The Cerebellum in Musicology: a Narrative Review

The cerebellum is involved in cognitive procressing including music perception and music production. This narrative review aims to summarize the current knowledge on the activation of the cerebellum by different musical stimuli, on the involvement of the cerebellum in cognitive loops underlying the analysis of music, and on the role of the cerebellum in the motor network underlying music production. A possible role of the cerebellum in therapeutic settings is also briefly discussed. In a second part, the cerebellum as object of musicology (i.e., in classical music, in contemporary music, cerebellar disorders of musicians) is described.

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.

The CODECS study: COgnitive DEficits in Cerebellar Stroke

Part of the extra-pyramidal system, the cerebellum is more and more recognized by its non-motor functions known as the cerebellar cognitive affective syndrome. Several studies have identified disturbances specifically in executive and attentional functions after focal cerebellar lesions. However, most studies were performed in small and heterogeneous patient groups. Furthermore, there is a substantial variation in the methodology of assessment. Here, we present the results of a large and homogeneous cohort of patients with isolated uniform cerebellar lesions. After three months post-stroke all patients underwent structural neuroimaging to confirm an isolated lesion and were given neuropsychological testing. The results show that cerebellar lesions relate to mild but long-term cognitive impairment in a broad spectrum of neurocognitive functions compared to normative values. These findings confirm involvement of the cerebellum in cognitive processing and supports the theory of 'dysmetria of thought' based upon uniform cerebellar processing in multiple cognitive domains. This study highlights the following results: 1-Cognitive impairments after isolated cerebellar stroke is confirmed in several cognitive domains. 2-Semantic and phonemic fluency are most affected in cerebellar stroke patients. 3-Verbal deficits show an age-independent long term effect post-stroke and should be studied further in depth. 4-Cognitive disorders after cerebellar stroke are more prominent in women than men.

CLINICAL NOTE: CEREBELLAR COGNITIVE AFFECTIVE SYNDROME IMPROVEMENT WITH SELECTIVE INHIBITOR OF SEROTONIN RECAPTATION

Cerebellar cognitive affective syndrome (CCAS) is characterized by alterations at the cognitive level (dysexecutive syndrome, visuospatial deficit, language ...), associated with affective / emotional changes. Its pathophysiology is not well known and there is currently no specific treatment. We describe a 64-year-old man with a rare condition of cognitive-behavioral disorder after an infarction in the left middle cerebral artery, dominated by executive dysfunctions, predominantly oral apraxia, interrupted divided attention, disturbed visuospatial organization and affective abnormalities with great apathy, and whose symptoms improved with a selective serotonin reuptake inhibitor (SSRI). In absence of cerebellar structural damage, a perfusion brain single photon emission computed tomography using 99mTc- hexamethyl-propylene-aminoxime (SPECT-HMPAO) showed left frontotemporal and parietoccipital hypoperfusion of known vascular etiology, and hypoperfusion in the right cerebellar hemisphere compatible with the phenomenon of crossed diaschisis. We hypothesize that cognitive and affective deficits are aggravated by the functional disruption of the reciprocal cerebellar interconnections with areas of cerebral association and paralimbic cortex, altering the contribution of the cerebellum to cognitive and affective processing and modulation. In the case described, both the clinical situation and the functional control images improved after treatment with SSRI, which increases the possibility that there is connectivity of some serotonergic transmission projections between cerebellum and contralateral association cortices, and that said connectivity dysfunctional is involved in the pathophysiology of CCAS.

Consensus Paper. Cerebellar Reserve: From Cerebellar Physiology to Cerebellar Disorders

Cerebellar reserve refers to the capacity of the cerebellum to compensate for tissue damage or loss of function resulting from many different etiologies. When the inciting event produces acute focal damage (e.g., stroke, trauma), impaired cerebellar function may be compensated for by other cerebellar areas or by extracerebellar structures (i.e., structural cerebellar reserve). In contrast, when pathological changes compromise cerebellar neuronal integrity gradually leading to cell death (e.g., metabolic and immune-mediated cerebellar ataxias, neurodegenerative ataxias), it is possible that the affected area itself can compensate for the slowly evolving cerebellar lesion (i.e., functional cerebellar reserve). Here, we examine cerebellar reserve from the perspective of the three cornerstones of clinical ataxiology: control of ocular movements, coordination of voluntary axial and appendicular movements, and cognitive functions. Current evidence indicates that cerebellar reserve is potentiated by environmental enrichment through the mechanisms of autophagy and synaptogenesis, suggesting that cerebellar reserve is not rigid or fixed, but exhibits plasticity potentiated by experience. These conclusions have therapeutic implications. During the period when cerebellar reserve is preserved, treatments should be directed at stopping disease progression and/or limiting the pathological process. Simultaneously, cerebellar reserve may be potentiated using multiple approaches. Potentiation of cerebellar reserve may lead to compensation and restoration of function in the setting of cerebellar diseases, and also in disorders primarily of the cerebral hemispheres by enhancing cerebellar mechanisms of action. It therefore appears that cerebellar reserve, and the underlying plasticity of cerebellar microcircuitry that enables it, may be of critical neurobiological importance to a wide range of neurological/neuropsychiatric conditions.

The Cerebellar Cognitive Affective/Schmahmann Syndrome: a Task Force Paper

Sporadically advocated over the last two centuries, a cerebellar role in cognition and affect has been rigorously established in the past few decades. In the clinical domain, such progress is epitomized by the "cerebellar cognitive affective syndrome" ("CCAS") or "Schmahmann syndrome." Introduced in the late 1990s, CCAS reflects a constellation of cerebellar-induced sequelae, comprising deficits in executive function, visuospatial cognition, emotion-affect, and language, over and above speech. The CCAS thus offers excellent grounds to investigate the functional topography of the cerebellum, and, ultimately, illustrate the precise mechanisms by which the cerebellum modulates cognition and affect. The primary objective of this task force paper is thus to stimulate further research in this area. After providing an up-to-date overview of the fundamental findings on cerebellar neurocognition, the paper substantiates the concept of CCAS with recent evidence from different scientific angles, promotes awareness of the CCAS as a clinical entity, and examines our current insight into the therapeutic options available. The paper finally identifies topics of divergence and outstanding questions for further research.

Double dissociation of single-interval and rhythmic temporal prediction in cerebellar degeneration and Parkinson's disease

Predicting the timing of upcoming events is critical for successful interaction in a dynamic world, and is recognized as a key computation for attentional orienting. Temporal predictions can be formed when recent events define a rhythmic structure, as well as in aperiodic streams or even in isolation, when a specified interval is known from previous exposure. However, whether predictions in these two contexts are mediated by a common mechanism, or by distinct, context-dependent mechanisms, is highly controversial. Moreover, although the basal ganglia and cerebellum have been linked to temporal processing, the role of these subcortical structures in temporal orienting of attention is unclear. To address these issues, we tested individuals with cerebellar degeneration or Parkinson's disease, with the latter serving as a model of basal ganglia dysfunction, on temporal prediction tasks in the subsecond range. The participants performed a visual detection task in which the onset of the target was predictable, based on either a rhythmic stream of stimuli, or a single interval, specified by two events that occurred within an aperiodic stream. Patients with cerebellar degeneration showed no benefit from single-interval cuing but preserved benefit from rhythm cuing, whereas patients with Parkinson's disease showed no benefit from rhythm cuing but preserved benefit from single-interval cuing. This double dissociation provides causal evidence for functionally nonoverlapping mechanisms of rhythm- and interval-based temporal prediction for attentional orienting, and establishes the separable contributions of the cerebellum and basal ganglia to these functions, suggesting a mechanistic specialization across timing domains.

Internally Versus Externally Cued Speech in Parkinson's Disease and Cerebellar Disease

PURPOSE

The purpose of this study was to examine the effects of an internally versus externally cued speech task on perceived understandability and naturalness in speakers with Parkinson's disease (PD) and cerebellar disease (CD).

METHOD

Sentences extracted from a covertly recorded conversation (internally cued) were compared to the same sentences read aloud (externally cued) by speakers with PD and a clinical comparison group of speakers with CD. Experienced listeners rated the speech samples using a visual analog scale for the perceptual dimensions of understandability and naturalness.

RESULTS

Results suggest that experienced listeners rated the speech of participants with PD as significantly more natural and more understandable during the reading condition. Participants with CD were also rated as significantly more understandable during the reading condition, but ratings of naturalness did not differ between conversation and reading.

CONCLUSIONS

Speech tasks can have a pronounced impact on perceived speech patterns. For individuals with PD, both understandability and naturalness can improve during reading tasks versus conversational tasks. The speech benefits from reading may be attributed to several mechanisms, including possible improvement from an externally cued speech task. These findings have implications for speech task selection in evaluating individuals with dysarthria.

Location of lesion determines motor vs. cognitive consequences in patients with cerebellar stroke

Cerebellar lesions can cause motor deficits and/or the cerebellar cognitive affective syndrome (CCAS; Schmahmann's syndrome). We used voxel-based lesion-symptom mapping to test the hypothesis that the cerebellar motor syndrome results from anterior lobe damage whereas lesions in the posterolateral cerebellum produce the CCAS. Eighteen patients with isolated cerebellar stroke (13 males, 5 females; 20-66 years old) were evaluated using measures of ataxia and neurocognitive ability. Patients showed a wide range of motor and cognitive performance, from normal to severely impaired; individual deficits varied according to lesion location within the cerebellum. Patients with damage to cerebellar lobules III-VI had worse ataxia scores: as predicted, the cerebellar motor syndrome resulted from lesions involving the anterior cerebellum. Poorer performance on fine motor tasks was associated primarily with strokes affecting the anterior lobe extending into lobule VI, with right-handed finger tapping and peg-placement associated with damage to the right cerebellum, and left-handed finger tapping associated with left cerebellar damage. Patients with the CCAS in the absence of cerebellar motor syndrome had damage to posterior lobe regions, with lesions leading to significantly poorer scores on language (e.g. right Crus I and II extending through IX), spatial (bilateral Crus I, Crus II, and right lobule VIII), and executive function measures (lobules VII-VIII). These data reveal clinically significant functional regions underpinning movement and cognition in the cerebellum, with a broad anterior-posterior distinction. Motor and cognitive outcomes following cerebellar damage appear to reflect the disruption of different cerebro-cerebellar motor and cognitive loops.

Cerebellar Stroke Impairs Temporal but not Spatial Accuracy during Implicit Motor Learning

Objective. Numerous studies have demonstrated cerebellar activity during implicit motor learning, but few have addressed its specific role. The purpose of this study was to determine if specific components (spatial or temporal) of an implicit motor-tracking task were affected by cerebellar stroke. Methods. The authors studied the performance of individuals with unilateral cerebellar stroke (n =7)and a control group (n = 10) across 3 acquisition days and at a delayed retention test as they practiced a unimanual tracking task with the contralesional upper extremity. Results. After cerebellar stroke, participants demonstrated reduced tracking errors for repeating sequences compared to random sequences; however, decomposition of tracking performance into temporal and spatial components revealed persistent deficits in tracking time lag despite improved spatial accuracy. A lesion analysis showed that the dentate nucleus was the only common region affected by all cerebellar strokes. Conclusions. During implicit motor learning, the cerebellum appears to participate in the formation of predictive strategies for the timing of motor responses, rather than for the accuracy of motor execution. Because deficits were found in the contralesional upper extremity, the authors suggest that this function is not lateralized to 1 hemisphere; cerebellar output may affect the formation of an internal model for timing movements in both upper extremities.

Developmental cerebellar cognitive affective syndrome in ex-preterm survivors following cerebellar injury

Cerebellar injury is increasingly recognized as an important complication of very preterm birth. However, the neurodevelopmental consequences of early life cerebellar injury in prematurely born infants have not been well elucidated. We performed a literature search of studies published between 1997 and 2014 describing neurodevelopmental outcomes of preterm infants following direct cerebellar injury or indirect cerebellar injury/underdevelopment. Available data suggests that both direct and indirect mechanisms of cerebellar injury appear to stunt cerebellar growth and adversely affect neurodevelopment. This review also provides important insights into the highly integrated cerebral-cerebellar structural and functional correlates. Finally, this review highlights that early life impairment of cerebellar growth extends far beyond motor impairments and plays a critical, previously underrecognized role in the long-term cognitive, behavioral, and social deficits associated with brain injury among premature infants. These data point to a developmental form of the cerebellar cognitive affective syndrome previously described in adults. Longitudinal prospective studies using serial advanced magnetic resonance imaging techniques are needed to better delineate the full extent of the role of prematurity-related cerebellar injury and topography in the genesis of cognitive, social-behavioral dysfunction.

Cause and outcome of cerebellar mutism: evidence from a systematic review

PURPOSE

Cerebellar mutism is a serious neurosurgical complication after posterior fossa surgery, but the cause, incidence and outcome remain incompletely defined. The aim of this paper was to identify and review all reports of this phenomenon to better delineate and improve the evidence base.

METHODS

A systematic search and retrieval of databases was conducted using advanced search techniques. Review/outcomes criteria were developed, and study quality was determined.

RESULTS

The retrieval identified 2,281 papers of which 96 were relevant, identifying 650 children with cerebellar mutism. Causative factors, clinical features and outcomes were reported variably; papers focussed on multiple areas, the majority reporting incidence in single or series of case studies with little or no analysis further than description.

CONCLUSIONS

The complexity and variability of data reporting, likely contributing factors and outcomes make cerebellar mutism difficult to predict in incidence and the degree of impact that may ensue. A clear and accepted universal definition would help improve reporting, as would the application of agreed outcome measures. Clear and consistent reporting of surgical technique remains absent. Recommendations for practice are provided.

The cerebellum: its role in language and related cognitive and affective functions

The traditional view on the cerebellum as the sole coordinator of motor function has been substantially redefined during the past decades. Neuroanatomical, neuroimaging and clinical studies have extended the role of the cerebellum to the modulation of cognitive and affective processing. Neuroanatomical studies have demonstrated cerebellar connectivity with the supratentorial association areas involved in higher cognitive and affective functioning, while functional neuroimaging and clinical studies have provided evidence of cerebellar involvement in a variety of cognitive and affective tasks. This paper reviews the recently acknowledged role of the cerebellum in linguistic and related cognitive and behavioral-affective functions. In addition, typical cerebellar syndromes such as the cerebellar cognitive affective syndrome (CCAS) and the posterior fossa syndrome (PFS) will be briefly discussed and the current hypotheses dealing with the presumed neurobiological mechanisms underlying the linguistic, cognitive and affective modulatory role of the cerebellum will be reviewed.

The functional role of the cerebellum in visually guided tracking movement

We propose a new method to provide a functional interpretation of motor commands (i.e., muscle activities) and their relationship to movement kinematics. We evaluated our method by analyzing the motor commands of normal controls and patients with cerebellar disorders for visually guided tracking movement of the wrist joint. Six control subjects and six patients with cerebellar disorders participated in this study. We asked the subjects to perform visually guided smooth tracking movement of the wrist joint with a manipulandum, and recorded the movements of the wrist joint and activities of the four wrist prime movers with surface electrodes. We found a symmetric relationship between the second-order linear equation of motion for the wrist joint and the linear sum of activities of the four wrist prime movers. The symmetric relationship determined a set of parameters to characterize the muscle activities and their similarity to the components of movement kinematics of the wrist joint. We found that muscle activities of the normal controls encoded both the velocity and the position of the moving target, resulting in precise tracking of the target. In contrast, muscle activities of the cerebellar patients were characterized by a severer impairment for velocity control and more dependence on position control, resulting in poor tracking of the smoothly moving target with many step-like awkward movements. Our results suggest that the cerebellum plays an important role in the generation of motor commands for smooth velocity and position control.

Evidence for topographic organization in the cerebellum of motor control versus cognitive and affective processing

Patients with cerebellar damage often present with the cerebellar motor syndrome of dysmetria, dysarthria and ataxia, yet cerebellar lesions can also result in the cerebellar cognitive affective syndrome (CCAS), including executive, visual spatial, and linguistic impairments, and affective dysregulation. We have hypothesized that there is topographic organization in the human cerebellum such that the anterior lobe and lobule VIII contain the representation of the sensorimotor cerebellum; lobules VI and VII of the posterior lobe comprise the cognitive cerebellum; and the posterior vermis is the anatomical substrate of the limbic cerebellum. Here we analyze anatomical, functional neuroimaging, and clinical data to test this hypothesis. We find converging lines of evidence supporting regional organization of motor, cognitive, and limbic behaviors in the cerebellum. The cerebellar motor syndrome results when lesions involve the anterior lobe and parts of lobule VI, interrupting cerebellar communication with cerebral and spinal motor systems. Cognitive impairments occur when posterior lobe lesions affect lobules VI and VII (including Crus I, Crus II, and lobule VIIB), disrupting cerebellar modulation of cognitive loops with cerebral association cortices. Neuropsychiatric disorders manifest when vermis lesions deprive cerebro-cerebellar-limbic loops of cerebellar input. We consider this functional topography to be a consequence of the differential arrangement of connections of the cerebellum with the spinal cord, brainstem, and cerebral hemispheres, reflecting cerebellar incorporation into the distributed neural circuits subserving movement, cognition, and emotion. These observations provide testable hypotheses for future investigations.

Insults to the developing brain and impact on neurodevelopmental outcome

Premature infants have a disproportionately increased risk for brain injury based on several mechanisms including intraventricular hemorrhage, ischemia and the vulnerability of developing neuronal progenitor cells. Injury to the developing brain often results in neurologic abnormalities that can be correlated with a structural lesion; however more subtle injury may result in disruption of critical neural pathways. There also appears to be an important relationship between brain injury in the cortex and the growth and developing cerebellum. Although the survival rate for premature has improved over the past decade, researchers remain concerned about the risk for adverse neurocognitive functioning in these early childhood, including an increased risk for cerebral palsy, cognitive impairment, speech and language delay and sensory dysfunction.

LEARNING OUTCOMES

After this activity, the learner will be able to (1) identify potential causes of brain injury in the premature infant, (2) understand that the maturational process for the human brain continues throughout gestation, (3) identify risk factors for adverse neurocognitive functioning in premature infants, and (4) identify abnormalities on central nervous system neuroimaging studies that correlate with an increased risk for adverse neurodevelopmental outcome in premature infants.

Survivors from beta-fluoroethyl acetate poisoning show a selective cerebellar syndrome

AIM/ BACKGROUND: beta-Fluoroethyl acetate (FEA), a derivative of sodium fluoroacetate (Compound 1080, FA), is one of the high-potency toxic chemicals, and it has been used against rats and wild animals. Human casualties from FA or FEA poisoning, accidental or suicidal, have been reported. Survivors of the poisoning are extremely rare. The objective of this study is to present survivors of FEA poisoning.

METHOD

Data on the survivors were collected at the Department of Neurology over the past 20 years. Reviews of the medical record and brain imaging were performed.

RESULTS

A total of 10 survivors of FEA poisoning were found. All of the cases were suicide attempts. The amount of FEA ingested varied from 600 to 1800 mg with a mean of 1200 mg, which is close to the lethal dose of FEA. Immediately after ingestion, all of the patients had an altered mental status. On awakening, all of the patients had severe cerebellar dysfunction, such as ataxic gait, dysarthria and intention tremor. The cerebellar dysfunction usually improved gradually over the years after the event, but this improvement eventually plateaued, resulting in residual and persistent cerebellar dysfunction. Serial imaging showed swelling in the posterior fossa during the acute phase and progressive cerebellar atrophy on follow-up.

CONCLUSION

In summary, FEA poisoning causes a selective cerebellar syndrome in its survivors. The pathomechanism underlying the selective cerebellar toxicity of FEA remains to be elucidated. The selective involvement of the cerebellum might provide a useful model for cerebellar degeneration.

A mild variant of pontocerebellar hypoplasia type 1 in a 12-year-old Indian boy

Pontocerebellar hypoplasia is a heterogeneous group of disorders characterized by abnormally small cerebellum and brainstem. Pontocerebellar hypoplasia type 1 is associated with spinal anterior horn cell degeneration, microcephaly, congenital contractures, polyhydramnios, and respiratory insufficiency leading to death in infancy. Recently, however, the spectrum of this disease has been extended to include less severe variants, some of which are associated with minimal atrophy of the brainstem. In two reported cases of late-onset variant pontocerebellar hypoplasia, the siblings were alive at 9 years and 6 years, respectively, but were severely crippled and anarthric; they had features of anterior horn cell involvement and cerebellar atrophy but the brainstem was spared. The present case is that of a 12-year-old boy with early onset of anterior horn cell involvement and slowly progressive cerebellar ataxia who is still able to walk with support and speak in sentences. He was found to be devoid of the exon 7 and exon 8 deletion of the survival motor neuron gene seen in classical spinal muscular atrophy, and magnetic resonance imaging indicated marked atrophy of the cerebellar vermis and hemispheres, with minimal involvement of the brainstem. This form is apparently the mildest variant of pontocerebellar hypoplasia type 1 described to date.

Stroke rehabilitation in a patient with cerebellar cognitive affective syndrome

OBJECTIVE

It has become evident that the cerebellum plays a role in cognitive function, and Schmahmann et al. have introduced the term "Cerebellar cognitive affective syndrome (CCAS)." In the present paper we report a patient with cerebellar hemorrhage who developed CCAS.

DESIGN

A case study.

METHODS

The patient was a 61-year-old right-handed man who was admitted to our hospital because of sudden headache, dizziness and vomiting. The patient showed ataxia of the trunk and the extremities, but no paralysis and disturbance of sensation. He was disoriented in time and showed recent memory disturbance, disturbance of attention, impairment of executive functions and reduced volition, and due to these symptoms, his daily living was also severely impaired.

RESULTS

With the aim of returning home, the patient received exercise therapy and cognitive rehabilitation, while home modification was performed, and living at home under the supervision of his family became possible. Cognitive function improved, while memory and attention disturbance, impairment of executive function remained.

CONCLUSION

Cognitive dysfunction in patients with cerebellar damage is assumed to develop from disturbance of the cerebrocerebellar circuit, and that rehabilitation of these patients must include assessment of not only the motor function, but also of detailed assessment of cerebral function.

Vision- and health-related quality of life before and after vision restoration training in cerebrally damaged patients

PURPOSE

The aim of the study was to examine if improvements of stimulus detection performance in visual field tests after intensive visual training of the visual field border zone in patients with visual field defects are associated with changes in self-reported vision- and health-related quality of life (QoL).

METHODS

We studied a clinical sample of 85 patients suffering from visual field loss after brain damage that underwent repetitive, daily light stimulation (vision restoration training, VRT) of the visual field border and the blind visual field for up to 75 hrs (N=16) or 150 hrs (N=69). Stimulus detection was quantified in the central visual field with a campimetric method before and after intervention. Health-related QoL was assessed by the Health-Survey SF-36 and vision-related QoL by the 39-item National Eye Institute Visual Function Questionnaire (NEI-VFQ).

RESULTS

Both vision- and health-related QoL measures improved after VRT. Significant increases were found in 8 out of 12 NEI-VFQ and 3 out of 8 SF-36 subscales. Of the 85 participants 6% showed a decrease in stimulus detection performance, 42% showed an increase of less than 5% detected stimuli, 24% showed an increase of 5-10% detected stimuli and 28% of more than 10% detected stimuli. Changes in campimetric stimulus detection rates were related to NEI-VFQ subscales point differences general vision (3 points), difficulty with near vision activities (4 points), limitations in social functioning due to vision (4 points) and driving problems (12 points). There was no relation of visual field changes to changes in SF-36 component and subscale scores.

CONCLUSIONS

The NEI-VFQ is a valuable measure of self-reported visual impairment in patients with visual field defects. Stimulation of the visual field by training may lead to improvements of vision-related QoL which were correlated with the extent of visual field enlargements.

Magnetic resonance imaging (MRI) findings and neuropsychological sequelae in children after severe traumatic brain injury: the role of cerebellar lesion

We studied the relationships between magnetic resonance imaging (MRI) findings and neuropsychological sequelae in children after severe traumatic brain injury. Twenty-three children ages 7-13 years underwent MRI assessment of brain lesion topography and volume and neuropsychological evaluations, more than 1 year after sustaining severe traumatic brain injury. Most children had lesions to the corpus callosum and frontal lobes. Total lesion volume and extent of cerebral atrophy did not impact on the neuropsychological evaluation. Additional relationships were observed: left frontal lesions with lower semantic verbal fluency, right occipital lesions with lower visual recognition task scores, dyscalculia with cerebellar lesions, and cerebellar damage with lower cognitive performances and lower visual recognition memory. This study demonstrates the significance of the cerebellum's role in neuropsychological outcomes after traumatic brain injury and the importance of the lesion depth classification in predicting functional results.

Language and Social Communication in Children with Cerebellar Dysgenesis

OBJECTIVE

Acquired cerebellar lesions in children and adults may determine deficits of executive functions, visuoperceptual skills, expressive language and modulation of affect; a complex pattern termed 'cerebellar cognitive affective syndrome'. However, the long-term sequelae of malformative cerebellar lesions have yet to be systematically investigated, particularly in children. The purpose of this study was to present preliminary longitudinal data on the development of language and social communication skills in children with congenital malformations confined to the cerebellum.

PATIENTS AND METHODS

Five children (3 males, 2 females) with cerebellar malformations confined to the cerebellum were selected. Three patients presented with cerebellar hypoplasia involving the vermis and the hemispheres, while the remaining 2 had a malformation affecting only the cerebellar hemispheres. Neurobehavioral and language development were traced through access to available clinical data.

RESULTS

In the patients with cerebellar vermis malformation, language and social communicative skills were affected to a variable extent: 1 patient did not present with social disturbances during development. Those with hemispheric cerebellar lesions presented with selective linguistic impairments.

CONCLUSIONS

The neurobehavioral profile of children with cerebellar malformations supports a key role of the cerebellum in language acquisition and affect regulation as distinguished functional domains.

Exaggerated crying and tremor with a cerebellar cyst

The authors describe clinical, neuropsychological, and neuroimaging findings in a 70-year-old man with a cystic lesion in the midline cerebellum. He presented with pathological crying in parallel to a worsening of his ataxia. This report suggests a role for the cerebellum in the regulation of emotional expression.

Posterior fossa syndrome after a vermian stroke: a new case and review of the literature

The posterior fossa syndrome (PFS) is a well-known clinical consequence of posterior fossa surgery that has only been reported in a limited number of cases with a nontumoral etiology. It consists of transient cerebellar mutism, behavioral abnormalities and personality changes. We describe a 12-year-old child who developed transient cerebellar mutism associated with behavioral and emotional symptoms following rupture of a vermis arteriovenous malformation (AVM). Following the stroke, the girl experienced a 24-hour symptom-free interval. After that, she became mute and her emotional state was characterized by severe anxiety, irritability and withdrawal. After 3 days, mutism resolved and dysarthria became apparent. Two weeks after stroke, the AVM was surgically removed and the postoperative course was uneventful. This case is the first reported in which the PFS occurred after focal nonsurgically induced cerebellar damage.

Cortical networks of procedural learning: evidence from cerebellar damage

The lateral cerebellum plays a critical role in procedural learning that goes beyond the strict motor control functions attributed to it. Patients with cerebellar damage show marked impairment in the acquisition of procedures, as revealed by their performance on the serial reaction time task (SRTT). Here we present the case of a patient affected by ischemic damage involving the left cerebellum who showed a selective deficit in procedural learning while performing the SRTT with the left hand. The deficit recovered when the cortical excitability of an extensive network involving both cerebellar hemispheres and the dorsolateral prefrontal cortex (DLPFC) was decreased by low-frequency repetitive transcranial magnetic stimulation (rTMS). Although inhibition of the right DLPFC or a control fronto-parietal region did not modify the patient's performance, inhibition of the right (unaffected) cerebellum and the left DLPFC markedly improved task performance. These findings could be explained by the modulation of a set of inhibitory and excitatory connections between the lateral cerebellum and the contralateral prefrontal area induced by rTMS. The presence of left cerebellar damage is likely associated with a reduced excitatory drive from sub-cortical left cerebellar nuclei towards the right DLPFC, causing reduced excitability of the right DLPFC and, conversely, unbalanced activation of the left DLPFC. Inhibition of the left DLPFC would reduce the unbalancing of cortical activation, thus explaining the observed selective recovery of procedural memory.

The cerebellum and emotional experience

While the role of the cerebellum in motor coordination is widely accepted, the notion that it is involved in emotion has only recently gained popularity. To date, functional neuroimaging has not been used in combination with lesion studies to elucidate the role of the cerebellum in the processing of emotional material. We examined six participants with cerebellar stroke and nine age and education matched healthy volunteers. In addition to a complete neuropsychological, neurologic, and psychiatric examination, participants underwent [15O]water positron emission tomography (PET) while responding to emotion-evoking visual stimuli. Cerebellar lesions were associated with reduced pleasant experience in response to happiness-evoking stimuli. Stroke patients reported an unpleasant experience to frightening stimuli similar to healthy controls, yet showed significantly lower activity in the right ventral lateral and left dorsolateral prefrontal cortex, amygdala, thalamus, and retrosplenial cingulate gyrus. Frightening stimuli led to increased activity in the ventral medial prefrontal, anterior cingulate, pulvinar, and insular cortex. This suggests that alternate neural circuitry became responsible for maintaining the evolutionarily critical fear response after cerebellar damage.

Cognitive function in multiple system atrophy of the cerebellar type

Dementia represents an exclusion criterion for the diagnosis of multiple system atrophy (MSA), but there have been reports of fronto-executive dysfunction in patients with MSA of the striatonigral type (MSA-P). To study the cognitive profile of MSA, 20 patients with MSA of the cerebellar type (MSA-C) were subjected to an extensive neuropsychological test battery comprising tests for IQ, attention, verbal and visuospatial memory, as well as executive function. There was evidence for impaired verbal memory and verbal fluency. Test performance was not related to the severity of motor disability. Regarding the similar cognitive syndrome of MSA-P, the otherwise subclinical problems in MSA-C result from subcortical rather than from cerebellar dysfunction.

Brain injury following neuroleptic malignant syndrome: case report and review of the literature

OBJECTIVE

To report a case of brain injury following neuroleptic malignant syndrome (NMS) and review the literature for similar documented cases.

CASE REPORT

A 30-year old woman presented to the ER with psychotic features and was treated with several anti-psychotics. Subsequently, she developed neurological symptoms and was diagnosed with neuroleptic malignant syndrome. Following a prolonged course in an acute care facility, she was admitted to a rehabilitation ward, where cognitive and physical examinations revealed significant findings. These included marked dysarthria, difficulties comprehending commands, attention problems, as well as abnormalities in her muscle tone, power, reflexes, gait, co-ordination and sensory function.

CONCLUSION

Literature reviews reveal few documented cases of brain injury following neuroleptic malignant syndrome. A further exploration of the effects of NMS on the brain is warranted to elicit whether cerebellar damage is indeed common following neuroleptic malignant syndrome. Such research could eventually lead to therapeutic interventions aimed at preventing permanent brain injury in persons with NMS.

Delineating and understanding cerebellar neuroprotective pathways: potential implication for protecting the cortex

The cerebellum is a brain region that is resistant to many of the neurodegenerative disorders such as stroke and Alzheimer's disease. In contrast, the neocortex (cerebrum, cerebral cortex) is vulnerable to these disorders. While there may be many reasons for the differences in vulnerability to acute and chronic neurodegenerative disorders, the cerebellum appears to be equipped with the tools necessary to protect itself against these types of insults. Over the last century, evidence has accumulated to suggest that the cerebellum is also involved in memory and higher cognitive function. We have discovered that intrinsic survival pathways exist in cerebellar granule cells that are regulated by low level stimulation of N-methyl-d-aspartate (NMDA) receptors. Activation of NMDA receptors protects vulnerable neurons against glutamate-mediated excitotoxicity acting on NMDA receptors. This report focuses on how modulation of neuronal survival by NMDA receptors through a brain-derived neurotrophic factor (BDNF)-mediated pathway may be incorporated into a network of cerebellar function, particularly in light of recent findings suggesting that the cerebellum plays a vital role in learning, memory, fear conditioning, and cognitive processing.

The effect of deep brain stimulation on quality of life in movement disorders

Deep brain stimulation (DBS) is a viable treatment alternative for patients with Parkinson's disease (PD), essential tremor (ET), dystonia, and cerebellar outflow tremors. When poorly controlled, these disorders have detrimental effects on the patient's health related quality of life (HRQoL). Instruments that measure HRQoL are useful tools to assess burden of disease and the impact of therapeutic interventions on activities of daily living, employment, and other functions. We systematically and critically reviewed the literature on the effects of DBS on HRQoL in PD, ET, dystonia, and cerebellar outflow tremor related to multiple sclerosis.

Normal IQ in a 55-year-old with newly diagnosed rhombencephalosynapsis

Rhombencephalosynapsis (RS) is a rare congenital disorder characterized principally by agenesis/hypogenesis of the cerebellar vermis and fusion of the dentate nuclei and cerebellar hemispheres. Fusion of the peduncles and colliculi is common, and associated anomalies of the cerebral hemispheres also can be present. Only about 50 cases with RS have been described and the majority of these have been children. While the literature suggests that RS often is associated with behavioral and/or intellectual impairment, no previous report has described overall neuropsychological functioning. This report describes an employed male who was diagnosed with RS by MRI at age 55. The neurological examination revealed only subtle sensory-motor abnormalities and the results of the neuropsychological evaluation were generally within normal limits, with the exception of poor immediate visual memory and motor dexterity. These findings suggest RS is not inevitably associated with substantial cognitive impairment.

Disturbed overt but normal covert shifts of attention in adult cerebellar patients

In an attempt to provide a common denominator for cognitive deficits observed in cerebellar patients, it has been suggested that they might be secondary to impaired control of attention, a 'dysmetria of attention', conceptually analogous to motor dysmetria. Albeit appealing and quite influential, the concept of attentional dysmetria as a consequence of cerebellar disease remains controversial. In an attempt to test this concept in a direct way, we compared the performance of patients with cerebellar disorders to that of normal controls on tasks requiring either overt or covert shifts of spatial attention. In the first experiment, visually guided saccades, i.e. overt shifts of spatial attention, were elicited. In the second experiment, covert shifts of attention were evoked by the need to discriminate the orientation of a Landolt C observed during controlled fixation and presented in the same locations as the saccade targets in the previous experiment. The allocation of attention was assessed by comparing acuity thresholds determined with and without spatial cueing. The patients exhibited dysmetric saccades as reflected by larger absolute position errors or a higher number of corrective saccades compared to controls. In contrast, the ability to shift attention covertly was unimpaired in the patients, as indicated by a robust improvement in visual acuity induced by spatial cueing which did not differ from the one observed in the controls and which was independent of the range of SOAs (stimulus onset asynchronies) tested. Finally, the individual amount of saccadic dysmetria did not correlate with the individual performance in the covert attentional paradigm. In summary, we conclude that the contributions of the cerebellum to attention are confined to overt manifestations based on goal-directed eye movements.

Cerebellar agenesis II: motor and language functions

In a former study of a patient with cerebellar agenesis (HK) mild motor deficits, problems in delay eyeblink conditioning and mild to moderate deficits in IQ, planning behavior, visuospatial abilities, visual memory, and attention were found. The present study reports additional findings in the same patient. In the motor domain, impairments in fine motor manipulations, trace eyeblink conditioning and motor imagination in a functional magnetic resonance (fMRI) study were found. Based on fMRI findings; however, cortical areas involved in a tapping task did not significantly differ from a healthy control group. In the cognitive domain, deficits in speech comprehension as well as verbal learning and declarative memory were present. No significant affective symptoms were observed. Although problems in executive, visuospatial and language tasks are in agreement with the so-called cerebellar cognitive affective syndrome-other possibilities remain. Non-motor impairments in HK might also be a consequence of lacking motor abilities in development and motor deficits may interfere with the performance of parts of the cognitive tasks. In addition, lack of promotion and learning opportunities in childhood may contribute and mental retardation based on extracerebellar dysfunction cannot be excluded.

Pure post-stroke cerebellar cognitive affective syndrome: a case report

Cerebellar pathology commonly shows important motor signs and less evident cognitive dysfunction. The 'cerebellar cognitive affective syndrome' is characterised by impairment on executive function, spatial cognition, language and behaviour. We report the case of a man with acute onset of transitory motor features and severe mental disorders. Cranial CT and brain MRI revealed extended cerebellar lesions. Neuropsychological assessment disclosed deficits of attention, executive function and memory. Auditory event-related potentials showed abnormal P300. These data suggest a pure "cerebellar cognitive affective syndrome"and strengthen the hypothesis of cerebellar cognitive function modulation.

Disorders of the cerebellum: ataxia, dysmetria of thought, and the cerebellar cognitive affective syndrome

Many diseases involve the cerebellum and produce ataxia, which is characterized by incoordination of balance, gait, extremity and eye movements, and dysarthria. Cerebellar lesions do not always manifest with ataxic motor syndromes, however. The cerebellar cognitive affective syndrome (CCAS) includes impairments in executive, visual-spatial, and linguistic abilities, with affective disturbance ranging from emotional blunting and depression, to disinhibition and psychotic features. The cognitive and psychiatric components of the CCAS, together with the ataxic motor disability of cerebellar disorders, are conceptualized within the dysmetria of thought hypothesis. This concept holds that a universal cerebellar transform facilitates automatic modulation of behavior around a homeostatic baseline, and the behavior being modulated is determined by the specificity of anatomic subcircuits, or loops, within the cerebrocerebellar system. Damage to the cerebellar component of the distributed neural circuit subserving sensorimotor, cognitive, and emotional processing disrupts the universal cerebellar transform, leading to the universal cerebellar impairment affecting the lesioned domain. The universal cerebellar impairment manifests as ataxia when the sensorimotor cerebellum is involved and as the CCAS when pathology is in the lateral hemisphere of the posterior cerebellum (involved in cognitive processing) or in the vermis (limbic cerebellum). Cognitive and emotional disorders may accompany cerebellar diseases or be their principal clinical presentation, and this has significance for the diagnosis and management of patients with cerebellar dysfunction.

Cerebellar dysfunction in neuroleptic naive schizophrenia patients: clinical, cognitive, and neuroanatomic correlates of cerebellar neurologic signs

BACKGROUND

There is increasing evidence that, aside from motor coordination, the cerebellum also plays an important role in cognition and psychiatric disorders. Our previous studies support the hypothesis that cerebellar dysfunction may disrupt the cortico-cerebellar-thalamic-cortical circuit and, in turn, lead to cognitive dysmetria in schizophrenia. The goal of this study was to investigate cerebellar dysfunction in schizophrenia by examining the clinical, cognitive, and neuroanatomic correlates of cerebellar neurologic signs in schizophrenia patients.

METHODS

We compared the prevalence of cerebellar neurologic signs in 155 neuroleptic-naive schizophrenia patients against 155 age- and gender-matched healthy control subjects. Differences in clinical characteristics, standardized neuropsychologic performance, and magnetic resonance imaging brain volumes between patients with and without cerebellar signs were also examined.

RESULTS

Patients had significantly higher rates of cerebellar signs than control subjects, with coordination of gait and stance being the most common abnormalities. Patients with lifetime alcohol abuse or dependence were no more likely than those without alcoholism to have cerebellar signs. Presence of cerebellar signs in patients was associated with poorer premorbid adjustment, more severe negative symptoms, poorer cognitive performance, and smaller cerebellar tissue volumes.

CONCLUSIONS

These findings lend further support for cerebellar dysfunction in schizophrenia.

Classically conditioned postural reflex in cerebellar patients

The aim of the current study was to compare postural responses to repetitive platform-evoked perturbations in cerebellar patients with those of healthy subjects using a classical conditioning paradigm. The perturbations consisted of tilting of the platform (unconditioned stimulus: US) at random time intervals, preceded by an auditory signal that represented the conditioning stimulus (CS). Physiological reactions were recorded biomechanically by measuring the vertical ground forces, yielding the center of vertical pressure (CVP), and electrophysiologically by EMG measurements of the main muscle groups of both legs. The recording session consisted of a control section with US-alone trials, a testing section with paired stimuli and a brief final section with US-alone trials. Healthy control subjects were divided into those establishing conditioned responses (CR) in all muscles tested (strategy I) and those with CR in the gastrocnemius muscles only (strategy II), suggesting an associative motor-related process is involved. Patients with a diffuse, non-localized disease were almost unable to establish CR. This was also true for a patient with a focal surgical lesion with no CR on the affected side but who, simultaneously, showed an essentially normal CR incidence on the intact side. During US-alone trials healthy controls exhibited a remarkable decay of the UR amplitude due to a non-associative motor-related process such as habituation. The decay was most prominent in the paired trials section. In contrast, patients showed no significant differences in the UR amplitude throughout the entire recording session. Analysis of the CVP supported the electrophysiological findings, showing CR in the controls only. The differences between the responses of control subjects and those of the cerebellar patients imply strongly that the cerebellum is involved critically in controlling associative and non-associative motor-related processes.

Long-term neuropsychological deficits after cerebellar infarctions in two young adult twins

Two young adult dizygotic twins with high schooling suffered two strokes at the ages of 26 and 30 years. On the first occasion, Case 2 suffered a stroke only a few months after Case 1; on the second occasion, Case 1 suffered a second stroke a few months after Case 2. In Case 1, lesions were mainly localized to the left cerebellar hemisphere in both stroke episodes. Case 2 suffered lesions localized to the right cerebellar hemisphere in the first stroke episode, and multiple lesions in both cerebellar hemispheres and the vermis, right pons and left thalamus during the second stroke episode. Seven years after the second stroke, despite full recovery of motor functions, the patients still show mild, yet selective, linguistic deficits (syntactic comprehension deficits, mild agrammatism, reading and writing disorders) without speech disturbances. They also present with selective dysfunctions in visuospatial short-term memory. Language disorders are ascribed to a dysfunction of the cerebellum in Case 1, while in Case 2 a dysfunction of the cerebellum and the thalamus is considered as both structures are part of the so-called 'frontal lobe system', which supports language generation. Visuospatial short-term memory disorders are attributed to an impaired ability to appreciate the organizing structure of the visual task and to poor planning strategies, which are in turn ascribed to cerebellar lesions. The role of the cerebellum in cognitive and linguistic functions is discussed.

Cognitive dysfunction in cortical cerebellar atrophy correlates with impairment of the inhibitory system

The aim of the present study was to evaluate the profile of cognitive impairment in patients with cortical cerebellar atrophy (CCA) by measurement of event-related potentials (ERP) and neuropsychological tests. We studied 13 CCA patients and 13 age-, sex- and education-matched normal controls. For ERP recording, we used the conventional auditory oddball task as well as the continuous performance task, which evaluates the attentional performance and ability to control a motor response, i.e., to execute ("Go") or inhibit a motor reaction ("No Go"). Brain electric activity was recorded using 20 scalp electrodes and computed into series of potential distribution maps. For components of ERP, reference-independent measures [global field power (GFP)] were determined, and low-resolution brain electromagnetic tomography (LORETA) was used to compute the three-dimensional intracerebral distribution of electric activity of the P3 component of Go and No Go responses. A comprehensive neuropsychological test battery was also assessed. GFP peak latency was prolonged and GFP peak was attenuated under the No Go condition in patients with CCA, although there were no differences in the auditory oddball task and in the Go condition between the two groups. LORETA showed low activation of frontal source in CCA patients in No Go P3 compared with the controls. However, neuropsychological tests revealed no differences between the two groups. Our results indicate that degeneration of the cerebellum contributes to frontal dysfunction, and suggest this dysfunction is characterized by an impairment of the inhibitory system.

Psychopathology in patients with degenerative cerebellar diseases: a comparison to Huntington's disease

OBJECTIVE

This study estimated the psychiatric morbidity of patients with degenerative cerebellar diseases.

METHOD

The study included a series of 31 patients with degenerative cerebellar diseases, compared with 21 patients with Huntington's disease and 29 neurologically healthy comparison subjects. Comprehensive psychiatric evaluations, including the Structured Clinical Interview for DSM-IV and psychopathology rating scales, were administered.

RESULTS

The overall rate of noncognitive psychiatric disorders was 77% in the patients with degenerative cerebellar diseases, nearly identical to that in the patients with Huntington's disease (81%) and about double that seen in the neurologically healthy subjects (41%). There were high rates of all mood disorders in both the degenerative cerebellar diseases group (68%) and the Huntington's disease group (43%); the rate in the degenerative cerebellar diseases group was significantly higher than that in the neurologically healthy subjects (31%). The frequency of personality change in the three groups was striking: change was present in 26% of the degenerative cerebellar diseases patients, 48% of the Huntington's disease patients, and none of the neurologically healthy comparison subjects. A total of 19% of the degenerative cerebellar diseases subjects and 71% of the Huntington's disease subjects met DSM-IV criteria for either cognitive disorder or dementia.

CONCLUSIONS

The high rate of psychiatric and cognitive disorders in the patients with degenerative cerebellar diseases suggests that many, if not most, patients with degenerative cerebellar diseases may benefit from psychiatric interventions. These results also support previous findings that the cerebellum may have a role in modulating emotion and cognition.

Differential role for the striatum and cerebellum in response to novel movements using a motor learning paradigm

The aim of this pilot study was to examine the role of the striatum and cerebellum in the adaptation to a novel movement within a sequence of practiced movements using a motor learning paradigm. The performance of patients in the early or advanced stages of Parkinson's disease (PD) and of patients with damage to the cerebellum (CE) was compared, respectively to a group of aged and young matched controls on an adapted version of the Mirror-Tracing Test. In this task, subjects were required to trace a series of complex figures in two conditions: (1) a Practiced condition, in which the figures were composed of the juxtaposition of three simple designs that were extensively practiced before; and (2) a Mixed condition in which triads were created by replacing the last simple figure of the triads in the Practiced condition by a new simple figure that had never been traced individually before. Results showed that all clinical groups were slower than controls at tracing the Practiced triads. Most interestingly, however, only patients in the advanced stages of PD showed increased completion time to trace the triads in the Mixed condition. This suggests that a bilateral striatal dysfunction affects the ability to adapt to a novel motion within a sequence of practiced movements. Although exploratory, these results support a functional dissociation between the striatum and cerebellum in acquiring visuomotor skilled behaviors.

Developmental dyslexia: the cerebellar deficit hypothesis

Surprisingly, the problems faced by many dyslexic children are by no means confined to reading and spelling. There appears to be a general impairment in the ability to perform skills automatically, an ability thought to be dependent upon the cerebellum. Specific behavioural and neuroimaging tests reviewed here indicate that dyslexia is indeed associated with cerebellar impairment in about 80% of cases. We propose that disorders of cerebellar development can in fact cause the impairments in reading and writing characteristic of dyslexia, a view consistent with the recently appreciated role of the cerebellum in language-related skills. This proposal has implications for early remedial treatment.

Right side neglect in right cerebellar lesion

A patient is described who developed right side hemineglect after a right cerebellar lesion. This spatial disorder was interpreted as a secondary effect of a deficit of the motor organisation in the right hemispace due to left frontal diaschisis. The pathological base may be the interruption of a highly integrated system which includes the lateral cerebellum and the contralateral frontal lobe.

Neuropsychological consequences of cerebellar tumour resection in children: cerebellar cognitive affective syndrome in a paediatric population

Acquired cerebellar lesions in adults have been shown to produce impairments in higher function as exemplified by the cerebellar cognitive affective syndrome. It is not yet known whether similar findings occur in children with acquired cerebellar lesions, and whether developmental factors influence their presentation. In studies to date, survivors of childhood cerebellar tumours who demonstrate long-term deficits in cognitive functions have undergone surgery as well as cranial irradiation or methotrexate treatment. Investigation of the effects of the cerebellar lesion independent of the known deleterious effects of these agents is important for understanding the role of the cerebellum in cognitive and affective development and for informing treatment and rehabilitation strategies. If the cerebellar contribution to cognition and affect is significant, then damage in childhood may influence a wide range of psychological processes, both as an immediate consequence and as these processes fail to develop normally later on. In this study we evaluated neuropsychological data in 19 children who underwent resection of cerebellar tumours but who received neither cranial irradiation nor methotrexate chemotherapy. Impairments were noted in executive function, including planning and sequencing, and in visual-spatial function, expressive language, verbal memory and modulation of affect. These deficits were common and in some cases could be dissociated from motor deficits. Lesions of the vermis in particular were associated with dysregulation of affect. Behavioural deficits were more apparent in older than younger children. These results reveal that clinically relevant neuropsychological changes may occur following cerebellar tumour resection in children. Age at the time of surgery and the site of the cerebellar lesion influence the neurobehavioural outcome. The results of the present study indicate that the cerebellar cognitive affective syndrome is evident in children as well as in adults, and they provide further clinical evidence that the cerebellum is an essential node in the distributed neural circuitry subserving higher-order behaviours.