Effect of Intraventricular Hemorrhage on Cerebellar Growth in Preterm Neonates

The aim of this study is to evaluate cerebellar growth of preterm infants with intraventricular hemorrhage. Vermis height (VH) and transverse cerebellar diameter (TCD) were measured by cranial ultrasound in 18 preterm infants (26–30 weeks) with intraventricular hemorrhage (IVH) at first 3 days of life and at term equivalent age (TEA). IVH was diagnosed by ultrasonography and scaled in accordance with the definitions by Papile et al. Measurements were compared with 18 preterm (26–30 weeks) infants without IVH. Both VH and TCD of preterm infants with IVH were significantly lower than those of preterm ones without IVH at TEA (p?<?0.001). No significant difference was found for head circumference (p?=?0.158) and weight (p?=?0.092). In subgroup analysis, preterm infants with grades 3–4 IVH had significantly lower TCD (p?=?0.008) and head circumference (p?=?0.033) than the ones with grades 1–2 IVH. However, VH (p?=?0.102) and weight (p?=?0.480) did not show any difference between these subgroups. IVH may have a significant impact on cerebellar growth on preterm infants at TEA, specially those with a severe IVH. TCD is affected more than VH.     

Small Cerebellar Hemorrhage in Preterm Infants: Perinatal and Postnatal Factors and Outcome

The objective of the study is to determine perinatal and postnatal factors that may affect the occurrence of small cerebellar hemorrhage (CBH) and to evaluate the effect of small CBH on neurodevelopmental outcome in very preterm infants. This prospective study in an unselected cohort of very preterm infants was approved by the medical ethics committee, and informed parental consent was obtained. Presence of small CBH (<4 mm) was assessed with magnetic resonance imaging around term equivalent age in 108 preterm infants (<32 weeks gestation). We compared infants with and without small CBH for perinatal and postnatal factors, supratentorial brain injury, and for neurodevelopmental outcome at 2 years corrected age. Follow-up consisted of a neurological examination, mental and developmental assessment (Bayley Scales of Infant Development), and behavior checklist. Univariate and multivariate logistic regression analyses were performed to examine the relationships between variables. Small CBH was diagnosed in 16/108 very preterm infants. Univariate analyses identified gestational age, high-frequency oscillation (HFO) ventilation, and grade 3–4 intraventricular hemorrhage (IVH) as factors associated with small CBH. HFO ventilation and severe IVH were independent predictors of small CBH. We found no association between small CBH and neurodevelopmental outcome at 2 years of age. Small CBH is a frequent finding in preterm infants. These hemorrhages are independently associated with HFO ventilation and severe supratentorial hemorrhage and seem to have a favorable short-term prognosis.     

Remote Cerebellar Hemorrhage after Lumbar Spinal Surgery

Remote cerebellar hemorrhage (RCH) is rare but potentially lethal as a complication of spinal surgery. We recently experienced a case of RCH in a 61-year-old man who showed mental deterioration after lumbar spinal surgery. There was dural tearing with subsequent cerebrospinal fluid (CSF) loss during the surgery. Brain computed tomography scan revealed cerebellar hemorrhage, 3rd and 4th ventricular hemorrhage and pneumocephalus. He underwent suboccipital craniectomy and hematoma removal. The most important pathomechanism leading to RCH after spinal surgery has been known to be venous bleeding due to caudal sagging of cerebellum by rapid leak of large amount of CSF which seems to be related with this case. Dural repair and minimizing CSF loss after intraoperative dural tearing would be helpful to prevent postoperative RCH.     

Transient Crossed Cerebellar Diaschisis Following Thalamic Hemorrhage

This report concerns a 65-year-old right-handed woman with cerebral hemorrhage who presented with mild right-sided hemiparesis. Computed tomography (CT) revealed hematoma in the left thalamus and compression of the posterior limb of the internal capsule by a brain edema surrounding the lesion. 99mTc-hexamethylpropyleneamine oxime (HMPAO) single photon emission computed tomography (SPECT) images obtained 4 days after onset showed hypoperfusion in the left thalamus containing a hematoma as well as contralateral cerebellar hypoperfusion to the supratentorial lesion, which is well recognized as crossed cerebellar diaschisis (CCD) after stroke. CT 14 days after the onset revealed reduction of the brain edema of the posterior limb of the internal capsule accompanied by gradual neurological improvement. SPECT obtained 14 and 28 days later showed that CCD had disappeared. In this case report, the authors discuss the disappearance of CCD due to transient edematous compression of the internal capsule following thalamic hemorrhage on serial 99mTc-HMPAO SPECT scans. CCD was possibly caused by the lesion confined to the posterior limb of the internal capsule, which anatomically constitutes the cerebropontocerebellar pathway.     

Remote Cerebellar Hemorrhage after Intradural Disc Surgery

We report a rare case of remote cerebellar hemorrhage after intradural disc surgery at the L1-2 level. Two days after the spine surgery, patient complained unexpected headache, dizziness, nausea and vomiting. From the urgently conducted brain CT, it was reported that the patient had cerebellar hemorrhage. Occipital craniotomy and hematoma evacuation was performed, and hemorrhagic lesion on the right cerebellum was effectively removed. After occipital craniotomy, the patient showed signs of improvement on headache, dizziness, nausea and vomiting. He was able to leave the hospital after two weeks of initial operation without any neurological deficit. Remote cerebellar hemorrhage following spinal surgery is extremely rare, but may occur from dural damage of spinal surgery, accompanied with cerebrospinal fluid leakage. Early diagnosis is particularly important for the optimal treatment of remote cerebellar hemorrhage.     

Long-Term Outcome and Prognostic Factors After Spontaneous Cerebellar Hemorrhage

Cerebellar hemorrhage is the least common type of intracranial hemorrhage (ICH) encountered in clinical practice, and clinical data concerning the long-term outcomes are limited. This study aimed to investigate the long-term outcomes following spontaneous cerebellar hemorrhage in a cohort of Chinese patients. This single-center observational study was carried out between 1996 and 2010 and included 72 consecutive Chinese patients with a first spontaneous cerebellar hemorrhage. Of 440 patients with primary ICH, 72 (16.4%) had primary cerebellar hemorrhage. The mean age was 67.5?±?12.3?years and patients were predominantly male (54%). The 30-day mortality was 16.7% with Glasgow coma scale ??8 as the only predictor. At 6?months, 56.7% of patients who survived the first 30?days had a persistently poor functional status with modified Rankin scale score >2. After a mean follow-up of 4.7?years, 3.3% of patients had recurrent ICH, a recurrence rate of 7.3 per 1,000 patient-years. Ischemic stroke occurred in 12% of patients, an incidence of 25.5 per 1,000 patient-years. This study provided data on the long-term outcome of post-cerebellar hemorrhage in Chinese patients.     

Cerebellar Disorders in Childhood: Cognitive Problems

Over the last decade, increasing evidence of cognitive functions of the cerebellum during development and learning processes could be ascertained. Posterior fossa malformations such as cerebellar hypoplasia or Joubert syndrome are known to be related to developmental problems in a marked to moderate extent. More detailed analyses reveal special deficits in attention, processing speed, visuospatial functions, and language. A study about Dandy Walker syndrome states a relationship of abnormalities in vermis lobulation with developmental problems. Further lobulation or volume abnormalities of the cerebellum and/or vermis can be detected in disorders as fragile X syndrome, Downs’s syndrome, William’s syndrome, and autism. Neuropsychological studies reveal a relation of dyslexia and attention deficit disorder with cerebellar functions. These functional studies are supported by structural abnormalities in neuroimaging in these disorders. Acquired cerebellar or vermis atrophy was found in groups of children with developmental problems such as prenatal alcohol exposure or extreme prematurity. Also, focal lesions during childhood or adolescence such as cerebellar tumor or stroke are related with neuropsychological abnormalities, which are most pronounced in visuospatial, language, and memory functions. In addition, cerebellar atrophy was shown to be a bad prognostic factor considering cognitive outcome in children after brain trauma and leukemia. In ataxia teleangiectasia, a neurodegenerative disorder affecting primarily the cerebellar cortex, a reduced verbal intelligence quotient and problems of judgment of duration are a hint of the importance of the cerebellum in cognition. In conclusion, the cerebellum seems to play an important role in many higher cognitive functions, especially in learning. There is a suggestion that the earlier the incorrect influence, the more pronounced the problems.     

Asymptomatic Remote Cerebellar Hemorrhage: CT and MRI Findings

The aim of this study was to evaluate the computed tomography (CT) and magnetic resonance imaging findings (MRI) of asymptomatic remote cerebellar hemorrhage (RCH) at the preoperative, early postoperative, and postoperative period. A total of 983 consecutive adult patients who underwent supratentorial craniotomies were included in the study. The ethics committee approved the study. The patient??s clinical records and radiological examinations were retrospectively analyzed. All patients had preoperative CT and MRI examinations, immediate postoperative CT, and postoperative MRI within 24?h. The patients with the radiological diagnosis of RCH were followed up to 5?years. Eight asymptomatic RCH cases were recruited. The prevalence of asymptomatic RCH was 0.8% in our series. RCH was unilateral in two patients and bilateral in six patients. The postoperative CT was positive in two cases. The hemorrhage presented on MRI as folial linear hypointensities in six cases. In three cases (including one mixed case), punctate hypointense spots were identified at the superior cerebellar folia. Diffuse hemorrhage in the cerebellar tonsil, subarachnoid hemorrhage, and hemorrhage in the cerebellar vermis and the ventricles were also seen. The MRI findings were stable up to 5?years. The prevalence of asymptomatic RCH is higher than previously reported. Immediate postoperative CT is usually unremarkable; however, MRI demonstrates various hemorrhagic patterns at the cerebellum other than classical ??zebra sign??. This condition is self-limiting and no further investigation or follow-up study is required. In the proper clinical setting, the awareness of different hemorrhagic patterns in patients with RCH would prevent unnecessary investigations.     

Neurogenic Cardiopulmonary Complications Associated with Spontaneous Cerebellar Hemorrhage

Introduction  

Neurogenic cardiopulmonary complications associated with acute brain injury other then subarachnoid hemorrhage were seldom reported, especially in the pediatric population. We report a child who developed cardiac arrhythmia, severe myocardial injury and neurogenic pulmonary edema after cerebellar hemorrhage.     

Remote Cerebellar Hemorrhage and Iliofemoral Vein Thrombosis After Supratentorial Craniotomy

Introduction  Cerebellar hemorrhage following supratentorial craniotomy is rare. Its clinical symptoms are often mild and transient. Discussion  Here, we report a case of cerebellar hemorrhage associated with iliofemoral vein thrombosis as a complication of anterior temporal lobectomy and amygdalohippocampectomy for refractory medial temporal epilepsy.     

自发性小脑出血的外科治疗选择

目的探讨自发性小脑出血的外科治疗方式。方法回顾性分析我院采用不同手术方式治疗的31例自发性小脑出血患者的临床资料。结果采用后颅窝开颅血肿清除及去骨瓣减压术治疗19例，其中恢复良好12例，重残4例，植物生存1例，死亡2例：采用CT．引导立体定向血肿穿刺引流术治疗7例，其中恢复良好5例，重残1例，死亡1例；采用单纯脑室外引流治疗5例，其中恢复良好4例，重残1例。结论对自发性小脑出血患者，要根据发病时间、病因、病情轻重、头颅CT表现，选择不同的手术方式；及时手术治疗可以取得良好的治疗效果。     

Recurrent Cerebellar Hemorrhage: Case Report and Review of the Literature

We report a case of cerebellar hemorrhage (CH) that recurred in other hemisphere after 4 months of the first attack. A 58-year-old man presented with general weakness and computerized tomography (CT) of the brain showed a 41 mm hematoma in the right cerebellum with intraventricular extension. The satisfactory outcome was obtained after emergency surgical intervention and intensive rehabilitation. However, the patient irregularly took the prescribed anti-hypertensive medication. Four months after first attack, the recurrent CH in left side showed by brain CT. Only 2 cases of recurrent CH have been published thus far. The patient is the third reported case of recurrent CH and the second case in which CH recurred in the other hemisphere. Further, no patient has been reported to develop recurrence of CH in such a short period after the first onset. We discuss the possible pathophysiology, clinical course, treatment outcome, risk factors associated with such events and the importance of blood pressure control for preventing recurrence.     

Cerebellar Pilocytic Astrocytomas with Spontaneous Intratumoral Hemorrhage in Adult

Cerebellar pilocytic astrocytomas (PAs) are benign gliomas predominantly found in the pediatric population. Intracranial hemorrhages are extremely rare in initial presentations of cerebellar PAs. There are no reports in the medical literature of adult cerebellar PA cases presenting with intratumoral hemorrhage. We report 2 cases of adult cerebellar pilocytic astrocytomas with intratumoral hemorrhage. The first case is a 37-year-old woman presenting with severe headache, nausea, and vomitting. Computed tomography demonstrated an acute hemorrhage adjacent to the right cerebellar hemisphere and hydrocephalus. Magnetic resonance imaging (MRI) revealed a cerebellar vermian tumor with the hemorrhage as a mixed isointense area in the T2-weighted image, and as a mixed hyperintense area in the contrast-enhanced T1-weighted image. The second case is a 53-year-old man presenting with headache for 3 weeks. MRI revealed a cerebellar hemispheric tumor with the hemorrhage as a mixed hyperintense area. It had a cystic mass with a heterogeneous enhanced mural nodule in the gadolinium-enhanced T1-weighted image and a fluid-fluid level within the cyst in the T2-weighted image. Both of them underwent radical resections of their respective lesions. Histological examination of the specimens revealed typical astrocytoma, including a hemorrhagic portion. Both patients recovered postoperatively and continue to do well at present. The medical literature on hemorrhagic cerebellar PAs is also reviewed.     

Size and Location of Ruptured Intracranial Aneurysms

Objective

The aim of study was to review our patient population to determine whether there is a critical aneurysm size at which the incidence of rupture increases and whether there is a correlation between aneurysm size and location.

Methods

We reviewed charts and radiological findings (computed tomography (CT) scans, angiograms, CT angiography, magnetic resonance angiography) for all patients operated on for intracranial aneurysms in our hospital between September 2002 and May 2004. Of the 336 aneurysms that were reviewed, measurements were obtained from angiograms for 239 ruptured aneurysms by a neuroradiologist at the time of diagnosis in our hospital.

Results

There were 115 male and 221 female patients assessed in this study. The locations of aneurysms were the middle cerebral artery (MCA, 61), anterior communicating artery (ACoA, 66), posterior communicating artery (PCoA, 52), the top of the basilar artery (15), internal carotid artery (ICA) including the cavernous portion (13), anterior choroidal artery (AChA, 7), A1 segment of the anterior cerebral artery (3), A2 segment of the anterior cerebral artery (11), posterior inferior cerebellar artery (PICA, 8), superior cerebellar artery (SCA, 2), P2 segment of the posterior cerebral artery (1), and the vertebral artery (2). The mean diameter of aneurysms was 5.47±2.536 mm in anterior cerebral artery (ACA), 6.84±3.941 mm in ICA, 7.09±3.652 mm in MCA and 6.21±3.697 mm in vertebrobasilar artery. The ACA aneurysms were smaller than the MCA aneurysms. Aneurysms less than 6 mm in diameter included 37 (60.65%) in patients with aneurysms in the MCA, 43 (65.15%) in patients with aneurysms in the ACoA and 29 (55.76%) in patients with aneurysms in the PCoA.

Conclusion

Ruptured aneurysms in the ACA were smaller than those in the MCA. The most prevalent aneurysm size was 3-6 mm in the MCA (55.73%), 3-6 mm in the ACoA (57.57%) and 4-6 mm in the PCoA (42.30%). The more prevalent size of the aneurysm to treat may differ in accordance with the location of the aneurysm.     

Risk Factors Associated with Germinal Matrix-Intraventricular Hemorrhage in Preterm Neonates

Objective

The purpose of this study is to identify the risk factors associated with the development of germinal matrix-intraventricular hemorrhage (GM-IVH) and the relationship of the severity of disease and prematurity.

Methods

A total of 168 premature neonates whose birth weight ≤1500 g or gestational age ≤34 weeks were examined by cranial ultrasound (CUS) for detection of GM-IVH among the babies admitted between January 2011 and December 2012 in our medical center neonatal intensive care unit. The babies were divided into two groups : GM-IVH and non-IVH. Clinical presentations, precipitating factors of the patients and maternal factors were analyzed.

Results

In univariate analysis, gestational age, birth weight, delivery method, presence of premature rupture of membrane (PROM) and level of sodium and glucose were statistically meaningful factors (p<0.05). But only two factors, gestational age and presence of patent ductus arteriosus (PDA) were statistically meaningful in multivariate logistic regression (p<0.05). Delivery method [normal vaginal delivery (NVD) to Caeserean section] was borderline significant (p<0.10).

Conclusion

Presence of PDA and gestational age were the important risk factors associated with development of GM-IVH.     

Spontaneous Cerebellar Hemorrhage with the Fourth Ventricular Hemorrhage : Risk Factors Associated with Ventriculoperitoneal Shunt

Objective

The purposes of this study are to investigate the factors that may be related to ventriculoperitoneal (VP) shunt in patients with cerebellar hematoma and the effect of severe fourth ventricular hemorrhage, causing obstructive hydrocephalus on subsequent VP shunt performance.

Methods

This study included 31 patients with spontaneous cerebellar hematoma and concomitant fourth ventricular hemorrhage, who did not undergo a surgical evacuation of hematoma. We divided this population into two groups; the VP shunt group, and the non-VP shunt group. The demographic data, radiologic findings, and clinical factors were compared in each group. The location of the hematoma (whether occupying the cerebellar hemisphere or the vermis) and the degree of the fourth ventricular obstruction were graded respectively. The intraventricular hemorrhage (IVH) score was used to assess the IVH severity.

Results

Ten out of 31 patients underwent VP shunt operations. The midline location of cerebellar hematoma, the grade of fourth ventricle obstruction, and IVH severity were significantly correlated with that of VP shunt operation (p=0.015, p=0.013, p=0.028). The significant variables into a logistic regression multivariate model resulted in statistical significance for the location of cerebellar hemorrhage [p=0.05; odds ratio (OR), 8.18; 95% confidence interval (CI), 1.00 to 67.0], the grade of fourth ventricle obstruction (p=0.044; OR, 19.26; 95% CI, 1.07 to 346.6).

Conclusion

The location of the cerebellar hematoma on CT scans and the degree of fourth ventricle obstruction by IVH were useful signs for the selection of VP shunt operation in patients with spontaneous cerebellar hematoma and concomitant acute hydrocephalus.     

SHH Pathway and Cerebellar Development

The morphogenetic factor Sonic hedgehog (SHH) has been discovered as one of the masterplayers in cerebellar patterning and was subjected to intensive investigation during the last decade. During early postnatal development, this continuously secreted cholesterol-modified protein drives the expansion of the largest neuronal population of the brain, the granular cells. Moreover, it acts on Bergmann glia differentiation and would potentially affect Purkinje cells homeostasis at adult age. The cerebellar cortex constituted an ideal developmental model to dissect out the upstream mechanisms and downstream targets of this complex pathway. Its deep understanding discloses some of the mechanistic disorders underlying pediatric tumorigenesis, congenital ataxia, and mental retardation. Therapeutical use of its regulators has been consolidated on murine transgenic models and is now considered as a realistic human clinical application. Here, we will review the most recent advances made in the comprehensive understanding of SHH involvement in cerebellar development and pathology.     

Cerebellar Vermis Size and Cognitive Ability in Community-Dwelling Elderly Men

The cerebellum participates in multiple cognitive functions, including those that are sensitive to decline with aging, and is also vulnerable to atrophy with aging. However, few studies have examined structure–function relationships in older adults. We measured the cross-sectional area of four areas of the cerebellar vermis in 45 community-dwelling men aged 71–76, and correlated this with individual cognitive test scores and two cognitive factors derived from principal components analysis. Two out of the four areas showed positive correlations; vermis area 4 (lobules VIII–X) correlated at r?=?0.47 (p?=?0.001) with a general cognitive factor accounting for almost half of the cognitive test variance. These findings support the hypothesis that variations in cerebellar structure are associated with cognitive ability in older adults.