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Suresh H, Morgan BR, Mithani K, Warsi NM, Yan H, Germann J, Boutet A, Loh A, Gouveia FV, Young J, Quon J, Morgado F, Lerch J, Lozano AM, Al-Fatly B, Kühn AA, Laughlin S, Dewan MC, Mabbott D, Gorodetsky C, Bartels U, Huang A, Tabori U, Rutka JT, Drake JM, Kulkarni AV, Dirks P, Taylor MD, Ramaswamy V, Ibrahim GM. Postoperative cerebellar mutism syndrome is an acquired autism-like network disturbance. Neuro Oncol 2024; 26:950-964. [PMID: 38079480 PMCID: PMC11066932 DOI: 10.1093/neuonc/noad230] [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] [Indexed: 05/04/2024] Open
Abstract
BACKGROUND Cerebellar mutism syndrome (CMS) is a common and debilitating complication of posterior fossa tumor surgery in children. Affected children exhibit communication and social impairments that overlap phenomenologically with subsets of deficits exhibited by children with Autism spectrum disorder (ASD). Although both CMS and ASD are thought to involve disrupted cerebro-cerebellar circuitry, they are considered independent conditions due to an incomplete understanding of their shared neural substrates. METHODS In this study, we analyzed postoperative cerebellar lesions from 90 children undergoing posterior fossa resection of medulloblastoma, 30 of whom developed CMS. Lesion locations were mapped to a standard atlas, and the networks functionally connected to each lesion were computed in normative adult and pediatric datasets. Generalizability to ASD was assessed using an independent cohort of children with ASD and matched controls (n = 427). RESULTS Lesions in children who developed CMS involved the vermis and inferomedial cerebellar lobules. They engaged large-scale cerebellothalamocortical circuits with a preponderance for the prefrontal and parietal cortices in the pediatric and adult connectomes, respectively. Moreover, with increasing connectomic age, CMS-associated lesions demonstrated stronger connectivity to the midbrain/red nuclei, thalami and inferior parietal lobules and weaker connectivity to the prefrontal cortex. Importantly, the CMS-associated lesion network was independently reproduced in ASD and correlated with communication and social deficits, but not repetitive behaviors. CONCLUSIONS Our findings indicate that CMS-associated lesions may result in an ASD-like network disturbance that occurs during sensitive windows of brain development. A common network disturbance between CMS and ASD may inform improved treatment strategies for affected children.
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Affiliation(s)
- Hrishikesh Suresh
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
- Program in Neuroscience and Mental Health, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Division of Neurosurgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin R Morgan
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Karim Mithani
- Division of Neurosurgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nebras M Warsi
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
- Program in Neuroscience and Mental Health, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Division of Neurosurgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Han Yan
- Program in Neuroscience and Mental Health, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Division of Neurosurgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jürgen Germann
- Division of Neurosurgery, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada
| | - Alexandre Boutet
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Aaron Loh
- Division of Neurosurgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Flavia Venetucci Gouveia
- Program in Neuroscience and Mental Health, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Julia Young
- Department of Psychology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jennifer Quon
- Division of Neurosurgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Felipe Morgado
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jason Lerch
- Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - Andres M Lozano
- Division of Neurosurgery, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada
| | - Bassam Al-Fatly
- Department of Neurology and Experimental Neurology, Movement Disorders and Neuromodulation Unit, Charité, Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Andrea A Kühn
- Department of Neurology and Experimental Neurology, Movement Disorders and Neuromodulation Unit, Charité, Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Exzellenzcluster NeuroCure, Charité, Universitätsmedizin, Berlin, Germany
| | - Suzanne Laughlin
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Michael C Dewan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Donald Mabbott
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada
| | - Carolina Gorodetsky
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ute Bartels
- Division of Neuro-Oncology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Annie Huang
- Division of Neuro-Oncology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Uri Tabori
- Division of Neuro-Oncology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - James T Rutka
- Division of Neurosurgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - James M Drake
- Division of Neurosurgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Abhaya V Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Peter Dirks
- Division of Neurosurgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael D Taylor
- Division of Neurosurgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Vijay Ramaswamy
- Division of Neuro-Oncology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - George M Ibrahim
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
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Ogut E, Armagan K, Tufekci D. The Guillain-Mollaret triangle: a key player in motor coordination and control with implications for neurological disorders. Neurosurg Rev 2023; 46:181. [DOI: https:/doi.org/10.1007/s10143-023-02086-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/01/2023] [Accepted: 07/07/2023] [Indexed: 07/22/2023]
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Ogut E, Armagan K, Tufekci D. The Guillain-Mollaret triangle: a key player in motor coordination and control with implications for neurological disorders. Neurosurg Rev 2023; 46:181. [PMID: 37468768 DOI: 10.1007/s10143-023-02086-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/01/2023] [Accepted: 07/07/2023] [Indexed: 07/21/2023]
Abstract
The dentato-rubro-olivary pathway, also known as the Guillain-Mollaret triangle (GMT) or myoclonic triangle, consists of the dentate nucleus, the red nucleus, and the inferior olivary nucleus (ION). GMT is important for motor coordination and control, and abnormalities in this network can lead to various neurological disorders. The present study followed a systematic approach in conducting a review on GMT studies. The inclusion criteria were limited to human subjects with primary objectives of characterizing and evaluating GMT syndromes, and the methodology used was not a determining factor for eligibility. The search strategy used MeSH terms and keywords relevant to the study's objective in various databases until August 2022. A total of 76 studies were included in the review after assessing 527 articles for eligibility based on the final inclusion criteria. Most of the studies evaluated the GMT in human subjects, with the majority utilizing magnetic resonance imaging (MRI), diffusion tensor imaging (DTI), or combination of them. The review found that Hypertrophic olivary degeneration (HOD), a common consequence of GMT damage, has diverse underlying causes, including stroke, brainstem cavernous malformations, and structural impairments. Palatal tremor, ocular myoclonus, ataxia, nystagmus, and vertigo were frequently reported symptoms associated with HOD. This systematic review provides comprehensive insights into the association between GMT and various neurological syndromes, shedding light on the diagnostic, etiological, and prognostic aspects of GMT dysfunction. Understanding the role of the GMT and its implications in movement disorders could pave the way for improved treatment options and better management of neurological conditions related to this critical brainstem pathway.
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Affiliation(s)
- Eren Ogut
- Department of Anatomy, Bahçeşehir University Faculty of Medicine, 34734, Istanbul, Turkey.
| | - Kutay Armagan
- Medical Faculty Student, Bahçeşehir University Faculty of Medicine, 34734, Istanbul, Turkey
| | - Doruktan Tufekci
- Medical Faculty Student, Bahçeşehir University Faculty of Medicine, 34734, Istanbul, Turkey
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Schmidt S, Kovacs E, Usta D, Behnisch R, Sahm F, Haux D, Witt O, Milde T, Unterberg A, El Damaty A. Cerebellar Mutism Syndrome After Posterior Fossa Tumor Surgery in Children-A Retrospective Single-Center Study. World Neurosurg 2023; 173:e622-e628. [PMID: 36871657 DOI: 10.1016/j.wneu.2023.02.117] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE Cerebellar mutism syndrome (CMS) is a well-known complication after posterior fossa tumor surgery in pediatric patients. We evaluated the incidence of CMS in our institute and analyzed its association with multiple risk factors, such as tumor entity, surgical approach, and hydrocephalus. METHODS All pediatric patients who had undergone intra-axial tumor resection in the posterior fossa between January 2010 and March 2021 were included in the retrospective analysis. Various data points, including demographic, tumor-associated, clinical, radiological, surgery-associated, complications, and follow-up data, were collected and statistically evaluated for an association with CMS. RESULTS A total of 63 surgeries in 60 patients were included. The median patient age was 8 years. Pilocytic astrocytoma was the most common tumor type (50%), followed by medulloblastoma (28%) and ependymomas (10%). Complete, subtotal, and partial resection was achieved in 67%, 23%, and 10%, respectively. A telovelar approach had been used the most often (43%) compared with a transvermian approach (8%). Of the 60 children, 10 (17%) had developed CMS and showed marked improvement but with residual deficits. The significant risk factors were a transvermian approach (P = 0.03), vermian splitting when added to another approach (P = 0.002), an initial presentation with acute hydrocephalus (P = 0.02), and hydrocephalus present after tumor surgery (P = 0.004). CONCLUSIONS Our CMS rate is comparable to those described in the literature. Despite the limitations of the retrospective study design, we found that CMS was not only associated with a transvermian approach but was also associated with a telovelar approach, although to a lesser extent. Acute hydrocephalus at the initial presentation necessitating urgent management was significantly associated with a greater incidence of CMS.
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Affiliation(s)
- Stephanie Schmidt
- Neurosurgery Department, Heidelberg University Hospital, Heidelberg, Germany
| | - Edina Kovacs
- Neurosurgery Department, Heidelberg University Hospital, Heidelberg, Germany
| | - Diren Usta
- Pediatric Neurooncology Department, Heidelberg University Hospital, Heidelberg, Germany
| | - Rouven Behnisch
- Institute of Medical Biometry, Heidelberg University, Heidelberg, Germany
| | - Felix Sahm
- Department of Neuropathology, Heidelberg University Hospital, Heidelberg, Germany; CCU Neuropathology, German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany
| | - Daniel Haux
- Neurosurgery Department, Heidelberg University Hospital, Heidelberg, Germany
| | - Olaf Witt
- Pediatric Neurooncology Department, Heidelberg University Hospital, Heidelberg, Germany
| | - Till Milde
- Pediatric Neurooncology Department, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas Unterberg
- Neurosurgery Department, Heidelberg University Hospital, Heidelberg, Germany
| | - Ahmed El Damaty
- Neurosurgery Department, Heidelberg University Hospital, Heidelberg, Germany.
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5
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Steidl E, Rauch M, Hattingen E, Breuer S, Schüre JR, Grapengeter M, Shrestha M, Foerch C, Schaller-Paule MA. Qualitative and quantitative detectability of hypertrophic olivary degeneration in T2, FLAIR, PD, and DTI: A prospective MRI study. Front Neurol 2022; 13:950191. [PMID: 35989923 PMCID: PMC9381965 DOI: 10.3389/fneur.2022.950191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose: Hypertrophic olivary degeneration (HOD) is a pathology of the inferior olivary nucleus (ION) that occurs after injuries to the Guillain-Mollaret triangle (GMT). Lacking a diagnostic gold standard, diagnosis is usually based on T2 or FLAIR imaging and expert rating. To facilitate precise HOD diagnosis in future studies, we assessed the reliability of this rater-based approach and explored alternative, quantitative analysis. Methods Patients who had suffered strokes in the GMT and a matched control group prospectively underwent an MRI examination including T2, FLAIR, and proton density (PD). Diffusion tensor imaging (DTI) was additionally performed in the patient group. The presence of HOD was assessed on FLAIR, T2, and PD separately by 3 blinded reviewers. Employing an easily reproducible segmentation approach, relative differences in intensity, fractional anisotropy (FA), and mean diffusivity (MD) between both IONs were calculated. Results In total, 15 patients were included in this study. The interrater reliability was best for FLAIR, followed by T2 and PD (Fleiss κ = 0.87 / 0.77 / 0.65). The 3 raters diagnosed HOD in 38–46% (FLAIR), 40–47% (T2), and 53–67% (PD) of patients. False-positive findings in the control group were less frequent in T2 than in PD and FLAIR (2.2% / 8.9% / 6.7%). In 53% of patients, the intensity difference between both IONs on PD was significantly increased in comparison with the control group. These patients also showed significantly decreased FA and increased MD. Conclusion While the rater-based approach yielded the best performance on T2 imaging, a quantitative, more sensitive HOD diagnosis based on ION intensities in PD and DTI imaging seems possible.
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Affiliation(s)
- Eike Steidl
- Institute of Neuroradiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Maximilian Rauch
- Institute of Neuroradiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Elke Hattingen
- Institute of Neuroradiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stella Breuer
- Institute of Neuroradiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Jan Rüdiger Schüre
- Institute of Neuroradiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Marike Grapengeter
- Brain Imaging Center (BIC), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Manoj Shrestha
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Christian Foerch
- Brain Imaging Center (BIC), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Martin A. Schaller-Paule
- Brain Imaging Center (BIC), Goethe-University Frankfurt, Frankfurt am Main, Germany
- *Correspondence: Martin A. Schaller-Paule
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6
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McAfee SS, Zhang S, Zou P, Conklin HM, Raches D, Robinson G, Gajjar A, Khan R, Klimo P, Patay Z, Scoggins MA. Fastigial nuclei surgical damage and focal midbrain disruption implicate PAG survival circuits in cerebellar mutism syndrome. Neuro Oncol 2022; 25:375-385. [PMID: 35789275 PMCID: PMC9925705 DOI: 10.1093/neuonc/noac168] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pediatric postoperative cerebellar mutism syndrome (CMS) is a rare but well-known complication of medulloblastoma (Mb) resection with devastating effects on expressive language, mobility, cognition, and emotional regulation that diminishes quality of life for many Mb survivors. The specific anatomical and neuronal basis of CMS remains obscure. We address this issue by identifying patterns of surgical damage and secondary axonal degeneration in Mb survivors with CMS. METHODS Children with Mb deemed high risk for CMS based on intraventricular location of the tumor had T1 images analyzed for location(s) of surgical damage using a specially developed algorithm. We used three complementary methods of spatial analysis to identify surgical damage linked to CMS diagnosis. Magnetization transfer ratio (MTR) images were analyzed for evidence of demyelination in anatomic regions downstream of the cerebellum, indicating neuronal dysfunction. RESULTS Spatial analyses highlighted damage to the fastigial nuclei and their associated cerebellar cortices as the strongest predictors of CMS. CMS-related MTR decrease was greatest in the ventral periaqueductal gray (PAG) area and highly consistent in the left red nucleus. CONCLUSION Our evidence points to disruption of output from the fastigial nuclei as a likely causal trigger for CMS. We propose that core CMS symptoms result from a disruption in the triggering of survival behaviors regulated by the PAG, including the gating of vocalization and volitional movement. The fastigial nuclei provide the densest output to the PAG from the cerebellum, thus sparing these structures may provide a greater likelihood of CMS prevention.
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Affiliation(s)
- Samuel S McAfee
- Corresponding Author: Samuel S. McAfee, PhD, Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, 262 Danny Thomas Pl, Chili’s Care Center, Room I3210, Memphis, TN 38105, USA ()
| | - Silu Zhang
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Ping Zou
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Heather M Conklin
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Darcy Raches
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Giles Robinson
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Amar Gajjar
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Raja Khan
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Paul Klimo
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Zoltan Patay
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Matthew A Scoggins
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
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7
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Structural damage burden and hypertrophic olivary degeneration in pediatric postoperative cerebellar mutism syndrome. Neurosurg Rev 2022; 45:2757-2765. [PMID: 35441993 PMCID: PMC9349162 DOI: 10.1007/s10143-022-01791-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/18/2022] [Accepted: 04/12/2022] [Indexed: 11/25/2022]
Abstract
Cerebellar mutism syndrome (CMS) occurs in one out of four children after posterior fossa tumor surgery, with open questions regarding risk factors, pathophysiology, and prevention strategies. Because of similarities between several cerebellar syndromes, a common pathophysiology with damage to the dentato-thalamo-cortical and dentato-rubro-olivary pathways has been proposed. Hypertrophic olivary degeneration (HOD) is an imaging correlate of cerebellar injury observed for instance in stroke patients. Aim of this study was to investigate whether the occurrence and severity of CMS correlates with the extent of damage to the relevant anatomical structures and whether HOD is a time-dependent postoperative neuroimaging correlate of CMS. We performed a retrospective single center study of CMS patients compared with matched non-CMS controls. CMS occurred in 10 children (13% of the overall cohort) with a median age of 8 years. Dentate nucleus (DN) injury significantly correlated with CMS, and superior cerebellar peduncle (SCP) injury was associated by tendency. HOD was observed as a dynamic neuroimaging phenomenon in the postoperative course and its presence significantly correlated with CMS and DN injury. Children who later developed HOD had an earlier onset and tended to have longer persistence of CMS. These findings can guide surgical measures to protect the DN and SCP during posterior fossa tumor resections and to avoid a high damage burden (i.e., bilateral damage). Development of intraoperative neuromonitoring of the cerebellar efferent pathways as well as improved preoperative risk stratification could help to establish a patient-specific strategy with optimal balance between degree of resection and functional integrity.
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Sidpra J, Marcus AP, Löbel U, Toescu SM, Yecies D, Grant G, Yeom K, Mirsky DM, Marcus HJ, Aquilina K, Mankad K. Improved prediction of postoperative paediatric cerebellar mutism syndrome using an artificial neural network. Neurooncol Adv 2022; 4:vdac003. [PMID: 35233531 PMCID: PMC8882257 DOI: 10.1093/noajnl/vdac003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Postoperative paediatric cerebellar mutism syndrome (pCMS) is a common but severe complication which may arise following the resection of posterior fossa tumours in children. Two previous studies have aimed to preoperatively predict pCMS, with varying results. In this work, we examine the generalisation of these models and determine if pCMS can be predicted more accurately using an artificial neural network (ANN).
Methods
An overview of reviews was performed to identify risk factors for pCMS, and a retrospective dataset collected as per these defined risk factors from children undergoing resection of primary posterior fossa tumours. The ANN was trained on this dataset and its performance evaluated in comparison to logistic regression and other predictive indices via analysis of receiver operator characteristic curves. Area under the curve (AUC) and accuracy were calculated and compared using a Wilcoxon signed rank test, with p<0.05 considered statistically significant.
Results
204 children were included, of whom 80 developed pCMS. The performance of the ANN (AUC 0.949; accuracy 90.9%) exceeded that of logistic regression (p<0.05) and both external models (p<0.001).
Conclusion
Using an ANN, we show improved prediction of pCMS in comparison to previous models and conventional methods.
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Affiliation(s)
- Jai Sidpra
- University College London Medical School, London, WC1E 6DE, UK
- Developmental Biology and Cancer Section, University College London Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Adam P Marcus
- Department of Brain Sciences and Computing, Imperial College London, London, SW7 2BU, UK
| | - Ulrike Löbel
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Sebastian M Toescu
- Department of Neurosurgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
- Developmental Imaging and Biophysics Section, University College London Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Derek Yecies
- Department of Neurosurgery, Lucile Packard Children’s Hospital, Stanford, CA 94304, USA
| | - Gerald Grant
- Department of Neurosurgery, Lucile Packard Children’s Hospital, Stanford, CA 94304, USA
| | - Kristen Yeom
- Department of Neuroradiology, Lucile Packard Children’s Hospital, Stanford, CA 94304, USA
| | - David M Mirsky
- Department of Radiology, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Hani J Marcus
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, WC1N 3BG, UK
- Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, London, WC1E 6BT, UK
| | - Kristian Aquilina
- Developmental Biology and Cancer Section, University College London Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Neurosurgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Kshitij Mankad
- Developmental Biology and Cancer Section, University College London Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
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9
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Khan RB, Patay Z, Klimo P, Huang J, Kumar R, Boop FA, Raches D, Conklin HM, Sharma R, Simmons A, Sadighi ZS, Onar-Thomas A, Gajjar A, Robinson GW. Clinical features, neurologic recovery, and risk factors of postoperative posterior fossa syndrome and delayed recovery: a prospective study. Neuro Oncol 2021; 23:1586-1596. [PMID: 33823018 DOI: 10.1093/neuonc/noab030] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Posterior fossa syndrome (PFS) is a known consequence of medulloblastoma resection. Our aim was to clinically define PFS, its evolution over time, and ascertain risk factors for its development and poor recovery. METHODS Children with medulloblastoma treated at St Jude Children's Research Hospital from 6/2013 to 7/2019 received standardized neurological examinations, before and periodically after radiation therapy. Most (98.3%) were enrolled on the ongoing multi-institutional protocol (SJMB12; NCT01878617). RESULTS Sixty (34%) of 178 evaluated children had PFS. Forty (23%) had complete mutism (PFS1) and 20 (11%) had diminished speech (PFS2). All children with PFS had severe ataxia and 42.5% of PFS1 had movement disorders. By multivariable analysis, younger age (P = .0005) and surgery in a low-volume surgery center (P = .0146) increased PFS risk, while Sonic Hedgehog tumors had reduced risk (P = .0025). Speech and gait returned in PFS1/PFS2 children at a median of 2.3/0.7 and 2.1/1.5 months, respectively, however, 12 (44.4%) of 27 PFS1 children with 12 months of follow-up were nonambulatory at 1 year. Movement disorder (P = .037) and high ataxia score (P < .0001) were associated with delayed speech recovery. Older age (P = .0147) and high ataxia score (P < .0001) were associated with delayed gait return. Symptoms improved in all children but no child with PFS had normal neurologic examination at a median of 23 months after surgery. CONCLUSIONS Categorizing PFS into types 1 and 2 has prognostic relevance. Almost half of the children with PFS1 with 12-month follow-up were nonambulatory. Surgical experience was a major modifiable contributor to the development of PFS.
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Affiliation(s)
- Raja B Khan
- Division of Neurology, Department of Pediatrics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Zoltan Patay
- Department of Radiology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Paul Klimo
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, USA
| | - Jie Huang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Rahul Kumar
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Frederick A Boop
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, USA
| | - Darcy Raches
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Heather M Conklin
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Richa Sharma
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Andrea Simmons
- Division of Neurology, Department of Pediatrics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Zsila S Sadighi
- Department of Oncology, MD Anderson Center, Houston, Texas, USA
| | - Arzu Onar-Thomas
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Amar Gajjar
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Giles W Robinson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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A Paravermal Trans-Cerebellar Approach to the Posterior Fossa Tumor Causes Hypertrophic Olivary Degeneration by Dentate Nucleus Injury. Cancers (Basel) 2021; 13:cancers13020258. [PMID: 33445527 PMCID: PMC7826586 DOI: 10.3390/cancers13020258] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/07/2021] [Accepted: 01/07/2021] [Indexed: 11/30/2022] Open
Abstract
Simple Summary Posterior fossa tumor surgery is challenging due to the proximity and exposure of cerebellar structures. A favorable operative approach is unknown. Following lesions to the dentato–rubro–olivary-pathway, a neurodegenerative disease called hypertrophic olivary degeneration (HOD) can occur. This study for the first time demonstrates that paravermal trans-cerebellar approaches are associated with a significantly higher likelihood of HOD on MRI when compared to other approaches. This finding can well be attributed to dentate nucleus (DN) injury. Furthermore, cerebellar mutism syndrome (CMS) was discussed in the literature to be correlated with HOD due to a functional overlap of pathways involved. We found no such correlation in this study, but HOD was shown to be a reliable indicator for surgical disruption of efferent cerebellar pathways involving the DN. Henceforth, neurosurgeons should consider more midline or lateral approaches in posterior fossa surgery to spare the DN whenever feasible, and focus on cerebellar functional anatomy in their preoperative planning. Abstract Background: In brain tumor surgery, injury to cerebellar connectivity pathways can induce a neurodegenerative disease called hypertrophic olivary degeneration (HOD), along with a disabling clinical syndrome. In children, cerebellar mutism syndrome (CMS) is another consequence of damage to cerebello–thalamo–cortical networks. The goal of this study was to compare paravermal trans-cerebellar to other more midline or lateral operative approaches in their risk of causing HOD on MR-imaging and CMS. Methods: We scanned our neurosurgical database for patients with surgical removal of pilocytic astrocytoma, ependymoma and medulloblastoma in the posterior fossa. Fifty patients with a mean age of 22.7 (±16.9) years were identified and analyzed. Results: HOD occurred in n = 10/50 (20%) patients within four months (median), always associated with contralateral dentate nucleus (DN)-lesions (p < 0.001). Patients with paravermal trans-cerebellar approach significantly more often developed HOD (7/11; 63.6%) when compared to other approaches (3/39; 7.7%; p < 0.001). Injury to the DN occurred more frequently after a paravermal approach (8/11 vs. 13/39 patients; p < 0.05). CMS was described for n = 12/50 patients (24%). Data indicated no correlation of radiological HOD and CMS development. Conclusions: A paravermal trans-cerebellar approach more likely causes HOD due to DN-injury when compared to more midline or lateral approaches. HOD is a radiological indicator for surgical disruption of cerebellar pathways involving the DN. Neurosurgeons should consider trajectories and approaches in the planning of posterior fossa surgery that spare the DN, whenever feasible.
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11
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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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Spiteri M, Guillemaut JY, Windridge D, Avula S, Kumar R, Lewis E. Fully-Automated Identification of Imaging Biomarkers for Post-Operative Cerebellar Mutism Syndrome Using Longitudinal Paediatric MRI. Neuroinformatics 2020; 18:151-162. [PMID: 31254271 PMCID: PMC6981105 DOI: 10.1007/s12021-019-09427-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Post-operative cerebellar mutism syndrome (POPCMS) in children is a post- surgical complication which occurs following the resection of tumors within the brain stem and cerebellum. High resolution brain magnetic resonance (MR) images acquired at multiple time points across a patient’s treatment allow the quantification of localized changes caused by the progression of this syndrome. However, MR images are not necessarily acquired at regular intervals throughout treatment and are often not volumetric. This restricts the analysis to 2D space and causes difficulty in intra- and inter-subject comparison. To address these challenges, we have developed an automated image processing and analysis pipeline. Multi-slice 2D MR image slices are interpolated in space and time to produce a 4D volumetric MR image dataset providing a longitudinal representation of the cerebellum and brain stem at specific time points across treatment. The deformations within the brain over time are represented using a novel metric known as the Jacobian of deformations determinant. This metric, together with the changing grey-level intensity of areas within the brain over time, are analyzed using machine learning techniques in order to identify biomarkers that correspond with the development of POPCMS following tumor resection. This study makes use of a fully automated approach which is not hypothesis-driven. As a result, we were able to automatically detect six potential biomarkers that are related to the development of POPCMS following tumor resection in the posterior fossa.
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Affiliation(s)
- Michaela Spiteri
- Centre for Vision, Speech and Signal Processing (CVSSP), University of Surrey, Guildford, GU27XH, UK.
| | - Jean-Yves Guillemaut
- Centre for Vision, Speech and Signal Processing (CVSSP), University of Surrey, Guildford, GU27XH, UK
| | - David Windridge
- Centre for Vision, Speech and Signal Processing (CVSSP), University of Surrey, Guildford, GU27XH, UK
| | - Shivaram Avula
- Alder Hey Children's NHS Trust, E Prescot Rd, Liverpool, L14 5AB, UK
| | - Ram Kumar
- Alder Hey Children's NHS Trust, E Prescot Rd, Liverpool, L14 5AB, UK
| | - Emma Lewis
- Centre for Vision, Speech and Signal Processing (CVSSP), University of Surrey, Guildford, GU27XH, UK
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13
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Grønbæk J, Molinari E, Avula S, Wibroe M, Oettingen G, Juhler M. The supplementary motor area syndrome and the cerebellar mutism syndrome: a pathoanatomical relationship? Childs Nerv Syst 2020; 36:1197-1204. [PMID: 31127340 DOI: 10.1007/s00381-019-04202-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/09/2019] [Indexed: 01/25/2023]
Abstract
PURPOSE The supplementary motor area (SMA) syndrome affects adults after tumour resection in SMA neighbouring motor cortex. Cerebellar mutism syndrome (CMS) affects children after tumour resection in the posterior fossa. Both syndromes include disturbances in speech and motor function. The causes of the syndromes are unknown; however, surgical damage to the dentato-thalamo-cortical pathway (DTCP) has been associated with CMS. Thus, an anatomical link between the areas associated with the syndromes is possible. We discuss the syndromes and their possible relationship through the DTCP. METHODS We identified 61 articles (cohort studies, case reports and reviews) in MEDLINE and Embase searching for CMS, SMA syndrome or DTCP or synonyms and reviewed for evidence linking CMS and SMA. RESULTS We found that SMA syndrome and CMS are similar regarding (1) surgical causation; (2) symptoms including speech impairment, disturbance in motor function and facial dysfunction; (3) delayed onset; (4) the courses of the syndromes are transient; and (5) long-term sequelae are seen in both. Relevant differences include age predominance of adults in SMA syndrome versus children in CMS. CONCLUSIONS The similarities of the two syndromes could be traced back to their mutual connection through the DTCP and their membership to a cerebro-cerebellar circuit. The connectivity network could explain the emotional changes and speech reduction in CMS. The difference in time of post-surgical onset may be related to the anatomical distance between the surgical damage to the cerebellum and the SMA, respectively, and the effector neural loop underpinning symptoms.
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Affiliation(s)
- Jonathan Grønbæk
- Department of Neurosurgery, The University Hospital Rigshospitalet, Copenhagen, Denmark.
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark.
| | - Emanuela Molinari
- Department of Neurology, The Queen Elizabeth University Hospital, University of Glasgow, Glasgow, UK
| | - Shivaram Avula
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Morten Wibroe
- Department of Neurosurgery, The University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Gorm Oettingen
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, The University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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14
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Avula S. Radiology of post-operative paediatric cerebellar mutism syndrome. Childs Nerv Syst 2020; 36:1187-1195. [PMID: 31183530 DOI: 10.1007/s00381-019-04224-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 05/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Post-operative paediatric cerebellar mutism syndrome is a well-recognized complication following posterior fossa tumour resection in children. Over the past few decades, imaging has played an important role in understanding this disorder. AIM This review article aims to focus on the disorder from a radiological perspective, summarizing the salient radiological evidence related to the anatomical structures, pathophysiology, and risk factors related to this disorder. CONCLUSION Radiological studies have been integral to the improved understanding of this condition. Future large multicentre studies and quantitative analysis techniques will be vital in further refinement of our understanding of this complex condition.
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Affiliation(s)
- Shivaram Avula
- Alder Hey Children's NHS Foundation Trust, East Prescot Road, Liverpool, L14 5AB, UK.
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15
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Posterior Fossa Society Consensus Meeting 2018: a synopsis. Childs Nerv Syst 2020; 36:1145-1151. [PMID: 31177321 DOI: 10.1007/s00381-019-04220-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/23/2019] [Indexed: 01/08/2023]
Abstract
PURPOSE The Posterior Fossa Society (PFS) was founded 4 years ago to systematically gather and exchange information on the post-operative (CMS) and cerebellar cognitive affective syndrome (CCAS). With its consensus meetings, the PFS orchestrates research studies in the field of cerebellar injury and progresses the knowledge of post-operative pediatric cerebellar mutism syndrome (CMS). In this article, we captured the 3-day program of presentations, group discussions, interactive workshops, and dialogue, highlighting the key topic areas of CMS and its research advances. METHODS This synopsis is based on the third consensus meeting which was held in Reykjavik, Iceland, in August 2018. RESULTS Three working groups have been defined to drive the future research priorities on post-surgical CMS: (i) refining definition and symptoms scoring of CMS; (ii) understanding the pathogenesis and enhancing risk-stratification strategies; and (iii) developing rehabilitation approaches and protocols. CONCLUSIONS The third consensus meeting highlighted a unanimous desire for data-driven information to advance the knowledge and guide future research efforts. The PFS constitutes an established and expanding network of multi-disciplinary expertise that can facilitate the development of collaborative studies and produce official guidelines on the topic.
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Signoriello E, D'Amico A, Fratta M, Ugga L, Altobelli C, Conchiglia G, Barbarulo AM, Di Pietro A, Anastasio P, Rossi F, Lus G. Alemtuzumab significantly improves posterior fossa syndrome presented as a relapse of multiple sclerosis. Mult Scler Relat Disord 2019; 38:101518. [PMID: 31778927 DOI: 10.1016/j.msard.2019.101518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 11/07/2019] [Accepted: 11/10/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Posterior fossa syndrome (PFS) is a rare manifestation of ponto-mesencephalic lesions frequently reported in post-surgical pediatric tumors, rarely described as a consequence of vascular, infective or inflammatory lesions. OBJECTIVE The aim of this article is to report the clinical and neuroradiological characteristics of a patient with an acute PFS presentation as a relapse in relapsing-remitting MS, significantly responsive to Alemtuzumab treatment. CASE REPORT 24-year-old patient affected by multiple sclerosis developed motor-cognitive and behavioral syndrome related to an extensive ponto-mesencephalic lesion under Fingolimod treatment. CONCLUSION Our case highlights the significant and rapid effect of Alemtuzumab therapy on both cognitive and motor symptoms occurring during a MS relapse with atypical neuroradiological localization.
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Affiliation(s)
- E Signoriello
- Multiple Sclerosis Center, II Division of Neurology, University of Campania Luigi Vanvitelli, Naples, Italy.
| | - A D'Amico
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - M Fratta
- Multiple Sclerosis Center, II Division of Neurology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - L Ugga
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - C Altobelli
- Unit of Nephrology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - G Conchiglia
- Alma Mater, Villa Camaldoli Hospital, Naples, Italy
| | - A M Barbarulo
- Multiple Sclerosis Center, II Division of Neurology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - A Di Pietro
- Multiple Sclerosis Center, II Division of Neurology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - P Anastasio
- Unit of Nephrology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - F Rossi
- Multiple Sclerosis Center, II Division of Neurology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - G Lus
- Multiple Sclerosis Center, II Division of Neurology, University of Campania Luigi Vanvitelli, Naples, Italy
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Gill JS, Sillitoe RV. Functional Outcomes of Cerebellar Malformations. Front Cell Neurosci 2019; 13:441. [PMID: 31636540 PMCID: PMC6787289 DOI: 10.3389/fncel.2019.00441] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/18/2019] [Indexed: 12/20/2022] Open
Abstract
The cerebellum is well-established as a primary center for controlling sensorimotor functions. However, recent experiments have demonstrated additional roles for the cerebellum in higher-order cognitive functions such as language, emotion, reward, social behavior, and working memory. Based on the diversity of behaviors that it can influence, it is therefore not surprising that cerebellar dysfunction is linked to motor diseases such as ataxia, dystonia, tremor, and Parkinson's disease as well to non-motor disorders including autism spectrum disorders (ASD), schizophrenia, depression, and anxiety. Regardless of the condition, there is a growing consensus that developmental disturbances of the cerebellum may be a central culprit in triggering a number of distinct pathophysiological processes. Here, we consider how cerebellar malformations and neuronal circuit wiring impact brain function and behavior during development. We use the cerebellum as a model to discuss the expanding view that local integrated brain circuits function within the context of distributed global networks to communicate the computations that drive complex behavior. We highlight growing concerns that neurological and neuropsychiatric diseases with severe behavioral outcomes originate from developmental insults to the cerebellum.
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Affiliation(s)
- Jason S. Gill
- Section of Pediatric Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, TX, United States
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United States
- Jan and Dan Duncan Neurological Research Institute of Texas Children’s Hospital, Houston, TX, United States
| | - Roy V. Sillitoe
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United States
- Jan and Dan Duncan Neurological Research Institute of Texas Children’s Hospital, Houston, TX, United States
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, United States
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18
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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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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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Molinari E, Oto M, Waterston A, Fullerton N. Modafinil in the rehabilitation of a patient with post-surgical posterior fossa syndrome: a lesson to be learned? CEREBELLUM & ATAXIAS 2019; 6:11. [PMID: 31428435 PMCID: PMC6694614 DOI: 10.1186/s40673-019-0105-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 08/02/2019] [Indexed: 11/10/2022]
Abstract
Disorders of the cerebellum may present with motor, cognitive, behavioral and affective symptoms. There is a growing interest in developing neuroanatomical models of symptoms generation that involve the cerebellum and the cerebello-cortical connections. We describe an exciting first case report of successful use of Modafinil in an adult patient with post-operative posterior fossa syndrome. Following resection of a melanoma metastasis in the cerebellum the patient developed striking affective and behavioral symptoms in the form of withdrawn flat mood and disengagement. This neurobehavioral presentation severely impacted on his quality of life, independence, and ability to engage in the neuro-rehabilitative program. Pharmacological treatment with Modafinil ameliorated these emotional and behavioral aspects, and also fatigue. Treatment with Modafinil hence affected recovery and outcome for the patient. To our knowledge, this is the first description of a successful pharmacological intervention in an adult with post-surgical posterior fossa syndrome and negative neurobehavioral presentation. Our findings illustrate the variability of the presentation of post-operative posterior fossa syndrome in adults, and the importance of delivering targeted treatment to maximize the benefits of neurorehabilitation. The manuscript highlights the following points: 1. post-operative consequences currently under the wide umbrella of posterior fossa syndrome, can indeed manifest in adults; 2. a wide spectrum of neurobehavioral symptoms can occur, including a presentation with predominantly negative features; 3. the type of neurobehavioral presentation should guide the treatment choice with particular consideration of drugs that potentially modulate the cerebello-frontal connections; 4. Modafinil can be a candidate for effective treatment in presentations with predominantly negative behavioral symptoms.
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Affiliation(s)
- Emanuela Molinari
- 1Department of Neurology, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow, G51 4TF UK.,2College of MVLS, School of Medicine, Dentistry & Nursing, University of Glasgow, University Avenue, Glasgow, G12 8QQ UK
| | - Maria Oto
- Scottish Epilepsy Centre, 20 St Kenneth Drive, Glasgow, G51 4QD UK
| | - Ashita Waterston
- Department of Medical Oncology, Beaton West of Scotland Cancer Centre, 1053 Great Western Rd, Glasgow, G12 0YN UK
| | - Natasha Fullerton
- 5Department of Neuroradiology, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow, G51 4TF UK
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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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Toescu SM, Hales PW, Aquilina K, Clark CA. Quantitative MRI in post-operative paediatric cerebellar mutism syndrome. Eur J Radiol 2018; 108:43-51. [PMID: 30396670 DOI: 10.1016/j.ejrad.2018.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/17/2018] [Accepted: 09/06/2018] [Indexed: 10/28/2022]
Abstract
Post-operative paediatric cerebellar mutism syndrome (pCMS) occurs in around 25% of children undergoing surgery for cerebellar and fourth ventricular tumours. Reversible mutism is the hallmark of a syndrome which comprises severe motor, cognitive and linguistic deficits. Recent evidence from advanced neuroimaging studies has led to the current theoretical understanding of the condition as a form of diaschisis contingent on damage to efferent cerebellar circuitry. Tractography data derived from diffusion MRI studies have shown disruption of the dentato-rubro-thalamo-cortical tract in patients with pCMS, and perfusion studies have indicated widespread supratentorial regions which may give rise to the florid signs and symptoms of pCMS. Given the difficulties in predicting pCMS from standard structural MRI, this review discusses findings from quantitative MRI modalities which have contributed to our understanding of this debilitating syndrome, and considers the goals and challenges which lie ahead in the field.
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Affiliation(s)
- Sebastian M Toescu
- Developmental Imaging and Biophysics Section, UCL GOS Institute of Child Health, 30 Guilford Street, London WC1N 1EH, United Kingdom; Department of Neurosurgery, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, United Kingdom.
| | - Patrick W Hales
- Developmental Imaging and Biophysics Section, UCL GOS Institute of Child Health, 30 Guilford Street, London WC1N 1EH, United Kingdom.
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, United Kingdom.
| | - Chris A Clark
- Developmental Imaging and Biophysics Section, UCL GOS Institute of Child Health, 30 Guilford Street, London WC1N 1EH, United Kingdom.
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Schreiber JE, Palmer SL, Conklin HM, Mabbott DJ, Swain MA, Bonner MJ, Chapieski ML, Huang L, Zhang H, Gajjar A. Posterior fossa syndrome and long-term neuropsychological outcomes among children treated for medulloblastoma on a multi-institutional, prospective study. Neuro Oncol 2018; 19:1673-1682. [PMID: 29016818 DOI: 10.1093/neuonc/nox135] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background Patients treated for medulloblastoma who experience posterior fossa syndrome (PFS) demonstrate increased risk for neurocognitive impairment at one year post diagnosis. The aim of the study was to examine longitudinal trajectories of neuropsychological outcomes in patients who experienced PFS compared with patients who did not. Methods Participants were 36 patients (22 males) who experienced PFS and 36 comparison patients (21 males) who were matched on age at diagnosis and treatment exposure but did not experience PFS. All patients underwent serial evaluation of neurocognitive functioning spanning 1 to 5 years post diagnosis. Results The PFS group demonstrated lower estimated mean scores at 1, 3, and 5 years post diagnosis on measures of general intellectual ability, processing speed, broad attention, working memory, and spatial relations compared with the non-PFS group. The PFS group exhibited estimated mean scores that were at least one standard deviation below the mean for intellectual ability, processing speed, and broad attention across all time points and for working memory by 5 years post diagnosis. Processing speed was stable over time. Attention and working memory declined over time. Despite some change over time, caregiver ratings of executive function and behavior problem symptoms remained within the average range. Conclusion Compared with patients who do not experience PFS, patients who experience PFS exhibit greater neurocognitive impairment, show little recovery over time, and decline further in some domains. Findings highlight the particularly high risk for long-term neurocognitive problems in patients who experience PFS and the need for close follow-up and intervention.
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Affiliation(s)
- Jane E Schreiber
- Department of Psychology, Department of Biostatistics, and Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA; Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; Lady Cilento Children's Hospital, South Brisbane, Queensland, Australia; Department of Psychiatry, Duke University Medical Center, Durham, North Carolina, USA; Department of Pediatric Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Shawna L Palmer
- Department of Psychology, Department of Biostatistics, and Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA; Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; Lady Cilento Children's Hospital, South Brisbane, Queensland, Australia; Department of Psychiatry, Duke University Medical Center, Durham, North Carolina, USA; Department of Pediatric Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Heather M Conklin
- Department of Psychology, Department of Biostatistics, and Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA; Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; Lady Cilento Children's Hospital, South Brisbane, Queensland, Australia; Department of Psychiatry, Duke University Medical Center, Durham, North Carolina, USA; Department of Pediatric Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Donald J Mabbott
- Department of Psychology, Department of Biostatistics, and Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA; Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; Lady Cilento Children's Hospital, South Brisbane, Queensland, Australia; Department of Psychiatry, Duke University Medical Center, Durham, North Carolina, USA; Department of Pediatric Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Michelle A Swain
- Department of Psychology, Department of Biostatistics, and Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA; Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; Lady Cilento Children's Hospital, South Brisbane, Queensland, Australia; Department of Psychiatry, Duke University Medical Center, Durham, North Carolina, USA; Department of Pediatric Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Melanie J Bonner
- Department of Psychology, Department of Biostatistics, and Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA; Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; Lady Cilento Children's Hospital, South Brisbane, Queensland, Australia; Department of Psychiatry, Duke University Medical Center, Durham, North Carolina, USA; Department of Pediatric Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Mary L Chapieski
- Department of Psychology, Department of Biostatistics, and Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA; Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; Lady Cilento Children's Hospital, South Brisbane, Queensland, Australia; Department of Psychiatry, Duke University Medical Center, Durham, North Carolina, USA; Department of Pediatric Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Lu Huang
- Department of Psychology, Department of Biostatistics, and Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA; Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; Lady Cilento Children's Hospital, South Brisbane, Queensland, Australia; Department of Psychiatry, Duke University Medical Center, Durham, North Carolina, USA; Department of Pediatric Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Hui Zhang
- Department of Psychology, Department of Biostatistics, and Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA; Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; Lady Cilento Children's Hospital, South Brisbane, Queensland, Australia; Department of Psychiatry, Duke University Medical Center, Durham, North Carolina, USA; Department of Pediatric Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Amar Gajjar
- Department of Psychology, Department of Biostatistics, and Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA; Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; Lady Cilento Children's Hospital, South Brisbane, Queensland, Australia; Department of Psychiatry, Duke University Medical Center, Durham, North Carolina, USA; Department of Pediatric Medicine, Texas Children's Hospital, Houston, Texas, USA
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Ballestero MFM, Viana DC, Teixeira TL, Santos MV, de Oliveira RS. Hypertrophic olivary degeneration in children after posterior fossa surgery. An underdiagnosed condition. Childs Nerv Syst 2018; 34:409-415. [PMID: 29279964 DOI: 10.1007/s00381-017-3705-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/17/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hypertrophic olivary degeneration (HOD) is a rare transsynaptic form of degeneration occurring after injury to the dentato-rubro-olivary pathway ("Guillain-Mollaret triangle"). The majority of studies have described HOD resulting from posterior fossa (PF) hemorrhage or infarction. HOD in patients undergoing PF surgery has not been well characterized. These lesions are rare and symptomatic children with HOD are even more uncommon. The purpose of this study was to evaluate HOD that develops after PF operations in children. MATERIALS AND METHODS A literature review was carried out describing 37 pediatric cases of HOD in 13 articles. In addition, two new cases of our own experience were included. CONCLUSIONS HOD is a rare complication related after PF tumors surgery and symptoms may be misdiagnosed with pediatric cerebellar mutism syndrome. Children with HOD usually do not develop palatal tremor but ataxia is common.
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Affiliation(s)
- Matheus Fernando Manzolli Ballestero
- Division of Pediatric Neurosurgery of the Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, 14049-900, Brazil.
| | - Dinark Conceição Viana
- Division of Pediatric Neurosurgery of the Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, 14049-900, Brazil
| | - Thiago Lyrio Teixeira
- Division of Pediatric Neurosurgery of the Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, 14049-900, Brazil
| | - Marcelo Volpon Santos
- Division of Pediatric Neurosurgery of the Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, 14049-900, Brazil
| | - Ricardo Santos de Oliveira
- Division of Pediatric Neurosurgery of the Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, 14049-900, Brazil
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25
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Onen MR, Moore K, Cikla U, Ucer M, Schmidt B, Field AS, Baskaya MK. Hypertrophic Olivary Degeneration: Neurosurgical Perspective and Literature Review. World Neurosurg 2018; 112:e763-e771. [PMID: 29382617 DOI: 10.1016/j.wneu.2018.01.150] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 01/17/2018] [Accepted: 01/18/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Hypertrophic olivary degeneration (HOD) occurs because of posterior fossa or brainstem lesions that disrupt the dentato-rubro-olivary tract, well known as the Guillain-Mollaret triangle. Clinical and radiologic hallmarks of this condition are palatal myoclonus and T2 hyperintensity of the inferior olivary complex on magnetic resonance imaging (MRI), respectively. Because symptomatic HOD can complicate the recovery of patients with posterior fossa or brainstem lesions, the purpose of this study is to evaluate clinical and imaging findings of patients with HOD. METHODS Sixteen patients (8 female and 8 male) with a mean age of 40.7 years, (range, 5-83 years) years were included in this study based on clinical symptoms and MRI findings. RESULTS We reviewed the clinical and imaging findings in 16 cases of HOD at our institution. Seven patients (43.7%) had posterior fossa tumors, 6 patients (37.5%) had cavernoma, 2 patients (12.5%) sustained traumatic brain injury, and only 1 patient (6.2%) had cerebellar infarction. Posterior fossa surgery was performed in 13 (81.2%) of these patients. HOD was detected a mean of 7.2 months (range, 0.5-18 months) after surgery or primary neurologic insult. Unilateral HOD was observed in 10 patients (62.5%), while bilateral HOD was observed in only 6 patients (37.5%). Seven patients (43.7%) were asymptomatic for HOD, whereas 5 patients (31.2%) had symptoms attributable to HOD. Two patients died because of primary tumors, although mean follow-up after detection of HOD on MRI was 52.2 months (range, 1-120 months) in the remaining 14 patients. In these cases, no change in clinical symptoms or imaging findings was detected during follow-up. CONCLUSIONS In this series, posterior fossa tumors and cavernomas were the most common causes of HOD. Although most of the patients with HOD remained asymptomatic, HOD complicated the course of recovery in almost one quarter of the patients included in this study. Neurosurgeons should be aware of HOD, which has characteristic clinical and imaging findings. In addition, HOD can complicate the recovery of patients with disruption to the dentato-rubro-olivary tract.
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Affiliation(s)
- Mehmet Resid Onen
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Kelli Moore
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Ulas Cikla
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Melih Ucer
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Bradley Schmidt
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Aaron S Field
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Mustafa K Baskaya
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA.
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26
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Toescu SM, Hettige S, Phipps K, Smith RJP, Haffenden V, Clark C, Hayward R, Mankad K, Aquilina K. Post-operative paediatric cerebellar mutism syndrome: time to move beyond structural MRI. Childs Nerv Syst 2018; 34:2249-2257. [PMID: 29926177 PMCID: PMC6208673 DOI: 10.1007/s00381-018-3867-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 06/08/2018] [Indexed: 12/02/2022]
Abstract
PURPOSE To determine the value of structural magnetic resonance imaging (MRI) in predicting post-operative paediatric cerebellar mutism syndrome (pCMS) in children undergoing surgical treatment for medulloblastoma. METHODS Retrospective cohort study design. Electronic/paper case note review of all children with medulloblastoma presenting to Great Ormond Street Hospital between 2003 and 2013. The diagnosis of pCMS was established through a scoring system incorporating mutism, ataxia, behavioural disturbance and cranial nerve deficits. MRI scans performed at three time points were assessed by neuroradiologists blinded to the diagnosis of pCMS. RESULTS Of 56 children included, 12 (21.4%) developed pCMS as judged by a core symptom of mutism. pCMS was more common in those aged 5 or younger. There was no statistically significant difference in pre-operative distortion or signal change of the dentate or red nuclei or superior cerebellar peduncles (SCPs) between those who did and did not develop pCMS. In both early (median 5 days) and late (median 31 months) post-operative scans, T2-weighted signal change in SCPs was more common in the pCMS group (p = 0.040 and 0.046 respectively). Late scans also showed statistically significant signal change in the dentate nuclei (p = 0.024). CONCLUSIONS The development of pCMS could not be linked to any observable changes on pre-operative structural MRI scans. Post-operative T2-weighted signal change in the SCPs and dentate nuclei underlines the role of cerebellar efferent injury in pCMS. Further research using advanced quantitative MRI sequences is warranted given the inability of conventional pre-surgical MRI to predict pCMS.
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Affiliation(s)
- Sebastian M Toescu
- Department of Neurosurgery, Great Ormond Street Hospital, London, WC1N 3JH, UK.
- Developmental Imaging and Biophysics Section, Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Samantha Hettige
- Department of Neurosurgery, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Kim Phipps
- Department of Neurosurgery, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - R J Paul Smith
- Department of Neuroradiology, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Verity Haffenden
- Department of Neurosurgery, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Chris Clark
- Developmental Imaging and Biophysics Section, Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Richard Hayward
- Department of Neurosurgery, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Kshitij Mankad
- Department of Neuroradiology, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital, London, WC1N 3JH, UK
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27
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Abstract
Cerebellar mutism most commonly, but not exclusively, develops in children after surgery for midline cerebellar or intraventricular tumors in the posterior fossa, typically medulloblastoma. Cerebellar mutism syndrome (CMS) comprises a complex set of neurologic and neurocognitive signs and symptoms, the cardinal and central component of which is an initially profound but usually reversible speech disorder. As such, CMS is currently recognized as an extreme form of the so-called cerebellar cognitive affective syndrome (Schmahmann syndrome). The putative cause of CMS is a substantial surgical injury to the proximal components of the bilateral efferent cerebellar pathways, disrupting cerebellar input to the supratentorial brain. The resultant cerebellocerebral diaschisis may lead to supratentorial cortical perfusion depression with frontal predominance. The speech disorder is, therefore, likely an apraxia. As our understanding of the mechanism and the clinical spectrum of CMS evolves, clinically useful preoperative risk stratification schemes, adjustments to surgical strategies and techniques, and possible early therapeutic-rehabilitative measures are being sought and developed to reduce the burden of this severe and particularly handicapping chronic morbidity on affected individuals and their families.
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28
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Choudhri AF, Siddiqui A, Klimo P. Pediatric Cerebellar Tumors: Emerging Imaging Techniques and Advances in Understanding of Genetic Features. Magn Reson Imaging Clin N Am 2017; 24:811-821. [PMID: 27742118 DOI: 10.1016/j.mric.2016.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cerebellar tumors are the most common group of solid tumors in children. MR imaging provides an important role in characterization of these lesions, surgical planning, and postsurgical surveillance. Preoperative imaging can help predict the histologic subtype of tumors, which can provide guidance for surgical planning. Beyond histology, pediatric brain tumors are undergoing new classification schemes based on genetic features. Intraoperative MR imaging has emerged as an important tool in the surgical management of pediatric brain tumors. Effective understanding of the imaging features of pediatric cerebellar tumors can benefit communication with neurosurgeons and neuro-oncologists and can improve patient management.
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Affiliation(s)
- Asim F Choudhri
- Department of Radiology, University of Tennessee Health Science Center, 848 Adams Ave, Memphis, TN 38103, USA; Department of Neurosurgery, University of Tennessee Health Science Center, 847 Monroe Avenue, Memphis, TN 38163, USA; Department of Ophthalmology, University of Tennessee Health Science Center, 930 Madison Avenue, Memphis, TN 38163, USA; Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN 38103, USA.
| | - Adeel Siddiqui
- Department of Radiology, University of Tennessee Health Science Center, 848 Adams Ave, Memphis, TN 38103, USA; Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN 38103, USA
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, 847 Monroe Avenue, Memphis, TN 38163, USA; Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN 38103, USA; Division of Neurosurgery, St. Jude's Children's Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA; Semmes Murphey Neurologic & Spine Institute, 6325 Humphreys Boulevard, Memphis, TN 38120, USA
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29
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Post-operative diffusion weighted imaging as a predictor of posterior fossa syndrome permanence in paediatric medulloblastoma. Childs Nerv Syst 2017; 33:457-465. [PMID: 28190209 DOI: 10.1007/s00381-017-3356-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 01/31/2017] [Indexed: 01/06/2023]
Abstract
PURPOSE Posterior fossa syndrome (PFS) is a serious complication faced by neurosurgeons and their patients, especially in paediatric medulloblastoma patients. The uncertain aetiology of PFS, myriad of cited risk factors and therapeutic challenges make this phenomenon an elusive entity. The primary objective of this study was to identify associative factors related to the development of PFS in medulloblastoma patient post-tumour resection. METHODS This is a retrospective study based at a single institution. Patient data and all related information were collected from the hospital records, in accordance to a list of possible risk factors associated with PFS. These included pre-operative tumour volume, hydrocephalus, age, gender, extent of resection, metastasis, ventriculoperitoneal shunt insertion, post-operative meningitis and radiological changes in MRI. Additional variables included molecular and histological subtypes of each patient's medulloblastoma tumour. Statistical analysis was employed to determine evidence of each variable's significance in PFS permanence. RESULTS A total of 19 patients with appropriately complete data was identified. Initial univariate analysis did not show any statistical significance. However, multivariate analysis for MRI-specific changes reported bilateral DWI restricted diffusion changes involving both right and left sides of the surgical cavity was of statistical significance for PFS permanence. CONCLUSION The authors performed a clinical study that evaluated possible risk factors for permanent PFS in paediatric medulloblastoma patients. Analysis of collated results found that post-operative DWI restriction in bilateral regions within the surgical cavity demonstrated statistical significance as a predictor of PFS permanence-a novel finding in the current literature.
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30
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Wahab SS, Hettige S, Mankad K, Aquilina K. Posterior fossa syndrome-a narrative review. Quant Imaging Med Surg 2016; 6:582-590. [PMID: 27942479 DOI: 10.21037/qims.2016.10.12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Posterior fossa syndrome (PFS), or cerebellar mutism syndrome (CMS), is a collection of neurological symptoms that occur following surgical resection of a posterior fossa tumour, and is characterised by either a reduction or an absence of speech. Some authors suggest that CM is only one symptom of the CMS complex that also includes ataxia, hypotonia and irritability as well as cranial nerve deficits, neurobehavioral changes and urinary retention or incontinence. It is seen almost exclusively in children. In 1985 Rekate et al. published the first work describing CM as a clinical entity, occurring as a consequence of bilateral cerebellar injury. Other associated symptoms include visual impairment, altered mood, impaired swallowing and significant gross and fine motor deficits. The effects of this can have a devastating impact on both the patient and their carers, posing a significant clinical challenge to neurorehabilitation services. The reported incidence was between 8% and 31% of children undergoing surgery for posterior fossa tumour. The underlying pathologies include vasospasm, oedema, and axonal/neuronal injury. Neuroimaging has contributed to a better understanding of the anatomical location of postoperative injury. There have been a number of suggestions for treatment interventions for PFS. However, apart from some individual reports, there have been no clinical trials indicating possible benefit. Occupational therapy, speech and language therapy, as well as neurocognitive support, contribute to the recovery of these patients.
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Affiliation(s)
- Salima S Wahab
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Samantha Hettige
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Kshtij Mankad
- Department of Neuroradiology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
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31
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Avula S, Spiteri M, Kumar R, Lewis E, Harave S, Windridge D, Ong C, Pizer B. Post-operative pediatric cerebellar mutism syndrome and its association with hypertrophic olivary degeneration. Quant Imaging Med Surg 2016; 6:535-544. [PMID: 27942473 DOI: 10.21037/qims.2016.10.11] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The dentato-thalamo-cortical (DTC) pathway is recognized as the anatomical substrate for postoperative pediatric cerebellar mutism (POPCMS), a well-recognized complication affecting up to 31% of children undergoing posterior fossa brain tumour resection. The proximal structures of the DTC pathway also form a segment of the Guillain and Mollaret triangle, a neural network which when disrupted causes hypertrophic olivary degeneration (HOD) of the inferior olivary nucleus (ION). We hypothesize that there is an association between the occurrence of POPCMS and HOD and aim to evaluate this on MR imaging using qualitative and quantitative analysis of the ION in children with and without POPCMS. METHODS In this retrospective study we qualitatively analysed the follow up MR imaging in 48 children who underwent posterior fossa tumour resection for presence of HOD. Quantitative analysis of the ION was possible in 28 children and was performed using semi-automated segmentation followed by feature extraction and feature selection techniques and relevance of the features to POPCMS were evaluated. The diagnosis of POPCMS was made independently based on clinical and nursing assessment notes. RESULTS There was significant association between POPCMS and bilateral HOD (P=0.002) but not unilateral HOD. Quantitative analysis showed that hyperintensity in the left ION was the most relevant feature in children with POPCMS. CONCLUSIONS Bilateral HOD can serve as a reliable radiological indicator in establishing the diagnosis of POPCMS particularly in equivocal cases. The strong association of signal change due to HOD in the left ION suggests that injury to the right proximal efferent cerebellar pathway plays an important role in the causation of POPCMS.
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Affiliation(s)
- Shivaram Avula
- Department of Radiology, Alder Hey Children's NHS Foundation, Liverpool, UK
| | - Michaela Spiteri
- Centre for Vision, Speech and Signal Processing, University of Surrey, Guildford, UK
| | | | - Emma Lewis
- Centre for Vision, Speech and Signal Processing, University of Surrey, Guildford, UK
| | - Srikrishna Harave
- Department of Radiology, Alder Hey Children's NHS Foundation, Liverpool, UK
| | - David Windridge
- Centre for Vision, Speech and Signal Processing, University of Surrey, Guildford, UK
| | - Chan Ong
- Department of Radiology, Alder Hey Children's NHS Foundation, Liverpool, UK
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32
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Choudhri AF, Siddiqui A, Klimo P. Pediatric Cerebellar Tumors: Emerging Imaging Techniques and Advances in Understanding of Genetic Features. Neuroimaging Clin N Am 2016; 26:459-69. [PMID: 27423803 DOI: 10.1016/j.nic.2016.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cerebellar tumors are the most common group of solid tumors in children. MR imaging provides an important role in characterization of these lesions, surgical planning, and postsurgical surveillance. Preoperative imaging can help predict the histologic subtype of tumors, which can provide guidance for surgical planning. Beyond histology, pediatric brain tumors are undergoing new classification schemes based on genetic features. Intraoperative MR imaging has emerged as an important tool in the surgical management of pediatric brain tumors. Effective understanding of the imaging features of pediatric cerebellar tumors can benefit communication with neurosurgeons and neuro-oncologists and can improve patient management.
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Affiliation(s)
- Asim F Choudhri
- Department of Radiology, University of Tennessee Health Science Center, 848 Adams Ave, Memphis, TN 38103, USA; Department of Neurosurgery, University of Tennessee Health Science Center, 847 Monroe Avenue, Memphis, TN 38163, USA; Department of Ophthalmology, University of Tennessee Health Science Center, 930 Madison Avenue, Memphis, TN 38163, USA; Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN 38103, USA.
| | - Adeel Siddiqui
- Department of Radiology, University of Tennessee Health Science Center, 848 Adams Ave, Memphis, TN 38103, USA; Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN 38103, USA
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, 847 Monroe Avenue, Memphis, TN 38163, USA; Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN 38103, USA; Division of Neurosurgery, St. Jude's Children's Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA; Semmes Murphey Neurologic & Spine Institute, 6325 Humphreys Boulevard, Memphis, TN 38120, USA
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33
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Tallen G, Resch A, Calaminus G, Wiener A, Leiss U, Pletschko T, Friedrich C, Langer T, Grabow D, Driever PH, Kortmann RD, Timmermann B, Pietsch T, Warmuth-Metz M, Bison B, Thomale UW, Krauss J, Mynarek M, von Hoff K, Ottensmeier H, Frühwald M, Kramm CM, Temming P, Müller HL, Witt O, Kordes U, Fleischhack G, Gnekow A, Rutkowski S. Strategies to improve the quality of survival for childhood brain tumour survivors. Eur J Paediatr Neurol 2015; 19:619-39. [PMID: 26278499 DOI: 10.1016/j.ejpn.2015.07.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 07/05/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Tumours of the central nervous system (CNS) are the most frequent solid tumours and the second most frequent type of cancer in children and adolescents. Overall survival has continuously improved in Germany, since an increasing number of patients have been treated according to standardised, multicentre, multimodal treatment recommendations, trials of the German Paediatric Brain Tumour Consortium (HIT-Network) or the International Society of Paediatric Oncology-Europe (SIOP-E) during the last decades. Today, two out of three patients survive. At least 8000 long-term childhood brain tumour survivors (CBTS) are currently living in Germany. They face lifelong disease- and treatment-related late effects (LE) and associated socioeconomic problems more than many other childhood cancer survivors (CCS). METHOD We review the LE and resulting special needs of this particular group of CCS. RESULTS Despite their increasing relevance for future treatment optimisation, neither the diversity of chronic and cumulative LE nor their pertinent risk factors and subsequent impact on quality of survival have yet been comprehensively addressed for CBTS treated according to HIT- or SIOP-E-protocols. Evidence-based information to empower survivors and stakeholders, as well as medical expertise to manage their individual health care, psychosocial and educational/vocational needs must still be generated and established. CONCLUSION The establishment of a long-term research- and care network in Germany shall contribute to a European platform, that aims at optimising CBTSs' transition into adulthood as resilient individuals with high quality of survival including optimal levels of activity, participation and acceptance by society.
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Affiliation(s)
- Gesche Tallen
- Department of Paediatric Oncology/Haematology, Charité-Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, 13353 Berlin, Germany; Department of Paediatrics, Faculty of Medicine, University of Calgary, 2888 Shaganappi Trail N.W., Calgary, Alberta T3B 6A8, Canada.
| | - Anika Resch
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
| | - Gabriele Calaminus
- Department of Paediatric Haematology and Oncology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Andreas Wiener
- Department of Paediatric Haematology and Oncology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Ulrike Leiss
- Medical University Vienna, Department of Paediatric and Adolescent Medicine, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Thomas Pletschko
- Medical University Vienna, Department of Paediatric and Adolescent Medicine, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Carsten Friedrich
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany; Division of Paediatric Oncology, Haematology and Haemostaseology, Department of Woman's and Children's Health, University Hospital Leipzig, Liebigstr. 20a, 04103 Leipzig, Germany.
| | - Thorsten Langer
- Department of Paediatric Oncology/Haematology, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
| | - Desiree Grabow
- German Childhood Cancer Registry (GCCR), Institute of Medical Biostatistics, Epidemiology, and Informatics (IMBEI), University Medical Center, University of Mainz, Gebäude 902, Obere Zahlbacher Straße 69, 55131 Mainz, Germany.
| | - Pablo Hernáiz Driever
- Department of Paediatric Oncology/Haematology, Charité-Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Rolf-Dieter Kortmann
- Department of Radiation Oncology, University of Leipzig, Stephanstr. 9a, 04103 Leipzig, Germany.
| | - Beate Timmermann
- Particle Therapy Clinic at West German Proton Therapy Centre Essen, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany.
| | - Torsten Pietsch
- Institute of Neuropathology, University of Bonn, Sigmund-Freud-Str. 25, 53105 Bonn, Germany.
| | - Monika Warmuth-Metz
- Dept. of Neuroradiology, University of Würzburg, Josef-Schneider-Str. 11, 97080 Würzburg, Germany.
| | - Brigitte Bison
- Dept. of Neuroradiology, University of Würzburg, Josef-Schneider-Str. 11, 97080 Würzburg, Germany.
| | - Ulrich-Wilhelm Thomale
- Department of Paediatric Neurosurgery, Charité-Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Jürgen Krauss
- Department of Neurosurgery, Head Clinic, University of Würzburg, Josef-Schneider-Str. 11, 97080 Würzburg, Germany.
| | - Martin Mynarek
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
| | - Katja von Hoff
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
| | - Holger Ottensmeier
- University Children's Hospital Würzburg, Dept. of Paed. Haematology, Oncology, Josef-Schneider-Str. 2, 97080 Würzburg, Germany.
| | - Michael Frühwald
- Department of Paediatric Oncology/Haematology, Klinikum Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany.
| | - Christof M Kramm
- Division of Paediatric Haematology and Oncology, University of Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany.
| | - Petra Temming
- Paediatric Haematology/Oncology, Paediatrics III, University of Essen, Hufelandstr. 55, 45147 Essen, Germany.
| | - Hermann L Müller
- Paediatric Oncology/Haematology, Klinikum Oldenburg, Medical Campus University Oldenburg, Rahel-Straus-Str. 10, 26133 Oldenburg, Germany.
| | - Olaf Witt
- German Cancer Research Centre (DKFZ) and Department of Paediatric Oncology/Haematology, University of Heidelberg, Heidelberg, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany.
| | - Uwe Kordes
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
| | - Gudrun Fleischhack
- Paediatric Haematology/Oncology, Paediatrics III, University of Essen, Hufelandstr. 55, 45147 Essen, Germany.
| | - Astrid Gnekow
- Department of Paediatric Oncology/Haematology, Klinikum Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany.
| | - Stefan Rutkowski
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
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Spiteri M, Windridge D, Avula S, Kumar R, Lewis E. Identifying quantitative imaging features of posterior fossa syndrome in longitudinal MRI. J Med Imaging (Bellingham) 2015; 2:044502. [PMID: 26835496 DOI: 10.1117/1.jmi.2.4.044502] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 09/22/2015] [Indexed: 11/14/2022] Open
Abstract
Up to 25% of children who undergo brain tumor resection surgery in the posterior fossa develop posterior fossa syndrome (PFS). This syndrome is characterized by mutism and disturbance in speech. Our hypothesis is that there is a correlation between PFS and the occurrence of hypertrophic olivary degeneration (HOD) in structures within the posterior fossa, known as the inferior olivary nuclei (ION). HOD is exhibited as an increase in size and intensity of the ION on an MR image. Longitudinal MRI datasets of 28 patients were acquired consisting of pre-, intra-, and postoperative scans. A semiautomated segmentation process was used to segment the ION on each MR image. A full set of imaging features describing the first- and second-order statistics and size of the ION were extracted for each image. Feature selection techniques were used to identify the most relevant features among the MRI features, demographics, and data based on neuroradiological assessment. A support vector machine was used to analyze the discriminative features selected by a generative k-nearest neighbor algorithm. The results indicate the presence of hyperintensity in the left ION as the most diagnostically relevant feature, providing a statistically significant improvement in the classification of patients ([Formula: see text]) when using this feature alone.
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Affiliation(s)
- Michaela Spiteri
- University of Surrey , Centre for Vision, Speech, and Signal Processing, Guildford GU2 7XH, United Kingdom
| | - David Windridge
- University of Surrey, Centre for Vision, Speech, and Signal Processing, Guildford GU2 7XH, United Kingdom; Middlesex University Hendon campus, School of Science and Technology, Department of Computer Science, The Burroughs, London NW4 4BT, United Kingdom
| | - Shivaram Avula
- Alder Hey Children's Hospital , Neurology Department, Eaton Road, Liverpool L12 2AP, United Kingdom
| | - Ram Kumar
- Alder Hey Children's Hospital , Neurology Department, Eaton Road, Liverpool L12 2AP, United Kingdom
| | - Emma Lewis
- University of Surrey , Centre for Vision, Speech, and Signal Processing, Guildford GU2 7XH, United Kingdom
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Avula S, Mallucci C, Kumar R, Pizer B. Posterior fossa syndrome following brain tumour resection: review of pathophysiology and a new hypothesis on its pathogenesis. Childs Nerv Syst 2015; 31:1859-67. [PMID: 26351235 DOI: 10.1007/s00381-015-2797-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 06/19/2015] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Posterior fossa syndrome (PFS), also known as cerebellar mutism syndrome (CMS), is a severe complication affecting children following surgery for posterior fossa brain tumours. Its incidence varies between 8 and 31 %, and its exact pathogenesis remains unclear. In this article, we aim to review the existing theories on its pathogenesis and propose a new hypothesis. DISCUSSION There is varying level of evidence on existing theories on the pathogenesis of PFS following surgery. These include cerebellar perfusion deficits due to vasospasm, oedema or axonal injury due to direct surgical injury and neuronal dysfunction. There is emerging evidence that interruption of the dentato-thalamo-cortical (DTC) pathway is responsible for PFS. Based on our experience with intraoperative MRI, radiological and pathological evidence on heat-related brain injury, we propose a new hypothesis implicating thermal injury resulting from the use of the Cavitron Ultrasonic Aspirator (CUSA) as an important mechanism in the pathogenesis of PFS. CONCLUSION The pathogenesis of PFS is likely to be multifactorial with direct injury from surgery being a major factor. We believe that thermal injury in addition to mechanical injury to the proximal segment of the DTC plays an important role in the pathogenesis of PFS and should be considered in future research related to the aetiology, prevention and management of PFS.
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Affiliation(s)
- Shivaram Avula
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK.
| | - Conor Mallucci
- Department of Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Ram Kumar
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Barry Pizer
- Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Postoperative posterior fossa syndrome: unraveling the etiology and underlying pathophysiology by using magnetic resonance imaging. Childs Nerv Syst 2015; 31:1853-8. [PMID: 26143277 DOI: 10.1007/s00381-015-2796-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 06/19/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Posterior fossa syndrome (PFS) is a severe, postoperative complication occurring in about 25 % of pediatric patients undergoing surgery for midline tumors in the posterior fossa. In recent years, MRI-based research elucidated the cause of PFS and shed new light on its putative pathophysiology. This review highlights the major advances arising from research of this topic. RESULTS Postsurgical damage patterns in patients after posterior fossa surgery show that PFS results from bilateral surgical damage to the proximal efferent cerebellar pathways (pECPs). Surgical pECP disruption has other MRI-detectable effects that are more remote. Patients with PFS tend to develop global supratentorial cortical hypoperfusion, likely representing reversed, cerebello-cerebral diaschisis. Because this hypoperfusion is most prominent in frontal regions, cerebellar mutism may indicate a dominantly frontal lobe dysfunction, hence a peculiar form of speech apraxia. Injury to the pECP also leads to contralateral inferior olivary nucleus degeneration. When bilateral hypertrophic olivary degeneration (HOD) is observed after posterior fossa surgery, affected patients have clinical PFS. Therefore, it is suggested that bilateral HOD may be a sensitive and, in appropriate clinical settings, reliable a posteriori surrogate imaging indicator of bilateral disruption of the pECPs and consequently of PFS. Having such a "validation tool" presents new opportunities to develop better definitions for the phenotypes within the clinical spectrum of PFS. CONCLUSIONS Anatomical and functional MRI techniques are suitable and valuable tools with which to detect structural changes and pathophysiological processes in the development and evolution of PFS and may be key, integral components of future clinical research endeavors.
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Manzano-Lopez Gonzalez D, Conesa Bertran G, Lafuente Baraza J. Unusual case of posterior fossa syndrome and bilateral hypertrophic olivary degeneration after surgical removal of a large fourth ventricle ependymoma in an adult. Acta Neurochir (Wien) 2015; 157:1271-3. [PMID: 25956396 DOI: 10.1007/s00701-015-2442-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 04/28/2015] [Indexed: 11/24/2022]
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Tartaglione T, Izzo G, Alexandre A, Botto A, Di Lella GM, Gaudino S, Caldarelli M, Colosimo C. MRI findings of olivary degeneration after surgery for posterior fossa tumours in children: incidence, time course and correlation with tumour grading. Radiol Med 2015; 120:474-82. [PMID: 25572537 DOI: 10.1007/s11547-014-0477-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 06/16/2014] [Indexed: 01/12/2023]
Abstract
PURPOSE Olivary degeneration is due to many posterior cranial fossa (PCF) lesions affecting the dentato-rubro-olivary pathway, also known as Guillain-Mollaret triangle. Triangle damage results in hyperexcitation and consequently in hypertrophy of the inferior olivary nucleus (ION). The aim of our study was to evaluate the incidence of magnetic resonance (MR) imaging changes in the ION after surgery in a large cohort of paediatric patients and to determine their correlation with tumour grade. MATERIALS AND METHODS We retrospectively evaluated 58 patients treated surgically for PCF tumours who underwent MR imaging between 2007 and 2014, 1 week to 5 years after surgery. Histopathology revealed 29 medulloblastomas (WHO IV), 6 ependymomas (WHO II), 2 anaplastic ependymomas (WHO III) and 21 pilocytic astrocytomas (WHO I). ION MR imaging changes were correlated with surgery-to-MR interval and with tumour grading. RESULTS ION MR imaging changes were observed in 19/64 (33 %), and all consisted of T2 signal alterations, 15 bilateral and four unilateral, with dentate nucleus damage in all cases. Olivary enlargement was observed in few cases only (7/19). ION T2 hyperintensity was always present between 1 and 6 months after surgery with a trend to decrease, becoming faint after 1 year. The Fisher test demonstrated a significant (p = 0.005) correlation between ION MR imaging changes and high tumour grade. CONCLUSIONS Our results demonstrate that olivary degeneration, with or without hypertrophy, is a relatively frequent consequence of posterior fossa surgery, particularly in children treated for high-grade tumours. Knowledge of this condition can prevent misdiagnoses and unnecessary investigations.
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Affiliation(s)
- Tommaso Tartaglione
- Istituto di Radiologia - Dipartimento di Bioimmagini e Scienze Radiologiche, Rome, Italy
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Avula S, Kumar R, Pizer B, Pettorini B, Abernethy L, Garlick D, Mallucci C. Diffusion abnormalities on intraoperative magnetic resonance imaging as an early predictor for the risk of posterior fossa syndrome. Neuro Oncol 2014; 17:614-22. [PMID: 25319997 DOI: 10.1093/neuonc/nou299] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Posterior fossa syndrome (PFS) is an important complication of posterior fossa surgery in children. The pathophysiology of this condition remains unclear, but there is evidence implicating surgical injury of the proximal efferent cerebellar pathway (pECP) and the cerebellar vermis to PFS. We aimed to evaluate if diffusion abnormalities involving these structures on the final intraoperative MRI can predict the development of PFS. METHODS Diffusion-weighted imaging from 31 posterior fossa resections were anonymized and evaluated for abnormalities involving the dentate nucleus, superior cerebellar peduncle, and the mesencephalic tegmentum forming the pECP, vermis, and middle cerebellar peduncle. The case notes were independently evaluated for evidence of PFS. RESULTS The diffusion imaging in 28 cases was of optimal quality for evaluation. Diffusion abnormalities were identified in 10 cases, 7 of which involved the pECP. Retrospective evaluation revealed evidence of PFS in 6 cases. There was a significant association between abnormalities involving pECP structures (P = .001) and development of PFS. Bilateral involvement of pECP (P = .006) was a highly specific risk factor for predicting the development of PFS. Diffusion abnormality of the inferior vermis was significantly associated with PFS (P = .001) but may not represent a risk factor in isolation. CONCLUSION This study demonstrates the feasibility of identifying children at risk for developing PFS at the earliest stage post tumor resection and thus adds to the growing evidence base on its pathophysiology.
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Affiliation(s)
- Shivaram Avula
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (S.A., L.A., D.G.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (R.K.); Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (Barry Pizer); Department of Neurosurgery, Alder Hey Children's N.H.S Foundation Trust, Liverpool, UK (Benedetta Pettorini, C.M.)
| | - Ram Kumar
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (S.A., L.A., D.G.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (R.K.); Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (Barry Pizer); Department of Neurosurgery, Alder Hey Children's N.H.S Foundation Trust, Liverpool, UK (Benedetta Pettorini, C.M.)
| | - Barry Pizer
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (S.A., L.A., D.G.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (R.K.); Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (Barry Pizer); Department of Neurosurgery, Alder Hey Children's N.H.S Foundation Trust, Liverpool, UK (Benedetta Pettorini, C.M.)
| | - Benedetta Pettorini
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (S.A., L.A., D.G.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (R.K.); Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (Barry Pizer); Department of Neurosurgery, Alder Hey Children's N.H.S Foundation Trust, Liverpool, UK (Benedetta Pettorini, C.M.)
| | - Laurence Abernethy
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (S.A., L.A., D.G.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (R.K.); Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (Barry Pizer); Department of Neurosurgery, Alder Hey Children's N.H.S Foundation Trust, Liverpool, UK (Benedetta Pettorini, C.M.)
| | - Deborah Garlick
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (S.A., L.A., D.G.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (R.K.); Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (Barry Pizer); Department of Neurosurgery, Alder Hey Children's N.H.S Foundation Trust, Liverpool, UK (Benedetta Pettorini, C.M.)
| | - Conor Mallucci
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (S.A., L.A., D.G.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (R.K.); Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (Barry Pizer); Department of Neurosurgery, Alder Hey Children's N.H.S Foundation Trust, Liverpool, UK (Benedetta Pettorini, C.M.)
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