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Drabek-Maunder ER, Mankad K, Aquilina K, Dean JA, Nisbet A, Clark CA. Using diffusion MRI to understand white matter damage and the link between brain microstructure and cognitive deficits in paediatric medulloblastoma patients. Eur J Radiol 2024; 177:111562. [PMID: 38901074 DOI: 10.1016/j.ejrad.2024.111562] [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: 03/01/2024] [Revised: 05/09/2024] [Accepted: 06/10/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE Survivors of medulloblastoma face a range of challenges after treatment, involving behavioural, cognitive, language and motor skills. Post-treatment outcomes are associated with structural changes within the brain resulting from both the tumour and the treatment. Diffusion magnetic resonance imaging (MRI) has been used to investigate the microstructure of the brain. In this review, we aim to summarise the literature on diffusion MRI in patients treated for medulloblastoma and discuss future directions on how diffusion imaging can be used to improve patient quality. METHOD This review summarises the current literature on medulloblastoma in children, focusing on the impact of both the tumour and its treatment on brain microstructure. We review studies where diffusion MRI has been correlated with either treatment characteristics or cognitive outcomes. We discuss the role diffusion MRI has taken in understanding the relationship between microstructural damage and cognitive and behavioural deficits. RESULTS We identified 35 studies that analysed diffusion MRI changes in patients treated for medulloblastoma. The majority of these studies found significant group differences in measures of brain microstructure between patients and controls, and some of these studies showed associations between microstructure and neurocognitive outcomes, which could be influenced by patient characteristics (e.g. age), treatment, radiation dose and treatment type. CONCLUSIONS In future, studies would benefit from being able to separate microstructural white matter damage caused by the tumour, tumour-related complications and treatment. Additionally, advanced diffusion modelling methods can be explored to understand and describe microstructural changes to white matter.
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Affiliation(s)
- Emily R Drabek-Maunder
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; UCL Dept of Medical Physics and Biomedical Engineering, Malet Place, Gower St, London WC1E 6BT, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK.
| | - Kshitij Mankad
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK
| | - Kristian Aquilina
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK
| | - Jamie A Dean
- UCL Dept of Medical Physics and Biomedical Engineering, Malet Place, Gower St, London WC1E 6BT, UK
| | - Andrew Nisbet
- UCL Dept of Medical Physics and Biomedical Engineering, Malet Place, Gower St, London WC1E 6BT, UK
| | - Chris A Clark
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK
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Traunwieser T, Loos E, Ottensmeier H, Gastberger K, Nemes K, Mynarek M, Bison B, Kandels D, Neumayer P, Neumann-Holbeck A, Lüttich P, Baust K, Faulstich-Ritter K, John R, Kreisch A, Landmann J, Manteufel E, Nest A, Prüfe J, Schubert L, Stamm W, Timmermann B, Gerss J, Rutkowski S, Schlegel PG, Eyrich M, Gnekow AK, Frühwald MC. Survivors of infant atypical teratoid/rhabdoid tumors present with severely impaired cognitive functions especially for fluid intelligence and visual processing: data from the German brain tumor studies. Pediatr Blood Cancer 2024; 71:e30910. [PMID: 38342954 DOI: 10.1002/pbc.30910] [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: 09/10/2023] [Revised: 01/12/2024] [Accepted: 01/23/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND The contribution of tumor type, multimodal treatment, and other patient-related factors upon long-term cognitive sequelae in infant brain tumor survivors remains undefined. We add our retrospective analysis of neuropsychological and quality of survival (QoS) outcome data of survivors of atypical teratoid/rhabdoid tumors (ATRT) and extracranial malignant rhabdoid tumors of the soft tissues (eMRT) and kidneys (RTK) treated within the same framework. Neuropsychological data from children with ATRT were compared to data from children with non-irradiated low-grade glioma (LGG). PATIENTS AND METHODS Following surgery, patients (0-36 months at diagnosis) had received radio-chemotherapy (up to 54 Gy; ATRT: n = 13; eMRT/RTK: n = 7), chemotherapy only (LGG: n = 4; eMRT/RTK: n = 1) or had been observed (LGG: n = 11). Neuropsychological evaluation employing comparable tests was performed at median 6.8 years (ATRT), 6.6 years (eMRT/RTK), and 5.2 years (LGG) post diagnosis. RESULTS We detected sequelae in various domains for all tumor types. Group comparison showed impairments, specifically in fluid intelligence (p = .041; d = 1.11) and visual processing (p = .001; d = 2.09) in ATRT patients when compared to LGG patients. Results for psychomotor speed and attention abilities were significantly below the norm for both groups (p < .001-.019; d = 0.79-1.90). Diagnosis predicted impairments of cognitive outcome, while sex- and age-related variables did not. QoS outcome for all rhabdoid patients displayed impairments mainly in social (p = .008; d = 0.74) and school functioning (p = .048; d = 0.67), as well as lower overall scores in psychosocial functioning (p = .023; d = 0.78) and quality of life (p = .006; d = 0.79) compared to healthy controls. CONCLUSION Survivors of infant ATRT experience various late effects in cognition and QoS following multimodal treatment, while infant LGG patients without radiotherapy demonstrated comparable impairments in psychomotor and attention abilities. Early onset and multimodal treatment of rhabdoid tumors require close monitoring of neuropsychological and QoS sequelae.
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Affiliation(s)
- Thomas Traunwieser
- Swabian Children's Cancer Center, Pediatrics and Adolescent Medicine, University Hospital Augsburg, Augsburg, Germany
- Bavarian Cancer Research Center, Augsburg, Germany
| | - Elena Loos
- Swabian Children's Cancer Center, Pediatrics and Adolescent Medicine, University Hospital Augsburg, Augsburg, Germany
- Bavarian Cancer Research Center, Augsburg, Germany
| | - Holger Ottensmeier
- Department of Pediatric Hematology and Oncology, University Hospital Würzburg, Würzburg, Germany
| | - Katharina Gastberger
- Swabian Children's Cancer Center, Pediatrics and Adolescent Medicine, University Hospital Augsburg, Augsburg, Germany
- Bavarian Cancer Research Center, Augsburg, Germany
| | - Karolina Nemes
- Swabian Children's Cancer Center, Pediatrics and Adolescent Medicine, University Hospital Augsburg, Augsburg, Germany
- Bavarian Cancer Research Center, Augsburg, Germany
| | - Martin Mynarek
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- Mildred Scheel Cancer Career Center HaTriCS4, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Brigitte Bison
- Diagnostic and Interventional Neuroradiology, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- Neuroradiological Reference Center for the Pediatric Brain Tumor (HIT) Studies of the German Society of Pediatric Oncology and Hematology, Faculty of Medicine, University Augsburg, Augsburg, Germany
| | - Daniela Kandels
- Swabian Children's Cancer Center, Pediatrics and Adolescent Medicine, University Hospital Augsburg, Augsburg, Germany
- Bavarian Cancer Research Center, Augsburg, Germany
| | - Petra Neumayer
- Swabian Children's Cancer Center, Pediatrics and Adolescent Medicine, University Hospital Augsburg, Augsburg, Germany
- Bavarian Cancer Research Center, Augsburg, Germany
| | - Anne Neumann-Holbeck
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Peggy Lüttich
- Hopp Children's Cancer Center Heidelberg (KiTZ), German Cancer Research Center (DKFZ) and Heidelberg, University Hospital, Heidelberg, Germany
| | - Katja Baust
- Department of Pediatric Hematology and Oncology, University Hospital Bonn, Bonn, Germany
| | | | - Rainer John
- Department Pediatric Hematology and Oncology, Center for Chronically Sick Children (SPZ), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andrea Kreisch
- Department of Pediatrics, University Hospital and Medical Faculty Carl-Gustav-Carus, Technische Universität Dresden, Dresden, Germany
| | - Judyta Landmann
- Department of Paediatric Haematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Eva Manteufel
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Justus-Liebig University of Giessen, Giessen, Germany
| | - Alexandra Nest
- Department of Pediatric Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Jenny Prüfe
- Department of Pediatric Hematology and Oncology, Pediatrics III, Essen University Hospital, Essen, Germany
| | - Lisa Schubert
- Department of Pediatric Hematology and Oncology, University Hospital Würzburg, Würzburg, Germany
| | - Walther Stamm
- Department of Pediatric Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), German Cancer Consortium (DKTK), Essen, Germany
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Stefan Rutkowski
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Paul-Gerhardt Schlegel
- Department of Pediatric Hematology and Oncology, University Hospital Würzburg, Würzburg, Germany
| | - Matthias Eyrich
- Department of Pediatric Hematology and Oncology, University Hospital Würzburg, Würzburg, Germany
| | - Astrid K Gnekow
- Swabian Children's Cancer Center, Pediatrics and Adolescent Medicine, University Hospital Augsburg, Augsburg, Germany
- Bavarian Cancer Research Center, Augsburg, Germany
| | - Michael C Frühwald
- Swabian Children's Cancer Center, Pediatrics and Adolescent Medicine, University Hospital Augsburg, Augsburg, Germany
- Bavarian Cancer Research Center, Augsburg, Germany
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Ortug A, Yuzbasioglu N, Akalan N, Levman J, Takahashi E. Preoperative and postoperative high angular resolution diffusion imaging tractography of cerebellar pathways in posterior fossa tumors. Clin Anat 2022; 35:1085-1099. [PMID: 35560729 PMCID: PMC9547814 DOI: 10.1002/ca.23914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 11/12/2022]
Abstract
This study aimed to utilize high angular resolution diffusion magnetic resonance imaging (HARDI) tractography in the mapping of the pathways of the cerebellum associated with posterior fossa tumors (infratentorial neoplasms) and to determine whether it is useful for preoperative and postoperative evaluation. Retrospective data from 30 patients (age 2-16 yr) with posterior fossa tumor (17 low grade, 13 high grade) and 30 age-sex-matched healthy controls were used. Structural and diffusion-weighted images were collected at a 3-tesla scanner. Tractography was performed using Diffusion Toolkit software, Q-ball model, FACT algorithm, and angle threshold of 45 degrees. Manually assessed regions of interest were placed to identify reconstructed fiber pathways passing through the superior, medial, and inferior cerebellar peduncles for the preoperative, postoperative, and healthy control groups. Fractional anisotropy (FA), apparent diffusion coefficient (ADC), and track volume measures were obtained and analyzed. Statistically significant differences were found between the preop/postop, preop/control, and postop/control comparisons for the volume of the tracts in both groups. Displacement and disruption of the pathways seemed to differ in relation to the severity of the tumor. The loss of pathways after the operation was associated with selective resection during surgery due to tumor infiltration. There were no FA differences but significantly higher ADC in low-grade tumors, and no difference in both FA and ADC in high-grade tumors. The effects of posterior fossa tumors on cerebellar peduncles and reconstructed pathways were successfully evaluated by HARDI tractography. The technique appears to be useful not only for preoperative but also for postoperative evaluation.
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Affiliation(s)
- A. Ortug
- Department of Anatomy, School of Medicine, Istanbul Medipol University, Istanbul, 34815, Turkey
- Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - N. Yuzbasioglu
- Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - N. Akalan
- Department of Neurosurgery, School of Medicine, Istanbul Medipol University, Istanbul, 34815, Turkey
| | - J. Levman
- Department of Computer Science, St. Francis Xavier University, Antigonish, Nova Scotia, B2G 2W5, Canada
| | - E. Takahashi
- Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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Radhakrishnan R, Shea LAG, Pruthi S, Silvera VM, Bosemani T, Desai NK, Gilbert DL, Glenn OA, Guimaraes CV, Ho ML, Lam HFS, Maheshwari M, Mirsky DM, Nadel HR, Partap S, Schooler GR, Udayasankar UK, Whitehead MT, Wright JN, Rigsby CK. ACR Appropriateness Criteria® Ataxia-Child. J Am Coll Radiol 2022; 19:S240-S255. [PMID: 36436955 DOI: 10.1016/j.jacr.2022.09.010] [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: 08/27/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
Childhood ataxia may be due to multifactorial causes of impairment in the coordination of movement and balance. Acutely presenting ataxia in children may be due to infectious, inflammatory, toxic, ischemic, or traumatic etiology. Intermittent or episodic ataxia in children may be manifestations of migraine, benign positional vertigo, or intermittent metabolic disorders. Nonprogressive childhood ataxia suggests a congenital brain malformation or early prenatal or perinatal brain injury, and progressive childhood ataxia indicates inherited causes or acquired posterior fossa lesions that result in gradual cerebellar dysfunction. CT and MRI of the central nervous system are the usual modalities used in imaging children presenting with ataxia, based on the clinical presentation. This document provides initial imaging guidelines for a child presenting with acute ataxia with or without a history of recent trauma, recurrent ataxia with interval normal neurological examination, chronic progressive ataxia, and chronic nonprogressive ataxia. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Rupa Radhakrishnan
- Associate Division Chief, Neuroradiology, Indiana University Health, Indianapolis, Indiana.
| | - Lindsey A G Shea
- Research Author, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sumit Pruthi
- Panel Chair, Vanderbilt Children's Hospital, Nashville, Tennessee
| | | | | | | | - Donald L Gilbert
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; American Academy of Neurology
| | - Orit A Glenn
- Director, Pediatric Neuroradiology, University of California, San Francisco, San Francisco, California
| | - Carolina V Guimaraes
- Division Chief, Pediatric Radiology, Lucile Packard Children's Hospital at Stanford, Stanford, California
| | - Mai-Lan Ho
- Nationwide Children's Hospital, Columbus, Ohio
| | - H F Samuel Lam
- Sutter Medical Center Sacramento, Sacramento, California; American College of Emergency Physicians
| | - Mohit Maheshwari
- Director of Pediatric Neuroradiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David M Mirsky
- Director of the Pediatric Neuroradiology Fellowship, Children's Hospital Colorado, Aurora, Colorado
| | - Helen R Nadel
- Lucile Packard Children's Hospital at Stanford, Stanford, California
| | - Sonia Partap
- Neuro-Oncology Fellowship Director, Stanford University, Stanford, California; American Academy of Pediatrics
| | - Gary R Schooler
- Associate Division Director, Pediatric Radiology, UT Southwestern Medical Center, Dallas, Texas
| | | | | | | | - Cynthia K Rigsby
- Specialty Chair; Chair, Medical Imaging Department, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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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: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [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
- *Correspondence: Alessandro De Benedictis
| | - 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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Ko N, Lee HH, Kim K, Kim BR, Moon WJ, Lee J. Role of Cortico-ponto-cerebellar Tract from Supplementary Motor Area in Ataxic Hemiparesis of Supratentorial Stroke Patients. BRAIN & NEUROREHABILITATION 2021; 14:e22. [PMID: 36741219 PMCID: PMC9879374 DOI: 10.12786/bn.2021.14.e22] [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: 06/03/2021] [Revised: 09/08/2021] [Accepted: 10/13/2021] [Indexed: 11/08/2022] Open
Abstract
Cortical lesions of the supplementary motor area (SMA) are important in balance control and postural recovery in stroke patients, while the role of subcortical lesions of the SMA has not been studied. This study aimed to investigate the subcortical projections of the SMA and its relationship with ataxia in supratentorial stroke patients. Thirty-three patients with hemiparesis were divided into 3 groups (severe ataxia, n = 9; mild to moderate ataxia, n = 13; no ataxia, n = 11). Ataxia severity was assessed using the Scale for Ataxia Rating Assessment. Diffusion tensor imaging analysis used the fractional anisotropy (FA) values and tract volume as parameters of white matter tract degeneration. The FA values of regions related to ataxia were analyzed, that is the SMA, posterior limb of the internal capsule, basal ganglia, superior cerebellar peduncle, middle cerebellar peduncle, inferior cerebellar peduncle, and cerebellum. Tract volumes of the corticostriatal tract and cortico-ponto-cerebellar (CPC) tract originating from the SMA were evaluated. There were significant differences among the 3 groups in FA values of the subcortical regions of the CPC tract. Furthermore, the volume of the CPC tract originating from the SMA showed significant negative correlation with ataxia severity. There was no correlation between ataxia and corticostriatal tract volume. Therefore, we found that subcortical lesions of the CPC tract originating from the SMA could contribute to ataxia severity in stroke patients with ataxic hemiparesis.
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Affiliation(s)
- Nayeon Ko
- Department of Rehabilitation Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Hyun Haeng Lee
- Department of Rehabilitation Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Kyungmin Kim
- Department of Rehabilitation Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Bo-Ram Kim
- Department of Rehabilitation Medicine, Gyeongin Rehabilitation Center Hospital, Incheon, Korea
| | - Won-Jin Moon
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jongmin Lee
- Department of Rehabilitation Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea.,Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea
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7
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Pruthi N, Kadri PAS, Türe U. Fiber Microdissection Technique for Demonstrating the Deep Cerebellar Nuclei and Cerebellar Peduncles. Oper Neurosurg (Hagerstown) 2021; 20:E118-E125. [PMID: 33047123 DOI: 10.1093/ons/opaa318] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 08/02/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The cerebellum is one of the most primitive and complex parts of the human brain. The fiber microdissection technique can be extremely useful for neurosurgeons to understand the topographical organization of the cerebellum's important contents, such as the deep cerebellar nuclei and the cerebellar peduncles, and their relationship with the brain stem. OBJECTIVE To dissect the deep cerebellar nuclei and the cerebellar peduncles using the fiber microdissection technique. METHODS Under the operating microscope, 5 previously frozen, formalin-fixed human cerebellums and brain stems were dissected from the superior surface, and 5 were dissected from the inferior surface. Each stage of the process is described. The primary dissection tools were handmade, thin, wooden spatulas with tips of various sizes, toothpicks, and a fine regulated suction. RESULTS In 15 simplified dissection steps (6 for the superior surface and 9 for the inferior surface), the deep cerebellar nuclei (dentate, interpositus, and fastigial) and the cerebellar peduncles (inferior, middle, and superior) are delineated. Their anatomical relationships with each other and other neighboring structures are demonstrated. CONCLUSION The anatomy of the deep cerebellar nuclei and the cerebellar peduncles are clearly defined and understood through the use of the fiber microdissection technique. These stepwise dissections will guide the neurosurgeon in acquiring a topographical understanding of these complex and deep structures of the cerebellum. This knowledge, along with radiological information, can help in planning the most appropriate surgical strategy for various lesions of the cerebellum.
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Affiliation(s)
- Nupur Pruthi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India.,Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Paulo A S Kadri
- Division of Neurosurgery, School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, Brazil
| | - Uğur Türe
- Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey
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8
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Gomes CA, Steiner KM, Ludolph N, Spisak T, Ernst TM, Mueller O, Göricke SL, Labrenz F, Ilg W, Axmacher N, Timmann D. Resection of cerebellar tumours causes widespread and functionally relevant white matter impairments. Hum Brain Mapp 2021; 42:1641-1656. [PMID: 33410575 PMCID: PMC7978119 DOI: 10.1002/hbm.25317] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/22/2020] [Indexed: 12/14/2022] Open
Abstract
Several diffusion tensor imaging studies reveal that white matter (WM) lesions are common in children suffering from benign cerebellar tumours who are treated with surgery only. The clinical implications of WM alterations that occur as a direct consequence of cerebellar disease have not been thoroughly studied. Here, we analysed structural and diffusion imaging data from cerebellar patients with chronic surgical lesions after resection for benign cerebellar tumours. We aimed to elucidate the impact of focal lesions of the cerebellum on WM integrity across the entire brain, and to investigate whether WM deficits were associated with behavioural impairment in three different motor tasks. Lesion symptom mapping analysis suggested that lesions in critical cerebellar regions were related to deficits in savings during an eyeblink conditioning task, as well as to deficits in motor action timing. Diffusion imaging analysis of cerebellar WM indicated that better behavioural performance was associated with higher fractional anisotropy (FA) in the superior cerebellar peduncle, cerebellum's main outflow path. Moreover, voxel‐wise analysis revealed a global pattern of WM deficits in patients within many cerebral WM tracts critical for motor and non‐motor function. Finally, we observed a positive correlation between FA and savings within cerebello‐thalamo‐cortical pathways in patients but not in controls, showing that saving effects partly depend on extracerebellar areas, and may be recruited for compensation. These results confirm that the cerebellum has extended connections with many cerebral areas involved in motor/cognitive functions, and the observed WM changes likely contribute to long‐term clinical deficits of posterior fossa tumour survivors.
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Affiliation(s)
- Carlos Alexandre Gomes
- Department of Neuropsychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany
| | - Katharina M Steiner
- Department of Neurology, Essen University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Nicolas Ludolph
- Cognitive Neurology, Section Computational Sensomotorics, Hertie Institute for Clinical Brain Research and Center for Integrative Neuroscience (HIH), Eberhard Karls University, Tübingen, Germany
| | - Tamas Spisak
- Predictive Neuroimaging Lab, Institute for Artificial Intelligence in Medicine - Institute of Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, Essen, Germany
| | - Thomas M Ernst
- Department of Neurology, Essen University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Oliver Mueller
- Department of Neurosurgery, Klinikum Dortmund, Dortmund, Germany.,Department of Neurosurgery, Essen University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Sophia L Göricke
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Franziska Labrenz
- Department of Neurology, Essen University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Winfried Ilg
- Cognitive Neurology, Section Computational Sensomotorics, Hertie Institute for Clinical Brain Research and Center for Integrative Neuroscience (HIH), Eberhard Karls University, Tübingen, Germany
| | - Nikolai Axmacher
- Department of Neuropsychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany
| | - Dagmar Timmann
- Department of Neurology, Essen University Hospital, University of Duisburg-Essen, Essen, Germany
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Hartley H, Lane S, Pizer B, Bunn L, Carter B, Cassidy E, Mallucci C, Kumar R. Ataxia and mobility in children following surgical resection of posterior fossa tumour: A longitudinal cohort study. Childs Nerv Syst 2021; 37:2831-2838. [PMID: 34232381 PMCID: PMC8423635 DOI: 10.1007/s00381-021-05246-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 04/23/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To report the course of ataxia in children up to 2 years post-operatively, following surgical resection of a posterior fossa tumour (PFT). METHODS Thirty-five children, (median age 9 years, range 4-15) having resection of PFT, were assessed using the Scale for the Assessment and Rating of Ataxia (SARA), Brief Ataxia Rating Scale (BARS) and the mobility domain of the Paediatric Evaluation of Disability Index (PEDI-m) at initial post-operative period (baseline), 3 months, 1 year and 2 years post-operatively. RESULTS Baseline median scores of the SARA and BARS were 8.5 (range 0-35.5), and 7 (0-25) respectively. Ataxia improved at 3 months (median SARA and BARS reduction 3.5 and 4, respectively). Additional gradual improvements in SARA were recorded at 1 (median reduction 2) and 2 years post-operatively (median reduction 0.5). Median baseline PEDI-m was 54.75 (range 15.2-100) with improvement at 3 months (median increase 36.95) and small improvement at 1 year (median increase 2.5) and 2 years (median increase 5.8). Children with medulloblastoma and midline tumours (median baseline SARA 10 and 11, respectively) demonstrated more severe ataxia than children with low-grade gliomas and unilateral tumours (median baseline SARA 7.5 and 6.5, respectively). CONCLUSION The largest improvement in ataxia scores and functional mobility scores is demonstrated within the first 3 months post-operatively, but ongoing gradual improvement is observed at 2 years. Children with medulloblastoma and midline tumour demonstrated higher ataxia scores long term.
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Affiliation(s)
- H Hartley
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - S Lane
- University of Liverpool, Liverpool, UK
| | - B Pizer
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - L Bunn
- University of Plymouth, Plymouth, UK
| | - B Carter
- Edge Hill University, Ormskirk, UK.
| | | | - C Mallucci
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - R Kumar
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
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10
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Grosse F, Rueckriegel SM, Thomale UW, Hernáiz Driever P. Mapping of long-term cognitive and motor deficits in pediatric cerebellar brain tumor survivors into a cerebellar white matter atlas. Childs Nerv Syst 2021; 37:2787-2797. [PMID: 34355257 PMCID: PMC8423645 DOI: 10.1007/s00381-021-05244-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 06/01/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Diaschisis of cerebrocerebellar loops contributes to cognitive and motor deficits in pediatric cerebellar brain tumor survivors. We used a cerebellar white matter atlas and hypothesized that lesion symptom mapping may reveal the critical lesions of cerebellar tracts. METHODS We examined 31 long-term survivors of pediatric posterior fossa tumors (13 pilocytic astrocytoma, 18 medulloblastoma). Patients underwent neuronal imaging, examination for ataxia, fine motor and cognitive function, planning abilities, and executive function. Individual consolidated cerebellar lesions were drawn manually onto patients' individual MRI and normalized into Montreal Neurologic Institute (MNI) space for further analysis with voxel-based lesion symptom mapping. RESULTS Lesion symptom mapping linked deficits of motor function to the superior cerebellar peduncle (SCP), deep cerebellar nuclei (interposed nucleus (IN), fastigial nucleus (FN), ventromedial dentate nucleus (DN)), and inferior vermis (VIIIa, VIIIb, IX, X). Statistical maps of deficits of intelligence and executive function mapped with minor variations to the same cerebellar structures. CONCLUSION We identified lesions to the SCP next to deep cerebellar nuclei as critical for limiting both motor and cognitive function in pediatric cerebellar tumor survivors. Future strategies safeguarding motor and cognitive function will have to identify patients preoperatively at risk for damage to these critical structures and adapt multimodal therapeutic options accordingly.
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Affiliation(s)
- Frederik Grosse
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Pediatric Oncology and Hematology, Berlin, Germany
| | | | - Ulrich-Wilhelm Thomale
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Pediatric Neurosurgery, Berlin, Germany
| | - Pablo Hernáiz Driever
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Pediatric Oncology and Hematology, Berlin, Germany.
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11
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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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12
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Perioperative Assessment of Cerebellar Masses and the Potential for Cerebellar Cognitive Affective Syndrome. World Neurosurg 2020; 144:222-230. [PMID: 32949806 DOI: 10.1016/j.wneu.2020.09.048] [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: 06/08/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 11/23/2022]
Abstract
The cerebellum was long perceived to be a region of limited importance with primary functions in the regulation of motor control. A degree of its functional topography in motor modulation has been traditionally appreciated. However, an evolving body of evidence supports its role in a range of cognitive processes, including executive decision making, language, emotional processing, and working memory. To this end, numerous studies of cerebellar stroke syndromes as well as investigations with functional magnetic resonance imaging and diffusion tensor imaging have given clinicians a better model of the functional topography within the cerebellum and the essential lanes of communication with the cerebrum. With this deeper understanding, neurosurgeons should integrate these domains into the perioperative evaluation and postoperative rehabilitation of patients with cerebellar tumors. This review aims to discuss these understandings and identify valuable tools for implementation into clinical practice.
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13
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Liguoro I, Passone E, Zilli T, Maieron M, De Colle MC, Skrap M, Dolcemascolo V, Sommariva G, Cogo P, Tomasino B. Possible association between the integrity of cerebellar pathways and neurocognitive performance in children with posterior fossa tumors. Pediatr Blood Cancer 2020; 67:e28538. [PMID: 32652734 DOI: 10.1002/pbc.28538] [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: 02/15/2020] [Revised: 06/04/2020] [Accepted: 06/10/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cerebellar tumor survivors often exhibit neuropsychological deficits that could be related to alterations in cerebro-cerebellar networks. This is a pilot study designed to understand if diffusion tensor imaging (DTI)-based tractography is able to identify possible correlations between cerebellar white matter structure and cognitive outcome in children on long-term follow-up for posterior fossa (PF) tumors who were thoroughly assessed for neuropsychological functioning. METHODS DTI-based tractography was performed in pediatric patients with PF tumors. Fractional anisotropy (FA) and volumetric measurements of spinocerebellar, dentorubrothalamocortical and corticopontocerebellar tracts were analyzed. Cognitive and neuropsychological functioning was assessed by the Wechsler Intelligence Scale for Children-IV Edition (WISC-IV) and the Developmental Neuropsychological Assessment (NEPSY II). The associations between Full-Scale Intelligence Quotient (FSIQ), NEPSY-II scores, and fiber tracts were tested by the Spearman rank correlation coefficient. RESULTS Seven patients (median age at diagnosis five years, range, 3-13) treated for medulloblastoma (2/7; 29%) and pilocytic astrocytoma (5/7; 71%) were retrospectively evaluated. All children had complete surgery. The median FSIQ was 84 (range, 67-93). Patients presented with several deficits on many NEPSY-II tasks; in particular, memory was impaired in nearly half of them. FSIQ and neurocognitive tasks significantly correlated with specific corticopontocerebellar tracts. CONCLUSION Children on follow-up for PF tumor showed scattered cognitive impairments, including deficits in long-term and immediate memory. Tractography allowed us to describe a possible association between the integrity of cerebellar pathways and neurocognitive performance, suggesting that the myelinization of these fibers may represent an indicator for the development of long-term cognitive sequelae.
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Affiliation(s)
- Ilaria Liguoro
- Division of Pediatrics, Department of Medicine-DAME, University of Udine, Udine, Italy
| | - Eva Passone
- Division of Pediatrics, University Hospital of Udine, Udine, Italy
| | - Tiziana Zilli
- San Vito al Tagliamento, Pordenone, Scientific Institute Eugenio Medea, Italy
| | - Marta Maieron
- Department of Medical Physics, University Hospital of Udine, Udine, Italy
| | | | - Miran Skrap
- Department of Neurosurgery, University Hospital of Udine, Udine, Italy
| | | | - Giulia Sommariva
- Division of Pediatrics, Department of Medicine-DAME, University of Udine, Udine, Italy.,Child Neuropsychiatry, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Paola Cogo
- Division of Pediatrics, Department of Medicine-DAME, University of Udine, Udine, Italy.,Division of Pediatrics, University Hospital of Udine, Udine, Italy
| | - Barbara Tomasino
- San Vito al Tagliamento, Pordenone, Scientific Institute Eugenio Medea, Italy
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Abstract
PURPOSE OF REVIEW Molecular subtyping in medulloblastoma (MB) has diagnostic and prognostic values which impact therapy. This paper provides guidance for the clinician caring for pediatric and adult patients with medulloblastoma in the modern era. RECENT FINDINGS Medulloblastoma comprises four molecularly distinct subgroups: wingless activated (WNT), sonic hedgehog activated (SHH), group 3, and group 4. Risk stratification before and after the discovery of molecular subgroups aims at minimizing toxicity by reducing radiation and chemotherapy doses in low-risk patients while maintaining favorable overall survival (OS). The mainstay of newly diagnosed medulloblastoma treatment is surgery, radiation therapy, and chemotherapy, except for children under 6 years of age, where high-dose chemotherapy with autologous stem cell rescue is used to avoid or delay radiotherapy, preventing neurocognitive sequelae. Management of recurrent/refractory medulloblastoma remains a challenge with immunotherapy and small-molecule inhibitors forming the backbone of novel strategies. Recent innovations in medulloblastoma research allow us to better understand pathogenesis and molecular characteristics resulting in advanced risk stratification models, new therapeutic approaches, and overall improved survival and quality of life.
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Affiliation(s)
- Luca Szalontay
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Yasmin Khakoo
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA. .,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA.
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15
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Zhang H, Bao Y, Feng Y, Hu H, Wang Y. Evidence for Reciprocal Structural Network Interactions Between Bilateral Crus Lobes and Broca's Complex. Front Neuroanat 2020; 14:27. [PMID: 32625067 PMCID: PMC7316155 DOI: 10.3389/fnana.2020.00027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/05/2020] [Indexed: 11/24/2022] Open
Abstract
While the proximal dentatothalamocortical tracts are considered pivotal in the occurrence of cerebellar mutism syndrome (CMS) after medulloblastoma resection, how the cerebellum participates in motor–speech networks through direct structural connectivity is still unclear. Via tractography, we provide evidence of cerebellar streamlines projecting into the left inferior frontal gyrus majorly connecting Broca’s complex and the bilateral Crus lobes. The streamlines, named Crus–Broca tracts, originated from the bilateral Crus lobes, synapsed onto the dentate nucleus, ascended into the superior cerebellar peduncle (where these streamlines were closely superior to the superior border of the supratonsillar cleft and the superolateral roof of the fourth ventricle), surprisingly bypassed the left red nucleus and the left thalamus, and ended at the subregions of Broca’s complex. The streamlines, named Broca–Crus tracts, originated from the subregions of Broca’s complex and ended predominantly at the right Crus lobes. If verified, the existence of these connections would support the notion of the bilateral cerebellums’ participation in motor–speech planning, and the anatomical relationship of Broca–Crus tracts with the supratonsillar cleft would merit consideration for further studies aimed at further elucidating CMS mechanisms.
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Affiliation(s)
- Hui Zhang
- Department of Neurosurgery, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China.,Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yue Bao
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Yuan Feng
- Sleep Medicine Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Haijun Hu
- Department of Neurosurgery, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China
| | - Yibao Wang
- Department of Neurosurgery, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China
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16
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Cobourn K, Marayati F, Tsering D, Ayers O, Myseros JS, Magge SN, Oluigbo CO, Keating RF. Cerebellar mutism syndrome: current approaches to minimize risk for CMS. Childs Nerv Syst 2020; 36:1171-1179. [PMID: 31273496 DOI: 10.1007/s00381-019-04240-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 05/28/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Cerebellar mutism syndrome (CMS) is a serious source of morbidity following posterior fossa surgery in the pediatric population. However, methods for effectively decreasing its incidence and impact remain unclear. It is our aim to examine the impact of adjusting surgical factors, namely the use of a telovelar approach and avoidance of cavitronic ultrasonic aspirator, on the incidence of CMS in our population as well as outlining potential pre-, intra-, and postoperative factors that may contribute to its development. METHODS Retrospective review was performed to identify patients undergoing posterior fossa surgery for resection of a medulloblastoma. Demographic, surgical, and postoperative data were collected. These data were analyzed for possible correlations to the risk of developing CMS via univariate analysis. For factors found to be significant, a multivariate analysis was performed to assess their independence. RESULTS Seven of 65 patients (10.8%) developed CMS postoperatively. Factors found to be significantly associated with a higher risk of CMS were the degree of retraction utilized during the procedure (p = 0.0000) and incision of the vermis (p = 0.0294). Although they did not reach the threshold of statistical significance, tumor vascularity (p = 0.19), adoption of a transvermian approach (p = 0.19), and lack of intraoperative imaging (p = 0.17) exhibited strongly suggestive trends towards a correlation with CMS. DISCUSSION In an effort to reduce the incidence and severity of CMS in our population, our institution adopted surgical practices that minimize tissue trauma and mitigate postoperative edema. This included the use of a telovelar over a transvermian approach to obviate the need for vermian incision, avoidance of the CUSA, and minimization of heavy retraction during surgery. This was successful in reducing the incidence of CMS from 39% in our medulloblastoma patients to 10.8%. The development of CMS after posterior fossa surgery appears to be a "two-hit" phenomenon requiring a combination of existing predisposition, surgical injury, and postoperative exacerbation. Therefore, it is critical to identify the factors involved at each stage and investigate treatments to target them appropriately.
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Affiliation(s)
- Kelsey Cobourn
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,Georgetown University School of Medicine, Washington, DC, USA
| | - Fares Marayati
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,Princeton University, Princeton, NJ, USA
| | - Deki Tsering
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Owen Ayers
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,Princeton University, Princeton, NJ, USA
| | - John S Myseros
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,George Washington University School of Medicine, Washington, DC, USA
| | - Suresh N Magge
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,George Washington University School of Medicine, Washington, DC, USA
| | - Chima O Oluigbo
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,George Washington University School of Medicine, Washington, DC, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA. .,George Washington University School of Medicine, Washington, DC, USA.
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17
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Wende T, Hoffmann KT, Meixensberger J. Tractography in Neurosurgery: A Systematic Review of Current Applications. J Neurol Surg A Cent Eur Neurosurg 2020; 81:442-455. [PMID: 32176926 DOI: 10.1055/s-0039-1691823] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The ability to visualize the brain's fiber connections noninvasively in vivo is relatively young compared with other possibilities of functional magnetic resonance imaging. Although many studies showed tractography to be of promising value for neurosurgical care, the implications remain inconclusive. An overview of current applications is presented in this systematic review. A search was conducted for (("tractography" or "fiber tracking" or "fibre tracking") and "neurosurgery") that produced 751 results. We identified 260 relevant articles and added 20 more from other sources. Most publications concerned surgical planning for resection of tumors (n = 193) and vascular lesions (n = 15). Preoperative use of transcranial magnetic stimulation was discussed in 22 of these articles. Tractography in skull base surgery presents a special challenge (n = 29). Fewer publications evaluated traumatic brain injury (TBI) (n = 25) and spontaneous intracranial bleeding (n = 22). Twenty-three articles focused on tractography in pediatric neurosurgery. Most authors found tractography to be a valuable addition in neurosurgical care. The accuracy of the technique has increased over time. There are articles suggesting that tractography improves patient outcome after tumor resection. However, no reliable biomarkers have yet been described. The better rehabilitation potential after TBI and spontaneous intracranial bleeding compared with brain tumors offers an insight into the process of neurorehabilitation. Tractography and diffusion measurements in some studies showed a correlation with patient outcome that might help uncover the neuroanatomical principles of rehabilitation itself. Alternative corticofugal and cortico-cortical networks have been implicated in motor recovery after ischemic stroke, suggesting more complex mechanisms in neurorehabilitation that go beyond current models. Hence tractography may potentially be able to predict clinical deficits and rehabilitation potential, as well as finding possible explanations for neurologic disorders in retrospect. However, large variations of the results indicate a lack of data to establish robust diagnostical concepts at this point. Therefore, in vivo tractography should still be interpreted with caution and by experienced surgeons.
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Affiliation(s)
- Tim Wende
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
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18
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Yecies D, Shpanskaya K, Jabarkheel R, Maleki M, Bruckert L, Cheshier SH, Hong D, Edwards MSB, Grant GA, Yeom KW. Arterial spin labeling perfusion changes of the frontal lobes in children with posterior fossa syndrome. J Neurosurg Pediatr 2019; 24:382-388. [PMID: 31374541 DOI: 10.3171/2019.5.peds18452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 05/15/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Posterior fossa syndrome (PFS) is a common complication following the resection of posterior fossa tumors in children. The pathophysiology of PFS remains incompletely elucidated; however, the wide-ranging symptoms of PFS suggest the possibility of widespread cortical dysfunction. In this study, the authors utilized arterial spin labeling (ASL), an MR perfusion modality that provides quantitative measurements of cerebral blood flow without the use of intravenous contrast, to assess cortical blood flow in patients with PFS. METHODS A database of medulloblastoma treated at the authors' institution from 2004 to 2016 was retrospectively reviewed, and 14 patients with PFS were identified. Immediate postoperative ASL for patients with PFS and medulloblastoma patients who did not develop PFS were compared. Additionally, in patients with PFS, ASL following the return of speech was compared with immediate postoperative ASL. RESULTS On immediate postoperative ASL, patients who subsequently developed PFS had statistically significant decreases in right frontal lobe perfusion and a trend toward decreased perfusion in the left frontal lobe compared with controls. Patients with PFS had statistically significant increases in bilateral frontal lobe perfusion after the resolution of symptoms compared with their immediate postoperative imaging findings. CONCLUSIONS ASL perfusion imaging identifies decreased frontal lobe blood flow as a strong physiological correlate of PFS that is consistent with the symptomatology of PFS. This is the first study to demonstrate that decreases in frontal lobe perfusion are present in the immediate postoperative period and resolve with the resolution of symptoms, suggesting a physiological explanation for the transient symptoms of PFS.
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Affiliation(s)
| | | | | | | | - Lisa Bruckert
- 4Division of Developmental-Behavioral Pediatrics, Stanford University School of Medicine, Stanford, California; and
| | - Samuel H Cheshier
- 3Department of Neurosurgery, University of Utah Primary Children's Hospital, Salt Lake City, Utah
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19
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Yecies D, Jabarkheel R, Han M, Kim YH, Bruckert L, Shpanskaya K, Perez A, Edwards MSB, Grant GA, Yeom KW. Posterior fossa syndrome and increased mean diffusivity in the olivary bodies. J Neurosurg Pediatr 2019; 24:376-381. [PMID: 31349230 DOI: 10.3171/2019.5.peds1964] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 05/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Posterior fossa syndrome (PFS) is a common postoperative complication following resection of posterior fossa tumors in children. It typically presents 1 to 2 days after surgery with mutism, ataxia, emotional lability, and other behavioral symptoms. Recent structural MRI studies have found an association between PFS and hypertrophic olivary degeneration, which is detectable as T2 hyperintensity in the inferior olivary nuclei (IONs) months after surgery. In this study, the authors investigated whether immediate postoperative diffusion tensor imaging (DTI) of the ION can serve as an early imaging marker of PFS. METHODS The authors retrospectively reviewed pediatric brain tumor patients treated at their institution, Lucile Packard Children's Hospital at Stanford, from 2004 to 2016. They compared the immediate postoperative DTI studies obtained in 6 medulloblastoma patients who developed PFS to those of 6 age-matched controls. RESULTS Patients with PFS had statistically significant increased mean diffusivity (MD) in the left ION (1085.17 ± 215.51 vs 860.17 ± 102.64, p = 0.044) and variably increased MD in the right ION (923.17 ± 119.2 vs 873.67 ± 60.16, p = 0.385) compared with age-matched controls. Patients with PFS had downward trending fractional anisotropy (FA) in both the left (0.28 ± 0.06 vs 0.23 ± 0.03, p = 0.085) and right (0.29 ± 0.06 vs 0.25 ± 0.02, p = 0.164) IONs compared with age-matched controls, although neither of these values reached statistical significance. CONCLUSIONS Increased MD in the ION is associated with development of PFS. ION MD changes may represent an early imaging marker of PFS.
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20
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Vedantam A, Stormes KM, Gadgil N, Kralik SF, Aldave G, Lam SK. Association between postoperative DTI metrics and neurological deficits after posterior fossa tumor resection in children. J Neurosurg Pediatr 2019; 24:364-370. [PMID: 31323626 DOI: 10.3171/2019.5.peds1912] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 05/09/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Resection of posterior fossa tumors in children may be associated with persistent neurological deficits. It is unclear if these neurological deficits are associated with persistent structural damage to the cerebellar pathways. The purpose of this research was to define longitudinal changes in diffusion tensor imaging (DTI) metrics in white matter cerebellar tracts and the clinical correlates of these metrics in children undergoing resection of posterior fossa tumors. METHODS Longitudinal brain DTI was performed in a cohort of pediatric patients who underwent resection of posterior fossa tumors. Fractional anisotropy (FA) of the superior cerebellar peduncles (SCPs) and middle cerebellar peduncles (MCPs) was measured on preoperative, postoperative, and follow-up DTI. Early postoperative (< 48 hours) and longer-term follow-up neurological deficits (mutism, ataxia, and extraocular movement dysfunction) were documented. Statistical analysis was performed to determine differences in FA values based on presence or absence of neurological deficits. Statistical significance was set at p < 0.05. RESULTS Twenty children (mean age 6.1 ± 4.1 years [SD], 12 males and 8 females) were included in this study. Follow-up DTI was performed at a median duration of 14.3 months after surgery, and the median duration of follow-up was 19.7 months. FA of the left SCP was significantly reduced on postoperative DTI in comparison with preoperative DTI (0.44 ± 0.07 vs 0.53 ± 0.1, p = 0.003). Presence of ataxia at follow-up was associated with a persistent reduction in the left SCP FA on follow-up DTI (0.43 ± 0.1 vs 0.55 ± 0.1, p = 0.016). Patients with early postoperative mutism who did not recover at follow-up had significantly decreased FA of the left SCP on early postoperative DTI in comparison with those who recovered (0.38 ± 0.05 vs 0.48 ± 0.06, p = 0.04). CONCLUSIONS DTI after resection of posterior fossa tumors in children shows that persistent reduction of SCP FA is associated with ataxia at follow-up.
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Affiliation(s)
- Aditya Vedantam
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Katie M Stormes
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Nisha Gadgil
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Stephen F Kralik
- 2Department of Radiology, Texas Children's Hospital, Houston, Texas
| | - Guillermo Aldave
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Sandi K Lam
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
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21
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Ji Q, Edwards A, Glass JO, Brinkman TM, Patay Z, Reddick WE. Measurement of Projections Between Dentate Nucleus and Contralateral Frontal Cortex in Human Brain Via Diffusion Tensor Tractography. THE CEREBELLUM 2019; 18:761-769. [DOI: 10.1007/s12311-019-01035-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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22
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Abstract
Medulloblastoma is the most common malignant solid tumor in childhood and the most common embryonal neuroepithelial tumor of the central nervous system. Several morphological variants are recognized: classic medulloblastoma, large cell/anaplastic medulloblastoma, desmoplastic/nodular medulloblastoma, and medulloblastoma with extensive nodularity. Recent advances in transcriptome and methylome profiling of these tumors led to a molecular classification that includes 4 major genetically defined groups. Accordingly, the 2016 revision of the World Health Organization's Classification of Tumors of the Central Nervous System recognizes the following medulloblastoma entities: Wingless (WNT)-activated, Sonic hedgehog (SHH)-activated, Group 3, and Group 4. This transcriptionally driven classification constitutes the basis of new risk stratification schemes applied to current therapeutic clinical trials. Because additional layers of molecular tumor heterogeneities are being progressively unveiled, several clinically relevant subgroups within the 4 major groups have already been identified. The purpose of this article is to review the recent basic science and clinical advances in the understanding of "medulloblastomas," and their diagnostic imaging correlates and the implications of those on current neuroimaging practice.
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Abstract
PURPOSE OF REVIEW This article describes the most common pediatric brain tumors and highlights recent developments in their diagnosis and treatment strategies. RECENT FINDINGS We are in the midst of a molecular era for pediatric brain tumors. Genetic and epigenetic profiling of tumors has impacted their diagnosis, allowing for the subgrouping of heterogeneous tumor groups and leading to the complete renaming of some tumor types. These advances are reflected in the new 2016 World Health Organization classification. For example, primitive neuroectodermal tumors have been completely eliminated and replaced by subgroups defined by the absence or presence of specific chromosomal amplification. Medulloblastomas, diffuse astrocytomas, and ependymomas now have specific subtypes that are based on defining molecular features. More recent epigenetic-based subgrouping of atypical teratoid/rhabdoid tumors have not yet made it into the official classification system, but will surely have an impact on how these tumors are regarded in future preclinical and clinical trials. SUMMARY Genetic and epigenetic data are changing how pediatric brain tumors are diagnosed, are leading to new guidelines for how treatment outcome analyses can be organized, and are offering molecular targets that can be used for the development of novel therapies.
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Marusak HA, Iadipaolo AS, Harper FW, Elrahal F, Taub JW, Goldberg E, Rabinak CA. Neurodevelopmental consequences of pediatric cancer and its treatment: applying an early adversity framework to understanding cognitive, behavioral, and emotional outcomes. Neuropsychol Rev 2018; 28:123-175. [PMID: 29270773 PMCID: PMC6639713 DOI: 10.1007/s11065-017-9365-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 11/08/2017] [Indexed: 01/29/2023]
Abstract
Today, children are surviving pediatric cancer at unprecedented rates, making it one of modern medicine's true success stories. However, we are increasingly becoming aware of several deleterious effects of cancer and the subsequent "cure" that extend beyond physical sequelae. Indeed, survivors of childhood cancer commonly report cognitive, emotional, and psychological difficulties, including attentional difficulties, anxiety, and posttraumatic stress symptoms (PTSS). Cognitive late- and long-term effects have been largely attributed to neurotoxic effects of cancer treatments (e.g., chemotherapy, cranial irradiation, surgery) on brain development. The role of childhood adversity in pediatric cancer - namely, the presence of a life-threatening disease and endurance of invasive medical procedures - has been largely ignored in the existing neuroscientific literature, despite compelling research by our group and others showing that exposure to more commonly studied adverse childhood experiences (i.e., domestic and community violence, physical, sexual, and emotional abuse) strongly imprints on neural development. While these adverse childhood experiences are different in many ways from the experience of childhood cancer (e.g., context, nature, source), they do share a common element of exposure to threat (i.e., threat to life or physical integrity). Therefore, we argue that the double hit of early threat and cancer treatments likely alters neural development, and ultimately, cognitive, behavioral, and emotional outcomes. In this paper, we (1) review the existing neuroimaging research on child, adolescent, and adult survivors of childhood cancer, (2) summarize gaps in our current understanding, (3) propose a novel neurobiological framework that characterizes childhood cancer as a type of childhood adversity, particularly a form of early threat, focusing on development of the hippocampus and the salience and emotion network (SEN), and (4) outline future directions for research.
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Affiliation(s)
- Hilary A Marusak
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave., Suite 2190, Detroit, MI, 48202, USA.
| | - Allesandra S Iadipaolo
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave., Suite 2190, Detroit, MI, 48202, USA
| | - Felicity W Harper
- Population Studies and Disparities Research Program, Karmanos Cancer Institute, Detroit, MI, USA
- Department of Oncology, School of Medicine, Wayne State University, Detroit, MI, USA
| | - Farrah Elrahal
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave., Suite 2190, Detroit, MI, 48202, USA
| | - Jeffrey W Taub
- Department of Pediatrics, School of Medicine, Wayne State University, Detroit, MI, USA
- Children's Hospital of Michigan, Detroit, MI, USA
| | - Elimelech Goldberg
- Department of Pediatrics, School of Medicine, Wayne State University, Detroit, MI, USA
- Kids Kicking Cancer, Southfield, MI, USA
| | - Christine A Rabinak
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave., Suite 2190, Detroit, MI, 48202, USA
- Department of Pharmaceutical Sciences, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI, USA
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Manto M, Huisman TAGM. The cerebellum from the fetus to the elderly: history, advances, and future challenges. HANDBOOK OF CLINICAL NEUROLOGY 2018; 155:407-413. [PMID: 29891075 DOI: 10.1016/b978-0-444-64189-2.00027-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
The cerebellum is now at the forefront of research in neuroscience. This is not just a coincidence, occurring about 250 years after the first description of the human cerebellum. The cerebellum contains the majority of neurons in the central nervous system and it is heavily connected with almost all cortical and subcortical areas of the supratentorial region as well as with the brainstem and the spinal cord. Cerebellar circuits are embedded in large-scale networks contributing to motor control and neurocognition. From a phenotypic standpoint, damage to cerebellar lobules interconnected with the sensorimotor cortices leads to a cerebellar motor syndrome, whereas lesions of the posterolateral cerebellum cause cognitive and neuropsychiatric impairments which may or may not be subtle. This topographic rule is valid in children and adults. Midline posterior vermal lesions cause behavioral/affective dysregulation, especially in kids. The extent of the spectrum of human cerebellar disorders is increasingly recognized from the fetus to the elderly, with recognition of consequences for the quality of life and socioeconomic costs due to lifelong morbidity of many cerebellar ataxias/pathologies. The prolonged duration of human cerebellar development makes the cerebellum especially susceptible to developmental disruption, both genetic and nongenetic. This explains the current emphasis on the clarification of the developmental course and impact of the cerebellum. The understanding of how germinal matrix zones and migration of neurons and glial cells end in a highly organized and foliated human cerebellum is essential. This is greatly accelerated by inputs from rodent developmental studies, in particular because cerebellar anatomy is conserved across species. Still, numerous questions on human fetal development remain unanswered. Although both advanced neuroimaging and genetic studies are currently leading to a better definition and understanding of the multitude of cerebellar symptoms, there is a gap, with a great need to develop therapies aiming at first, protection of the cerebellum during development, and second, restoration of cerebellar function in children and in adults. Dynamic profiles of the compensatory processes from newborns to elderly require specific studies.
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Affiliation(s)
- Mario Manto
- Neurology Service, CHU-Charleroi, Charleroi, Belgium; Neuroscience Service, Université de Mons, Mons, Belgium.
| | - Thierry A G M Huisman
- Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Abstract
Diffusion tensor imaging (DTI) is a noninvasive neuroimaging tool assessing the organization of white-matter tracts and brain microstructure in vivo. The technique takes into account the three-dimensional (3D) direction of diffusion of water in space, the brownian movements of water being constrained by the brain microstructure. The main direction of diffusion in the brain is extracted to obtain the principal direction of axonal projection within a given voxel. Overall, the diffusion tensor is a mathematic analysis of the magnitude/directionality (anisotropy) of the movement of water molecules in 3D space. Tracts running in the white matter are subsequently reconstructed graphically with fiber tractography. Tractography can be applied to myelinated and unmyelinated fibers or axonopathy. Decreased fractional anisotropy in white-matter tracts occurs in cases of injury with disorganized or disrupted myelin sheaths. Furthermore, high angular resolution methods enable detection of fiber crossings or convergence. DTI is a modern tool which complements conventional magnetic resonance techniques and is particularly relevant to assess the organization of cerebellar tracts. Indeed, both the afferent and efferent pathways of the cerebellar circuitry passing through the inferior, middle, and superior cerebellar peduncles can be visualized in vivo, including in children. The microanatomy of the cerebellar cortex and cerebellar nuclei is also emerging as a future assessment. Applications in the field of cerebellar disorders are multiple, ranging from developmental disorders to adult-onset cerebellar ataxias.
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Konakondla S, Brimley CJ, Sublett JM, Stefanowicz E, Flora S, Mongelluzzo G, Schirmer CM. Multimodality 3D Superposition and Automated Whole Brain Tractography: Comprehensive Printing of the Functional Brain. Cureus 2017; 9:e1731. [PMID: 29201580 PMCID: PMC5707174 DOI: 10.7759/cureus.1731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Whole brain tractography using diffusion tensor imaging (DTI) sequences can be used to map cerebral connectivity; however, this can be time-consuming due to the manual component of image manipulation required, calling for the need for a standardized, automated, and accurate fiber tracking protocol with automatic whole brain tractography (AWBT). Interpreting conventional two-dimensional (2D) images, such as computed tomography (CT) and magnetic resonance imaging (MRI), as an intraoperative three-dimensional (3D) environment is a difficult task with recognized inter-operator variability. Three-dimensional printing in neurosurgery has gained significant traction in the past decade, and as software, equipment, and practices become more refined, trainee education, surgical skills, research endeavors, innovation, patient education, and outcomes via valued care is projected to improve. We describe a novel multimodality 3D superposition (MMTS) technique, which fuses multiple imaging sequences alongside cerebral tractography into one patient-specific 3D printed model. Inferences on cost and improved outcomes fueled by encouraging patient engagement are explored.
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Affiliation(s)
- Sanjay Konakondla
- Neurosurgery Department, Neuroscience Institute, Geisinger Health System
| | - Cameron J Brimley
- Neurosurgery Department, Neuroscience Institute, Geisinger Health System
| | | | | | - Sarah Flora
- Department of Radiology and Neuroradiology, Geisinger Health System
| | - Gino Mongelluzzo
- Department of Radiology and Neuroradiology, Geisinger Health System
| | - Clemens M Schirmer
- Neurosurgery Department, Neuroscience Institute, Geisinger Health System
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