Crossed cerebellar diaschisis refers to a depression in function, metabolism, and perfusion affecting a cerebellar hemisphere occurring as a result of a contralateral focal supratentorial lesion, classically an infarct.
Other than neurological deficits and other clinical features associated with the contralateral supratentorial lesion, this condition is generally asymptomatic 1.
Diaschisis in the brain, by definition, refers to an acute inhibition of function and metabolism produced by a focal disturbance in a portion of the brain at a distance from the original site of injury but connected via white matter tracts 1. Although initially defined as caused by an acute lesion, many sources in the literature employ a more liberal definition and refer to it being related to a lesion of any temporal duration 1.
When affecting the cerebellum, it is a well-recognised phenomenon following cerebral infarction 2-4, although it can be a sequela of any significant supratentorial lesion (e.g. tumours 1, intracerebral haemorrhage 5, encephalitis 5, Dyke-Davidoff-Masson syndrome 6, radiation necrosis, etc.). The most likely mechanism is thought to be interruption of cortico-ponto-cerebellar white matter tracts, which then results in deafferentation and hypometabolism of the contralateral cerebellar hemisphere 2.
The same phenomenon can also occur in other regions of the brain after various insults 8,9:
- ipsilateral thalamic diaschisis, occurring after an ipsilateral middle cerebral artery territory infarction
- crossed transhemispheric diaschisis, occurring after a contralateral infarct
- ipsilateral thalamocortical diaschisis, occurring after an ipsilateral thalamic infarct
By definition, nuclear medicine should be performed to formally detect hypometabolism in the contralateral cerebellar hemisphere 1, however other imaging modalities may be useful if interpreted in the correct clinical context.
CT perfusion / MRI perfusion
CT perfusion performed during an acute stroke may show a contralateral perfusion abnormality in about 20% of cases 4. In particular, CBF and CBV maps show only mild-to-moderate reduction in these parameters, which are not low enough to classify as infarctions 7. MR perfusion can also play a similar role 3,4. In chronic stages, there can be associated volume loss to the contralateral cerebellar hemisphere, known as crossed cerebellar atrophy 1,2.
FDG-PET shows hypometabolism in the affected cerebellar hemisphere, which is diagnostic of this phenomenon 1.
Treatment and prognosis
No treatment, other than management of the supratentorial insult and prevention of further insults, is available or necessary.
History and etymology
The term 'diaschisis' was first coined by Constantin von Monakow (1853-1930), a Russian neuropathologist, in 1914 8,10, although the concept was first proposed by Charles-Édouard Brown-Séquard (1817-1894) who debated the topic with Jean-Martin Charcot (1825-1893) in the late 1800s 8,11.
- 1. Tien RD, Ashdown BC. Crossed cerebellar diaschisis and crossed cerebellar atrophy: correlation of MR findings, clinical symptoms, and supratentorial diseases in 26 patients. AJR Am J Roentgenol. 1992;158 (5): 1155-9. AJR Am J Roentgenol (abstract) - Pubmed citation
- 2. Infeld B, Davis SM, Lichtenstein M et-al. Crossed cerebellar diaschisis and brain recovery after stroke. Stroke. 1995;26 (1): 90-5. Stroke (link) - Pubmed citation
- 3. Lin DD, Kleinman JT, Wityk RJ et-al. Crossed cerebellar diaschisis in acute stroke detected by dynamic susceptibility contrast MR perfusion imaging. AJNR Am J Neuroradiol. 2009;30 (4): 710-5. doi:10.3174/ajnr.A1435 - Free text at pubmed - Pubmed citation
- 4. Förster A, Kerl HU, Goerlitz J et-al. Crossed cerebellar diaschisis in acute isolated thalamic infarction detected by dynamic susceptibility contrast perfusion MRI. PLoS ONE. 2014;9 (2): e88044. doi:10.1371/journal.pone.0088044 - Free text at pubmed - Pubmed citation
- 5. Jiménez-Caballero PE. Crossed cerebellar atrophy: Update. Journal of neurosciences in rural practice. 3 (3): 235-6. doi:10.4103/0976-3147.102588 - Pubmed
- 6. Demir Y, Sürücü E, Çilingir V, Bulut MD, Tombul T. Dyke-Davidoff-Masson Syndrome With Cerebral Hypometabolism and Unique Crossed Cerebellar Diaschisis in 18F-FDG PET/CT. Clinical nuclear medicine. 40 (9): 757-8. doi:10.1097/RLU.0000000000000890 - Pubmed
- 7. Jeon YW, Kim SH, Lee JY, Whang K, Kim MS, Kim YJ, Lee MS. Dynamic CT perfusion imaging for the detection of crossed cerebellar diaschisis in acute ischemic stroke. Korean journal of radiology. 13 (1): 12-9. doi:10.3348/kjr.2012.13.1.12 - Pubmed
- 8. Carrera E, Tononi G. Diaschisis: past, present, future. (2014) Brain : a journal of neurology. 137 (Pt 9): 2408-22. doi:10.1093/brain/awu101 - Pubmed
- 9. Reidler P, Thierfelder KM, Fabritius MP, Sommer WH, Meinel FG, Dorn F, Wollenweber FA, Duering M, Kunz WG. Thalamic Diaschisis in Acute Ischemic Stroke. (2018) Stroke. doi:10.1161/STROKEAHA.118.020698 - Pubmed
- 10. von Monakow C. Die Lokalisation im Grosshirn und der Abbau der Funktion durch Kortikale Herde. (1914) Wiesbaden, Germany JF Bergmann.
- 11. Brown-Séquard CE. Seance du 18 decembre, C R Soc Biol. (1875). Vol. 424.
Stroke and intracranial haemorrhage
stroke and intracranial haemorrhage
- general discussions
- scoring and classification systems
- by region
- hemispheric infarcts
- frontal lobe infarct
- parietal lobe infarct
- temporal lobe infarct
- occipital lobe infarct
- internal capsule infarct
- ataxic hemiparesis syndrome: MCA perforators or basilar artery perforators
- lacunar infarct
- thalamic infarct
- striatocapsular infarct
- cerebellar infarct
- midbrain infarct
- Brissaud-Sicard syndrome
- facial colliculus syndrome
- Gasperini syndrome: basilar artery or AICA
- inferior medial pontine syndrome (Foville syndrome): basilar artery
- lateral pontine syndrome (Marie-Foix syndrome): basilar artery or AICA
- locked-in syndrome: basilar artery
- Millard-Gubler syndrome: basilar artery
- Raymond syndrome: basilar artery
- medullary infarct
- acute spinal cord ischaemia syndrome
- hemispheric infarcts
- by vascular territory
- anterior cerebral artery infarct
- anterior choroidal artery infarct
- anterior inferior cerebellar artery infarct
- basilar artery infarct
- middle cerebral artery infarct
- posterior cerebral artery infarct
- posterior inferior cerebellar artery infarct
- superior cerebellar artery infarct
- treatment options
- by region
- basal ganglia haemorrhage
- cerebellar haemorrhage
- cerebral contusions
- haemorrhagic venous infarct
- haemorrhagic transformation of an ischaemic infarct
- hypertensive intracranial haemorrhage
- intraventricular haemorrhage (IVH)
- lobar haemorrhage
- pontine haemorrhage
- extra-axial haemorrhage
- extradural versus subdural haemorrhage
- extradural haemorrhage (EDH)
- intralaminar dural haemorrhage
- subdural haemorrhage (SDH)
- subarachnoid haemorrhage (SAH)
- intra-axial haemorrhage
- ischaemic stroke