Cerebellar cognitive affective syndrome after acute cerebellar stroke

Validation of the Spanish version of the cerebellar cognitive-affective syndrome scale

Objective: To validate the Spanish version of the Cerebellar Cognitive-Affective Syndrome scale (CCAS-S), originally published in 2018, in patients with cerebellar ataxia and healthy subjects, as an adapted Spanish version based on normative data has not yet been published or validated. Methods: Spanish CCAS-S was -administered prospectively to 158 patients with cerebellar ataxia and 164 matched healthy subjects from -different regions of Spain. Discriminant validity and reliability were evaluated. A subgroup of 30 patients underwent detailed neuropsychological examinations to confirm the construct validity. The Scale for the Assessment and Rating of Ataxia (SARA) and the Brief Ataxia Rating Scale (BARS) were used to assess motor performance. Results: This Spanish instrument demonstrates reliability and exhibits statistically significant differences in performance between patients and healthy subjects. Our analysis revealed lower values for specificity in detecting possible, probable, or definite CCAS compared to those reported in the US validation study when utilizing the original cutoff values. Upon application of the appropriate -correction factor for education, the specificity values approximated those reported for probable and definite CCAS diagnostics in the original investigation. Conclusions: The adapted Spanish CCAS-S has demonstrated validity and good reliability in this cohort. Discriminant validity was satisfactory for probable and definite CCAS when the correction for education was applied, and modified template and instructions have been developed. Further research is necessary to investigate the significance of the possible CCAS category, as diagnosed using the Spanish version, as well as to assess the performance of the corrected scale in other Spanish-speaking countries.

Optimizing selectivity of the Cerebellar Cognitive Affective Syndrome Scale by use of correction formulas, and validation of its German version

BACKGROUND

Cerebellar disease may result in Cerebellar Cognitive Affective Syndrome (CCAS). The CCAS-Scale, designed to screen for CCAS, has been validated in English Hoche (Brain 141:248-270, 2018) and adapted to other languages.

METHODS

Here, the German CCAS-Scale Thieme (Neurol Res Pract 2:39, 2020) was validated in 209 patients with cerebellar disorders and 232 healthy controls. Correction formulas for the outcome parameters [failed test items (range: 1-10) and sum raw score (range: 0-120)] were developed, controlling for age, education, and sex effects. Diagnostic accuracy and reliability were assessed.

RESULTS

Correction formulas improved selectivity in controls, reducing false positives (failed items: 40%; sum score: 13% vs. original method Hoche (Brain 141:248-270, 2018): 67%), while maintaining moderate sensitivity (failed items: 69%; sum score: 48% vs. original method Hoche (Brain 141:248-270, 2018): 87%). Word fluency tests differentiated best between patients and controls, while other items did not. Internal consistency (α = 0.71) was acceptable. Removal of word fluency tests worsened it. Retest and interrater reliability were high [intraclass correlation coefficients (ICC): 0.77-0.95]. However, these ICCs yielded a large minimal detectable change (MDC; 2.2-2.4 failed items, 9.5-11.4 raw score points) in patients, limiting the use of the CCAS-Scale in follow-up examinations.

CONCLUSION

The correction formulas improved diagnostic accuracy of the CCAS-Scale, particularly for the sum raw score. Therefore, we recommend using the corrected sum raw score for evaluation instead of the uncorrected number of failed items, proposed originally Hoche (Brain 141:248-270, 2018). Some test items, however, did not differentiate well between patients and controls and MDCs were large, highlighting the need for refined CCAS assessment instruments as progression or treatment outcomes.

Exploring neuropsychiatric symptoms in Friedreich ataxia

Neuropsychiatric symptoms (NPS) are common in hereditary ataxias as a part of the cerebellar cognitive affective syndrome. In Friedreich ataxia (FRDA), one of the most common hereditary ataxias, depressive symptoms were previously reported, but little is known about other NPS. We aimed to study the presence and severity of a broad range of NPS in individuals with FRDA and assess the relationship between the NPS and the disease severity, cognition, and quality of life and to examine the concordance between the NPS reported by the patients and by their informants. Mild Behavioral Impairment Checklist (MBI-C), a questionnaire designed for screening NPS in the early stages of neurodegenerative diseases, was administered to informants of individuals with FRDA and healthy controls and to people with FRDA themselves. Compared to healthy controls, patients with FRDA scored significantly higher in the total MBI-C score, emotion dysregulation domain (corresponding to depression and anxiety), and decreased motivation domain. When assessed by caregiver, the total MBI-C score and several NPS domains correlated with activities of daily living. Only psychotic symptoms were related to ataxia severity and general cognition. When endorsed by patients, only the relation between few MBI-C domains and quality of life was observed. We found slight to moderate agreement between informant-rated and patient-rated scores. NPS, particularly emotion dysregulation and decreased motivation, are common and clinically relevant in FRDA and should receive more attention due to their potential impact on quality of life and the possibility of therapeutic intervention.

Characteristics of cerebellar cognitive affective syndrome in patients with acute cerebellar stroke and its impact on outcome

PURPOSE

To evaluate the cerebellar cognitive affective syndrome scale (CCAS-S) in patients with acute cerebellar stroke (ACS) and examine its relationship with the discharge destination.

METHODS

Patients with first-time ACS admitted to our hospital between April 2021 and April 2023 were included. The CCAS-S, Mini-Mental State Examination (MMSE), and Scale for the Assessment and Rating of Ataxia (SARA) were evaluated 1 week after stroke onset, and Functional Independence Measure (FIM)/Barthel Index (BI) at discharge, duration of hospitalization, and discharge destination were evaluated. The Mann-Whitney U test was used to compare CCAS-S and variables.

RESULTS

Thirteen consecutive patients with ACS and age-matched comparison groups were included. The MMSE was within the normal range in all patients; however, patients with stroke had a lower total CCAS-S score (median 72, IQR 66-80) and a higher number of failed tests (median 4, IQR 3-5) than comparison. Significant deficits were observed in semantic fluency (p = 0.008), category switching (p = 0001), and similarity (p = 009). Definite CCAS were diagnosed 10 patients, respectively. Patients discharged home showed better SARA and FIM/BI but similar CCAS-S compared to those discharged to rehabilitation hospitals.

CONCLUSION

In patients with ACS, it is the impairment of motor function, not CCAS, that affects discharge destination.

Bipolar Camouflage: A Cerebellar Cognitive Affective Syndrome Case Report

The cerebellar cognitive affective syndrome is a neuropsychiatric syndrome composed of affective (anxiety, depression, euphoria, and emotional lability) and cognitive symptoms (executive, attentional, and visuospatial deficits) that was described in the 1990s. We present the case of a 49-year-old woman with a history of an acute neurological episode at the age of 28, after which she reported a change in personality, brief and alternating periods of depression, hypomania, and mixed episodes, and cognitive impairment that had a major impact on her personal and occupational level of functioning. She was initially diagnosed with bipolar disorder, but a clinical, neuropsychological, and imaging re-evaluation prompted a diagnostic reconsideration in favor of a cerebellar cognitive affective syndrome. This enabled therapeutical and prognostic refinement. Here, we discuss the diagnostic challenges of this syndrome and the implications that an accurate diagnosis has for patients.

Cognitive impairment in young adults following cerebellar stroke: Prevalence and longitudinal course

INTRODUCTION

Cognitive impairment is a well-known result of a stroke, but for cerebellar stroke in young patients detailed knowledge on the nature and extent of cognitive deficits is limited. This study examined the prevalence and course of cognitive impairment in a large cohort of patients with cerebellar stroke.

METHODS

Sixty young (18-49 years) cerebellar stroke patients completed extensive neuropsychological assessments in the subacute (<9 months post-stroke) and/or chronic phase (≥9 months post-stroke). Performance and course were assessed using standardized scores and Reliable Change Index analyses. Associations between cognitive deficits and lesion locations were explored using subtraction analyses, and associations with subjective cognitive complaints and fatigue were examined.

RESULTS

Sixty patients (52% male) were included with a mean age at event of 43.1 years. Cognitive impairment was observed in 60.3% of patients in the subacute phase and 51.2% during the chronic phase. Deficits were most frequent for visuo-spatial skills and executive functioning (42.5-54.6%). Both improvement and decline were observed over time, in 17.9% and 41.0% of participants, respectively. Cognitive deficits seem to be associated with lesions in certain cerebellar regions, however, no distinct correlation was found for a specific subregion. Subjective cognitive complaints were present in the majority of participants (61-80.5%) and positively correlated with fatigue in both phases (ρ = -.661 and ρ = -.757, p < .001, respectively).

DISCUSSION

Cognitive impairment in cerebellar stroke patients is common, with deficits most pronounced for visuo-spatial skills and executive functioning, as in line with the Cerebellar Cognitive Affective Syndrome. The course of cognitive performance was heterogenous, with cognitive decline despite the fact that no recurrent strokes occurred. No clear association between lesion location and cognitive deficits was observed. Subjective cognitive complaints and fatigue were prevalent and positively correlated. Clinicians could use this information to actively screen for and better inform patients about possible cognitive sequalae.

Cognitive Complaints and Their Impact on Daily Life in Patients with Degenerative Cerebellar Disorders

Cognitive and affective sequelae of cerebellar disease are receiving increased attention, but their actual rate of occurrence remains unclear. Complaints may have a significant impact on patients, affecting social behavior and psychological well-being. This study aims to explore the extent of subjective cognitive and affective symptoms in patients with degenerative ataxias in the Netherlands. An explorative study was set up in a heterogeneous group of degenerative ataxia patients. Self-reported cognition was evaluated in terms of executive functioning and affect (Dysexecutive Questionnaire/DEX), and memory/attention (Cognitive Failures Questionnaire/CFQ). The Daily Living Questionnaire (DLQ) was administered to quantify the impact on daily life. Furthermore, informants completed questionnaires to obtain insight into patients' self-awareness and social cognition (Observable Social Cognition Rating Scale/OSCARS). This study shows that subjective complaints in the domains of (1) executive functioning and/or (2) memory and attention were reported by 29% of all patients (n = 24/84). In addition, more difficulties in daily life in terms of language/comprehension and community/participation were reported, and this was more common for patients with cognitive complaints than those without. Discrepancies between patients and informants about executive functioning were present in both directions. Deficits in social cognition were not identified at the group level, but more social-cognitive problems were observed in patients with more executive problems rated by informants. Taken together, our findings indicate that cognitive complaints are common in patients with degenerative cerebellar disorders and have an impact on daily life functioning. These results may help to increase awareness of cognitive symptoms and their impact in patients with cerebellar ataxia, their significant others, and professional caregivers.

Hungarian adaptation of the cerebellar cognitive affective/Schmahmann Syndrome Scale

Recent studies have reported that cerebellar lesions can cause cognitive, behavioral, and affective symptoms. This constellation is called the cerebellar cognitive affective syndrome (CCAS). A bedside instrument, the CCAS-Scale, has been developed to screen for this clinical presentation. The aim of this study is to adapt the CCAS-Scale to Hungarian according to international cross-cultural guidelines. In cooperation with the senior author of the original CCAS-Scale, we defined a five-step adaptation protocol (license number 6758-1/2021). Step 1: translation of the scale from English to Hungarian by two separate teams. Step 2: comparison of the two translated versions, synthesis (preliminary version). Step 3: back translation by an independent professional translator. Step 4: authorization, revision, and correction. Step 5: pre-testing the scale, measuring the test times. Following our protocol, we produced the CCAS-H and the instructions booklet. We pre-tested healthy (n = 10) and cerebellar stroke patients (n = 10) and finalized the scale. Although not significantly, but cerebellar patients reached lower raw scores compared with healthy subjects. Testing times differed significantly between the two groups. A meticulous validation protocol was outlined to assess the validity and reliability of the newly adapted test. CCAS-H is a quick and adequate scale to examine the cerebellar-cognitive affective syndrome, which will be available for Hungarian professionals. Our main challenge was to define the stimuli and cues with adequate psycholinguistic and psychometric properties. As a next step, we are gathering data for the validation with the help of six other Hungarian Neurology departments.

Reduced cerebral blood flow and cognitive dysfunction following isolated cerebellar infarction: two case reports

Cognitive impairment in focal cerebellar disorders has been widely recognized and is described as cerebellar cognitive affective syndrome (CCAS). However, the relationship between CCAS and crossed cerebello-cerebral diaschisis (CCD) has rarely been discussed. The present report describes the uncommon phenomenon of CCD in two cases with isolated cerebellar infarction, and discuss its contribution to cognitive impairment. Cognitive performance was examined using the CCAS scale and a battery of neuropsychological assessments. Moreover, the relative distribution of cerebral and cerebellar blood flow was measured using three-dimensional arterial spin labeling imaging. Case 1 showed deficits in general cognition and had impaired language, episodic memory, and executive function. Case 2 showed deficits in general cognition at baseline, and cognitive deterioration of visuospatial abilities, language, episodic memory, and executive function was observed at the 3-month follow-up. Both cases met the diagnosis criteria of CCAS. Reduced cerebral blood flow was observed in the cerebral hemisphere contralateral to the cerebellar infarction at baseline in Case 1, and at the 3-month follow-up in Case 2. The present report describes cognitive decline after isolated cerebellar infarction in combination with contralateral cerebral hypoperfusion, as measured using quantitative arterial spin labeling. One possible mechanism involves the functional depression of cerebello-cerebral pathways.

Infarct-related structural disconnection and delirium in surgical aortic valve replacement patients

OBJECTIVE

Although acute brain infarcts are common after surgical aortic valve replacement (SAVR), they are often unassociated with clinical stroke symptoms. The relationship between clinically "silent" infarcts and in-hospital delirium remains uncertain; obscured, in part, by how infarcts have been traditionally summarized as global metrics, independent of location or structural consequence. We sought to determine if infarct location and related structural connectivity changes were associated with postoperative delirium after SAVR.

METHODS

A secondary analysis of a randomized multicenter SAVR trial of embolic protection devices (NCT02389894) was conducted, excluding participants with clinical stroke or incomplete neuroimaging (N = 298; 39% female, 7% non-White, 74 ± 7 years). Delirium during in-hospital recovery was serially screened using the Confusion Assessment Method. Parcellation and tractography atlas-based neuroimaging methods were used to determine infarct locations and cortical connectivity effects. Mixed-effect, zero-inflated gaussian modeling analyses, accounting for brain region-specific infarct characteristics, were conducted to examine for differences within and between groups by delirium status and perioperative neuroprotection device strategy.

RESULTS

23.5% participants experienced postoperative delirium. Delirium was associated with significantly increased lesion volumes in the right cerebellum and temporal lobe white matter, while diffusion weighted imaging infarct-related structural disconnection (DWI-ISD) was observed in frontal and temporal lobe regions (p-FDR < 0.05). Fewer brain regions demonstrated DWI-ISD loss in the suction-based neuroprotection device group, relative to filtration-based device or standard aortic cannula.

INTERPRETATION

Structural disconnection from acute infarcts was greater in patients who experienced postoperative delirium, suggesting that the impact from covert perioperative infarcts may not be as clinically "silent" as commonly assumed.

Cognitive-Affective Functions of the Cerebellum

The cerebellum, traditionally associated with motor coordination and balance, also plays a crucial role in various aspects of higher-order function and dysfunction. Emerging research has shed light on the cerebellum's broader contributions to cognitive, emotional, and reward processes. The cerebellum's influence on autonomic function further highlights its significance in regulating motivational and emotional states. Perturbations in cerebellar development and function have been implicated in various neurodevelopmental disorders, including autism spectrum disorder and attention deficit hyperactivity disorder. An increasing appreciation for neuropsychiatric symptoms that arise from cerebellar dysfunction underscores the importance of elucidating the circuit mechanisms that underlie complex interactions between the cerebellum and other brain regions for a comprehensive understanding of complex behavior. By briefly discussing new advances in mapping cerebellar function in affective, cognitive, autonomic, and social processing and reviewing the role of the cerebellum in neuropathology beyond the motor domain, this Mini-Symposium review aims to provide a broad perspective of cerebellar intersections with the limbic brain in health and disease.

Cognitive impairment in essential tremor assessed by the cerebellar cognitive affective syndrome scale

Background

Essential tremor (ET) is a movement disorder characterized by cerebellar neurodegenerative changes. ET is also associated with non-motor symptoms including cognitive impairment. The neuropsychologic profile of a patient with ET could relate to cerebellar cognitive affective syndrome (CCAS).

Objective

This study aimed to assess the prevalence of cognitive impairment in patients with ET and identify whether the cognitive impairment in ET corresponds to a CCAS.

Methods

Cognitive functions were evaluated with the CCAS-Scale (CCAS-S) in 20 patients with ET and 20 controls matched for age, sex, and level of education. The results of the CCAS-S were compared between patients and controls. The underlying determinant of CCAS inpatients with ET was identified through the correlation between the results of the CCAS-S and age at onset of symptoms, disease duration, and the Essential Tremor Rating Assessment Scale (TETRAS).

Results

On a group level, ET patients performed significantly worse than matched controls. In total, 13 individuals with ET had a definite CCAS (CCAS-S failed items ≥ 3). ASO and TETRAS scores significantly correlated with CCAS-S performances in ET patients.

Conclusion

CCAS is highly prevalent in patients with ET which supports the cerebellar pathophysiology of associated cognitive impairment and supports a more systematic use of the CCAS-S to cognitively assessed patients with ET.