Magnetic resonance imaging findings in acute cerebellitis

A Novel Radiological Score System to Assess the Clinical Severity in Patients with Acute Cerebellitis

To develop a radiological score system to assess the severity of acute cerebellitis (AC) and to compare radiological severity score at the onset to cerebellar atrophy at follow-up. Clinical and MRI findings were recorded in 16 patients with AC. Radiological severity score considering topographic patterns, gray/white matter involvement, enhancement, tonsillar herniation or hydrocephalus development and clinical severity score taking into account clinical symptoms were assessed for each patient at the onset of the symptoms. Radiological and neurological sequelae were assessed at follow-up. At symptoms onset, clinical severity scale ranged from mild to severe and radiological severity score ranged from 3 to 7 with higher scores indicating a greater severity. The cut-off value of 5 for radiological score well segregated severe patients defined by clinical scale. A significant correlation between clinical scale and radiological severity scores (p < 0.001, r = 0.75) was found. At follow-up visit, all children developed cerebellar atrophy and 5 children showed neurologic sequelae while adults showed complete resolution without atrophy. Patients in whom atrophy was not observed had both older ages (p < 0.001) and a focal cerebellar involvement (p = 0.03). In patients with AC, radiological severity score may be a useful tool in evaluating clinical severity, but it is not capable to predict neither neurological sequelae nor evolution towards atrophy. Cerebellar atrophy, observed in children with AC, may be caused by several factors such as the age of patient and the extension of cerebellar involvement and it may be counterbalanced by neuronal restoring processes due to neuroplasticity.

Anti-homer-3 Antibody Encephalitis in a 10-Year-Old Child: Case Report and Review of the Literature

Objective

We present a rare case with anti-Homer-3 antibodies positive encephalitis in the youngest patient ever identified and reviewed the literature.

Case Report

A 10-year-old, Chinese boy came for evaluation of a 2-week history of cognitive impairment, irritability, dysarthria, and cautious gait. The neurological examination was consistent with the pan-cerebellar syndrome and encephalopathy. Cerebrospinal fluid (CSF) was inflammatory with increased leukocytes. Magnetic resonance imaging of the brain showed hyperintensities in both cerebellar hemispheres and vermis in Fluid-attenuated inversion recovery (FLAIR) and T2- weighted sequences. Infectious disorders were ruled out, but positivity for anti-Homer-3 antibodies was detected in the CSF, but not in the serum. Additionally, low titers of voltage-gated calcium channel (VGCC) antibodies were found in the serum. Treatment with intravenous (IV) corticosteroids did not provide meaningful clinical improvement; however, the patient achieved almost complete recovery (modified Ranking Scale score: 1) following IV immunoglobulin.

Conclusion

Anti-Homer-3 cerebellar ataxia with encephalopathy should be considered within the differential diagnosis of acute inflammatory cerebellar disease in children and it may coexist with VGCC antibodies.

A Case of Influenza Virus-Induced Acute Cerebellitis Treated with Steroid Pulse Therapy

Acute cerebellitis (AC) is characterized by acute onset cerebellar ataxia brain magnetic resonance imaging (MRI) abnormalities of the cerebellum. The most common cause of AC is viral infection, and some patients with AC experience neurological sequelae. AC associated with influenza virus is extremely rare, and its prognosis and treatment are unknown. We present the case of a 2-year-old boy with influenza virus-induced AC who was treated with pulse steroid therapy. The patient presented with fever, anorexia, vomiting, malaise, altered consciousness, truncal ataxia, dysmetria, and dysarthria. He was diagnosed with influenza using a nasopharyngeal antigen test. Brain MRI showed hyperintense T2 and diffusion-weighted signal abnormalities in the cerebellar white matter and dentate nuclei bilaterally. The patient was treated with two courses of pulse methylprednisolone therapy and recovered completely in 2 months after the onset. The prognosis of AC is poorer than that of acute cerebellar ataxia, which shows similar symptoms to AC with normal brain MRI. The type of virus might also be associated with the prognosis of AC. Literature review showed that one of the five cases (including the present case, 20%) reported with influenza-associated AC was noted to have neurological sequelae, which might be more severe than those of varicella-zoster-related AC. Given that the pathogenesis of AC is assumed to be immune-mediated, pulse methylprednisolone therapy might be a good option for the treatment of influenza virus-induced AC.

Imaging pitfalls in paediatric posterior fossa neoplastic and non-neoplastic lesions

Paediatric posterior fossa lesions can have much overlap in their clinical and radiological presentation. There are, however, a number of key imaging features that can help the reading radiologist to distinguish tumours from important tumour mimics which are often inflammatory or metabolic entities. This pictorial review provides a number of important cases that proved challenging on imaging and illustrates some common pitfalls when interpreting lesions in the posterior fossa in children. Not everything that is abnormal will be a tumour, but often other causes are overlooked and misinterpreted as tumours, leading to great morbidity for that child. This article highlights some lesions that were mistaken as tumours and will introduce the reader to less commonly seen pathologies which are important to consider on a differential list for this location.

Acute hemicerebellitis in a child: a case report of a rare neuropsychiatric disorder

BACKGROUND

Acute cerebellitis is an inflammatory process commonly involving both cerebellar hemispheres. Bilateral cerebellar hemisphere involvement is the most common finding. Acute hemicerebellitis in childhood is an extremely rare unilateral presentation of cerebellitis mimicking a tumor. Its etiology is unknown, although an inflammatory or post infectious origin is presumed. Its clinical outcome is generally good and a self-limited evolution. Clinical improvement and regression of the pathological findings in serial MRI will help differentiate acute hemicerebellitis from a neoplastic process.

CASE PRESENTATION

We present a case of hemicerebellitis in a 7-year-old girl, presenting with severe headache, projectile vomiting, and mixed neuropsychiatric manifestation. MRI of the brain revealed a unilateral cerebellar involvement.

Acute Ataxia in Childhood: 11-Year Experience at a Major Pediatric Neurology Referral Center

We categorized the causes of acute ataxia in the pediatric population-referred to the Division of Neurology-at a large, urban pediatric medical center. Of the 120 cases identified over the past 11 years, post-infectious cerebellar ataxia was the most commonly diagnosed (59%), followed by drug intoxication, opsoclonus-myoclonus ataxia syndrome, episodic ataxia, acute cerebellitis, cerebellar stroke, ADEM, meningitis, cerebral vein thrombosis, Leigh's disease, Miller-Fisher syndrome, and concussion. Among the patients with post-infectious cerebellar ataxia, 85% were 1-6 years old and all had a history of antecedent viral illness. CSF pleocytosis was present in 40% of patients; all had normal brain MRIs. The majority (91%) recovered within 30 days. We conclude that post-infectious cerebellar ataxia remains the most common cause of acute ataxia in childhood and that it carries a good prognosis. We also differentiate acute post-infectious cerebellar ataxia from other causes with similar presentations.

Subclinical immune reactions to viral infections may correlate with child and adolescent diagnosis of attention-deficit/hyperactivity disorder: a preliminary study from Turkey

BACKGROUND

Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most common neuro-developmental disorders of childhood and adolescence. Studies focusing on the relationship of infectious agents and ADHD are scarce. It is also known that cerebellar injury may lead to hyperactive behavior. This study aimed to evaluate the relationship between viral agents of cerebellitis and the diagnosis of ADHD.

METHODS

The study group was formed of 60 consecutive ADHD patients and 30 healthy children. IgG levels for VZV; HSV-1, CMV, Measles, Mumps, Rubella and EBV were evaluated.

RESULTS

Males were significantly higher among patients with ADHD (65% vs. 40%, p=0.025). Patients with ADHD displayed significantly higher positivity for measles IgG (80% vs. 60%, p=0.044). When patients with ADHD were classified according to their pubertal status, adolescents with ADHD displayed higher positivity for mumps (100% vs. 74.4%, p=0.043). Most of the patients were diagnosed with ADHD-Combined or Hyperactive/Impulsive Subtypes (56.6%) while 43.3% were diagnosed with ADHD-predominantly inattentive type. When patients with subtypes of ADHD were compared in terms of seropositivity, it was found that patients with ADHD-Combined/ Hyperactive-Impulsive subtypes had significantly elevated reactions for Rubella (100% vs. 88.5%, p=0.044).

CONCLUSION

Although limited to a single center and may be prone to sampling biases, our results may support the notion that immune reactions may be related with ADHD among children and adolescents. Further, prospective studies from multiple centers are needed to support our findings and establish causality.

An unusual cause of altered mental status in elderly-acute cerebellitis: a case report and review

Acute cerebellitis is a rare diagnosis found mostly in the pediatric population. The etiology, in most instances, is unknown. We describe the case of a 61-year-old woman who presented with acute mental status changes, signs of cerebellar dysfunction, and MRI findings of acute cerebellitis. A brief review of the existing literature and comparison of our case with previous reports are also presented.

Cerebellitis developing after tricyclic antidepressant poisoning

Acute cerebellitis is a rare inflammatory disease involving the cerebellum and is characterized by acute compromise of cerebellar functions. It most frequently originates from infectious causes, although cases of cerebellitis associated with other causes have also been reported. This report discusses a case of cerebellitis developing in a 4-year-old girl who had to be intubated after accidental ingestion of tricyclic antidepressant. There are no previous reports of cerebellitis after tricyclic antidepressant. This case shows that cerebellitis can develop in patients with poisoning of this kind.

Heroin spongiform leukoencephalopathy (HSLE)

PURPOSE

An increasing number of heroin addicts-especially young and first-time users-prefer inhaling the drug to intravenous injection. A rare complication of inhaling heroin is the development of a spongiform leukoencephalopathy (HSLE).

METHODS

Pathological background, symptoms, imaging, and therapeutical options are discussed on the basis of an example case.

RESULTS

Pathophysiologically, a dysfunction of the oligodendrocyte mitochondria is suspected. Three distinct stages based on key symptoms are defined. Patients may remain in one stage, or pass through two, or all three stages. Magnetic resonance imaging (MRI) is necessary for diagnosis. There are few therapeutical options. Antioxidants and coenzyme Q may be beneficial. The disorder is self-limiting in the majority of cases. Complications such as hydrocephalus and diffuse cerebellar swelling may, however, require neurosurgical intervention.

CONCLUSIONS

HSLE is a rare occurrence in patients with heroin abuse. The number of undetected cases in drug-related deaths may be high. Clinical appearance may be easily mistaken for withdrawal symptoms.

Chronological diffusion-weighted imaging changes and mutism in the course of rotavirus-associated acute cerebellitis/cerebellopathy concurrent with encephalitis/encephalopathy

Rotavirus is one of the most common causes of gastroenteritis in children and is known to accompany some neurological disorders such as encephalitis/encephalopathy and seizures. Although cerebellar disorders sometime occur as a complication of rotavirus gastroenteritis in Japan, few reports have addressed these issues. Here, we report three cases of insulted cerebellums in addition to encephalitis/encephalopathy associated with rotavirus. Similar to posterior fossa syndrome after surgery, mutism was a notable symptom that lasted about 1 month. Brain diffusion-weighted imaging (DWI) revealed chronological changes, i.e., marked hyperintensity in the bilateral dentate nucleus followed by the vermis and cerebellar hemisphere. The bilateral dentate nucleus is known to be a key lesion site for mutism, and these clinical and radiological findings may be tightly connected in rotavirus-associated cerebellitis/cerebellopathy.

Pseudotumoural Hemicerebellitis: Conventional MR Imaging and MR Spectroscopy Evolution

Acute cerebellitis is an inflammatory process commonly involving both cerebellar hemispheres. Bilateral cerebellar hemispheres involvement is the most common finding. It typically occurs as a primary infectious, post-infectious or post-vaccination disorder, but is also a disease entity with heterogeneous pathogenesis including paraneoplasia. Acute cerebellitis is usually a benign, self-limiting and rarely fatal disease. Typically, cerebellar atrophy is a late consequence of the syndrome. We describe the radiological features of a case of pseudotumoural hemicerebellitis with emphasis on MRI and spectroscopy findings as non-invasive diagnostic tools to avoid unnecessary surgical procedures.

Acute cerebellitis with cerebellar swelling successfully treated with standard dexamethasone treatment

Although cerebellitis is common in childhood but cerebellitis with cerebellar swelling is rarely reported. Pulsed high dose methylprednisolone treatment is the choice of treatment for cases who have non-progressive symptoms. An 8-year-old girl presented acutely with vertigo, headache, and vomiting. Brain magnetic resonance imaging showed marked bilateral cerebellar swelling with increased signal on T2-weighted imaging. Following treatment with standard dexamethasone dose, the clinical and radiological signs resolved in 1 week. We conclude that standard dexamethasone treatment should be used in mild cases of acute cerebellitis in order to avoid adverse reactions of pulsed high dose methylprednisolone treatment.

Postoperative hemicerebellar inflammation mimicking recurrent tumor after resection of a medulloblastoma. Case report

The authors present the case of a 4-year-old boy in whom a medulloblastoma in the left cerebellar hemisphere was successfully resected with no signs of residual tumor on the postoperative magnetic resonance (MR) images. A second MR imaging study performed 1 month after surgery demonstrated an extensive, contrast-enhancing lesion in the left cerebellar hemisphere, which simulated massive recurrent tumor, and repeated surgery was considered. A third postoperative MR imaging study, performed for evaluation of the craniospinal axis 10 days after the second postoperative study, still showed some contrast enhancement in the left cerebellar hemisphere, but the lesion had almost disappeared. Postoperative hemicerebellar inflammation seemed to be the most likely explanation. This case illustrates that early postoperative inflammation can mimic recurrent tumor on MR images obtained after resection of a medulloblastoma and caution should be taken in interpreting such images. Clinical history, neurological examination, laboratory findings, and repeated MR imaging studies can be helpful in evaluating the patient accurately.

Severe cerebellitis following methadone poisoning

We report a 3-year-old girl with an unusual presentation of cerebellitis following ingestion of methadone. CT showed diffuse symmetrical swelling and oedema of the cerebellum resulting in compression of the fourth ventricle and hydrocephalus. The changes were confirmed on MRI with the addition of watershed injuries. These findings represent a toxic encephalopathy and have been reported in previous cases of heroin intoxication by inhalation, but rarely following opioid ingestion. The aetiology of the watershed infarcts is discussed.

+H-proton-magnetic resonance spectroscopic findings in a patient with acute hemicerebellitis presenting without localized signs: a case report

Acute cerebellitis (AC) is an inflammatory process involving the cerebellum. Usually, this pathology is bilateral; it is unusual to have a unilateral cerebellitis. Only seven cases of hemicerebellitis have been reported in the literature. Here, we review the literature and report the magnetic resonance imaging (MRI) and proton-magnetic resonance spectroscopic (+H-MRS) findings of a case of acute hemicerebellitis in a 15-year-old girl presenting with 15 days' history of headache.

Cerebellar atrophy attributed to cerebellitis in two patients

In a review of magnetic resonance (MR) images from patients with spinocerebellar degeneration (SCD), we found 2 rare patients considered to be in late-stage cerebellitis who showed isolated cerebellar atrophy. The patients were negative for the spinocerebellar ataxia (SCA) genes and had no symptoms of hypothyroidism, history of malignant tumors, or history of alcohol and drug (phenytoin) abuse, which may cause cerebellar atrophy. MR images demonstrated generalized atrophy of the cerebellum, excluding the brainstem or cerebrum. In these cases, moreover, slightly high intensities were noted in the affected cerebellar cortices on fluid-attenuated inversion recovery (FLAIR) images. The distribution of widening of the folia and cortical high intensities on FLAIR images might be important clues with which to diagnose late-stage cerebellitis.

Imagerie des cérébellites aiguës chez l’enfant

Acute cerebellitis is one of the main causes of acute cerebellar dysfunction in children. It is either infectious, usually viral, post-infectious or post vaccinal in etiology. Diagnosing acute cerebellitis may be difficult in patients with only subtle cerebellar signs and when cerebro-spinal fluid examination is normal. MRI is the most adequate imaging technique to demonstrate cerebellar involvement. The authors report the clinical and neuro-imaging findings in 4 paediatric cases. Patient's age varied from 2 to 7 years and predominant clinical symptoms were fever, headache and vomiting; ataxia was noted only in 2 cases. Viral serologic tests were negative in 3 cases and demonstrated Epstein-Barr virus in 1. Initial MRI examination (2 cases) demonstrated increased intensity on T2W and Flair sequences of the cerebellar gray matter with pial enhancement. Clinical outcome was good with complete resolution of symptoms in 3 cases and persistent mild right upper limb paresis in one. The resolution of the signal abnormality was well demonstrated on MRI in one case, suggesting an inflammatory etiology with moderate residual cerebellar atrophy.

The role of posterior fossa decompression in acute cerebellitis

BACKGROUND

We present two cases of children who were diagnosed with cerebellitis with acute cerebellar swelling. This rare pathology is potentially fatal, and no clear treatment guidelines are described in the literature.

DISCUSSION

Considering our experience, we discuss the different therapeutic strategies and propose aggressive surgical measures consisting of external ventricular drainage and posterior fossa decompression in case of failure of early response to medical treatment to limit secondary cerebellar and brainstem lesions.

MRI findings in acute cerebellitis

Acute cerebellitis is an inflammatory process involving the cerebellum. We report the clinical, CT and MRI features of four cases and a review of the literature. Bilateral diffuse hemispheric abnormalities represent the most common imaging presentations. Our observations demonstrate the various imaging appearances of acute cerebellitis. Simultaneous involvement of both hemispheres and the vermis has not been reported previously. The development of cerebellar atrophy following an initial normal MR imaging examination is also a new finding. In atypical clinical presentation, MR imaging can lead to the diagnosis. MR imaging findings have, however, no prognostic value.

Transient cerebellar mutism in the course of acute cerebellitis

Transient mutism after posterior fossa surgery in children or associated with cerebellar hemorrhage or trauma is a recognized phenomenon. However, its association with parainflammatory cerebellitis has been rarely described. We report on a previously healthy 3-year-old child with severe cerebellitis after acute gastroenteritis of unidentified cause. Severe ataxia and transient mutism were the prevailing clinical features. Magnetic resonance imaging revealed swelling of the cerebellum with protruding cerebellar tonsils at the level of the occipital foramen. Recovery from the acute illness was slow and incomplete. Residual cerebellar dysfunction manifested with dysphonic and dysarthric speech, as well as motor coordination problems and was associated with atrophy of the vermis and cerebellar hemispheres in follow-up studies.

[Description and prognostic value of cerebellar MRI lesions in children with severe acute ataxia]

The aim of this work was to evaluate NMR cerebellar abnormalities in children with severe acute ataxia. Among 8 consecutively observed children, NMR performed in 6 during the acute phase was pathological in 4, demonstrating hyperintense signal in the T2-weighed sequences of dentate nuclei (2 cases, associated in 1 with hyperintense signal in the medium cerebellar peduncle) or of the cerebellar cortex associated with cerebellar swelling (2 cases). NMR performed in 7 cases after at least 1 month of evolution showed cerebellar atrophy in 4 cases. After 1 to 6 years of clinical follow-up, 4/8 children had clinical sequellae, including 3 of the 4 children with initially abnormal NMR. Conversely, the 2 patients with initially normal NMR had a good clinical recovery. NMR during the acute phase gives informations on prognosis in patients with severe acute ataxia.

Acute cerebellitis caused by herpes simplex virus type 1

Cerebellar disorders due to herpes simplex virus (HSV) infection are rare and always associated with herpes simplex encephalitis. We report 2 cases of severe primary acute cerebellitis caused by HSV type 1 that were identified by nested polymerase chain reaction performed on cerebrospinal fluid samples.

Hemicerebellitis mimicking a tumour on MRI

CASE REPORT

We report a case of hemicerebellitis in a 13-year-old girl presenting with symptoms of intracranial hypertension with acute onset.

RESULTS

MRI of the brain revealed a unilateral cerebellar swelling with foliaform enhancement. The patient was still symptomatic even with high doses of intravenous steroids, so we decided to operate on her for diagnosis and decompression. The pathology showed leptomeningitis. She had a good postoperative outcome and a normal brain MRI 2 months later.

DISCUSSION

It is unusual to have a unilateral cerebellitis; only two cases have been published so far.

CONCLUSION

Although cerebellitis is considered to be benign and self limited, surgical intervention is sometimes mandatory.

Near-fatal cerebellar swelling caused by acute multifocal cerebellar necrosis

We report a case of acute near-fatal cerebellar swelling, which was accompanied by multifocal cerebellar necrosis. Acute, near-fatal cerebellar swelling is a rare problem thought to be of parainfectious aetiology. Initiation by multifocal cerebellar necrosis has not been reported so far with this disorder.

Proton MR spectroscopy of cerebellitis

Single voxel proton MR spectroscopy ((1)H-MRS) of the vermis was obtained in two patients with cerebellitis. In the acute phase (1)H-MRS revealed low N-acetyl-aspartate (NAA)/creatine (Cr) and NAA/choline (Cho) and normal Cho/Cr ratios. Decrease of the concentration of NAA was confirmed by quantitative analysis in one patient. The NAA/Cr and NAA/Cho ratios and NAA concentration were increased in (1)H-MRS examinations obtained 10 and 24 months after the acute episode. (1)H-MRS demonstrates reversible metabolite changes in cerebellitis.

Acute cerebellitis

Many recent reports of acute cerebellitis with a critical or potentially critical course have changed the conception of the disease from an acute cerebellar ataxia with a benign course to a notable disease entity with a heterogeneous pathogenesis. The most characteristic finding by magnetic resonance imaging is diffuse cortical swelling of the cerebellum, often complicated by hydrocephalus or tonsillar herniation. A timely assessment and appropriate choice of treatment, including surgical intervention when indicated, are key to improving the outcome of affected patients.

Neuroimaging of acute cerebellitis

Acute cerebellitis is one of the main causes of acute cerebellar dysfunction in childhood and may be infectious, postinfectious, or postvaccination. The etiology of acute cerebellitis is usually viral. Varicella zoster, Epsten-Barr, rubeola, pertussis, diphtheria, and coxsackie viruses are the most frequently involved agents. Diagnosing of acute cerebellitis can sometimes be difficult because the patient may present only mild cerebellar signs and the examination of cerebrospinal fluid may be normal. The authors present the clinical and neuroimaging findings of 2 patients presenting with acute cerebellitis. Their magnetic resonance imaging showed hyperintense signal of cerebellar gray matter in T2-weighted sequences, which is a strong indication of a diagnosis of acute cerebellitis.

Cerebelite aguda causada por vírus Epstein-Barr: relato de caso

A cerebelite aguda pode ocorrer em associação a infecção pelo vírus da varicela-zoster, enterovirus, caxumba, micoplasma e outros agentes infecciosos. A cerebelite aguda é uma complicação rara da infecção pelo vírus Epstein-Barr (EBV). Relatamos o caso de uma mulher de 21 anos com história de 12 dias de evolução com náuseas, vômitos, ataxia de marcha e membros, tremor cefálico e de membros, opsoclono, mioclonias e rash cutâneo. Sorologia para EBV foi positiva. A infecção pelo EBV, com complicações neurológicas, pode não se apresentar com os sinais e sintomas clássicos da mononucleose infeciosa.

Cerebellar stimulation in acute cerebellar ataxia

OBJECTIVES

To report follow-up studies of cerebellar stimulation in patients with acute cerebellar ataxia (ACA).

METHODS

We studied two patients with ACA. One patient also had decreased deep sensations in the feet due to combined diseases such as diabetic polyneuropathy and lumbosacral radiculopathies. We applied the technique of electrical stimulation over the cerebellum which was reported previously (Ugawa et al., J Physiol 441 (1991a) 57).

RESULTS

Conditioning stimulation over the cerebellum did not reduce the size of motor-evoked potentials to test magnetic stimulation of the motor cortex at conditioning-test intervals of 5, 6, and 7 ms in the acute stage in both patients. However, normal suppression was recognized in the recovery stage in both patients.

CONCLUSIONS

This technique was useful for follow-up evaluation of cerebellar function in patients with ACA and was also useful for distinguishing cerebellar ataxia from sensory ataxia in a patient with combined diseases.