Cerebellar Stroke Research Articles

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.

Abstract 4135311: Cryptogenic stroke associated with a double interatrial septum treated with surgical closure

Introduction: A double atrium septum is a rare congenital anomaly characterized by a double-walled atrial septum with persistent interatrial space. This could be an asymptomatic presentation but also serve as a nidus of thromboembolic complications. We hereby present a case of a 57-year-old female with a cryptogenic stroke found to have a patent foramen ovale and double atrial septum. Case Description: A 57 year-old-female with a past medical history of hypertension presented with acute complaints of word-finding difficulty, left-sided neck pain and lightheadedness after a head strike while swimming. She was found to have a right-sided cerebellar stroke. A carotid artery ultrasound showed no evidence of atherosclerotic disease. Her lipid profile was normal. A transthoracic echocardiogram showed a patent foramen ovale with a positive bubble study revealing a large right to left shunt with Valsalva. A transesophageal echocardiogram confirmed a patent foramen ovale with an incidental finding of a double atrial septum with extreme redundancy of septal issue. The patient had a surgical closure of the interatrial septum and resection of the accessory interatrial septum tissue. She developed chronic post-sternotomy pain and subsequently had sternal wire removal. Discussion: A double atrial septum is a rare congenital anomaly seen as two parallel interatrial septa accompanied by a distinct echo-lucent midline space that expands during systole and contracts during diastole. It can happen embryologically by either the abnormal development of the septum secundum, resorption failure of the superior portion of the septum primum, or the persistence of the left venous valve of the sinus venosus. Typically, individuals with double atrial septum are asymptomatic, but they may encounter cardioembolic events due to the potential thrombi formation in the interatrial space. Communication between the septa increases the likelihood of such events. Unlike atrial fibrillation/flutter, there are currently no established criteria for initiating anticoagulation therapy for double atrial septum, primarily due to its rarity. Some options include antiplatelet agents, oral anticoagulation therapy, and percutaneous or surgical PFO closure. Surgical closure provides a permanent closure of the defect, thereby preventing future paradoxical emboli without the potential risks associated with long-term anticoagulation.

Transient biopsy-proven progressive multifocal leukoencephalopathy-immune reconstitution inflammatory syndrome (PML-IRIS) in an elderly woman without known immunodeficiency: a case report

BackgroundProgressive multifocal leukoencephalopathy (PML) is a severe opportunistic brain disease caused by lytic JC polyomavirus (JCPyV) replication in oligodendrocytes. Although JCPyV infection is common in the general population, PML almost exclusively occurs in patients immunocompromised due to untreated HIV/AIDS, haematological malignancies, primary immunodeficiencies, solid organ transplantation, or immunomodulatory treatment of autoimmune diseases. There is no effective antiviral treatment, and recovery depends on immune reconstitution. Paradoxically, initiation of antiretroviral therapy for HIV/AIDS or interruption of immunomodulating treatment can worsen the clinical manifestations due to immune reconstitution inflammatory syndrome (IRIS). Here, we report an unusual case of spontaneous IRIS in a 76-year-old immunocompetent woman, unmasking PML and leading to unexpected recovery.Case presentationThe patient was admitted to the hospital due to psychosis, speech impairment, and behavioral changes over the last three months. She had previously been healthy, except for a cerebellar stroke secondary to paroxysmal atrial fibrillation. Magnetic resonance imaging (MRI) revealed multiple contrast-enhancing white matter lesions suspicious of cancer metastases. Due to suspicion of edema, dexamethasone was administered, and the patient was released while waiting for a stereotactic brain biopsy. Eight days later, she suffered tonic seizures and was readmitted. Intravenous levetiracetam gave rapid effect, but the patient was paranoid and non-cooperative, and dexamethasone was unintentionally discontinued. Ten days later, the brain biopsy revealed demyelination, abundant perivascular T cells, macrophages, and scattered JCPyV-infected oligodendrocytes, rendering the diagnosis of PML-IRIS. The cerebrospinal fluid contained low amounts of JCPyV-DNA, and plasma contained high levels of anti-JCPyV immunoglobulin G. Despite extensive immunological testing, no evidence of immunodeficiency was found. The patient gradually recovered clinically and radiologically. More than 19 months after diagnosis, the patient has only a slight impairment in language and behavior.ConclusionsAn apparently immunocompetent elderly person developed clinically symptomatic PML, which spontaneously resolved with symptoms and signs of IRIS. The atypical MRI lesions with contrast enhancement and the lack of known immunological risk factors for PML delayed the diagnosis, eventually proved by biopsy. PML and PML-IRIS should be considered in the differential diagnosis of patients presenting CNS symptoms and focal lesions with contrast enhancement on MRI.

Balance and Walking Speed Outcomes in Individuals Receiving Inpatient Rehabilitation for Acute Cerebellar Stroke.

Cerebellar strokes account for only 2-3% of all strokes occurring annually in the United States but represent a disproportionally higher share of morbidity and mortality. Evidence examining the effect of inpatient rehabilitation on functional outcomes following a cerebellar stroke is limited. This study aimed to examine the effects of inpatient rehabilitation on balance and walking speed in individuals with cerebellar stroke. A secondary purpose of this study was to examine the length of inpatient rehabilitation stay of the included patients. A retrospective analysis was conducted using review of patient records during their inpatient rehabilitation stay from January 2021 to February 2022 at a large hospital system in the southeast United States. Balance and gait outcomes were examined on admission and discharge from inpatient rehabilitation that included physical therapy interventions. A paired t-test examined for changes in outcomes from admission to discharge. Pearson correlation examined for the association between length of stay and outcomes. A total of 15 records were reviewed. There were significant improvements in the Berg Balance Scale (BBS), Postural Assessment Scale for Stroke (PASS), and the 10-Meter Walk Test (10MWT) (p's < 0.01) from admission to discharge with large effect sizes (range d = 0.70-1.67) following inpatient rehabilitation. The average length of stay was 12.67 days (SD = 6.5) and the mean total hours of combined occupational, physical, and speech therapy was 27.33 (SD = 6.52) h. There was a moderate association between length of stay and PASS (r = 0.525, p = 0.04) and BBS (r = 0.546, p = 0.04) outcomes. Patients who underwent inpatient rehabilitation following acute cerebellar strokes demonstrated improvements in balance and gait speed. Study results could assist clinicians designing interventions for patients with cerebellar strokes in the inpatient rehabilitation setting.

Cough-induced vertebral artery dissection: A case report and literature review.

Spontaneous vertebral artery dissection (VAD) is common after minor neck trauma or abrupt neck manipulation, which may result in stroke. However, violent cough is a less recognised cause of VAD. Only a few cases are reported in the literature. We review the literature and report a case of a 62-year-old man who presented with a headache and neck pain following a period of intermittent coughing, which led to VAD and a cerebellar ischaemic stroke. He responded well to medical treatment and made a full recovery. Therefore, VAD should be considered in the differential diagnosis for patients presenting with neck pain and headache after episodes of violent coughing.

Life-threatening presentation of an acute cerebellar ischemic stroke secondary to a protein C deficiency.

Acute cerebellar ischemic stroke is a rare disease in children. Typically, patients present with ataxia and cranial nerve palsy. Rarely, some patients show a severe intracranial hypertension syndrome with a life-threatening clinical presentation. We report a case of a 2-year-old male child who was admitted for deterioration of his consciousness level and vomiting. Cerebral imaging revealed a right cerebellar and brainstem infarction with an obstructive hydrocephalus and a tonsillar herniation. Angiography identified an occlusion of the right anterior inferior cerebellar artery. The child was referred to a neurosurgeon for the treatment of acute hydrocephalus and posterior fossa craniectomy. Etiological investigations revealed a protein C deficiency. Initially, the patient was maintained under fluid restriction and received mannitol several times as he had clinical and radiological signs of intracranial hypertension. He was also kept on mechanical ventilation and monitored. However, the evolution was complicated by the occurrence of a thrombosis of the vena cava and the renal vein.

Virtual reality assessment of reaching accuracy in patients with recent cerebellar stroke

BackgroundDysmetria, the inability to accurately estimate distance in motor tasks, is a characteristic clinical feature of cerebellar injury. Even though subjective dysmetria can be quickly detected during the neurological examination with the finger-to-nose test, objective quantification of reaching accuracy for clinical assessment is still lacking. Emerging VR technology allows for the delivery of rich multisensory environmental stimuli with a high degree of control. Furthermore, recent improvements in the hand-tracking feature offer an opportunity to closely examine the speed, accuracy, and consistency of fine hand movements and proprioceptive function. This study aims to investigate the application of virtual reality (VR) with hand tracking in the rapid quantification of reaching accuracy at the bedside for patients with cerebellar stroke (CS).Methods and resultsThirty individuals (10 CS patients and 20 age-matched neurologically healthy controls) performed a simple task that allowed us to measure reaching accuracy using a VR headset (Oculus Quest 2). During this task, the participant was asked to reach for a target placed along a horizontal sixty-degree arc. Once the fingertip passed through the arc, the target immediately extinguished. 50% of the trials displayed a visible, real-time rendering of the hand as the participant reached for the target (visible hand condition), while the remaining 50% only showed the target being extinguished (invisible hand condition). The invisible hand condition isolates proprioception-guided movements by removing the visibility of the participant’s hand. Reaching error was calculated as the difference in degrees between the location of the target, and where the fingertip contacted the arc. Both CS patients and age-matched controls displayed higher average reaching error and took longer to perform a reaching motion in the invisible hand condition than in the visible hand condition. Reaching error was higher in CS than in controls in the invisible hand condition but not in the visible hand condition. Average time taken to perform each trial was higher in CS than in controls in the invisible hand conditions but not in the visible hand condition.ConclusionsReaching accuracy assessed by VR offers a non-invasive and rapid approach to quantifying fine motor functions in clinical settings. Furthermore, this technology enhances our understanding of proprioceptive function in patients with visuomotor disabilities by allowing the isolation of proprioception from vision. Future studies with larger cohorts and longitudinal designs will examine the quantitative changes in reaching accuracy after stroke and explore the long-term benefits of VR in functional recovery.

Treating Intractable Nausea and Vomiting in Cerebellar and Medullary Stroke

Treating Intractable Nausea and Vomiting in Cerebellar and Medullary Stroke

A Comparative Study on Cognitive Assessment in Cerebellar and Supratentorial Stroke.

This study aims to understand the cognitive profiles of cerebellar infarction patients and compare them to those with supratentorial infarctions, particularly frontal infarctions. This current study also aims to find reliable assessment tools for detecting cognitive impairment in cerebellar infarction patients. A total of fifty cerebellar infarction patients, sixty supratentorial infarction patients, and thirty-nine healthy controls were recruited. The Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Addenbrooke's Cognitive Examination III (ACE-III), and Cerebellar Cognitive Affective Syndrome scale (CCAS-s) were used to assess global cognitive function. An extensive neuropsychological assessment battery was also tested to evaluate the characteristics of each cognitive domain. To assess the features of cognitive function, a comprehensive neuropsychological evaluation tool was also utilized. The cerebral infarction patients demonstrated cognitive impairment comparable to those with frontal infarcts, notably characterized by disturbance in attention and executive function. However, the degree of cognitive impairment was comparatively milder in cerebellar infarction patients. Furthermore, the patients in the cerebellar group had worse scores in the ACE-III and CCAS-s compared to healthy controls. The two assessments also demonstrated a significant area under the curve values, indicating their effectiveness in distinguishing cognitive impairment in cerebellar infarctions. In conclusion, cognitive impairment in a cerebellar infarction resembles frontal lobe dysfunction but is generally mild. It can be accurately assessed using the ACE-III and CCAS-s scales.

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

IntroductionCognitive 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. MethodsSixty 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. ResultsSixty 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). DiscussionCognitive 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.

Prevalence, recovery and phenotype of dysphagia in patients with ischaemic cerebellar stroke.

Swallowing is a complex task, moderated by a sophisticated bilateral network including multiple supratentorial regions, the brainstem and the cerebellum. To date, conflicting data exist about whether focal lesions to the cerebellum are associated with dysphagia. Therefore, the aim of the study was to evaluate dysphagia prevalence, recovery and dysphagia pattern in patients with ischaemic cerebellar stroke. A retrospective analysis of patients consecutively admitted to an academic stroke centre with ischaemic stroke found only in the cerebellum was performed. The presence of dysphagia was the primary end-point and was assessed by a speech-language pathologist, according to defined criteria. Dysphagia pattern was evaluated by analysing the videos of the flexible endoscopic evaluation of swallowing. Brain imaging was used to identify lesion size and location associated with dysphagia. Between January 2016 and December 2021, 102 patients (35.3% female) with a mean age of 52.8 ± 17.3 years were included. Thirteen (12.7%) patients presented with dysphagia. The most frequently observed flexible endoscopic evaluation of swallowing phenotype was premature spillage (n = 7; 58.3%), whilst significant residues or aspiration did not occur. One patient died (7.7%); the other patients showed improvement of dysphagia and one patient (7.7%) was discharged with dietary restrictions. Although the involvement of the cerebellum in deglutition has become increasingly evident, isolated lesions to the cerebellum are less likely to cause clinically relevant and persisting dysphagia compared to other brain regions. The observed dysphagia pattern shows a lack of coordination and control, resulting in premature spillage or fragmented bolus transfer in some patients.

Isolated cerebellar stroke in a paediatric patient with typical haemolytic uraemic syndrome: a case report and literature review

Haemolytic Uraemic Syndrome (HUS) is a rare medical condition characterised by microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury. Neurological complications are documented but rarely involve the cerebellum. We present a unique case of a 23-month-old male with HUS triggered by Escherichia coli-O157 (E.coli-O157) infection leading to an isolated cerebellar stroke.The patient initially presented with fever, bloody stools, and seizures. Confirmation of E.coli-O157 infection was obtained, and MRI revealed an isolated cerebellar stroke. Treatment included supportive care, anticoagulation for a right atrial thrombus, with gradual improvement observed.This case highlights the unusual occurrence of isolated cerebellar stroke in HUS patients, emphasising the importance of promptly recognizing manifestations of the central nervous system and the necessity for a multidisciplinary approach. Finally, a comprehensive literature review was conducted to identify cases of HUS patients with cerebellar involvement.

Predictors of Outcomes in Cerebellar Stroke: A Retrospective Cohort Study From the National Inpatient Sample Data.

Cerebellar strokes have highmorbidity and mortality due to bleeding or edema, leading to increased pressure in the posterior fossa. This retrospective cohort study analyzed three outcomes following a cerebellar stroke: in-hospital mortality, length of hospital stay, and total hospitalization costs.It uses data from the National Inpatient Sample (NIS) and aims to identify the predictors of outcomes in cerebellar stroke patients, including 464,324 patients, 18 years of age and older, hospitalized between 2010 and 2015 in US hospitals with cerebellar strokes. In our study, for every decade age increased beyond 59 years, there was a significant increase in mortality; those aged 80+ years had 5.65 odds of mortality (95% CI: 5.32-6.00; P < 0.0001). Significant differences in patient characteristics were observed between patients who survived to discharge and those who did not, including older age (77.4 vs. 70.3 years; P < 0.0001), female sex (58% vs. 52%; P < 0.0001), and being transferred from another healthcare facility (17% vs. 10%; P < 0.0001).Patients admitted directly rather than through the emergency department were more likely to die (29% vs. 16%; P < 0.0001). The mortality rate was lower for blacks (OR: 0.75; P < 0.0001), Hispanics (OR: 0.91; P = 0.005), and Asians (OR: 0.89; P = 0.03), as compared to the white population, for females in comparison to males, and geographically, in all other areas (Midwest, South, and West) in contrast to the Northeast. Cerebellar stroke incidence and high mortality were seen in the traditional stroke belt. Mortality is also affected by the severity of the disease and increases with the Charlson Comorbidity Index (CCI), All Patient Refined Diagnosis Related Groups (APR-DRG) scores, and indirectly by place of receiving care, length of stay (LOS), cost of stay, type of insurance, and emergency department admissions. LOSincreased with age, in males in the Northeast, and was less in whites compared to other races. Trend analysis showed a decrease in LOS and costs from 2010 to 2015. Increased costswere seen in non-whites, males, higher household income based on zip code, being covered under Medicaid,transfers, CCI ≥ 5, and discharges in the western US. Median household income based on the patient's zip code was well-balanced between those who lived and those who died (P = 0.091). However, payers were not evenly distributed between the two groups (P < 0.0001 for the overall comparison). A higher proportion of discharges associated with in-hospital mortality were covered under Medicare (70% vs. 65% in the died vs. lived groups, respectively). Fewer discharges were associated with death if they were covered by commercial insurance or paid for out-of-pocket (15% vs. 19% for commercial insurance and 3% vs. 5% for out-of-pocket).In-hospital mortality was associated with a longer length of hospital stay (5.6 days vs. 4.5 days; P < 0.0001) and higher costs ($16,815 vs. $11,859; P < 0.0001).Variables that were significantly associated with lower total costs were older age, having commercial insurance, paying out-of-pocketor other payers, not being admitted through the emergency department, having a lower comorbidity index (CCI = 1-2), and being discharged from a hospital that was small- or medium-sized, located in the Midwest or South, and/or was non-teaching (rural or urban).

Case Report: Bullous Pemphigoid and the Association with Dipeptidyl-peptidase 4 Inhibitors

&lt;p&gt;大皰性類天皰瘡(bullous pemphigoid)是一種自體免疫表皮下水泡疾病，表現為全身性瘙癢性蕁麻疹斑塊和緊繃的表皮下水泡。發生率大約每百萬人年為4至22例個案，而且有逐漸增加之趨勢。這種疾病最常影響老年人，除了老年化社會增加罹患風險外，神經疾病增加、與可能誘發類天皰瘡之藥物使用增加皆與該疾病增加的趨勢有關。&lt;/p&gt; &lt;p&gt;本個案為一位90歲的女性，過去疾病包括小腦出血性中風、帕金森氏症、失智症、高血壓、及糖尿病。糖尿病於一年前新診斷並開始使用 linagliptin及glimepiride等藥物控制血糖。主訴近半年多來開始會有全身的癢疹，尤其是軀幹及四肢，兩週前開始在皮膚縐摺處出現水泡及破裂傷口，經過臨床檢驗後診斷為大皰性類天皰瘡，搜索相關文獻後懷疑與 Linagliptin 的使用有關，於是改用其他藥物控制血糖，並開始使用外用及口服類固醇治療。經治療後皮膚明顯改善，不再有新水泡產生。本個案報告簡介大皰性類天皰瘡，亦討論該疾病與降血糖藥物dipeptidyl-peptidase 4 inhibitors (DPP4-inhibitor)之關係，研究發現某些類型的DPP4-inhibitor例如linagliptin與大皰性類天皰瘡的發生機率相關。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;Bullous pemphigoid is an autoimmune subepidermal blistering disease characterized by generalized pruritic urticarial plaques and tense subepidermal blisters. The incidence is approximately 4 to 22 cases per million people per year, with a rising trend. This disease predominantly affects the elderly, and the increasing trend is attributed to the aging population, rising incidence of neurological disorders, and the use of medications that may trigger bullous pemphigoid.&lt;/p&gt; &lt;p&gt;This case is a 90-year-old female with a medical history of cerebellar hemorrhagic stroke, Parkinson’s disease, dementia, hypertension, and diabetes. Diabetes was newly diagnosed a year ago, and medications like linagliptin and glimepiride were initiated for blood sugar control. The patient complained of generalized itching and rash for the past six months, particularly on the trunk and limbs. Two weeks ago, blisters and ruptured wounds appeared in the skin folds. After clinical examination, the diagnosis of bullous pemphigoid was made. After reviewing relevant literature, it was suspected to have connection with the use of linagliptin and bullous pemphigoid. We shifted linagliptin to other drugs to control blood sugar, and topical and oral corticosteroid treatment was initiated. The skin significantly improved after treatment. This case report not only introduces bullous pemphigoid but also discusses the association between this disease and dipeptidyl-peptidase 4 inhibitors (DPP-4 inhibitors). Research suggests a correlation between certain types of DPP-4 inhibitors, such as linagliptin, and the occurrence of bullous pemphigoid.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Surgical infarct volume reduction and functional outcomes in patients with ischemic cerebellar stroke: results from a multicentric retrospective study

OBJECTIVE Recent work on ischemic cerebellar stroke has suggested that the resection of infarcted tissue may lead to improved functional outcomes compared with decompressive surgery alone. Nonetheless, no studies have assessed the extent to which necrotic tissue should be resected or if there are any volumetric thresholds capable of predicting functional outcomes in this patient population. In this study, the authors aimed to determine potential thresholds for volume reduction in ischemic cerebellar stroke in an effort to optimize the management of ischemic cerebellar stroke and, in so doing, improve functional outcomes. METHODS This study is a multicentric retrospective study of patients who underwent surgery for the management of ischemic cerebellar stroke. Volumetric analyses of infarcted tissue present on CT scans were performed before and after surgical intervention(s). The final infarct volume (FIV) was computed as a percentage of the initial infarct volume (postoperative infarct volume/preoperative infarct volume × 100). The primary endpoint was functional outcome at 3 months, as determined by the modified Rankin Scale (mRS) score; mRS scores 0–2 were considered as favorable and mRS scores 3–6 as unfavorable. Receiver operating characteristic curves were used to explore the relationship between postoperative infarct volumes and FIV versus mRS score, and Youden’s index was used to estimate potential volumetric thresholds. RESULTS A total of 91 patients were included in the study. The mean pre- and postoperative infarct volumes were 45.25 (SD 18.32) cm3 and 29.56 (SD 26.61) cm3, respectively. Patients undergoing necrosectomy, regardless of whether via craniotomy or craniectomy, were more likely to have a favorable outcome at discharge (OR 16.62, 95% CI 2.12–130.33; p = 0.008) and at 3 months (OR 24.12, 95% CI 3.03–192.18; p = 0.003) postoperatively. Postoperative infarct volumes ≤ 17 cm3 yielded a sensitivity of 77% and a specificity of 68% with regard to the prediction of favorable outcome at 3 months. The resection ≥ 50% of infarcted tissue was also predictive of favorable outcomes at 3 months (OR 7.7, 95% CI 2.7–21.8; p &lt; 0.001). CONCLUSIONS The reduction of necrotic tissue volumes by at least 50% and/or the reduction of the infarct volume by ≤ 17 cm3 appear to be associated with favorable outcomes in patients with surgically managed ischemic cerebellar strokes.

Bimanual coordinated motor skill learning in patients with a chronic cerebellar stroke.

Cerebellar strokes induce coordination disorders that can affect activities of daily living. Evidence-based neurorehabilitation programs are founded on motor learning principles. The cerebellum is a key neural structure in motor learning. It is unknown whether and how well chronic cerebellar stroke individuals (CCSIs) can learn to coordinate their upper limbs through bimanual motor skill learning. The aim was to determine whether CCSIs could achieve bimanual skill learning through a serious game with the REAplan® robot and to compare CCSIs with healthy individuals (HIs). Over three consecutive days, sixteen CCSIs and eighteen HIs were trained on an asymmetric bimanual coordination task ("CIRCUIT" game) with the REAplan® robot, allowing quantification of speed, accuracy and coordination. The primary outcomes were the bimanual speed/accuracy trade-off (BiSAT) and bimanual coordination factor (BiCo). They were also evaluated on a bimanual REACHING task on Days 1 and 3. Correlation analyses between the robotic outcomes and clinical scale scores were computed. Throughout the sessions, BiSAT and BiCo improved during the CIRCUIT task in both HIs and CCSIs. On Day 3, HIs and CCSIs showed generalization of BiSAT, BiCo and transferred to the REACHING task. There was no significant between-group difference in progression. Four CCSIs and two HIs were categorized as "poor learners" according to BiSAT and/or BiCo. Increasing age correlated with reduced BiSAT but not BiCo progression. Over three days of training, HIs and CCSIs improved, retained, generalized and transferred a coordinated bimanual skill. There was no between-group difference, suggesting plastic compensation in CCSIs. Clinical trial NCT04642599 approved the 24th of November 2020.

Safety considerations in the treatment with anti-CGRP(R) monoclonal antibodies in patients with migraine.

Anti-CGRP-(receptor-)monoclonal antibodies (anti-CGRP(R)-mAbs) represent a novel class of drugs for migraine treatment, but their long-term cerebrovascular and cardiovascular (CV) safety warrants further examination. In this observational cohort study we assessed the CV safety for erenumab and fremanezumab in a real-world setting during a follow-up period of at least 1 year. Patients with hypertension or CV history were excluded. We conducted ECGs and collected clinical data at treatment initiation and thereafter every 3 months, including liver and kidney function, lipid-, electrolyte-and glucose levels. Among patients receiving erenumab (n = 101) or fremanezumab (n = 92), 3.1% (6/193) developed abnormal ECGs or CV adverse events. Of these, three (1.6%) experienced moderate to severe CV adverse events (cerebellar stroke, spontaneous coronary artery dissection, and pericarditis) and discontinued treatment. The remaining three (1.6%) developed non-threatening ECG abnormalities without physical complaints. No significant changes were observed in liver and kidney function, lipid-, electrolyte-, or glucose levels. We observed CV events in 1.6% of patients with 1.5-year follow-up of anti-CGRP(R)-mAbs treatment. We advise awareness regarding CV events in patients with migraine undergoing CGRP-targeted treatment, not as a confirmation of increased risk but as a proactive measure to address potential multifactorial influences.

Comparative Analysis of Physical Therapy Outcomes in Acute Ischemic and Hemorrhagic Stroke Rehabilitation

Background: Stroke rehabilitation demands an effective therapeutic approach to enhance functional recovery. This study aims to compare the outcomes of physical therapy in patients with acute ischemic and hemorrhagic stroke using the Motor Relearning Programme (MRP). Methodology: Based on stroke type, confirmed via CT thirty-eight participants were stratified into ischemic &amp; hemorrhagic stroke group. Eligible participants were over 35 years old, had a Glasgow Coma Scale score above 5, and presented with hemiplegia. Exclusion criteria included trauma-induced hemorrhage, cerebellar or brainstem stroke, severe cognitive impairment, or pre-existing disabilities. The participants underwent a standardized four-week physiotherapy regimen based on the MRP, with assessments using the Motor Assessment Scale (MAS) and Functional Independence Measure (FIM) to evaluate the outcomes. Results: These results underscore the significant improvements in the functional outcomes observed in both ischemic and hemorrhagic stroke patients following physical therapy, with hemorrhagic stroke patients showing more substantial gains in both MAS and FIM scores. Conclusion: Our study contributes to a nuanced understanding of stroke rehabilitation, emphasizing that while both ischemic and hemorrhagic stroke patients significantly benefit from structured physical therapy interventions like MRP, the specifics of their recovery processes vary.

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.

Cryptococcal Cerebellitis in the Setting of Fingolimod Use for Multiple Sclerosis: Atypical Presentation of Dystonia and Imaging Finding Misinterpreted as Subacute Ischemic Stroke

Objective: Describe a case of cryptococcal cerebellitis in a patient on Fingolimod with atypical findings of generalized dystonia and imaging findings mistaken for bilateral subacute cerebellar strokes. Background: Fingolimod is used for multiple sclerosis (MS) and is often associated with lymphopenia with prolonged use. Cryptococcal opportunistic infections in patients on Fingolimod, have been rarely described. Design/Methods: Case report and review of literature. Results: 44-year-old man with MS in remission treated with Fingolimod for the last 8 years, and poorly controlled type-II diabetes mellitus (A1c 10.4), transferred to our facility for stroke work-up with brain MRI findings reportedly showing subacute bicerebellar ischemic strokes. On exam, he was somnolent and intermittently followed commands. He had nuchal rigidity and positive Kernig and Brudzinski signs. Meningitis was suspected and empiric treatment was initiated. MRI findings on DWI/ADC/FLAIR sequences were inconsistent with any vascular territory. Leptomeningeal enhancement was noted in the cerebellar folia, basal cisterns, suprasellar cistern, and brainstem surface. Labs were remarkable for lymphopenia (250), cerebrospinal fluid (CSF) and blood culture grew cryptococcus neoformans, so treatment with liposomal amphotericin B and flucytosine was started. On day 4, patient developed generalized dystonia that resolved with diphenhydramine. Unfortunately, patient did not respond to therapy as evident on repeat LP on day 6. His physical exam worsened, and he was intubated 2 days after. Repeat MRI showed with tonsillar herniation and patient expired. Conclusion: Cryptococcal cerebellitis is a rare opportunistic infection occurring in MS patients on Fingolimod. Early recognition is crucial to avoid rapidly worsening neurological outcomes.