Neurnradinlogt]
Neuroradiology 18, 77-79 (1979)
© by Springer-Verlag 1979
Computed Tomography in Alcoholic Cerebellar Atrophy A. Haubek and K. Lee Department of Radiology,HvidovreHospital,Universityof Copenhagen,and Department of Neurology,MunicipalHospital, Copenhagen, Denmark
Sununary. This is a controlled CT evaluation of the infratentorial region in 41 male alcoholics under age 35. Criteria for the presence of atrophy are outlined. Twelve patients had cerebellar atrophy. Vermian atrophy was present in all. Atrophy of the cerebellar hemispheres was demonstrated in eight patients as well. The results are statistically significant when compared to an age-matched group of 40 nonalcoholic males among whom two cases of vermian atrophy were found. There were clinical signs of alcoholic cerebellar atrophy in one patient only. The disparity between the clinical and the radiological data are discussed with reference to previous pneumoencephalographic findings. Key words: Cerebellar atrophy - CT - Alcoholism
[3]. They stated that chronic alcoholics represent the majority of cases of cerebellar atrophy. The normal CT appearance of the infratentorial region has been described by Gawler et al. [4]. These authors also mentioned the findings in cerebellar atrophy [5], The quadrigeminal cistern, the ambient cisterns and the vermian sulci are regularly identified, as is the superior cerebellar cistern. The latter is variable in size. When cerebellar atrophy is present, widening of the space between the vermian sulci, strikingly prominent cisterns surrounding the brainstem, especially the ambient cisterns, and visible sulci laterally over the cerebellar hemispheres are seen. Computed tomography was performed on young alcoholics as part of a comprehensive study of the neurological, psychological, and hepatological complications of alcoholism conducted from April 1977 to May 1978. This report concerns itself with the neuroradiological findings in the infratentorial region.
Introduction
In 1955 Skillicorn [1] described the syndrome of cerebellar ataxia in chronic alcoholics and, in 1959 Victor et al. [2] presented their extensive clinical and pathological observations about this entity. The disease characteristically presents itself clinically with ataxia of gait. Even in its mildest form heel-to-toewalking is impaired. Incoordination of the upper extremities is conspicuously absent as a rule. Histological studies have demonstrated degeneration of all neurocellular elements of the cerebellar cortex with a striking topographical restriction to the anterior and superior aspects of the vermis and cerebellar hemispheres. Macroscopically there was shrinkage of folia and widening of sulci [2]. Pneumoencephalographic criteria for cerebellar atrophy were suggested by LeMay and Abramowicz in 1966
Material and Method
Considered for studying were alcoholic males under age 35, who suffered no acute illness other than alcoholism. The patients were referred from an outpatient clinic for the treatment of alcoholics. Patients Table 1. Exclusioncriteria 1. Severehead trauma (cerebral contusion,cranialfracture) 2. Coma due to prolongedanesthesiaor attemptedsuicide 3. Epilepsysince childhood 4. Mental retardation 5. Previousbacterial meningitis 6. Major psychiatricillness 7. Occupationalexposureto organicsolvents
0028-3940/79/0018/0077/$01.00
78
A. Haubek and K. Lee: CT in AlcoholicCerebellar Atrophy Atrophy of the cortex of the cerebellar hemispheres was considered present when hemispheric sulci were visible. A t r o p h y of the vermis was considered present when two or more clearly visible sulci were seen in the midline on two sections. Furthermore, an estimation was made of the cisterns surrounding the brainstem as well as the lateral and dorsal extension of the superior cerebellar cistern. Following these criteria the material was subdivided into atrophic and normal groups. Grading of the degree of atrophy has not been attempted. Thus the atrophic group includes patients with marked atrophy as well as less severe cases. Doubtful cases have been included in the normal group. Figure l a and b demonstrates vermian atrophy. Figure 2 a and b demonstrates atrophy of the cerebellar hemispheres. These criteria of atrophy were tested against an age-matched control group of 40 non-alcoholic males. F r o m January 1977 to September 1978, 2220 CT scans were performed in our department. Of these, 155 were performed on males between the ages of 21 and 35 years. The controls were selected consecutively among these, excluding those who met the exclusion criteria of the study group. In addition patients with final diagnoses of a space occupying intracranial lesion, cerebral infarct or multiple sclerosis were excluded. Table 2 lists the discharge diagnoses of the 40 patients constituting the control group.
Fig. 1
Fig. 2
Table 2. Clinical diagnosis in 40 control patients
Diagnosis
No. of patients
Epilepsy (< 3 years duration) Observatio sine indicatione therapiae Neurosis Optic or retrobulbar neuritis Headache Migraine
14 11 6 4 4 1
Total
40
with a history of factors other than alcoholism, which are known to cause brain damage, were excluded (Table 1). Included in the study were 42 males. The age range was 2 1 - 3 5 years (average 30 years). O n average they had consumed 150 g ethanol daily for 10 years. The patients were examined neurologically, special attention being paid to signs of cerebellar atrophy. CT was performed with the EMI 1010 brain scanner operated at 33 m A and 120 kV. The scanning plane was parallel to the orbitomeatal line. A total of 5 to 6 double sections were made; 2 to 3 of these included the posterior fossa.
Results
A satisfactory CT evaluation of the infratentorial region was possible in all but one case. Following the criteria outlined above, infratentorial atrophy was apparent in 12 of the 41 patients. In eight of these there was atrophy of the vermis as well as of the cerebellar hemispheres. In four cases only vermian atrophy was present. Isolated atrophy of the cerebellar hemispheres did not occur. In two patients the cisterna magna was very large, extending to a level just below the tentorium. This may represent a normal anatomical variant, making the interpretation of midline atrophy difficult. We have included these two patients in the normal group. All of the 12 patients with infratentorial atrophy had some degree of supratentorial cortical atrophy as well. Two cases of vermian atrophy were found among the controls. None had atrophy of the cerebellar hemispheres. In one case the cisterna magna was very large, extending to the level of the tentorium. Some degree of supratentorial cortical atrophy was also present in the two cases of vermian atrophy. The diagnoses in these two cases were: epilepsy in one,
79
A. Haubek and K. Lee: CT in AlcoholicCerebellar Atrophy retrobulbar neuritis in the other. Using the Fisher exact probability test, the difference between the study population (12/41) and the', controls (2/40) is significant at the 1% level. Clinically only one patient from the study group had signs of alcoholic cerebellar cortical atrophy. H e was a man of 33 years who had difficulty in walking for 6 months. His gait was ataxic and he was unable to walk heel-to-toe. Horizontal and vertical nystagmus and a fine tremor of the hands were also observed. H e showed obvious signs of intellectual impairment. H e was among the eight patients with combined vermian and cerebellar hemispheric atrophy.
study seem justified by the significant difference found between the study patients and the controls. Our results, as revealed by CT scan, correspond to the topographical distribution of cerebellar atrophy in chronic alcoholics demonstrated in the neuropathological study of Victor et al. [2] and in the above mentioned pneumographic studies. The most severe atrophy was localized in the midline structures. The problem of clinically silent cerebellar atrophy is unsolved. In accordance with the pneumographic literature and with our results, alcoholics seem to constitute the majority of these cases. The finding of cerebellar atrophy in 12 of 41 cases seems remarkable, particularly when taking into account the young age of these patients.
Discussion The pneumoencephalographic criteria for cerebellar atrophy suggested by L e M a y and Abramovicz in 1966 [3] were questioned by Kennedy et al. in 1976 [6]. The latter defined vermian atrophy as two or more midline sulci exceeding 2 mrn in width. In addition Kennedy et al. ranked their material according to an overall estimation of the severity of cerebellar atrophy. In 44 cases they found a significant correlation between the severity of the clinical signs of cerebellar disease and the degree of atrophy demonstrated by pneumoencephalography. However, there were no clinical signs of cerebellar disease in 23 of the 44 patients with pneumographic atrophy. This disparity between the clinical and the radiological signs was also observed by L e M a y and Abramovicz [3]. A m o n g 37 patients without clinical evidence of cerebellar disease they found 12 cases of cerebellar atrophy and of these six were alcoholics. The clarity with which the cisterns around the brainstem and the vermian sulci are visualized on C T depends in part upon the angulation of the head. This makes the establishment of metric criteria for normalcy of this region difficult. The criteria used in this
References 1. Skillicorn, S.A.: Presenile cerebellar ataxia in chronic alcoholics. Neurology 5, 528-534 (1955) 2. Victor, M., Adams, R. D., Mancall, E. L.: A restricted from of cerebellar cortical degeneration ocurring in alcoholicpatients. Arch. Neurol. 1, 579-688 (1959) 3. LeMay, M., Abramovicz,A.: Encephalographyin the diagnosis of cerebellar atrophy. Acta Radiol. 5, 667-674 (1966) 4. Gawler, J., Bull, J. W. D., Du Boulay, G. H., Marshall, J.: Computerized axial tomography: the normal EMI scan. J. Neurol. Neurosurg. Psychiatry 38, 935-947 (1975) 5. Gawler, J., Du Boulay, G. H., Bull, J. W. D., Marshall, J.: Computerized tomography (the EMI scanner): a comparison with pneumoencephalography and ventriculography. J. Neurol. Neurosurg. Psychiatry 39, 203-211 (1976) 6. Kennedy, P., Swash, M., Wylie, I. G.: The clinical significance of pneumographic cerebellar atrophy. Br. J. Radiol. 49, 903-911 (1976) Received: 2 October 1978 in revised form: 30 March 1979 Dr. Aksel Haubek Department of Radiology Hvidovre Hospital DK-2650 Hvidovre, Denmark
Neuroradiology 18, 77-79 (1979)
© by Springer-Verlag 1979
Computed Tomography in Alcoholic Cerebellar Atrophy A. Haubek and K. Lee Department of Radiology,HvidovreHospital,Universityof Copenhagen,and Department of Neurology,MunicipalHospital, Copenhagen, Denmark
Sununary. This is a controlled CT evaluation of the infratentorial region in 41 male alcoholics under age 35. Criteria for the presence of atrophy are outlined. Twelve patients had cerebellar atrophy. Vermian atrophy was present in all. Atrophy of the cerebellar hemispheres was demonstrated in eight patients as well. The results are statistically significant when compared to an age-matched group of 40 nonalcoholic males among whom two cases of vermian atrophy were found. There were clinical signs of alcoholic cerebellar atrophy in one patient only. The disparity between the clinical and the radiological data are discussed with reference to previous pneumoencephalographic findings. Key words: Cerebellar atrophy - CT - Alcoholism
[3]. They stated that chronic alcoholics represent the majority of cases of cerebellar atrophy. The normal CT appearance of the infratentorial region has been described by Gawler et al. [4]. These authors also mentioned the findings in cerebellar atrophy [5], The quadrigeminal cistern, the ambient cisterns and the vermian sulci are regularly identified, as is the superior cerebellar cistern. The latter is variable in size. When cerebellar atrophy is present, widening of the space between the vermian sulci, strikingly prominent cisterns surrounding the brainstem, especially the ambient cisterns, and visible sulci laterally over the cerebellar hemispheres are seen. Computed tomography was performed on young alcoholics as part of a comprehensive study of the neurological, psychological, and hepatological complications of alcoholism conducted from April 1977 to May 1978. This report concerns itself with the neuroradiological findings in the infratentorial region.
Introduction
In 1955 Skillicorn [1] described the syndrome of cerebellar ataxia in chronic alcoholics and, in 1959 Victor et al. [2] presented their extensive clinical and pathological observations about this entity. The disease characteristically presents itself clinically with ataxia of gait. Even in its mildest form heel-to-toewalking is impaired. Incoordination of the upper extremities is conspicuously absent as a rule. Histological studies have demonstrated degeneration of all neurocellular elements of the cerebellar cortex with a striking topographical restriction to the anterior and superior aspects of the vermis and cerebellar hemispheres. Macroscopically there was shrinkage of folia and widening of sulci [2]. Pneumoencephalographic criteria for cerebellar atrophy were suggested by LeMay and Abramowicz in 1966
Material and Method
Considered for studying were alcoholic males under age 35, who suffered no acute illness other than alcoholism. The patients were referred from an outpatient clinic for the treatment of alcoholics. Patients Table 1. Exclusioncriteria 1. Severehead trauma (cerebral contusion,cranialfracture) 2. Coma due to prolongedanesthesiaor attemptedsuicide 3. Epilepsysince childhood 4. Mental retardation 5. Previousbacterial meningitis 6. Major psychiatricillness 7. Occupationalexposureto organicsolvents
0028-3940/79/0018/0077/$01.00
78
A. Haubek and K. Lee: CT in AlcoholicCerebellar Atrophy Atrophy of the cortex of the cerebellar hemispheres was considered present when hemispheric sulci were visible. A t r o p h y of the vermis was considered present when two or more clearly visible sulci were seen in the midline on two sections. Furthermore, an estimation was made of the cisterns surrounding the brainstem as well as the lateral and dorsal extension of the superior cerebellar cistern. Following these criteria the material was subdivided into atrophic and normal groups. Grading of the degree of atrophy has not been attempted. Thus the atrophic group includes patients with marked atrophy as well as less severe cases. Doubtful cases have been included in the normal group. Figure l a and b demonstrates vermian atrophy. Figure 2 a and b demonstrates atrophy of the cerebellar hemispheres. These criteria of atrophy were tested against an age-matched control group of 40 non-alcoholic males. F r o m January 1977 to September 1978, 2220 CT scans were performed in our department. Of these, 155 were performed on males between the ages of 21 and 35 years. The controls were selected consecutively among these, excluding those who met the exclusion criteria of the study group. In addition patients with final diagnoses of a space occupying intracranial lesion, cerebral infarct or multiple sclerosis were excluded. Table 2 lists the discharge diagnoses of the 40 patients constituting the control group.
Fig. 1
Fig. 2
Table 2. Clinical diagnosis in 40 control patients
Diagnosis
No. of patients
Epilepsy (< 3 years duration) Observatio sine indicatione therapiae Neurosis Optic or retrobulbar neuritis Headache Migraine
14 11 6 4 4 1
Total
40
with a history of factors other than alcoholism, which are known to cause brain damage, were excluded (Table 1). Included in the study were 42 males. The age range was 2 1 - 3 5 years (average 30 years). O n average they had consumed 150 g ethanol daily for 10 years. The patients were examined neurologically, special attention being paid to signs of cerebellar atrophy. CT was performed with the EMI 1010 brain scanner operated at 33 m A and 120 kV. The scanning plane was parallel to the orbitomeatal line. A total of 5 to 6 double sections were made; 2 to 3 of these included the posterior fossa.
Results
A satisfactory CT evaluation of the infratentorial region was possible in all but one case. Following the criteria outlined above, infratentorial atrophy was apparent in 12 of the 41 patients. In eight of these there was atrophy of the vermis as well as of the cerebellar hemispheres. In four cases only vermian atrophy was present. Isolated atrophy of the cerebellar hemispheres did not occur. In two patients the cisterna magna was very large, extending to a level just below the tentorium. This may represent a normal anatomical variant, making the interpretation of midline atrophy difficult. We have included these two patients in the normal group. All of the 12 patients with infratentorial atrophy had some degree of supratentorial cortical atrophy as well. Two cases of vermian atrophy were found among the controls. None had atrophy of the cerebellar hemispheres. In one case the cisterna magna was very large, extending to the level of the tentorium. Some degree of supratentorial cortical atrophy was also present in the two cases of vermian atrophy. The diagnoses in these two cases were: epilepsy in one,
79
A. Haubek and K. Lee: CT in AlcoholicCerebellar Atrophy retrobulbar neuritis in the other. Using the Fisher exact probability test, the difference between the study population (12/41) and the', controls (2/40) is significant at the 1% level. Clinically only one patient from the study group had signs of alcoholic cerebellar cortical atrophy. H e was a man of 33 years who had difficulty in walking for 6 months. His gait was ataxic and he was unable to walk heel-to-toe. Horizontal and vertical nystagmus and a fine tremor of the hands were also observed. H e showed obvious signs of intellectual impairment. H e was among the eight patients with combined vermian and cerebellar hemispheric atrophy.
study seem justified by the significant difference found between the study patients and the controls. Our results, as revealed by CT scan, correspond to the topographical distribution of cerebellar atrophy in chronic alcoholics demonstrated in the neuropathological study of Victor et al. [2] and in the above mentioned pneumographic studies. The most severe atrophy was localized in the midline structures. The problem of clinically silent cerebellar atrophy is unsolved. In accordance with the pneumographic literature and with our results, alcoholics seem to constitute the majority of these cases. The finding of cerebellar atrophy in 12 of 41 cases seems remarkable, particularly when taking into account the young age of these patients.
Discussion The pneumoencephalographic criteria for cerebellar atrophy suggested by L e M a y and Abramovicz in 1966 [3] were questioned by Kennedy et al. in 1976 [6]. The latter defined vermian atrophy as two or more midline sulci exceeding 2 mrn in width. In addition Kennedy et al. ranked their material according to an overall estimation of the severity of cerebellar atrophy. In 44 cases they found a significant correlation between the severity of the clinical signs of cerebellar disease and the degree of atrophy demonstrated by pneumoencephalography. However, there were no clinical signs of cerebellar disease in 23 of the 44 patients with pneumographic atrophy. This disparity between the clinical and the radiological signs was also observed by L e M a y and Abramovicz [3]. A m o n g 37 patients without clinical evidence of cerebellar disease they found 12 cases of cerebellar atrophy and of these six were alcoholics. The clarity with which the cisterns around the brainstem and the vermian sulci are visualized on C T depends in part upon the angulation of the head. This makes the establishment of metric criteria for normalcy of this region difficult. The criteria used in this
References 1. Skillicorn, S.A.: Presenile cerebellar ataxia in chronic alcoholics. Neurology 5, 528-534 (1955) 2. Victor, M., Adams, R. D., Mancall, E. L.: A restricted from of cerebellar cortical degeneration ocurring in alcoholicpatients. Arch. Neurol. 1, 579-688 (1959) 3. LeMay, M., Abramovicz,A.: Encephalographyin the diagnosis of cerebellar atrophy. Acta Radiol. 5, 667-674 (1966) 4. Gawler, J., Bull, J. W. D., Du Boulay, G. H., Marshall, J.: Computerized axial tomography: the normal EMI scan. J. Neurol. Neurosurg. Psychiatry 38, 935-947 (1975) 5. Gawler, J., Du Boulay, G. H., Bull, J. W. D., Marshall, J.: Computerized tomography (the EMI scanner): a comparison with pneumoencephalography and ventriculography. J. Neurol. Neurosurg. Psychiatry 39, 203-211 (1976) 6. Kennedy, P., Swash, M., Wylie, I. G.: The clinical significance of pneumographic cerebellar atrophy. Br. J. Radiol. 49, 903-911 (1976) Received: 2 October 1978 in revised form: 30 March 1979 Dr. Aksel Haubek Department of Radiology Hvidovre Hospital DK-2650 Hvidovre, Denmark
