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1fa14dfd-71ea-4960-908e-e720313bc63a Santhosh Gaddikeri, MD
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a25c450b-3d34-4f64-bba3-cc0834813df6 Miral D. Jhaveri, MD, MBA
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Brain
Diagnosis
Pathology-Based Diagnoses
Acquired Toxic/Metabolic/Degenerative Disorders
Dementias and Degenerative Disorders
Crossed Cerebellar Diaschisis

title: "Crossed Cerebellar Diaschisis" docid: "c1e384b3-3c6e-4f67-bf79-5187bd6a1b86" authors:

  • key: "1fa14dfd-71ea-4960-908e-e720313bc63a" value: "Santhosh Gaddikeri, MD"
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  • name: "Crossed Cerebellar Diaschisis" slug: "crossed-cerebellar-diaschisis" treeNodeId: null category: "Brain" documentVersionId: "f0556a11-5363-4d70-a9f4-bc824351bc45" imageCount: 14 lastUpdated: "08/07/20" pageDescription: "Crossed Cerebellar Diaschisis" pageKeywords: "Brain, Diagnosis, Pathology-Based Diagnoses, Acquired Toxic/Metabolic/Degenerative Disorders, Dementias and Degenerative Disorders, Crossed Cerebellar Diaschisis" pageTitle: "Crossed Cerebellar Diaschisis | STATdx" enhancedTitle: "Crossed Cerebellar Diaschisis" type: "DX" references: true breadcrumbs:
  • "Brain"
  • "Diagnosis"
  • "Pathology-Based Diagnoses"
  • "Acquired Toxic/Metabolic/Degenerative Disorders"
  • "Dementias and Degenerative Disorders"
  • "Crossed Cerebellar Diaschisis"

KEY FACTS

  • Terminology

    • Diaschisis: Sudden loss of function in brain connected to (but at distance from) damaged area
    • CCD: ↓ blood flow/metabolism in cerebellar hemisphere contralateral to supratentorial infarct

  • Imaging

    • Acute: CT/MR perfusion shows ↓ CBF in cerebellar hemisphere opposite acute hemispheric infarct - ↑ TTP, ↓ CBF in cerebellum contralateral to infarct - Add DTI as subtle cases may show ↓ FA when conventional MR normal - F-18 FDG PET/CT shows diffusely reduced uptake in contralateral cerebellar hemisphere
    • Chronic: CT or MR shows atrophic cerebellar hemisphere opposite old cerebral hemispheric infarct/insult

  • Top Differential Diagnoses

    • Superior cerebellar artery infarct - CCD involved > just SCA territory
    • Encephalomalacia - Trauma, infection, surgery
    • Cerebellitis - Cerebellum swollen, hyperintense (not shrunken, atrophic) - Bilateral > unilateral

  • Pathology

    • CPC tract - Input to cerebellum via CPC tracts 40x all other afferent sources combined - Injury at any point along CPC can result in ↓ CBF, metabolism in contralateral cerebellar hemisphere - Most common cause: MCA infarct - Others: Status epilepticus, neoplasm, trauma, surgery,migraine, Rasmussen encephalitis, etc.
    • Occurrence & severity of CCD related to degree of low supratentorial perfusion & decrease in ADC value of infarct

TERMINOLOGY

  • Abbreviations

    • Crossed cerebellar diaschisis (CCD)

  • Definitions

    • Diaschisis: Sudden loss of function in brain connected to (but at distance from) damaged area
    • CCD: Decreased blood flow/metabolism in cerebellar hemisphere contralateral to supratentorial infarct - Caused by interrupted afferent input through corticopontocerebellar tract (CPC)
    • CCD occurs in both acute & chronic phases - Acute CCD results from functional deafferentation - Subacute, chronic CCD reflects transneuronal degeneration

IMAGING

  • General Features

    • Best diagnostic clue

      - Acute: CT/MR perfusion shows ↓ cerebral blood flow (CBF) in cerebellar hemisphere opposite acute cerebral hemispheric infarct
- Chronic: CT or MR shows atrophic cerebellar hemisphere opposite old cerebral hemispheric infarct/insult

    • Location

      - Cerebellar hemisphere opposite cerebral hemispheric infarct

  • Imaging Recommendations

    • Best imaging tool

      - Acute: CT or MR perfusion
        - PET/CT also effective but expensive; variable availability
- Chronic: MR with T2WI, FLAIR, DTI

    • Protocol advice

      - Add DTI as subtle cases may show ↓ fractional anisotropy (FA) when conventional MR normal

  • CT Findings

    • NECT

      - Acute: Normal
- Chronic: Cerebellar atrophy contralateral to supratentorial infarct

    • CTA

      - Middle cerebral artery (MCA) occlusion
- Cerebellar vessels appear normal

    • CT perfusion - ↑ TTP, ↓ CBF in cerebellum contralateral to infarct

  • MR Findings

    • T1WI

      - Unilateral cerebellar atrophy

    • T2WI

      - Folia shrunken, fissures enlarged

    • FLAIR

      - Except for atrophy, cerebellum usually normal

    • MRA

      - Posterior fossa vasculature normal

    • DTI - Shows ↓ FA in middle cerebellar peduncle - Visualizes altered CPC in chronic CCD that may not be seen on conventional MR

    • Arterial spin labeling (ASL) perfusion - ↓ CBF in cerebellum contralateral to cerebral hemispheric abnormality

  • Nuclear Medicine Findings

    • PET/CT

      - F-18 FDG PET/CT shows diffusely reduced uptake in contralateral cerebellar hemisphere
- L-(methyl-11C) methionine (MET) uptake not reduced

    • Tc-99m sulfur colloid

      - Tc-99m ECD, HMPAO SPECT can demonstrate distant areas of ↓ CBF, metabolism (diaschisis)

DIFFERENTIAL DIAGNOSIS

  • Superior Cerebellar Artery Infarct

    • CCD involves most of cerebellum, not just superior cerebellar artery (SCA) territory
    • Contralateral MCA infarct absent

  • Encephalomalacia

    • No history of trauma, contralateral MCA infarct

  • Cerebellitis

    • Cerebellum swollen, not shrunken
    • Bilateral > unilateral

PATHOLOGY

  • General Features

    • Etiology

      - CPC tract
        - Large afferent pathway derived from very extensive areas of cortex
        - Input to cerebellum via CPC tracts 40x all other afferent sources combined
                  - 1st-order neurons arrive in ipsilateral pons
                  - Synapse with 2nd-order neurons
                  - Then cross to opposite cerebellar hemisphere via middle cerebellar peduncle
- Injury at any point along CPC can result in ↓ CBF, metabolism in contralateral cerebellar hemisphere
        - Most common cause: MCA infarct
        - Others: Status epilepticus, neoplasm, trauma, surgery, migraine, Rasmussen encephalitis, etc.
- Occurrence & severity of CCD related to degree of low supratentorial perfusion & decrease in ADC value of infarct

CLINICAL ISSUES

  • Natural History & Prognosis

    • CCD represents temporal continuum - Early, reversible functional hypometabolism - Cerebellum recovers (typical) - Irreversible degeneration in up to 20% - Cerebellar atrophy - Can be seen decades after initial insult

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References

Selected References

  1. Zhang M et al: Characteristics of cerebral perfusion and diffusion associated with crossed cerebellar diaschisis after acute ischemic stroke. Jpn J Radiol. 38(2):126-34, 2020
  2. Kim JS et al: Degeneration of the inferior cerebellar peduncle after middle cerebral artery stroke: another perspective on crossed cerebellar diaschisis. Stroke. 50(10):2700-7, 2019
  3. Yokota H et al: Crossed cerebellar diaschisis in status epilepticus. Neurochirurgie. 65(6):425-6, 2019
  4. Liu X et al: Pathological factors contributing to crossed cerebellar diaschisis in cerebral gliomas: a study combining perfusion, diffusion, and structural MR imaging. Neuroradiology. 60(6):643-50, 2018
  5. Reesink FE et al: Crossed cerebellar diaschisis in Alzheimer's disease. Curr Alzheimer Res. 15(13):1267-75, 2018
  6. Strother MK et al: Crossed cerebellar diaschisis after stroke identified noninvasively with cerebral blood flow-weighted arterial spin labeling MRI. Eur J Radiol. 85(1):136-42, 2016
  7. Chen S et al: Crossed cerebellar diaschisis detected by arterial spin-labeled perfusion magnetic resonance imaging in subacute ischemic stroke. J Stroke Cerebrovasc Dis. 23(9):2378-83, 2014
  8. Zaidi SA et al: Crossed cerebellar diaschisis: a radiological finding in status epilepticus not to miss. BMJ Case Rep. 2013, 2013
  9. Jeon YW et al: Dynamic CT perfusion imaging for the detection of crossed cerebellar diaschisis in acute ischemic stroke. Korean J Radiol. 13(1):12-9, 2012
  10. Massaro AM: Teaching neuroimages: crossed cerebellar diaschisis in hemispheric status epilepticus. Neurology. 79(20):e182, 2012
  11. Agrawal KL et al: Crossed cerebellar diaschisis on F-18 FDG PET/CT. Indian J Nucl Med. 26(2):102-3, 2011
  12. Garg G et al: Crossed cerebellar diaschisis demonstrated by (18)F- FDG-PET/CT. Hell J Nucl Med. 12(2):171-2, 2009
  13. Huang YC et al: Periictal magnetic resonance imaging in status epilepticus. Epilepsy Res. 86(1):72-81, 2009
  14. Lin DD et al: Crossed cerebellar diaschisis in acute stroke detected by dynamic susceptibility contrast MR perfusion imaging. AJNR Am J Neuroradiol. 30(4):710-5, 2009
  15. Dodick DW et al: Crossed cerebellar diaschisis during migraine with prolonged aura: a possible mechanism for cerebellar infarctions. Cephalalgia. 28(1):83-6, 2008
  16. Kajimoto K et al: Crossed cerebellar diaschisis: a positron emission tomography study with L-[methyl-11C]methionine and 2-deoxy-2-[18F]fluoro-D-glucose. Ann Nucl Med. 21(2):109-13, 2007
  17. Liu Y et al: Crossed cerebellar diaschisis in acute ischemic stroke: a study with serial SPECT and MRI. J Cereb Blood Flow Metab. 27(10):1724-32, 2007
  18. Kim J et al: Decreased fractional anisotropy of middle cerebellar peduncle in crossed cerebellar diaschisis: diffusion-tensor imaging-positron-emission tomography correlation study. AJNR Am J Neuroradiol. 26(9):2224-8, 2005

Images

Selected Images

Coronal T2 TSE of 55-year-old man with past history of right middle cerebral artery (MCA) distribution infarction shows encephalomalacia in the right frontal & temporal lobes with ex vacuo dilation of right lateral ventricle due to volume loss. Coronal T2 TSE of 55-year-old man with past history of right middle cerebral artery (MCA) distribution infarction shows encephalomalacia in the right frontal & temporal lobes with ex vacuo dilation of right lateral ventricle due to volume loss.

Coronal T2 TSE through the posterior fossa in the same patient shows asymmetric atrophy with shrunken folia & prominent fissures of the left cerebellar hemisphere contralateral to supratentorial insult due to crossed cerebellar diaschisis (CCD). Coronal T2 TSE through the posterior fossa in the same patient shows asymmetric atrophy with shrunken folia & prominent fissures of the left cerebellar hemisphere contralateral to supratentorial insult due to crossed cerebellar diaschisis (CCD).

Axial CECT in 72-year-old woman with history of metastatic lung cancer & remote lacunar infarction in left basal ganglia & adjacent internal capsule shows a remote lacunar infarction in left gangliocapsular region . Axial CECT in 72-year-old woman with history of metastatic lung cancer & remote lacunar infarction in left basal ganglia & adjacent internal capsule shows a remote lacunar infarction in left gangliocapsular region .

Axial F-18 FDG PET/CT in the same patient performed for lung cancer restaging is shown. Axial fused images through the inferior aspect of posterior fossa show asymmetric ↓ metabolic activity in the right cerebellum due to CCD. (Courtesy M. Matesan, MD.) Axial F-18 FDG PET/CT in the same patient performed for lung cancer restaging is shown. Axial fused images through the inferior aspect of posterior fossa show asymmetric ↓ metabolic activity in the right cerebellum due to CCD. (Courtesy M. Matesan, MD.)

Additional Images

Axial T2 MR in the same patient shows ipsilateral hypertrophic olivary degeneration (chronic, with shrunken hyperintense olive). CCD with atrophy of the contralateral cerebellar hemisphere is also present . While CCD is usually caused by an MCA stroke in the contralateral cerebral hemisphere, interruption of the corticopontocerebellar (CPC) tract anywhere along its course can result in similar findings. In this case, midbrain surgery caused deafferentation of the contralateral cerebellar hemisphere. It is rare to find both hypertrophic olivary degeneration & CCD in the same patient. Axial T2 MR in the same patient shows ipsilateral hypertrophic olivary degeneration (chronic, with shrunken hyperintense olive). CCD with atrophy of the contralateral cerebellar hemisphere is also present . While CCD is usually caused by an MCA stroke in the contralateral cerebral hemisphere, interruption of the corticopontocerebellar (CPC) tract anywhere along its course can result in similar findings. In this case, midbrain surgery caused deafferentation of the contralateral cerebellar hemisphere. It is rare to find both hypertrophic olivary degeneration & CCD in the same patient.

Axial T2 MR shows a 29-year-old man who developed palatal myoclonus several months following midbrain surgery for cavernous malformation. Imaging was obtained 1 year after surgery. This scan through the upper midbrain shows atrophy of the left pons & cerebral peduncle . Axial T2 MR shows a 29-year-old man who developed palatal myoclonus several months following midbrain surgery for cavernous malformation. Imaging was obtained 1 year after surgery. This scan through the upper midbrain shows atrophy of the left pons & cerebral peduncle .

Axial T2 MR in a patient with a history of remote right MCA infarct shows the typical changes of volume loss & hyperintensity in the cortex & subcortical white matter . The ipsilateral ventricle is enlarged. Axial T2 MR in a patient with a history of remote right MCA infarct shows the typical changes of volume loss & hyperintensity in the cortex & subcortical white matter . The ipsilateral ventricle is enlarged.

Axial T2 MR in the same patient shows volume loss with enlarged horizontal sulci in the contralateral cerebellar hemisphere . These findings are consistent with chronic CCD. Axial T2 MR in the same patient shows volume loss with enlarged horizontal sulci in the contralateral cerebellar hemisphere . These findings are consistent with chronic CCD.

Whole-brain CT perfusion study was obtained as part of an emergency stroke evaluation in a patient with acute onset of right-sided weakness. CBF shows ↓ blood flow (blue area) in the left MCA distribution. Whole-brain CT perfusion study was obtained as part of an emergency stroke evaluation in a patient with acute onset of right-sided weakness. CBF shows ↓ blood flow (blue area) in the left MCA distribution.

Section through the cerebellar hemispheres in the same patient shows acutely ↓ CBF in the right cerebellar hemisphere . As afferent input to the cerebellum is reduced, regional metabolism diminishes & CBF falls. This is hyperacute CCD. Section through the cerebellar hemispheres in the same patient shows acutely ↓ CBF in the right cerebellar hemisphere . As afferent input to the cerebellum is reduced, regional metabolism diminishes & CBF falls. This is hyperacute CCD.

CBF map in the same patient demonstrates ↓ CBF in the right cerebellar hemisphere consistent with acute CCD. CCD is caused by an interruption of the CPC fibers. As a result of ↓ afferent input, there is a ↓ in cerebellar metabolism, coupled with a ↓ in cerebellar perfusion. CBF map in the same patient demonstrates ↓ CBF in the right cerebellar hemisphere consistent with acute CCD. CCD is caused by an interruption of the CPC fibers. As a result of ↓ afferent input, there is a ↓ in cerebellar metabolism, coupled with a ↓ in cerebellar perfusion.

MR perfusion study CBF map in a patient with acute right hemiparesis shows ↓ blood flow (blue area) in the left MCA distribution. MR perfusion study CBF map in a patient with acute right hemiparesis shows ↓ blood flow (blue area) in the left MCA distribution.

Axial T2 MR in a patient with a remote left MCA infarct shows the typical changes of encephalomalacia & volume loss . The ipsilateral ventricle is enlarged . Axial T2 MR in a patient with a remote left MCA infarct shows the typical changes of encephalomalacia & volume loss . The ipsilateral ventricle is enlarged .

Axial T2 MR in the same patient shows volume loss with enlarged horizontal sulci in the contralateral cerebellar hemisphere . These findings are consistent with chronic CCD. Axial T2 MR in the same patient shows volume loss with enlarged horizontal sulci in the contralateral cerebellar hemisphere . These findings are consistent with chronic CCD.

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