Crossed Cerebellar Diaschisis in Acute Human Stroke: A PET Study of Serial Changes and Response to Supratentorial Reperfusion

Abstract

Crossed cerebellar diaschisis (CCD) is well described in the chronic phase of stroke, but few data describe acute CCD and its serial changes after reperfusion. Using positron emission tomography (PET), we studied acute CCD with respect to supratentorial perfusion and outcome measures. In 19 acute stroke patients receiving intravenous thrombolysis (<3 h), 15O-water PET assessed CCD and supratentorial hypoperfusion volume before thrombolysis, 3, 24 h and 14 days later. Infarct volume at day 14 and NIHSS score at 3 months were assessed. Supratentorial hypoperfusion decreased from 25 cm3 (median) before thrombolysis to 0.1 cm3 at day 14. Baseline CCD was 13.4% and decreased continuously to 6.1% after 14 days. The NIHSS score decreased from 11 to 4 pts after 3 months. Infarct volume was 1.1 cm3. Crossed cerebellar diaschisis correlated to the hypoperfusion volume within the first 24 h after stroke, but not later. Hypoperfusion correlated to outcome measures at the early stage only. In contrast, CCD correlated to outcome values at all four measurements. Reperfusion with recovery of CCD was seen in patients with small infarcts and good clinical outcome and vice versa. Our data suggest that (i) CCD occurs as early as 3 h after stroke and might be reversible; (ii) acute CCD is closely related to the volume of supratentorial hypoperfusion. At later time points, however, CCD is disconnected from supratentorial perfusion but strongly associated to outcome measures; (iii) CCD is not susceptible to nonnutritional reperfusion and adds valuable information to interpret supratentorial reperfusion patterns.

Correlation of Asymmetry Indices Measured by Arterial Spin-Labeling MR Imaging and SPECT in Patients with Crossed Cerebellar Diaschisis

“…However, few studies have reported a correlation between the clinical outcome and treatment response in patients and the quantitative value of CCD. [10][11][12][13]18,20 One reason is that PET and SPECT have been used as criterion standards for diagnosing and studying CCD, and the need to inject radioisotopes and the exposure to radiation have made long-term follow-up difficult. However, noninvasive ASL MR perfusion imaging has emerged as a valuable method that can be used to obtain brain-flow information noninvasively and repeatedly.…”

“…39 A few previous studies reported that infarct volume contributes to the development of CCD, but the sample sizes (n ϭ 20 and 17, respectively) were too small. 11,20 In addition, the patient populations in these previous studies were all in the acute stages of stroke. However, our population was in the subacute to chronic infarction (n ϭ 2), chronic infarction (n ϭ 10), or previous intracranial hemorrhage (n ϭ 4) stage.…”

“…The degree of CCD was measured on a section of axial scan representing the greatest cerebellar asymmetry. 26 The AI was calculated between the affected cerebellar hemisphere (A) and the unaffected cerebellar hemisphere (U) as follows 11,19,20 :…”

“…[4][5][6][7][8] CCD is not only a secondary result of supratentorial infarction but also a prognostic indicator of neurologic improvement and clinical outcomes after infarction. [9][10][11][12][13] For example, in one study, CCD in the chronic stage was associated with neurologic improvement after infarction in the territory of the middle cerebral artery. 12 In another study, CCD in the early subacute stage of supratentorial infarction indicated a worse clinical outcome.…”

“…1,9,11,[14][15][16][17][18] Regarding perfusion MR imaging, there have been 2 studies performed by using DSC MR perfusion imaging. Yamada et al 19 reported that a lower regional cerebellar blood volume was observed in the affected cerebellum, and researchers in the other study 20 identified the frequency of CCD observed in acute stroke by using time-to-peak maps and calculated the reduction by using CBF maps.…”