A case of marked cerebellar atrophy in a woman with anorexia nervosa and cerebral atrophy and a review of the literature

The cerebellum gains weight: A systematic review of alterations in cerebellar volume and cerebro-cerebellar functional alterations in individuals with eating disorders

BACKGROUND

Brain imaging studies on eating disorders (EDs) often reported volumetric and functional changes involving the cerebellum. Nevertheless, few studies performed in-depth examinations and suggested a cerebellar role in the EDs' pathophysiology.

METHODS

A systematic literature search on volumetric changes and functional alterations involving the cerebellum in individuals with EDs was conducted using PubMed, PsychInfo and Web of Science. This review was conducted according to the Preferred Reporting Items for Systematic Reviews (PRISMA) statement and Rayyan web application for screening studies.

RESULTS

Twenty-four papers reporting cerebellar alterations in individuals with EDs were included in the study: 9 assessing brain volumetric changes, 9 investigating task-based functional brain activation and 6 investigating brain functional connectivity at rest. Most studies focused on anorectic-type EDs (n.22), while fewer involved bulimic-type EDs (n.9) and eating disorders not otherwise specified (n.2), revealing subtypes-specific patterns of altered cerebellar volume and functionality.

CONCLUSIONS

This review proposes critical arguments to consider the cerebellum as a key structure in the pathophysiology of EDs that requires further forthcoming exploration.

Evaluating anorexia-related brain atrophy using MP2RAGE-based morphometry

AIM

To evaluate brain atrophy in anorexic patients by automated cerebral segmentation with the magnetization-prepared 2 rapid acquisition gradient echo (MP2RAGE) MRI sequence.

MATERIAL AND METHODS

Twenty patients (female; mean age, 27.9 years), presenting consecutively for brain MRI between August 2014-December 2016 with clinical suspicion of anorexia nervosa and BMI<18.5 kg/m² were included. Controls were ten healthy females (mean age, 26.5 years). Automated brain morphometry was performed based on MP2RAGE. Means of morphometric results in the two groups were compared and correlation with BMI was analysed.

RESULTS

Significantly lower volumes of total brain, grey matter (GM), white matter (WM), cerebellum and insula were found in anorexic patients. Anorexics had higher volumes of CSF, ventricles, lateral ventricles and third ventricle. When adjusted means for weight and height were compared, the volume of WM and cerebellum were not significantly different. However, volume of WM was significantly affected by weight and positively correlated with BMI. Significant positive correlations were found between BMI and volumes of total brain, GM, cortical GM and WM. BMI was negatively correlated with volumes of CSF and third ventricle.

CONCLUSION

Brain atrophy was demonstrated in anorexic patients with MP2RAGE-based automated segmentation, which seems to reliably estimate brain volume.

KEY POINTS

• Automated brain segmentation based on 3-D MRI seems to reliably estimate brain volume. • This technique detected brain atrophy in patients suffering from anorexia nervosa. • Brain changes in anorexia nervosa can be quantitatively and qualitatively followed-up by MRI.

Brain volumetric abnormalities in patients with anorexia and bulimia nervosa: a voxel-based morphometry study

Recent studies focussing on neuroimaging features of eating disorders have observed that anorexia nervosa (AN) is characterized by significant grey matter (GM) atrophy in many brain regions, especially in the cerebellum and anterior cingulate cortex. To date, no studies have found GM atrophy in bulimia nervosa (BN) or have directly compared patients with AN and BN. We used voxel-based morphometry (VBM) to characterize brain abnormalities in AN and BN patients, comparing them with each other and with a control group, and correlating brain volume with clinical features. We recruited 17 AN, 13 BN and 14 healthy controls. All subjects underwent high-resolution magnetic resonance imaging (MRI) with a T1-weighted 3D image. VBM analysis was carried out with the FSL-VBM 4.1 tool. We found no global atrophy, but regional GM reduction in AN with respect to controls and BN in the cerebellum, fusiform area, supplementary motor area, and occipital cortex, and in the caudate in BN compared to AN and controls. Both groups of patients had a volumetric increase bilaterally in somatosensory regions with respect to controls, in areas that are typically involved in the sensory-motor integration of body stimuli and in mental representation of the body image. Our VBM study documented, for the first time in BN patients, the presence of volumetric alterations and replicated previous findings in AN patients. We evidenced morphological differences between AN and BN, demonstrating in the latter atrophy of the caudate nucleus, a region involved in reward mechanisms and processes of self-regulation, perhaps involved in the genesis of the binge-eating behaviors of this disorder.

Review

Neuroanatomical and functional studies in the eating disorders (ED) are reviewed. Typically, anorexia nervosa (AN) is associated with cerebral spinal fluid spaces enlargement which generally recover as a function of re-feeding. However, specific cortical areas fail to correct in weight restored anorectic patients suggesting trait-related abnormalities. Functional changes in AN associated with starvation reverse with weight recovery, however, reduced 5-HT2A receptor binding may be fundamental to the pathophysiology of AN since this remains after long term weight restoration. Structural studies of bulimia nervosa (BN) provide evidence of brain atrophy, in the absence of significant weight loss but potentially related to chronic dietary restriction. Functional investigations reveal reduced thalamic and hypothalamic serotonin transporter availability in BN which increases with longer illness duration. Thus, BN is associated with substantial structural and functional alterations despite normal weight. Recent advances in neuroimaging techniques and their interpretation are increasing our understanding of normal processes in the control of food intake including neuroanatomical correlates of hunger and satiety. Taken together with the structural and functional changes observed in the ED, neuroimaging provides a powerful platform to identify the underlying trait-related pathophysiological mechanisms in the aetiology and maintenance of AN and BN.

Functional recovery of a patient with anorexia nervosa: physical therapist management in the acute care hospital setting

BACKGROUND AND PURPOSE

People with severe, long-standing anorexia nervosa (AN) often develop physical manifestations of medical starvation. Functional deficits are not well described, and little information is available to guide physical intervention. This case report describes the physical therapy clinical decision-making process and intervention provided to a patient with severe AN.

CASE DESCRIPTION

The patient was a 48-year-old woman admitted to an acute care hospital with medical complications associated with AN and requiring medical stabilization. On admission, she was unable to complete basic functional activities (eg, bed mobility, transfers, ambulation). She was considered at risk for falls, with a score of 17 on the Performance-Oriented Motor Assessment (POMA) and a score of 19.27 seconds on the Timed "Up & Go" Test (TUG). Physical therapist examination and intervention focused on functional testing and training, strengthening, and postural stability training for return to independence.

OUTCOMES

In 9 weeks, the patient returned to independence in basic activities of daily living, as measured by 3 items from the motor domain (bed mobility, transfers, and ambulation) of the Functional Independence Measure, with improvements from 1 ("total assistance") to 6 ("modified independence") on each item. Postural stability improved to "low risk" for falls (POMA score of 24). Her TUG score improved to 11.00 seconds. Walking speed improved from 0.35 to 0.81 m/s. Once she attained medical stability, she was discharged home with her parents with outpatient services.

DISCUSSION

Physical therapist management of this severely deconditioned patient hospitalized with severe AN focused on the restoration of functional activities, with intervention intensity being guided by physiologic responses. Traditional aerobic and endurance training were de-emphasized to minimize kilocalorie expenditure and tendencies toward exercise compulsion in this patient population.

In vivo evidence of global and focal brain alterations in anorexia nervosa

Brain alterations are known to be associated with anorexia nervosa (AN) and tend to be distributed across brain structures, with only a few reports describing focal damage. Magnetic resonance images of 21 anorexic patients with different disease duration and 27 control subjects were acquired and compared using voxel-based morphometry (VBM). Patients had a significant reduction of total white matter (WM) volume and focal gray matter (GM) atrophy in cerebellum, hypothalamus, caudate nucleus and frontal, parietal and temporal areas. The cerebellum was more affected in patients with longer disease duration, whereas the hypothalamic alterations were more pronounced in patients with shorter food restriction. A correlation with body mass index (BMI) and GM was found in the hypothalamus. Our data demonstrate a diffuse reduction of WM together with focal areas of GM atrophy in AN. The finding of a hypothalamic focal atrophy points to hormonal dysfunction and opens the possibility for a central dysregulation of homeostasis. The involvement of temporoparietal areas could account for body image distortion. Finally, the cerebellar GM atrophy confirms previous findings and seems to be a late consequence of AN that could play a role in the chronic phase of the disease.

Anorexia nerviosa y atrofia cerebral en adolescentes

BACKGROUND AND OBJECTIVE

The incidence of cerebral atrophy in patients with anorexia nervosa and its relation to nutritional parameters has not been considered yet.

PATIENTS AND METHOD

The medical records of 55 patients were reviewed. 47 of them underwent a cerebral magnetic resonance, anthropometric and nutritional study.

RESULTS

Cerebral atrophy was found in 10 (21.2%) out of the 47 patients studied. Those patients with cerebral atrophy showed an older age and greater percentage of weight loss than patients without atrophy (p = 0.014 and p = 0.001) but lower triceps skinfold average (p = 0.001).

CONCLUSIONS

Cerebral atrophy is common in patients with anorexia nervosa, mainly in those with a severe weight loss and lower body fat.

Cerebellar atrophy in a patient with anorexia nervosa

Reversible cerebral atrophy (pseudoatrophy) is observable in patients with anorexia nervosa. However, it is extremely rare to see marked cerebellar atrophy.

OBJECTIVES

We report on a patient who developed cerebellar atrophy after the severe deterioration of cardiac and respiratory functions resulting from undernutririon.

RESULTS

A 30-year-old Japanese woman was admitted to the Wakayama Medical University Hospital (Wakayama, Japan) because of unsteadiness of gait. She had a 7-year history of anorexia nervosa and had been admitted to an emergency hospital because of asthenic shock resulting from severe undernutrition at the age of 28. On admission to our hospital, neurologic examination revealed dysarthria and cerebellar ataxia of the trunk and lower extremities without nystagmus. A brain magnetic resonance imaging scan demonstrated marked atrophy of the cerebellum.

DISCUSSION

Because her cerebellar ataxia appeared during severe deterioration of her general condition, and there has been no subsequent progression, it is possible that her cerebellar atrophy was induced by undernutrition.

Regional cerebral hypoperfusion in patients with celiac disease

BACKGROUND

Neurological and psychiatric disorders occur in approximately 10% of patients with celiac disease. Although some of these alterations respond to a gluten-free diet, the etiology of these abnormalities is uncertain. Because of a case report that cerebral hypoperfusion in a celiac patient resolved after a gluten-free diet, we studied brain perfusion changes in untreated celiac patients, treated celiac patients, and healthy controls.

METHODS

A total of 15 untreated celiac patients without conditions affecting brain perfusion were enrolled; none had neurological or psychiatric disorders other than anxiety or depression. We also studied 15 celiac patients who were on a gluten-free diet for almost 1 year, and 24 healthy volunteers of similar sex and age. All subjects underwent cerebral single photon emission computed tomography examination.

RESULTS

Of the 15 untreated celiac patients, 11 (73%) had at least one hypoperfused brain region, compared with only 1 (7%) of the 15 celiac patients on a gluten-free diet and none of the controls (P = 0.01). Cerebral perfusion was significantly lower (P <0.05) in untreated celiac patients, compared with healthy controls, in 7 of 26 brain regions. No significant differences in cerebral perfusion were found between celiac patients on a gluten-free diet and healthy controls.

CONCLUSION

There is evidence of regional cerebral blood flow alteration in untreated celiac patients.

The integration of primary anorexia nervosa and obsessive-compulsive disorder

This paper explores the relationship between primary anorexia nervosa (PAN) and obsessive-compulsive disorder (OCD) in both their concomitant and their sequential presentation. Their clinical descriptions demonstrate the presence of obsessionality and compulsiveness that seem to interface during their course and overlap in their symptomatologies has been noted for over sixty years. However, recent research in this regard is scant. Commonalities in pathophysiology indicate disturbances in neurotransmitters, notably serotonin. Biological challenges have failed to establish a definitive correlation with PAN and OCD, whether in combination or individually. We may postulate that, with limitations, they share some anatomical pathways. The areas affected are the amygdala, cingulum and orbito-frontal cortex. Few studies, however, have been devoted to the treatment of concomitant PAN and OCD.