Cerebellar stroke in adults and children

Differential Protective Effects of Edaravone in Cerebellar and Hippocampal Ischemic Injury Models

Ischemic stroke is a leading cause of mortality and disability, with cerebellar strokes posing severe complications such as herniation and brainstem compression. Edaravone, a radical scavenger known for reducing oxidative stress, has shown neuroprotective effects in cerebral strokes, but its impact on cerebellar strokes remains unclear. This study investigates Edaravone's protective properties in organotypic slice cultures of rat cerebellum and hippocampus, employing an oxygen-glucose deprivation (OGD) model to simulate ischemic stroke. The hippocampus served as comparative structure due to its high hypoxia sensitivity. Our results confirmed effective hypoxic induction with increases in HIF-1α and HIF-2α expression. Edaravone significantly reduced lactate dehydrogenase (LDH) levels, indicating diminished cellular damage, with cerebellar tissues showing greater vulnerability. Additionally, Edaravone reduced reactive oxygen species (ROS) in both tissues, though its efficacy may be limited by higher oxidative stress in cerebellar cultures. Seahorse XF analysis revealed that Edaravone preserved mitochondrial respiration and tissue integrity in cerebellar and hippocampal slice cultures. However, Edaravone was more effective in preserving mitochondrial respiration in hippocampal slices, suggesting that OGD-induced damage is more severe in cerebellar tissue. In conclusion, Edaravone demonstrates significant cell protective effects in both cerebellar and hippocampal tissues under OGD conditions, preserving tissue integrity and enhancing mitochondrial function in a tissue-dependent manner. These findings suggest Edaravone as a promising therapeutic candidate for cerebellar stroke. Further in vivo studies are required to assess its full clinical potential.

Development of Extubation Success Prediction Model for Mechanically Ventilated Patients with Spontaneous Cerebellar Hemorrhage

Spontaneous cerebellar hemorrhage (SCH) patients have a low success rate in extubation, but there are currently no guidelines establishing specifically for SCH patients extubation. The study included 68 SCH patients who received mechanical ventilation for more than 24 h, with 39 cases (57.3%) resulting in successful extubation. The multivariate analysis identified four factors significantly associated with extubation success: patient age under 66 years, an Intracerebral Hemorrhage (ICH) score less than 4 points, the presence of tissue shift, and a Glasgow Coma Scale (GCS) score (excluding language) above 6 points at extubation. By simplifying the prediction model, we obtained the Spontaneous Cerebellar Hemorrhage Extubation Success scoring system (SCHES-SCORE). Within the scoring system, 2 points were allocated for a GCS score (excluding language) above 6 at extubation, 1 point each for age under 66 years and an ICH score below 4, while tissue shift was assigned a negative point. A score of Grade A (SCHES-SCORE = 3-4) was found to correlate with a 92.9% success rate for extubation. The area under the receiver operating characteristic curve was 0.923 (95% CI, 0.863 to 0.983). Notably, successful extubation was significantly linked to reduced durations of mechanical ventilation, intensive care unit (ICU) stay, and total hospital stay. In conclusion, the scoring system developed for assessing extubation outcomes in SCH patients has the potential to enhance the rate of successful extubation and overall patient outcomes.

Life-threatening presentation of an acute cerebellar ischemic stroke secondary to a protein C deficiency

Acute cerebellar ischemic stroke is a rare disease in children. Typically, patients present with ataxia and cranial nerve palsy. Rarely, some patients show a severe intracranial hypertension syndrome with a life-threatening clinical presentation. We report a case of a 2-year-old male child who was admitted for deterioration of his consciousness level and vomiting. Cerebral imaging revealed a right cerebellar and brainstem infarction with an obstructive hydrocephalus and a tonsillar herniation. Angiography identified an occlusion of the right anterior inferior cerebellar artery. The child was referred to a neurosurgeon for the treatment of acute hydrocephalus and posterior fossa craniectomy. Etiological investigations revealed a protein C deficiency. Initially, the patient was maintained under fluid restriction and received mannitol several times as he had clinical and radiological signs of intracranial hypertension. He was also kept on mechanical ventilation and monitored. However, the evolution was complicated by the occurrence of a thrombosis of the vena cava and the renal vein.

Incidence and Risk Factors for Dysphagia Following Cerebellar Stroke: a Retrospective Cohort Study

The cerebellum is known to play a supportive role in swallowing-related functions; however, wide discrepancies about the incidence rate of swallowing disorders following cerebellar strokes exist within the literature. This study aimed to investigate the incidence rate of dysphagia and the factors which may affect the presence of dysphagia and clinical recovery in individuals diagnosed with cerebellar stroke. A retrospective chart audit of 1651 post-stroke patients (1049 males and 602 females) admitted with a cerebellar stroke to a comprehensive tertiary hospital in China was conducted. Data on demographics, medical, along with swallowing function assessment were collected. Differences between dysphagic and non-dysphagic groups were evaluated using t-tests and Pearson's chi-square test. Univariate logistic regression analysis was performed to establish factors associated with the presence of dysphagia. A total of 11.45% of participants were identified with dysphagia during inpatient admission. Individuals with mixed types of stroke, multiple lesions in the cerebellum, and ages older than 85 years old were more likely to develop dysphagia. Moreover, the prognosis of dysphagia following a cerebellar stroke was associated with lesions in different parts of the cerebellum. The cumulative recovery rates from the best to worse were the right hemisphere group, the cerebellum vermis or peduncle group, and both the hemisphere group and the left hemisphere group, respectively.

The Arterial Anatomy of the Cerebellum-A Comprehensive Review

The cerebellum, a major feature of the hindbrain, lies posterior to the pons and medulla and inferior to the posterior part of the cerebrum. It lies beneath the tentorium cerebelli in the posterior cranial fossa and consists of two lateral hemispheres connected by the vermis. The cerebellum is primarily supplied by three arteries originating from the vertebrobasilar system: the superior cerebellar artery (SCA), the anterior inferior cerebellar artery (AICA), and the posterior inferior cerebellar artery (PICA). However, variations of the cerebellar arteries may occur, such as duplication of the SCA, SCA creating a common trunk with the posterior cerebral artery, triplication of the AICA, and agenesis of PICA, amongst others. Knowledge of the arterial anatomy of the cerebellum is crucial, as inadequate blood supply to this region can result in diminished motor functioning, significantly impacting the quality of life for patients. The present study demonstrated the importance of adequate anatomical knowledge of the arteries supplying the cerebellum. The PubMed and Embase databases were searched to gather articles on the anatomical characteristics and variations of the arterial supply of the cerebellum. It is the most comprehensive and up-to-date review available in the literature. The possible variations of these vessels may be clinically silent or present with clinical symptoms such as neurovascular compression syndromes of the cranial nerves and aneurysms. With a comprehensive understanding of the cerebellar arterial system, physicians can enhance their diagnostic and treatment capabilities, ultimately leading to more effective management of cerebellar vascular-related issues and other neurological deficits.

Dynamics of Cerebral Function in Patients with Acute Cerebellar Infarction

Few studies were devoted to investigating cerebral functional changes after acute cerebellar infarction (CI). The purpose of this study was to examine the brain functional dynamics of CI using electroencephalographic (EEG) microstate analysis. And the possible heterogenicity in neural dynamics between CI with vertigo and CI with dizziness was explored. Thirty-four CI patients and 37 age- and gender-matched healthy controls(HC) were included in the study. Each included subject underwent a 19-channel video EEG examination. Five 10-s resting-state EEG epochs were extracted after data preprocessing. Then, microstate analysis and source localization were performed using the LORETA-KEY tool. Microstate parameters such as duration, coverage, occurrence, and transition probability are all extracted. The current study showed that the duration, coverage, and occurrence of microstate(Ms) B significantly increased in CI patients, but the duration and coverage of MsA and MsD decreased. Compared CI with vertigo to dizziness, finding a decreased trend in the coverage of MsD and the transition from MsA and MsB to MsD. Taken together, our study sheds new light on the dynamics of cerebral function after CI, mainly reflecting increased activity in functional networks involved in MsB and decreased activity in functional networks involved in MsA and MsD. Vertigo and dizziness post-CI may be suggested by cerebral functional dynamics. Further longitudinal studies are needed to validate and explore the alterations in brain dynamics to what extent depict the clinical traits and their potential applications in the recovery of CI.

Recent Advances in Immune-Mediated Cerebellar Ataxias: Pathogenesis, Diagnostic Approaches, Therapies, and Future Challenges-Editorial

The clinical category of immune-mediated cerebellar ataxias (IMCAs) has been established after 3 decades of clinical and experimental research. The cerebellum is particularly enriched in antigens (ion channels and related proteins, synaptic adhesion/organizing proteins, transmitter receptors, glial cells) and is vulnerable to immune attacks. IMCAs include various disorders, including gluten ataxia (GA), post-infectious cerebellitis (PIC), Miller Fisher syndrome (MFS), paraneoplastic cerebellar degeneration (PCD), opsoclonus myoclonus syndrome (OMS), and anti-GAD ataxia. Other disorders such as multiple sclerosis (MS), acute disseminated encephalomyelitis (ADEM), Behçet disease, and collagen vascular disorders may also present with cerebellar symptoms when lesions are localized to cerebellar pathways. The triggers of autoimmunity are established in GA (gluten sensitivity), PIC and MFS (infections), PCD (malignancy), and OMS (infections or malignant tumors). Patients whose clinical profiles do not match those of classic types of IMCAs are now included in the spectrum of primary autoimmune cerebellar ataxia (PACA). Recent remarkable progress has clarified various characteristics of these etiologies and therapeutic strategies in terms of immunotherapies. However, it still remains to be elucidated as to how immune tolerance is broken, leading to autoimmune insults of the cerebellum, and the consecutive sequence of events occurring during cerebellar damage caused by antibody- or cell-mediated mechanisms. Antibodies may specifically target the cerebellar circuitry and impair synaptic mechanisms (synaptopathies). The present Special Issue aims to illuminate what is solved and what is unsolved in clinical practice and the pathophysiology of IMCAs. Immune ataxias now represent a genuine category of immune insults to the central nervous system (CNS).

Baseline Factors Affecting the Prognosis of Ischemic Cerebellar Stroke Patients in Turkey: A Cross-Sectional Study

BACKGROUND

Cerebellar infarcts are encountered commonly in clinical practice; however, they are likely to be misinterpreted. They cannot be adequately evaluated on scales such as the National Institute of Health Stroke Scale (NIHSS), which can have fatal consequences.

AIM

To evaluate the baseline features, prognosis, and 6-month survival in patients with cerebellar stroke.

METHODS

A total of 200 patients with cerebellar ischemia were included in the study. Patients were analyzed retrospectively from 10 years of data. Both univariate and multivariate analyses were evaluated.

RESULTS

Mean age was 68 years old, and men were more frequently affected. The most common symptoms were dysarthria and vertiginous sensations. Ischemic lesions were usually cortical/juxtacortical, multiple, hemispheric, and small (below 1.5 cm). The most commonly affected artery was the medial branch of the posterior inferior cerebellar artery. Cardioembolism was the more frequent etiology. Gait ataxia was associated with a more favorable prognosis and 6-month modified Rankin Scale (mRS) scores (OR: 0.15, 95% CI, P = 0.03). Older age (OR: 1.75, 95%, P = 0.02), female gender (OR: 6.72, 95%, P = 0.02), multiple (OR: 10.92, 95%, P = 0.01) and large lesions (OR: 6.56, 95% CI, P = 0.01), posterior circulation ischemic lesions extra-cerebellum (OR: 8.33, 95% CI, P = 0.01), left ventricular apical hypokinesia or AF (OR: 5.58, 95% CI, P = 0.02), and a high mRS score on admission (OR: 5.21, 95% CI, P < 0.001) was correlated with higher 6-month mRS and a lower survival rates.

CONCLUSION

The study found that some baseline clinical, neurovascular imaging findings, and the mRS score on admission are useful predictors of cerebellar stroke prognosis and outcome.

Vertigo and dizziness in children: When to consider a neurological cause

Vertigo is common in childhood and adolescence. Although children and adults share common causes of vertigo, epidemiology changes with aging. For instance, ischemic stroke is less frequent in childhood, whereas audiovestibular disorders, such as vestibular neuritis and the migraine equivalent, are the leading causes of vertigo. However, even if severe causes of vertigo are rare, clinicians must not miss them. In this review, we discuss the neurological causes of central vertigo in children. The diagnostic approaches reviewed here are focused on the search for signs of severity, such as an abrupt onset, infectious context, or intracranial hypertension, which may subsequently require brain imaging.

miR-101-3p improves neuronal morphology and attenuates neuronal apoptosis in ischemic stroke in young mice by downregulating HDAC9

Objective

MiRNAs play a key role in ischemic stroke (IS). Although miR-101-3p can participate in multiple disease processes, its role and mechanism in IS are not clear. The aim of the present study was to observe the effect of miR-101-3p activation on IS in young mice and the role of HDAC9 in this effect.

Methods

The young mice were first subjected to transient middle cerebral artery occlusion (tMCAO) or sham surgery, and the cerebral infarct area was assessed with 2,3,5-triphenyltetrazolium chloride staining. Meanwhile, the expressions of miR-101-3p and HDAC9 were tested using RT-qPCR or western blot. Besides, neuron morphology and apoptosis were confirmed using Nissl staining and TUNEL staining.

Results

We first verified that miR-101-3p was downregulated and HDAC9 was upregulated in the brain tissue of tMCAO young mice. Moreover, we proved that overexpression of miR-101-3p could improve cerebral infarction, neuronal morphology, and neuronal apoptosis in tMCAO young mice by lowering the expression of HDAC9.

Conclusions

Activation of miR-101-3p can protect against IS in young mice, and its mechanism is relevant to the inhibition of HDAC9. Therefore, miR-101-3p and HDAC9 might be the latent targets for IS therapy.

Brief composite mobility index predicts post-stroke fallers after hospital discharge

Introduction

Community-dwelling, ambulatory stroke survivors fall at very high rates in the first 3-6 months. Current inpatient clinical assessments for fall risk have inadequate predictive accuracy. We found that a pre-discharge obstacle-crossing test has excellent specificity (83%) but lacks acceptable sensitivity (67%) for identifying would-be fallers and non-fallers post discharge.

Hypothesis

We assessed the hypothesis that combining the obstacle-crossing test with other highly discriminatory fall risk factors would compensate for the obstacle test's fair sensitivity and yield an instrument with superior prediction accuracy.

Methods

45 ambulatory stroke survivors (60 ± 11 years old, 15 ± 11 days post stroke) being discharged home completed a battery of physical performance-based and self-reported measures 1-5 days prior to discharge. After discharge, participants were prospectively followed and classified as fallers (≥1 fall) or non-fallers at 3 months. Pre-discharge measures with the largest effect sizes for differentiating fallers and non-fallers were combined into a composite index. Several variations of the composite index were examined to optimize accuracy.

Results

A 4-item discharge composite index significantly predicted fall status at 3-months. The goodness of fit of the regression model was significantly better than the obstacle-crossing test alone, χ ²(1) = 6.036, p = 0.014. Furthermore, whereas the obstacle-crossing test had acceptable overall accuracy (AUC 0.78, 95% CI, 0.60-0.90), the composite index had excellent accuracy (AUC 0.85, 95% CI, 0.74-0.96). Combining the obstacle-crossing test with only the step test produced a model of equivalent accuracy (AUC 0.85, 95% CI, 0.73-0.96) and with better symmetry between sensitivity and specificity (0.71, 0.83) than the 4-item composite index (0.86, 0.67). This 2-item index was validated in an independent sample of n = 30 and with bootstrapping 1,000 samples from the pooled cohorts. The 4-item index was internally validated with bootstrapping 1,000 samples from the derivation cohort plus n = 9 additional participants.

Conclusion

This study provides convincing proof-of-concept that strategic aggregation of performance-based and self-reported mobility measures, including a novel and demanding obstacle-crossing test, can predict post-discharge fallers with excellent accuracy. Further instrument development is warranted to construct a brief aggregate tool that will be pragmatic for inpatient use and improve identification of future post-stroke fallers before the first fall.

Acute Cytotoxic Cerebellar Edema Subsequent to Fentanyl Patch Intoxication in an Infant

The opioid epidemic continues to have devastating consequences for children and families across the United States with rising prevalence of opioid use and abuse. Given the ease of access to these medications, accidental ingestion and overdose by children are becoming increasingly more common. The recognition of opioid-induced neurotoxicity and the associated life-threatening complication of acute cerebellar cytotoxic edema are crucial, as are the high morbidity and mortality without timely intervention. We discuss an infant with acute cytotoxic cerebellar edema following mucosal exposure to a transdermal fentanyl patch.

From Cerebellar Apoplexy in 1849 to Cerebellar Stroke in the 2020s: Robert Dunn's Contribution

Stroke of the cerebellum represents about 10% of strokes of the brain. Both infarction and hemorrhage manifest with symptoms related to the location and extent of the lesion(s). Bilateral cerebellar infarcts constitute up to one third of all cerebellar infarctions. The leading cause of cerebellar infarcts is emboli of cardiac origin or from intra-arterial sources. Potential complications include brainstem compression and hydrocephalus. Malignant cerebellar edema is a life-threatening complication of ischemic posterior circulation stroke requiring urgent management. The advent of MRI has revolutionized the early diagnosis in vivo, showing small and large territorial infarcts, hemorrhages, and venous infarcts. Endovascular procedures are growingly applied and are impacting on the prognosis of stroke, although cerebellar stroke from occlusion of small cerebellar arteries is currently not accessible to thrombectomy. Surgical procedures of space-occupying stroke include external ventricular drainage, suboccipital craniotomy, or combined procedures. In 1849, Robert Dunn (1799-1877), an English surgeon, reported the details of a case of apoplexy of the cerebellum in a 52-year-old man, pointing to the importance of post-mortem studies of patients followed meticulously during lifetime. Dunn discussed inflammation surrounding hemorrhage as a source of cerebral degeneration, linking for the first time cerebellar stroke, neuroinflammation, and atherosclerosis.

In vitro P38MAPK inhibition in aged astrocytes decreases reactive astrocytes, inflammation and increases nutritive capacity after oxygen-glucose deprivation

Proper astroglial functioning is essential for the development and survival of neurons and oligodendroglia under physiologic and pathological circumstances. Indeed, malfunctioning of astrocytes represents an important factor contributing to brain injury. However, the molecular pathways of this astroglial dysfunction are poorly defined. In this work we show that aging itself can drastically perturb astrocyte viability with an increase of inflammation, cell death and astrogliosis. Moreover, we demonstrate that oxygen glucose deprivation (OGD) has a higher impact on nutritive loss in aged astrocytes compared to young ones, whereas aged astrocytes have a higher activity of the anti-oxidant systems. P38MAPK signaling has been identified to be upregulated in neurons, astrocytes and microglia after ischemic stroke. By using a pharmacological p38α specific inhibitor (PH-797804), we show that p38MAPK pathway has an important role in aged astrocytes for inflammatory and oxidative stress responses with the subsequent cell death that occurs after OGD.

A New Insight on the Role of the Cerebellum for Executive Functions and Emotion Processing in Adults

Objective: We investigated whether the cerebellum plays a critical or supportive role in in executive and emotion processes in adults. Many investigators now espouse the hypothesis that participants with cerebellar lesions experience executive functions and emotions (EE) disorders. But we hypothesized that these disorders would be milder if the damage is relatively limited to the cerebellum compared to damage involving the cerebellum plus additional cortical areas. Methods: We studied veterans with penetrating Traumatic Brain Injury (pTBI) participating in the Vietnam Head Injury Study (VHIS). We selected veterans with a cerebellar lesion (n = 24), a prefrontal cortex lesion (n = 20), along with healthy controls (HC) (n = 55). Tests of executive functions and emotions were analyzed as well as caregiver burden. We performed between-group null hypothesis significance testing, Bayesian hypothesis tests and correlational analyses. Results: Performance of participants with cerebellar lesions which extended to the cerebral cortex was similar to the HC on the Executive Function tests but they were significantly impaired on the Working Memory Index. No differences were found on the emotional processing tasks with one exception-the Facial Expression of Emotion-Test (FEEST). We then examined a sub-group of participants with large cerebellar lesions (>15%) but minimal lesions in the cerebral cortex (<15%). This sub-group of participants performed similarly to the HC on the Working Memory Index and on the FEEST. Conclusions: We suggest that the cerebellar cortex may not be critical for executive functions or processing emotional stimuli in adults as suggested. Instead, we find that the cerebellum has a supportive role characterized by its computing of the motor requirements when EE processing is required.

Effects of Gastrodin on BV2 cells under oxygen-glucose deprivation and its mechanism

OBJECTIVE

Cerebrovascular disease is one of the major diseases that seriously harm human health currently. The purpose of this study is to find an effective treatment and clarify its mechanism of action to provide a new idea and drug target for the clinical treatment of ischemic cerebrovascular disease.

METHODS

The microglia cell line (BV2 cell line) was cultured in vitro. Prepare a hypoxia ischemia cell model by OGD and simulate the pathophysiological process of ischemic cerebrovascular disease in vivo. According to the techniques of LDH Cytotoxicity Assay Kit, flow cytometry of Annexin V-FITC Apoptosis Detection Kit, Laser Confocal Fluorescence Immunostaining (Double staining method), enzyme-linked immunosorbent assay (ELISA), and Western blotting, BV2 cells are observed through morphology and function changes induced by OGD. Moreover, these techniques were used to analyze changes in key proteins expression of signal transduction pathway in ischemic cerebrovascular disease, to explore the mechanism of gastrodin on ischemic cerebrovascular disease, and to elucidate the available ways for cell protection following ischemia and hypoxia.

RESULTS

Gastrodin has no obvious toxic effect on BV-2 cells under physiological conditions. The death rate of BV-2 cells increases as the time of hypoxia increase. In the absence of oxygen, Gastrodin has a protective effect on the survival of BV-2 cells. This protective effect is related to the reduction of apoptosis rate. It can also improve the hypoxic tolerance of BV-2 cells, and there is no obvious Gastrodin dose-dependence. Moreover, Gastrodin has dual effects on BV-2 cells. The dual role of Gastrodin is closely related to the expression of several proteins which can affect the MAPK signal transduction pathway.

CONCLUSION

Gastrodin has a dual effect on microglia with OGD. On the one hand, Gastrodin can inhibit the inflammatory cytokines secreted by microglia and aggravate the inflammatory response; on the other hand, Gastrodin can promote the secretion of protective cytokines from microglia to reduce the inflammatory response.

Ischemic stroke in neonatal and adult astrocytes

The objective of this paper is to review current information regarding astrocytes function after a stroke in neonatal and adult brain. Based on the current literature, there are some molecular differences related to blood brain barrier (BBB) homeostasis disruption, inflammation and reactive oxygen species (ROS) mediated injury between the immature and mature brain after an ischemic event. In particular, astrocytes, the main glial cells in brain, play a different role in neonatal and adult brain after stroke, as time course of glial activation is strongly age dependent. Moreover, the present review provides further insight into the therapeutic approaches of using neonatal and adult astrocytes after stroke. More research will be needed in order to translate them into an effective treatment against stroke, the second main cause of death and disability worldwide.

Rehabilitation training combined acupuncture for limb hemiplegia caused by cerebral hemorrhage: A protocol for a systematic review of randomized controlled trial

BACKGROUND

Previous studies have reported that rehabilitation training combined acupuncture (RTA) can be used for the treatment of limb hemiplegia (LH) caused by cerebral hemorrhage (CH). However, its effectiveness is still unclear. In this systematic review study, we aim to evaluate the effectiveness and safety of RTA for LH following CH.

METHODS

We will retrieve the databases of CENTRAL, EMBASE, MEDILINE, CINAHL, AMED, CBM, and CNKI from inception to March 1, 2019 with no language restrictions. The randomized controlled trials of RTA for evaluating effectiveness and safety in patients with LH following CH will be included. Cochrane risk of bias tool will be used to measure the methodological quality for all included studies. Two authors will independently select the studies, extract the data, and assess the methodological quality of included studies. A third author will be invited to discuss if any disagreements exist between 2 authors. If more than 2 eligible studies will be included, the outcome data will be pooled, and meta-analysis will be conducted if it is possible.

RESULTS

This systematic review will assess the effectiveness and safety of RTA for LH caused by CH. The primary outcome includes limbs function. The secondary outcomes consist of muscle strength, muscle tone, quality of life, and any adverse events.

CONCLUSION

The findings of this study will summarize the current evidence of RTA for LH caused by CH, and may provide helpful evidence for the clinical treatment.

DISSEMINATION AND ETHICS

The results of this study will be published in peer-reviewed journals or will be presented on conference meeting. This work does not require ethic approval, because it will be conducted based on the published studies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019120034.