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Ashida R, Nazar N, Edwards R, Teo M. Cerebellar Mutism Syndrome: An Overview of the Pathophysiology in Relation to the Cerebrocerebellar Anatomy, Risk Factors, Potential Treatments, and Outcomes. World Neurosurg 2021; 153:63-74. [PMID: 34157457 DOI: 10.1016/j.wneu.2021.06.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/11/2021] [Accepted: 06/12/2021] [Indexed: 10/21/2022]
Abstract
Cerebellar mutism syndrome (CMS) is one the most disabling postoperative neurological complications after posterior fossa surgery in children. CMS is characterized by a transient mutism with a typical onset demonstrated within 2 days postoperatively accompanied by associated ataxia, hypotonia, and irritability. Several hypotheses for the anatomical basis of pathophysiology and risk factors have been suggested. However, a definitive theory and treatment protocols have not yet been determined. Animal histological and electrophysiological studies and more recent human imaging studies have demonstrated the existence of a compartmentalized representation of cerebellar function, the understanding of which might provide more information on the pathophysiology. Damage to the dentatothalamocortical pathway and cerebrocerebellar diaschisis have been described as the anatomical substrate to the CMS. The risk factors, which include tumor type, brainstem invasion, tumor localization, tumor size, and vermal splitting technique, have not yet been clearly elucidated. The efficacy of potential pharmacological and speech therapies has been studied in small trials. Long-term motor speech deficits and associated cognitive and behavioral disturbances have now been found to be common among CMS survivors, affecting their development and requiring rehabilitation, leading to significant financial effects on the healthcare system and distress to the family. The aim of the present review was to outline the cerebellar anatomy and function and its connections in relationship to the pathophysiology and to refine the risk factors and treatment strategies for CMS.
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Affiliation(s)
- Reiko Ashida
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Naadir Nazar
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Richard Edwards
- Department of Paediatric Neurosurgery, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Mario Teo
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom.
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Tran S, Lim PS, Bojaxhiu B, Teske C, Baust K, Zepter S, Kliebsch U, Timmermann B, Calaminus G, Weber DC. Clinical outcomes and quality of life in children and adolescents with primary brain tumors treated with pencil beam scanning proton therapy. Pediatr Blood Cancer 2020; 67:e28465. [PMID: 32902137 DOI: 10.1002/pbc.28465] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/01/2020] [Accepted: 05/15/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Long-term treatment-related toxicity may substantially impact well-being, quality of life (QoL), and health of children/adolescents with brain tumors (CBTs). Strategies to reduce toxicity include pencil beam scanning (PBS) proton therapy (PT). This study aims to report clinical outcomes and QoL in PBS-treated CBTs. PROCEDURE We retrospectively reviewed 221 PBS-treated CBTs aged <18 years. Overall-free (OS), disease-free (DFS), and late-toxicity-free survivals (TFS), local control (LC) and distant (DC) brain/spinal control were calculated using Kaplan-Meier estimates. Prospective QoL reports from 206 patients (proxies only ≤4 years old [yo], proxies and patients ≥5 yo) were descriptively analyzed. Median follow-up was 51 months (range, 4-222). RESULTS Median age at diagnosis was 3.1 years (range, 0.3-17.7). The main histologies were ependymoma (n = 88; 39.8%), glioma (n = 37; 16.7%), craniopharyngioma (n = 22; 10.0%), atypical teratoid/rhabdoid tumor (ATRT) (n = 21; 9.5%) and medulloblastoma (n = 15; 6.8%). One hundred sixty (72.4%) patients received chemotherapy. Median PT dose was 54 Gy(relative biological effectiveness) (range, 18.0-64.8). The 5-year OS, DFS, LC, and DC (95% CI) were 79.9% (74-85.8), 65.2% (59.8-70.6), 72.1% (65.4-78.8), and 81.8% (76.3-87.3), respectively. Late PT-related ≥G3 toxicity occurred in 19 (8.6%) patients. The 5-year ≥G3 TFS was 91.0% (86.3-95.7). Three (1.4%) secondary malignancies were observed. Patients aged ≤3 years at PT (P = .044) or receiving chemotherapy (P = .043) experienced more ≥G3 toxicity. ATRT histology independently predicted distant brain failure (P = .046) and death (P = .01). Patients aged ≥5 years self-rated QoL higher than their parents (proxy assessment). Both reported lower social functioning and cognition after PT than at baseline, but near-normal long-term global well-being. QoL was well below normal before and after PT in children ≤4 years. CONCLUSIONS The outcome of CBTs was excellent after PBS. Few patients had late ≥G3 toxicity. Patients aged <5 years showed worse QoL and toxicity outcomes.
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Affiliation(s)
- Sebastien Tran
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Pei S Lim
- Department of Radiation Oncology, University College London Hospitals, London, United Kingdom
| | - Beat Bojaxhiu
- Department of Radiation Oncology, Triemli Hospital, Zurich, Switzerland.,Department of Radiation Oncology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Carmen Teske
- Department of Pediatric Hematology and Oncology, University Hospital Bonn, Bonn, Germany
| | - Katja Baust
- Department of Pediatric Hematology and Oncology, University Hospital Bonn, Bonn, Germany
| | - Stefan Zepter
- Center for Proton Therapy (CPT), Paul Scherrer Institute (PSI), ETH Domain, Villigen, Switzerland
| | - Ulrike Kliebsch
- Center for Proton Therapy (CPT), Paul Scherrer Institute (PSI), ETH Domain, Villigen, Switzerland
| | - Beate Timmermann
- Department of Particle Therapy, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), German Cancer Consortium (DKTK), University Hospital Essen, Essen, Germany
| | - Gabriele Calaminus
- Department of Pediatric Hematology and Oncology, University Hospital Bonn, Bonn, Germany
| | - Damien Charles Weber
- Department of Radiation Oncology, Inselspital, University Hospital Bern, Bern, Switzerland.,Center for Proton Therapy (CPT), Paul Scherrer Institute (PSI), ETH Domain, Villigen, Switzerland.,Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
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