 12 children with and 12 without posterior fossa syndrome after surgery for midline intraventricular tumor in the posterior fossa. The Fisher exact test was performed to investigate the association between posterior fossa syndrome and hypertrophic olivary degeneration on MR imaging. The sensitivity and specificity of MR imaging findings of bilateral hypertrophic olivary degeneration for posterior fossa syndrome were measured. RESULTS Of the 12 patients with posterior fossa syndrome, 9 had bilateral inferior olivary nucleus abnormalities. The 12 patients without posterior fossa syndrome had either unilateral or no inferior olivary nucleus abnormalities. The association of posterior fossa syndrome and hypertrophic olivary degeneration was statistically significant (P < .0001). CONCLUSIONS Hypertrophic olivary degeneration may be a surrogate imaging indicator for damage to the contralateral proximal efferent cerebellar pathway. In the appropriate clinical setting, bilateral hypertrophic olivary degeneration may be a sensitive and specific indicator of posterior fossa syndrome.
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Affiliation(s)
- Z Patay
- From the Departments of Radiological Sciences (Z.P., J.H.H., U.L.)
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Gudrunardottir T, Sehested A, Juhler M, Schmiegelow K. Fronto-cerebellar fiber tractography in pediatric patients following posterior fossa tumor surgery. Childs Nerv Syst 2013; 29:715-6. [PMID: 23508349 DOI: 10.1007/s00381-013-2070-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 02/28/2013] [Indexed: 11/28/2022]
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Thomale UW, Driever PH. Inconsistent terminology for cerebellar mutism. Childs Nerv Syst 2013; 29:717-8. [PMID: 23503612 DOI: 10.1007/s00381-013-2074-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 02/28/2013] [Indexed: 10/27/2022]
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Abstract
OBJECTIVE Fronto-cerebellar association fibers (FCF) are involved in neurocognitive regulatory circuitry. This may also be relevant for cerebellar mutism syndrome (CMS) as a complication following posterior fossa tumor removal in children. In the present study, we investigated FCF by diffusion tensor imaging in affected children and controls. METHODS Diffusion-weighted MR imaging at 3 T (GE) allowed tractography of FCF using a fiber tracking algorithm software (Brainlab 2.6) in 29 patients after posterior fossa tumor removal and in 10 healthy peers. Fiber tract volumes were assessed and fiber signals were evaluated in a semiquantitative manner along the anatomical course. RESULTS Volumes of FCF revealed significant diminished values in pediatric patients with symptoms of CMS (19.3 ± 11.7 cm(3)) when compared with patients without symptoms of CMS (26.9 ± 11.9 cm(3)) and with healthy peers (36.5 ± 13.82 cm(3)). In medulloblastoma patients, the volume of FCF was also significantly reduced in patients with symptoms of CMS despite having the same antitumor therapy. In semiquantitative analysis of the fiber tract signals, differences were observed in the superior cerebellar peduncles and midline cerebellar structures in patients with symptoms of CMS. CONCLUSION Using DTI, which allows the visualization of fronto-cerebellar fiber tracts, lower FCF tract volumes and diminished fiber signal intensities at the level of the superior cerebellar peduncles and in midline cerebellar structures were identified in patients with postoperative symptoms of CMS. Our study refers to the role of a neural circuitry between frontal lobes and the cerebellum being involved in neurocognitive impairment after posterior fossa tumor treatment in children.
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