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Consensus paper on post-operative pediatric cerebellar mutism syndrome: the Iceland Delphi results

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Abstract

Introduction

Confusion has surrounded the description of post-operative mutism and associated morbidity in pediatric patients with cerebellar tumors for years. The heterogeneity of definitions and diagnostic features has hampered research progress within the field, and to date, no international guidelines exist on diagnosis, prevention, treatment, or follow-up of this debilitating condition. An international group of clinicians and researchers from multiple relevant disciplines recently formed a cohesive panel to formulate a new working definition and agree upon standardized methods for diagnosis and follow-up.

Methods

Consensus was obtained using the modified nominal group technique, involving four rounds of online Delphi questionnaires interspersed with a structured consensus conference with lectures, group work, and open discussion sessions.

Results

A new, proposed definition of “post-operative pediatric CMS” was formed, preliminary recommendations for diagnostic and follow-up procedures were created, two working groups on a new scoring scale and risk prediction and prevention were established, and areas were identified where further information is needed.

Discussion

The consensus process was motivated by desire to further research and improve quality of life for pediatric brain tumor patients. The Delphi rounds identified relevant topics and established basic agreement, while face-to-face engagement helped resolve matters of conflict and refine terminology. The new definition is intended to provide a more solid foundation for future clinical and research work. It is thought as a consensus for moving forward and hopefully paves the way to developing a standard approach to this challenging problem with the advent of better scoring methods and ultimate goal of reducing the risk of CMS.

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Notes

  1. International multi-disciplinary group of researchers and health care professionals including adult and pediatric neurosurgeons, adult and pediatric neurologists, (neuro)radiologists, (neuro)psychologists, speech pathologists, linguists and neuroscientists who are active within the field of posterior fossa research.

  2. Speech production that is severely reduced and limited to single words or short sentences that can only be elicited after vigorous stimulation [49].

  3. Impairment of gait (ataxia), extremity coordination (dysmetria), disordered eye movements, poor articulation (dysarthria), impaired swallowing (dysphagia) and tremor [90].

  4. A pattern of behavioral abnormalities that includes impairments of executive function (planning, set-shifting, abstract reasoning, verbal fluency, working memory), often with perseveration, distractibility or inattention; visual-spatial disorganization and impaired visual-spatial memory; personality change with blunting of affect or disinhibited and inappropriate behavior; and difficulties with language production including dysprosodia, agrammatism and mild anomia [35].

  5. Symptoms such as urinary retention/incontinence and hemiparesis, which are frequently observed in this patient population [40, 91].

Abbreviations

AM:

Akinetic mutism

CM:

Cerebellar mutism

CCAS:

Cerebellar cognitive affective syndrome

CMS:

Cerebellar mutism syndrome

ISPNO:

International Symposium on Pediatric Neuro-Oncology

MSD:

Cerebellar mutism and subsequent dysarthria

PFS:

Posterior fossa syndrome

R1:

Round one (of the Delphi procedure)

R2:

Round two

R3:

Round three

R4:

Round four

TCM:

Transient cerebellar mutism

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Acknowledgments

The Iceland Delphi Group:

Femke Aarsen, Neuropsychologist. Erasmus MC - Sophia Children’s Hospital, Rotterdam, The Netherlands; Shivaram Avula, Radiologist. Alder Hey Children’s NHS Foundation Trust, Liverpool, UK; Kirsten van Baarsen, Neurosurgery Resident. Radboud University Medical Centre, Nijmegen, The Netherlands; Johan Cappelen, Neurosurgeon. St. Olav Hospital HF, Trondheim, Norway; Coriene Catsman-Berrevoets, Pediatric Neurologist. Erasmus MC/Sophia Children’s Hospital, Rotterdam, The Netherlands; Robert Dineen, Radiologist. Queens Medical Centre and the University of Nottingham, UK; Kimberley Docking, Speech Pathologist. University of Sydney, Australia; Jacques Grill, Pediatric Oncologist. Gustave Roussy, University Paris-Sud, Villejuif, France; Pablo Hernáiz Driever, Pediatric Oncologist. Charité-Universitätsmedizin Berlin, Germany; Thora Gudrunardottir, MD, Researcher. North Zealand Hospital, Hilleroed, Denmark; Marianne Juhler, Neurosurgeon. Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Caelyn Kaise, Speech-Language Pathologist. Hospital for Sick Children, Toronto, Canada; Robert F. Keating, Pediatric Neurosurgeon. Children’s National Health System, Washington, DC, USA; Mark D. Krieger, Pediatric Neurosurgeon. Children’s Hospital Los Angeles, USA; Ram Kumar, Pediatric Neurologist. Alder Hey Children’s Hospital, Liverpool, UK; Alvaro Lassaletta, Neuro-Oncology Fellow. Hospital for Sick Children, Toronto, Canada; Nicole Law, Psychologist and Neuroscientist. Hospital for Sick Children and the University of Toronto, Canada; Andrew L. Lux, Pediatric Neurologist. Bristol Royal Hospital for Children, Bristol, UK; Donald D. Mabbott, Psychologist. Hospital for Sick Children, Toronto, Canada; Conor Mallucci, Pediatric Neurosurgeon. Alder Hey Children’s Hospital, Liverpool, UK; Angela T. Morgan, Speech Pathologist and Speech Neuroscientist. University of Melbourne and Murdoch Children’s Research Institute, Melbourne, Australia; Iska Moxon-Emre, Doctoral Student in Psychology. Hospital for Sick Children and University of Toronto, Canada. Peter Mariën, Neurolingust. ZNA Middelheim Hospital, Antwerp and Vrije Universiteit, Brussels, Belgium; Roger J. Packer, Pediatric Neurologist. Children’s National Health System, Washington, DC, USA; Philippe Paquier, Neurolinguist. ULB - Hopital Erasme and Vrije Universiteit, Brussels, Belgium; Zoltan Patay, Radiologist. St. Jude Children’s Research Hospital, Memphis, USA; Barry Pizer, Pediatric Oncologist. Alder Hey Children’s Hospital and the University of Liverpool, UK; Stephanie Puget, Pediatric Neurosurgeon. Hôpital Necker-Enfants Malades, Paris, France; Christian Sainte-Rose, Pediatric Neurosurgeon. Hôpital Necker-Enfants Malades, Paris, France; Jeremy D. Schmahmann, Neurologist. Massachusetts General Hospital and Harvard Medical School, Boston, USA; Ulrich-Wilhelm Thomale, Pediatric Neurosurgeon. Charité-Universitätsmedizin Berlin, Germany; Katja von Hoff, Pediatric Oncologist. University Medical Center Hamburg-Eppendorf, Germany; David A. Walker, Pediatric Oncologist. Queen’s Medical Centre and Children’s Brain Tumor Research Centre, Nottingham, UK; Karin S. Walsh, Neuropsychologist. Children’s National Health System, Washington, DC, USA; Elizabeth M. Wells, Pediatric Neurologist. Children’s National Health System, Washington, DC, USA; Jeffrey H. Wisoff, Pediatric Neurosurgeon, New York University Langone Medical Center, New York, USA.

Authors’ contributions

Thora Gudrunardottir initiated the consensus process, acted as facilitator of the Delphi Rounds, and organized the consensus conference. She drafted the initial manuscript, contributed substantially to and revised all versions, and approved it as submitted. Angela T. Morgan served on the consensus committee and applied for funding for the consensus conference. She contributed substantially to and revised all versions of the manuscript. She was responsible for graphics, critically reviewed the final manuscript, and approved it as submitted. Andrew L. Lux served as guarantor of the Delphi Process. He was also group discussion facilitator at the consensus conference and chaired the working group on follow-up. He contributed substantially to and revised all versions of the manuscript and approved it as submitted. David A. Walker served as guarantor of the Delphi Process. He was also group discussion facilitator at the consensus conference and chaired the working group on diagnosis. He contributed substantially to the manuscript, revised and approved it as submitted. Karin S. Walsh served on the consensus committee, contributed to and revised all versions of the manuscript, and approved it as submitted. Elizabeth M. Wells served on the consensus committee, contributed to, revised and approved the manuscript as submitted. Jeffrey H. Wisoff documented the consensus conference and revised and approved the manuscript as submitted. Marianne Juhler served as group discussion facilitator at the consensus conference and chaired the working group on definitions. She contributed to and approved the manuscript as submitted. Jeremy D. Schmahmann contributed substantially to the manuscript, revised and accepted it as submitted. Robert F. Keating served on the consensus committee, contributed substantially to and revised all versions of the manuscript, and accepted it as submitted. Coriene Catsman-Berrevoets served on the consensus committee, contributed substantially to and revised all versions of the manuscript, critically reviewed and accepted it as submitted. All authors participated in the consensus conference. For a list of all participants in the conference by specialty and country, see Appendix III.

Author information

Authors and Affiliations

  1. Department of Oncology and Palliation, North Zealand Hospital, Dyrehavevej 29, 3400, Hilleroed, Denmark

    Thora Gudrunardottir

  2. Centre for Neuroscience of Speech, University of Melbourne, Melbourne, Australia

    Angela T. Morgan

  3. Neuroscience of Speech, Murdoch Children’s Research Institute, Melbourne, Australia

    Angela T. Morgan

  4. Department of Paediatric Neurology, Bristol Royal Hospital for Children, Bristol, UK

    Andrew L. Lux

  5. Department of Oncology, Queen’s Medical Centre, Nottingham, UK

    David A. Walker

  6. Children’s Brain Tumour Research Centre, University of Nottingham, Nottingham, UK

    David A. Walker

  7. Division of Neuropsychology, Brain Tumor Institute, Neurofibromatosis Institute, Children’s National Health System, Washington, DC, USA

    Karin S. Walsh

  8. Division of Neurology, Brain Tumor Institute, Children’s National Health System, Washington, DC, USA

    Elizabeth M. Wells

  9. Division of Pediatric Neurosurgery, New York University Langone Medical Center, New York, USA

    Jeffrey H. Wisoff

  10. Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark

    Marianne Juhler

  11. Department of Neurology, Ataxia Unit, Cognitive Behavioral Neurology Unit, Laboratory for Neuroanatomy and Cerebellar Neurobiology, Massachusetts General Hospital, Boston, MA, USA

    Jeremy D. Schmahmann

  12. Harvard Medical School, Boston, MA, USA

    Jeremy D. Schmahmann

  13. Department of Pediatric Neurosurgery, Children’s National Health System, Washington, DC, USA

    Robert F. Keating

  14. Department of Pediatric Neurology, Erasmus MC/Sophia Children’s Hospital, Rotterdam, The Netherlands

    Coriene Catsman-Berrevoets

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  1. Thora Gudrunardottir
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  2. Angela T. Morgan
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  3. Andrew L. Lux
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Consortia

For the Iceland Delphi Group

Corresponding author

Correspondence to Thora Gudrunardottir.

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No external funding for this manuscript.

Financial disclosure

David Walker is affiliated with the Children’s Brain Tumor Research Centre, Nottingham, UK, which provided partial funding for the consensus conference. The other authors have no financial relationships relevant to this article to disclose.

Conflict of interest

The authors declare that they have no conflict of interest.

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Gudrunardottir, T., Morgan, A.T., Lux, A.L. et al. Consensus paper on post-operative pediatric cerebellar mutism syndrome: the Iceland Delphi results. Childs Nerv Syst 32, 1195–1203 (2016). https://doi.org/10.1007/s00381-016-3093-3

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