Cerebellar Atrophy in Childhood Arterial Ischemic Stroke

Individualized cerebellar damage predicts the presence of behavioral disorders in children with brainstem tumors

BACKGROUND

Brainstem tumors often cause intractable neurobehavioral issues, which can be a challenge for patients and surgeons. Research on cerebellar changes in these patients is limited, despite symptoms similar to cerebellar injuries. This study aims to investigate cerebellar damage pattern resulting from brainstem tumors and its association with behavioral disorders.

METHODS

This study enrolled 147 children with brainstem tumors. A U-Net-based segmentation algorithm is used to divide their cerebellums into 26 lobules. And these lobules are then used to build a normative model for assessing individual structural deviations. Furthermore, a behavior prediction model is developed using the total outlier count (tOC) index and cerebellar lobule volume as predictive features.

RESULTS

Over 95% of patients are found to have negative deviations in cerebellar regions, particularly in anterior lobules like Left V. Higher tOC is significantly associated with severe social problems (r = 0.31, p = 0.001) and withdrawal behavior (r = 0.28, p = 0.001). Smaller size of cerebellar regions strongly correlates with more pronounced social problems (r = 0.27, p = 0.007) and withdrawal behavior (r = 0.25, p = 0.015). Notably, lobules Right X, V, IV, VIIB, Left IX, VIII, and X influence social problems, while Left V, Right IV, Vermis VI, and VIII impact withdrawal behavior.

CONCLUSIONS

Our study reveals cerebellar damage patterns in patients with brainstem tumors, emphasizing the role of both anterior and posterior cerebellar lobes in social problems and withdrawal behavior. This research sheds light on the cerebro-brainstem-cerebellar underlying complex behavioral disorders in brainstem tumor patients.

Stroke in children and adolescents: Analysis of electrophysiological and behavioral assessment findings of auditory processing

PURPOSE

This study aimed to analyze the auditory processing behavior of children and adolescents diagnosed with stroke and compare it with that of typically developing individuals.

METHODS

This was an analytical cross-sectional study involving 48 participants aged between 7 and 17 years with adequate schooling for age and grade, allocated equally to two groups: Stroke (SG) and Control Groups (CG). For the SG, cases identified between 2003 and 2018 were considered. In the CG, school-aged participants with typical development were randomized. After screening for differential audiological assessment and confirmation of auditory pathway integrity at the brainstem level, binaural analyses of the auditory processing behavior were conducted using the Dichotic Digit Test (DDT), Frequency Pattern Test (FPT), and electrophysiological assessment (P300). The Shapiro-Wilk test for normality was conducted, followed by the T and Mann-Whitney tests, with a 95 % confidence level and significance offset at p < 0.05, using the SPSS software (IBM®, v. 22.) RESULTS: The CG performed better in terms of auditory processing. These differences were significant (p < 0.0001) for the binaural integration of DDT, FPT humming and Labeling, and P300 latency. The P300 results were similar; however, with a greater amplitude in the SG.

CONCLUSION

This study showed that children and adolescents with stroke performed worse in electrophysiological and behavioral tests of auditory processing assessed using the auditory evoked potentials. These data reinforce the hypothesis that stroke-related lesions compromise the neural mechanisms underlying auditory processing.

Perinatal Ischemic Stroke: Etiology and Imaging

Perinatal ischemic stroke is a common cause of lifelong disability.

Neonatal stroke in premature neonates

There are many neuro-imaging studies on the presence of brain lesions in the preterm infant, using cranial ultrasound (cUS) and/or term equivalent age MRI (TEA-MRI). These studies however tend to focus on germinal matrix-intraventricular hemorrhage (GMH-IVH) and white matter injury. Data about perinatal arterial ischemic stroke (PAIS) or cerebral sinovenous thrombosis (CSVT) in the preterm infant are very limited. In fact, several large cohort studies on neuro-imaging in preterm infants do not even mention neonatal stroke.^1-4 Most studies about PAIS exclude preterm infants.⁵ The aim of this review was to provide an update on neonatal stroke in the preterm infant, with a focus on neuro-imaging findings.

Primary Sonic Hedgehog-activated dorsal brainstem medulloblastoma and ipsilateral cerebellar atrophy in an adult

Medulloblastoma (MB) that arises outside the cerebellum from cells of the dorsal brainstem is rare. The most common subtype of MB in the dorsal brainstem is the Wingless (WNT) subtype that contains activating mutations in the WNT pathway effector CTNNB1. Ipsilateral cerebellar hemi-atrophy with a brainstem tumour is a finding that is usually documented with brainstem gangliogliomas as a possible specific imaging sign. We present a case of a 23-year-old female with progressive headache, imbalance on walking, double vision and difficulty in swallowing for a year. Magnetic resonance imaging demonstrated a mass with prominent restricted diffusion on the dorsal surface of the lower brainstem with ipsilateral cerebellar atrophy. The final histopathological diagnosis was a Sonic Hedgehog (SHH)-activated and TP53 wild-type primary lower dorsal brainstem MB. Primary SHH-activated TP53 wild-type dorsal brainstem MB is extremely rare, and as far as we know, the association of the tumour with ipsilateral cerebellar hemi-atrophy in an adult has never been reported. MB should be included in the differential diagnosis of focal dorsal brainstem tumours, even in the presence of ipsilateral cerebellar hemi-atrophy.

Diffusion Imaging of Cerebral Diaschisis in Neonatal Arterial Ischemic Stroke

BACKGROUND

Neonatal arterial ischemic stroke is a leading cause of cerebral palsy and lifelong disability. Diffusion-weighted imaging has revolutionized diagnosis and facilitated outcome prognostication in acute neonatal arterial ischemic stroke. Diaschisis refers to changes in brain areas functionally connected but structurally remote from primary injury. We hypothesized that acute diffusion-weighted imaging can quantify cerebral diaschisis and is associated with outcome from neonatal arterial ischemic stroke.

METHODS

Subjects were identified from a prospective, population-based research cohort (Alberta Perinatal Stroke Project). Inclusion criteria were unilateral middle cerebral artery neonatal arterial ischemic stroke, diffusion-weighted magnetic resonance imaging within 10 days of birth, and more than 12-months follow-up (pediatric stroke outcome measure). Diaschisis was characterized and quantified using a validated software method (ImageJ). Volumetric analysis assessed atrophy of affected structures. Diaschisis scores were corrected for infarct size and compared with outcomes (Mann-Whitney).

RESULTS

From 20 eligible neonatal arterial ischemic strokes, two were excluded for poor image quality. Of 18 remaining (61% male, median age 3.2 days), 16 (89%) demonstrated diaschisis. Thalamus (88%) was the most common location in addition to corpus callosum (50%). Age at imaging was not associated with diaschisis. Affected structures demonstrated atrophy on imaging. Long-term outcomes available in 81% (median age 7.5 years) were not associated with diaschisis scores.

CONCLUSIONS

Cerebral diaschisis occurs in neonatal arterial ischemic stroke and can be quantified with diffusion-weighted imaging. Occurrence is common and should not be mistaken for additional infarction. Determining clinical significance will require larger samples with well-characterized long-term outcomes.

Crossed Cerebellar Diaschisis Has an Adverse Effect on Functional Outcome in the Subacute Rehabilitation Phase of Stroke: A Case-Control Study

OBJECTIVE

To investigate whether crossed cerebellar diaschisis (CCD) is associated with functional outcome in the subacute rehabilitation phase of stroke.

DESIGN

Retrospective case-control study.

SETTING

Hospital-based cohort.

PARTICIPANTS

The study enrolled participants who underwent brain single-photon emission computed tomography (N=48). Patients with CCD were identified (n=24). Twenty-four controls were selected for each case-patient by matching age, stroke type (ischemic or hemorrhagic), lesion laterality, and lesion location.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The functional ambulation category (FAC), modified Barthel Index (MBI), and Mini-Mental State Examination (MMSE) were administered at the initial (initiation of rehabilitation therapy) and the follow-up (4wk after rehabilitation therapy) assessments.

RESULTS

The CCD group had lower MMSE, FAC, MBI, and MMSE scores at the initial assessment (P=.032, .016, and .001, respectively) and lower FAC and MBI scores at the follow-up assessment, than the non-CCD group (P=.001 and .036, respectively). Although CCD was not associated with cognitive impairment, nonambulatory status, and dependent activities of daily living (ADL) at the initial assessment (P=.538, .083, and >.99, respectively), the CCD group had a higher risk of cognitive impairment (adjusted odds ratio [aOR]=4.044; 95% confidence interval [CI], 1.071-15.270; P=.039), nonambulatory status (aOR=7.000; 95% CI, 1.641-29.854; P=.009) and dependent ADL (aOR=13.500; 95% CI, 1.535-118.692; P=.019) at the follow-up assessment.

CONCLUSIONS

CCD is associated with severe functional impairment and may have an adverse effect on functional outcomes related to cognition, ambulatory function, and ADL during the subacute rehabilitation phase of stroke. This suggests that CCD may be a valuable predictor of functional outcome in the subacute rehabilitation phase of stroke.

Thalamic diaschisis following perinatal stroke is associated with clinical disability

BACKGROUND

Perinatal stroke causes most hemiparetic cerebral palsy and leads to lifelong disability. Understanding developmental neuroplasticity following early stroke is increasingly translated into novel therapies. Diaschisis refers to alterations brain structures remote from, but connected to, stroke lesions. Ipsilesional thalamic diaschisis has been described following adult stroke but has not been investigated in perinatal stroke. We hypothesized that thalamic diaschisis occurs in perinatal stroke and its degree would be inversely correlated with clinical motor function.

METHODS

Population-based, controlled cohort study. Participants were children (<19 years) with unilateral perinatal stroke (arterial ischemic stroke [AIS] or periventricular venous infarction [PVI]), anatomical magnetic resonance imaging (MRI) >6 months of age, symptomatic hemiparetic cerebral palsy, and no additional neurologic disorders. Typically developing controls had comparable age and gender proportions. T1-weighted anatomical scans were parcellated into 99 regions of interest followed by generation of regional volumes. The primary outcome was thalamic volume expressed as ipsilesional (ILTV), contralesional (CLTV) and thalamic ratio (CLTV/ILTV). Standardized clinical motor assessments were correlated with thalamic volume metrics.

RESULTS

Fifty-nine participants (12.9 years old ±4.0 years, 46% female) included 20 AIS, 11 PVI, and 28 controls. ILTV was reduced in both AIS and PVI compared to controls (p < .001, p = .029, respectively). Ipsilesional thalamic diaschisis was not associated with clinical motor function. However, CLTV was significantly larger in AIS compared to both controls and PVI (p = .005, p < .001, respectively). CLTV was inversely correlated with all four clinical motor assessments (all p < .003).

CONCLUSION

Bilateral thalamic volume changes occur after perinatal stroke. Ipsilesional volume loss is not associated with clinical motor function. Contralesional volume is inversely correlated with clinical motor function, suggesting the thalamus is involved in the known developmental plasticity that occurs in the contralesional hemisphere after early unilateral injury.

Crossed Cerebellar Atrophy in Perinatal Stroke

Background and Purpose- Perinatal stroke causes most hemiparetic cerebral palsy and lifelong disability. Crossed cerebellar atrophy (CCA) is chronic cerebellar volume loss following contralateral motor pathway injury. We hypothesized that CCA is quantifiable in perinatal stroke and associated with poor motor outcome. Methods- Term-born children with perinatal stroke, magnetic resonance imaging beyond 6 months of age, and no additional neurological disorders were recruited. Blinded scorers measured cerebellar volumes expressed as ratios (contralesional/ipsilesional), with values <1 suggesting CCA. Motor outcomes including perinatal stroke outcome measure (PSOM) motor and cognitive scores (good/poor), Assisting Hand Assessment, and Melbourne Assessment were compared with cerebellar volume measures. Results- Seventy-three children met criteria (53% male). Mean cerebellar ratios were <1.0 (0.975±0.04; range, 0.885-1.079; P<0.001) suggesting occurrence of CCA. Cerebellar ratios did not differ between stroke types or across PSOM motor outcomes. Larger ipsilesional cerebellar volume was associated with poor PSOM cognitive outcome (P=0.042), possibly with poor PSOM motor outcome (P=0.063), and overall PSOM score (P=0.034). Conclusions- CCA occurs in perinatal stroke but is not strongly associated with motor outcome. However, ipsilesional cerebellar volume is associated with poor cognitive and overall outcomes.

O impacto do acidente vascular cerebral na qualidade de vida de crianças e adolescentes

RESUMO O objetivo deste estudo foi avaliar a qualidade de vida (QV) de crianças/adolescentes com diagnóstico de acidente vascular cerebral (AVC) segundo as percepções do responsável e das próprias crianças/adolescentes comparados com um grupo controle (GC). Participaram 78 sujeitos divididos em: Grupo de crianças/adolescentes que tiveram histórico de AVC (GAVC, n=39) e um Grupo de crianças/adolescentes saudáveis como Controle (GC, n=39), sendo pareados por sexo e idade. Utilizou-se de entrevista semiestruturada para descrever os aspectos sociodemográficos e do instrumento Pediatric Quality of Life Inventory (PedsQLTM 4.0) para avaliar a QV dos sujeitos no seu desenvolvimento. A mediana de idade do diagnóstico de AVC do GAVC foi sete meses, sendo que a maioria apresentou AVC isquêmico (71,8%) e hemiparesia. De acordo com os responsáveis do GAVC, a Capacidade Funcional dos seus filhos foi significativamente diferente, apresentando inferioridade em relação ao GC. Para os responsáveis também a variável escolaridade do pai manteve efeito positivo significativo nos aspectos emocionais da criança, e a variável idade da criança/adolescente e tempo do AVC >29 dias de vida apresentou efeito negativo nos aspectos escolares. Já para as crianças/adolescentes, a variável idade em que entrou na escola e gênero apresentou efeito significativo negativo no desfecho de aspectos escolares em relação ao GC. Concluímos que a percepção dos responsáveis difere da percepção da criança/adolescente em relação à capacidade funcional desta; a escolaridade do pai influenciou positivamente nos aspectos emocionais da criança, e as crianças sentem-se com um prejuízo no desempenho escolar, principalmente os meninos.

Impact of Early High-protein Diet on Neurofunctional Recovery in Rats with Ischemic Stroke

BACKGROUND Ischemic stroke, featuring high incidence, morbidity, and mortality, is one of the three major diseases troubling human beings. The purpose of the study was to examine the impact of early high-protein diet on neurofunctional recovery in rats with ischemic stroke as well as their cerebral infarct areas and molecular expressions of oxidative stress. MATERIAL AND METHODS The middle cerebral artery occlusion model (MCAO) was established, and 48 adult, male Sprague Dawley (SD) rats of clean grade aged seven to eight months (250-280 g body weight) were randomized into four groups: the MCAO group with high-protein diet (MH), the MCAO group with standard-protein diet (MS), the sham group with high-protein diet (SH), and the sham group with standard-protein diet (SS). High-protein diet intervention started on the first day of the surgery, and the rats' body weights and their neurological deficit scores were measured on each postoperative day while the scores of motors coordination and balance ability were recorded every other day. In addition, their cerebral infant areas and the molecular expressions of oxidative stress injuries were detected as well. RESULTS Compared to the MS group, the rats in the MH group gained faster weight growth (p<0.05), presented significantly lower neurological impairment scores (p<0.05), remarkably improved motor coordination and balance ability (p<0.05) as well as showed smaller cerebral infarct areas (p<0.05), increased expression of SOD (superoxide dismutase), and reduced expressions of MDA (malondialdehyde) and iNOS (inducible nitric oxide synthase). However, there was no significant difference between the SS group and the SH group (p>0.05). CONCLUSIONS Early high-protein diet facilitates the recovery of body weights and neurological functions as well the reduction of the cerebral infarct areas of rats, thus alleviating ischemic stroke-caused oxidative stress injuries.

Diffusion imaging of cerebral diaschisis in childhood arterial ischemic stroke

BACKGROUND

Diffusion-weighted imaging magnetic resonance imaging may detect changes in brain structures remote but connected to stroke consistent with neuropathological descriptions of diaschisis. Early diffusion-weighted imaging demonstrates restriction in corticospinal pathways after arterial ischemic stroke of all ages that correlates with motor outcome.

AIM/HYPOTHESIS

We hypothesized that cerebral diaschisis is measurable in childhood arterial ischemic stroke and explored associations with outcome.

METHODS

This sub-study of the validation of the Pediatric NIH Stroke Scale study prospectively enrolled children with acute arterial ischemic stroke and both acute and early follow-up (5-14 days) diffusion-weighted imaging. Inclusion criteria were (1) unilateral middle cerebral artery arterial ischemic stroke, (2) acute and subacute diffusion-weighted imaging (b = 1000), and (3) 12 month neurological follow-up (Pediatric Stroke Outcome Measure). A validated method using ImageJ software quantified diffusion-weighted imaging diaschisis in anatomically connected structures. Diaschisis measures were corrected for infarct volume, compared to age, imaging timing, and outcomes (Chi square/Fisher, Mann-Whitney test).

RESULTS

Nineteen children (53% male, median 8.1 years) had magnetic resonance imaging at medians of 21 and 168 h post-stroke onset. Diaschisis was common and evolved over time, observed in one (5%) on acute but eight (42%) by follow-up diffusion-weighted imaging. Thalamic and callosal diaschisis were most common (5, 26%). Estimates of perilesional diaschisis varied (54 ± 18% of infarct volume). Children with diaschisis tended to be younger (7.02 ± 5.4 vs. 11.82 ± 4.3 years, p = 0.08). Total diaschisis score was associated with poor cognitive outcomes (p = 0.03). Corticospinal tract diaschisis was associated with motor outcome (p = 0.004). Method reliability was excellent.

CONCLUSIONS

Diffusion-weighted imaging diaschisis occurs in childhood arterial ischemic stroke. Mistaking diaschisis for new areas of infarction carries important clinical implications. Improved recognition and study are required to establish clinical relevance.

Increased brain iron deposition is a risk factor for brain atrophy in patients with haemodialysis: a combined study of quantitative susceptibility mapping and whole brain volume analysis

To explore the correlation between increased brain iron deposition and brain atrophy in patients with haemodialysis and their correlation with clinical biomarkers and neuropsychological test. Forty two patients with haemodialysis and forty one age- and gender-matched healthy controls were recruited in this prospective study. 3D whole brain high resolution T1WI and susceptibility weighted imaging were scanned on a 3 T MRI system. The brain volume was analyzed using voxel-based morphometry (VBM) in patients and to compare with that of healthy controls. Quantitative susceptibility mapping was used to measure and compare the susceptibility of different structures between patients and healthy controls. Correlation analysis was used to investigate the relationship between the brain volume, iron deposition and neuropsychological scores. Stepwise multiple regression analysis was used to explore the effect of clinical biomarkers on the brain volumes in patients. Compared with healthy controls, patients with haemodialysis showed decreased volume of bilateral putamen and left insular lobe (All P < 0.05). Susceptibilities of bilateral caudate head, putamen, substantia nigra, red nucleus and dentate nucleus were significantly higher (All P < 0.05). The increased brain iron deposition is negatively correlated with the decreased volume of bilateral putamen (P < 0.01). Neuropsychological scores positively correlated with decreased volume of left insular lobe (P < 0.05). Dialysis duration was negatively associated with decreased volume of bilateral putamen (P < 0.05). Our study indicated increased brain iron deposition and dialysis duration was risk factors for brain atrophy in patients with haemodialysis. The decreased gray matter volume of the left insular lobe was correlated with neurocognitive impairment.

Corticopontocerebellar Connectivity Disruption in Congenital Hemiplegia

BACKGROUND

Crossed cerebellar diaschisis is the disruption of functional connectivity between cerebrum and cerebellum after hemispheric unilateral brain lesions. In adults and to a lesser extent in children, crossed cerebellar diaschisis has been largely investigated by functional connectivity and demonstrated to influence paretic hand function.

OBJECTIVE

We aim to demonstrate a disruption in structural corticopontocerebellar (CPC) connectivity in children with congenital brain lesions and examine its correlation with paretic hand motor function.

METHODS

Thirty-six children (Manual Ability Classification System: I, n = 21; II, n = 15) with unilateral brain lesions and 18 controls were analyzed in a case-control study, and diffusion magnetic resonance imaging data were acquired at 3T. High angular resolution diffusion imaging probabilistic tractography was employed for the region of interest-based reconstruction of CPC tracts. To identify statistical differences in structural cerebrocerebellar connectivity between case and control groups, an asymmetry index based on the number of streamlines of CPC tracts was used. In the case group, the correlation between asymmetry index and hand function measures was also determined.

RESULTS

Projections through the middle cerebellar peduncle to the contralateral cerebral cortex showed greater asymmetry in children with congenital unilateral brain lesion compared to controls (P = .03), thus indicating a disruption of structural cerebrocerebellar connectivity. The degree of asymmetry index showed a correlation (P < .03; r = -0.31) with impaired hand abilities in bimanual tasks.

CONCLUSIONS

Disruption of structural cerebrocerebellar connectivity is present in patients with congenital unilateral brain injury and might be related to impaired hand function in bimanual skills, with potential implication in tailoring early intervention strategies.