Neurological Features and Mechanisms of Acute Bilateral Cerebellar Infarction

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1 Neurological Features and Mechanisms of Acute Bilateral Cerebellar Infarction Ji-Man Hong, M.D., Sang Geon Shin, M.D., Jang-Sung Kim, M.D., Oh-Young Bang, M.D., In-Soo Joo, M.D., Kyoon-Huh, M.D. Department of Neurology, School of Medicine, Ajou University Address for correspondence Background : Many studies about unilateral cerebellar infarctions (UCI) have been reported to delineate the clinical findings and stroke mechanisms but have not been studied extensively in acute bilateral cerebellar infarctions (BCI). In order to evaluate the neurological features and mechanisms of BCI, we compared those between BCI and UCI. M e t h o d s : Using diffusion-weighted imaging, we divided 103 patients with acute cerebellar infarctions into two groups: BCI and UCI. Clinical features, outcome and their mechanisms were compared between the groups. Results : Among the 103 patients, 45 patients (44%) had BCI and the remaining 58 patients had UCI. The PICA territory was the most frequently involved site in both groups, and 15 patients were non-territorial infarctions. Clinical symptoms and signs were not different between the groups, however, most patients with decreased mentality had BCI (86%) and also had concomitant lesions outside the cerebellum (72%). Patients with BCI showed poorer prognosis than UCI (modified Rankin score, 1.41 and 2.87 respectively). Other factors included the presence of concomitant lesiona outside the cerebellum, however, mass effect did not affect their prognosis. The main cause of BCI was large artery disease (57%), whereas about half of the patients with UCI (51%) had no demonstrable cause of stroke. Conclusions : Owing to its poorer outcome and its higher frequency of demonstrable causes of stroke, more intensive work-up, such as vascular study, may be warranted in the patients with acute BCI. J Korean Neurol Assoc 21(1):7~13, 2003 Key Words : Cerebellar infarction, Magnetic resonance imaging, Prognosis, Mechanism Oh Young Bang, M.D. Copyright 2003 by the Korean Neurological Association 7

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3 Table 1. Frequency of 103 patients according to territory and laterality Unilateral Bilateral Total (N=58) (N=45) (N=103) Territorial PICA AICA SCA Combined* Non-territorial PICA; posterior inferior cerebellar artery, AICA; anterior inferior cerebellar artery, SCA; superior cerebellar artery * infarction on the PICA+AICA or AICA+SCA or PICA+SCA or PICA+AICA+SCA Table 3. Consciousness and concomitant lesions in patients Numbers in the parenthesis are concomitant lesions Consciousness Alertness Drowsiness Stupor Total (Patient number) UCI 55 3 (1) 58 BCI (9) 6 (6) 45 UCI; unilateral cerebellar infarction BCI; bilateral cerebellar infarction Table 2. Score of modified Rankin disability scale (mrds) according to laterality concomitant lesion, territory, and mass effect in the cerebellar infarction (N=103) Factors mrs (meansd) p-value Laterality Unilateral Bilateral Concomitant lesion Absent Present (patient numbers) Brain stem (28) Thalamus (2) Other (6) Multiple lesions (8) Territory (bilaterality, concomitant lesion) PICA (30%, 17%) AICA (43%, 100%) SCA (62%, 54%) Combined (73%, 67%) Mass effect Absent Present < < PICA; posterior inferior cerebellar artery, AICA; anterior inferior cerebellar artery, SCA; superior cerebellar artery J Korean Neurol Assoc / Volume 21 / February,

4 Figure 1. Clinical manifestations of territorial infarction according to the laterality. There is no difference of symptoms between bilateral cerebellar infarction (BCI) and unilateral cerebellar infarction (UCI), except mental change. Mental change is more frequent in BCI than in UCI. PICA; posterior inferior cerebellar artery, AICA; anterior inferior cerebellar artery, SCA; superior cerebellar artery. Figure 2. Mechanisms of cerebellar infarction. LAD is more frequent in BCI than in UCI, whereas cryptogenic cause is more frequent in the latter (p < 0.05, x 2 test). LAD; large artery disease, CE; cardioembolism, BCI; bilateral cerebellar infarction, UCI; unilateral cerebellar infarction. 10 J Korean Neurol Assoc / Volume 21 / February, 2003

5 A B C Figure 3. Radiologic features of patients with acute bilateral cerebellar infarction. There are diffusionweighted MRI and magnetic resonance angiography findings in bilateral SCA (A), bilateral AICA (B), and bilateral PICA territorial infarcts (C). White arrows show large artery disease (LAD) on posterior circularion. J Korean Neurol Assoc / Volume 21 / February,

6 01. Macdonell RA, Kalnins RM, Donnan GA. Cerebellar infarction: natural history, prognosis and pathology. Stroke 1987;18: Canaple S, Bogousslavsky J. Multiple large and small cerebellar infarcts. J Neurol Neurosurg Psychiatry 1999;66: Amarenco P, Levy C, Cohen A, Touboul PJ, Roullet E, 12 J Korean Neurol Assoc / Volume 21 / February, 2003

7 Bousser MG. Causes and mechanisms of territorial and nonterritorial cerebellar infarcts in 115 consecutive patients. Stroke 1994;25: Kase CS, Norrving B, Levin SR, Babikian VL, Chodosh EH, Wolf PA et al. Cerebellar infarction. Clinical and anatomic observations in 66 cases. Stroke 1993;24: Hornig CR, Rust DS, Busse O, Jass M, Laun A. Spaceoccupying cerebellar infarction. Clinical course and prognosis. Stroke 1994;25: Koh MG, Phan TG, Atkinsm JI Wijdicks EF. Neuroimaging in deteriorating patients with cerebellar infarcts and mass effect. Stroke 2000;31: Jung S, Yu KH, Hwang SH, Kim SM, Kwon KH, Song HK, et al. Clinical features and pathophysiology of small cerebellar infarcts. Korean J Stroke 2001;3: Stangel M, Stapf C, Marx P. Presentation and prognosis of bilateral infarcts in the territory of the superior cerebellar artery. Cerebrovasc Dis 1999;9: Kang DW, Lee SH, Bar HJ, Han MH, Yoon BW, Roh JK. Acute bilateral cerebellar infarcts in the territory of posterior inferior cerebellar artery. Neurology 2000;55: Amarenco P, Hauw JJ. Cerebellar infarction in the territory of the anterior inferior cerebellar artery. A clinicopathological study of 20 cases. Brain 1990;113: Amarenco P, Rosengart A, DeWitt D, Pessin MS, Caplan LR. Anterior inferior cerebellar artery territory infarcts. Mechanisms and clinical features. Arch Neurol ; 50: Tohgi H, Takahashi S, Chiba K, Hirata Y. Cereballr infarction. Clinical and neuroimaging analysis in 293 pateints. The Tohoku Cerebellar Infarction Study Group. Stroke 1993;24: Amarenco P, Kase CS, Rosengart A, Pressin MS, Bousser MG, Caplan LR. Very small(border zone) cerebellar infarcts. Distribution, mechanisms, causes and clinical features. Brain 1993;116: Herndon RM. Handbook of neurologic rating scales. 1st ed. New York: Desmos Vermande, 1997; Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL et al. Classification of subtype of acute ischemic stroke. Definitions for use in a muticenter clinical trial, TOAST. Trial of Org in Acute Stroke Treatment. Stroke 1993;24: Min WK, Kim YS, Kim JY, Park SP, Suh CK. Atherothrombotic cerebellar infarction: vascular lesion- MRI correlation of 31 cases. Stroke 1999;30: Kandel ER, Schwartz JH, Jessell TM. Principles of neural science. 4th ed. New York: McGraw-Hill, 2000; Thajeb P. Large vessel disease in Chinese patients with capsular infarcts and prior ipsilateral transient ischemia. Neuroradiology 1993;35: The Korean Neurological Association. Epidemiology of cerebrovascular disease in Korea. J Kor Med Sci 1993;8: Caplan LR. Posterior circulation disease: Clinical find - ings, Diagnosis, and management. 1st ed. Boston: Blackwell Science, 1996; J Korean Neurol Assoc / Volume 21 / February,