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Visual and auditory hallucinations revealing cerebellar extraventricular neurocytoma: uncommon presentation for uncommon tumor in uncommon location
General Hospital Psychiatry 35 (2013) 680.e1–680.e3
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
Case Report
Visual and auditory hallucinations revealing cerebellar extraventricular neurocytoma: uncommon presentation for uncommon tumor in uncommon location Gentian Kaloshi, M.D., Ph.D. a,⁎, Valbona Alikaj, M.D. b, Arben Rroji, M.D. c, Gjergji Vreto, M.D., Ph.D. c, Mentor Petrela, M.D., Ph.D. a a b c
Department of Neurosurgery, School of Medicine, University of Tirana, Albania Department of Psychiatry, Child and Adolescent Psychiatry Service, School of Medicine, University of Tirana, Albania Department of Radiology, School of Medicine, University of Tirana, Albania
a r t i c l e
i n f o
Article history: Received 20 January 2013 Revised 14 March 2013 Accepted 16 March 2013 Keywords: Psychiatric disorders Cerebellum Extraventricular neurocytoma IDH mutation
a b s t r a c t Objective: Visual and auditory hallucinations in relation to a cerebellar tumor are rarely reported in children. Primary origin of extraventricular neurocytoma (EVN) in the cerebellum is very rare. Clinical Presentation: We report on a case of a cerebellar EVN in a 13-year-old girl with the initial symptoms of psychiatric manifestations for more than 2 months. Magnetic resonance imaging of the brain revealed a patchy enhanced tumor in the paramedian left cerebellar region. No obstructive hydrocephalus was noted. Intervention: Total surgical removal of the tumor was performed. The tumor was initially diagnosed as an oligodendroglioma. After special immunohistochemical studies, the final definitive diagnosis was an EVN without isocitrate dehydrogenase mutation. Conclusion: EVNs located in the cerebellum are extremely rare. We discuss the clinical symptoms and histological–immunohistochemical features of this rare tumor in that rare location. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Auditory and visual hallucinations involve perceiving sounds and figures without auditory and/or visual stimulus. This may be associated with psychotic disorders such as schizophrenia or mania. The emergence of such psychiatric disorders has been reported in individual with cerebellar lesions (stroke, abscesses, megacisterna magna, Dandy–Walker and tumors) [1]. Extraventricular neurocytoma (EVN) are rare neurocytoma arising outside their stereotypic location within ventricular system. Since the first cases described on 1997 [2], there is a growing evidence of this probable underdiagnosed tumor, recently added in the World Health Organization (WHO) classification [3]. Cerebellum is a very rare location. Thus, we report on such unique case in a 13-year-old girl manifesting auditory hallucinations due to cerebellar EVN. 2. Case presentation This 13-year-old girl came at our intention for a 2-year history of frequent psychotic manifestations with visual and auditory hallucinations. On admission, she complained/told the examiner of auditory ⁎ Corresponding author. Department of Neurosurgery, School of Medicine, University of Tirana, Tirana, Albania. Tel.: +355 42 36 26 41; fax: +355 42 36 26 41. E-mail address: [email protected] (G. Kaloshi). 0163-8343/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2013.03.011
hallucinations heard like male and female voices arguing with each other or talking about the patient. She also reported visual hallucinations of human forms of his family or other familiar persons that were experienced as the source of auditory hallucinations referred as living in a parallel environment. Furthermore, the girl believed these complex visual/auditory experiences to be real, being often emotionally jarred by their occurrence. Neurological examination found only a mild left dysmetria in association with puerile attitude and spasmodic laughter. She showed psychomotor slowing with minimal spontaneous speech. Formal bedside cognitive tests were not performed because of her illiteracy. An electroencephalogram (EEG) performed at another institution reportedly showed no paroxistic abnormalities. A following brain MRI confirmed the presence of heterogeneous lesion with multiple foci of contrast enhancement highly difficult to differentiate a definite radiological diagnosis (Fig 1A). Subsequently, the patient underwent the operation through a suboccipital median craniectomy. A partially cystic lesion, grey– yellow hue, with a few necrotic foci was seen and then removed. Her postoperative course was uneventful. MRI of control confirmed the total removal of the tumor (Fig 1B). First hematoxylin and eosin examination was suggestive of an anaplastic oligodendroglioma. A second histological opinion confirmed the presence of a cerebellar tissue infiltrated by a monomorphic population of oligodendrogliallike cells with sparse nuclear polymorphism. Microcystic formations
680.e2
G. Kaloshi et al. / General Hospital Psychiatry 35 (2013) 680.e1–680.e3
were noted. A frank astrocytic proliferation was noted positive for glial fibrillary acidic protein (GFAP) on some fields. Calcifications and vascular proliferations were present. Cells were positive for synaptophysin and negative for isocitrate dehydrogenase 1 (IDH1). Rare mitosis were observed (b1 per 10HPF). Cell proliferation index valued by Ki67 was about 1%. These findings were highly suggestive of a lowgrade glioneuronal neoplasm, EVN. Postoperative MRI confirmed the macroscopically total removal of the tumor, as showed by the last MRI of control (Fig 1C). One year after the operation, the patient still experienced the same visual and auditory hallucinations even if in a decreased frequency. 3. Discussion Visual and/or auditory hallucinations are an important symptom, often but not always explained by a psychiatric disease. Experience in the evaluation and management of hallucinations is important. Alternative conditions causing visual or auditory hallucinations should be ruled out. Assessment should focus on temporal features, potential underlying psychiatric illness and medication. For example, complex visual hallucinations associated with spasmodic laughing may occur with vascular pseudobulbar paralysis (peduncular hallucinosis) as well as with epileptic fits. As a mixed glial and neuronal tumor, like gangliogliomas and dysembryoplastic neuroepithelial tumors, EVN would express some abnormal hyperexcitability underlying a likely intrinsic propensity to epileptic fits. However, the EEG of
our patient was devoid of epileptiform features. Furthermore, our patient did not significantly improve after the lesionectomy contrarily of the reported effectiveness of the removal of glioneuronal tumors on seizure outcome [4]. The clinical presentation in this case consisted of pathologic visual and auditory hallucinations and an initial working hypothesis of schizophrenia. However, atypical neurologic symptoms, headaches and mild left dysmetria prompted additional investigations. Computed tomography and MRI of the brain revealed a cerebellar EVN, confirmed by histopathological examination. The typical neurocytoma is a rare low-grade neuroepithelial tumor located in the supratentorial ventricular system (lateral ventricles in 77% and third ventricle 21% of the cases). In 1997, Giangaspero et al. reported the first cases of a tumor that mimicked central neurocytoma but was located in the extraventricular area [2]. Despite histological similarities, different locations and genetic abnormalities (such as the presence of 1p/19q codeletion) [5,6] prompted the recognition of EVN as a separate entity from its intraventricular/central counterpart in the recent 2007 WHO classification [3]. In a recently published report, EVNs were immunohistochemically characterized by the absence of p53 overexpression, a-internexin positivity, O 6-methylguanine–DNA methyltransferase promoter methylation and IDH1/IDH2 mutation [7]. With the strong positivity for synaptophysin and lack of expression for IDH1 mutation, our case demonstrated that cerebellar EVN presented the same characteristics of other “triple negative” EVNs. The presence of GFAP positivity (as in our case) represents a potential
Fig. 1. MRI axial T2 weighted and T1 weighted with contrast at presentation (A), immediately after operation (B) and 1 year after (C).
G. Kaloshi et al. / General Hospital Psychiatry 35 (2013) 680.e1–680.e3
glial differentiation. Thus, these above-mentioned remnant cells would have capacity of potential neuronal and glial differentiation. On the other hand, it has been shown that combined losses of 1p and 19q, the genetic hallmark of oligodendroglioma, were not observed in cerebellar oligodendroglioma [8]. Do these differentiations represent different stages of the same progenitor cell or different processes? To date, there are not sufficient data to discern. It has been suggested that IDH mutations occur early in the development of a glioma from a stem cell that can give rise to both astrocytes and oligodendrocytes [9]. Taken together, we can speculate that the neuronal differentiation toward neurocytoma occurs more prematurely than glial differentiation. Most likely, the intrinsic characteristics of progenitor cell location may play a crucial role in promoting these differentiations. Intracerebellar EVNs are exceedingly rare. A large review of the literature found only three cases of EVN in cerebellum [10–12]. Patients usually presented with symptoms not related to tumor location (neck pain). Our patient presented with complex visual/ auditory hallucinations. Characterizing these hallucinations as secondary to an acquired cerebellar lesion is challenging. In last decades, in addition to motor and coordination function, the cerebellum has been also implicated in several psychiatric disorders with the cortico–cerebellar–thalamic– cortical circuit receiving a particular interest [13]. Schmahmann et al. used the term “cerebellar cognitive affective syndrome” describing a characteristic constellation of cognitive impairments, affecting executive, visual–spatial, linguistic and behavioral functions in adult patients with acquired cerebellar lesions [14]. This syndrome has been also documented to occur in children [15]. An increasing number of neuropsychological, neurophysiological and neuroimaging studies have contributed to identify the specific regions where the psychiatric patients differed from the normal volunteers. It has been shown that lesions of the posterior lobe resulted in more cognitive dysfunction [14]. Another study found an attenuation of the BOLD fMRI response in the cerebellum in patients with a history of prominent hallucinations. In their study, when the rate of inner speech generation was increased, the BOLD response was correspondingly reduced in hemispheric cerebellar areas [16]. However, the exact mechanism of the cerebellar involvement in cognitive processes is not well understood. In our case, the posterior and hemispheric location of the tumor and the absence of personal and familial psychiatric history lead us to believe that complex auditory/visual hallucinations and cerebellar lesion was closely related. This association has rarely been reported in children. In conclusion, clinical symptoms and abnormal neurological examination within a constellation suggestive of a psychiatric or
680.e3
psychosomatic syndrome should warrant directed additional investigations, to detect less obvious causes of pathologic hallucinations such as cerebellar lesions.
Acknowledgment We express our gratitude to Professor F. Giangaspero, the pioneer of EVN, for his invaluable help in reviewing and confirming the pathological diagnosis of our case.
References [1] Pollak L, Klein C, Rabey JM, Schiffer J. Posterior fossa lesions associated with neuropsychiatric symptomatology. Int J Neurosci 1996;87(3–4):119–26. [2] Giangaspero F, Cenacchi G, Losi L, et al. Extraventricular neoplasms with neurocytoma features. A clinicopathological study of 11 cases. Am J Surg Pathol 1997;21:206–12. [3] Figarella-Branger D, Soylemezoglu F, Burger P. Central neurocytoma and extraventricular neurocytoma. In: Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, editors. Who Rodriguez et al. Page 6 Brain Pathol. Classification of Tumours of the Central Nervous System. Lyon, France: International Agency For Research On Cancer; 2007. p. 106–9. [4] Giulioni M, Rubboli G, Marucci G. Seizure outcome of epilepsy surgery in focal epilepsies associated with temporomesial glioneuronal tumors: lesionectomy compared with tailored resection. J Neurosurg 2009;111:1275–82. [5] Leenstra JL, Rodriguez FJ, Frechette CM, Giannini C, Stafford SL, Pollock BE, et al. Central neurocytoma: management recommendations based on a 35-year experience. Int J Radiat Oncol Biol Phys 2007;67:1145–54. [6] Perry A, Fuller CE, Banerjee R, Brat DJ, Scheithauer BW. Ancillary FISH analysis for 1p and 19q status: preliminary observations in 287 gliomas and oligodendroglioma mimics. Front Biosci 2003;8:a1–9. [7] Clinicopathological and genetic characteristics of extraventricular neurocytomas. Jae Kyung Myung,1 Hwa Jin Cho, Chul-Kee Park, Chun Kee Chung, Seung Hong Choi, Seung-Ki Kim4 and Sung-Hye Park Neuropathology 2012 DOI: 10.1111/j.1440-1789.2012.01330.x. [8] Miwa T, Hirose Y, Sasaki H, Ikeda E, Yoshida K, Kawase T. Genetic characterization of adult infratentorial gliomas. J Neurooncol 2009;91(3):251–5. [9] Sanson M, Marie Y, Paris S, et al. Isocitrate dehydrogenase 1 codon 132 mutation is an important prognostic biomarker in gliomas. J Clin Oncol 2009;27:4150–4. [10] Enam SA, Rosenblum ML, Ho KL. Neurocytoma in the cerebellum. Case report. J Neurosurg 1997;87:100–2. [11] Ogiwara H, Dubner S, Bigio E, Chandler J. Neurocytoma of the cerebellum. Surg Neurol Int 2011;2:36. [12] Ahmad F, Rosenblum MK, Chamyan G, Sandberg DI. Infiltrative brainstem and cerebellar neurocytoma: case report. J Neurosurg Pediatr 2012;5:418–22. [13] Konarski JZ, McIntyre RS, Grupp LA, Kennedy SH. Is the cerebellum relevant in the circuitry of neuropsychiatric disorders? J Psychiatry Neurosci 2005;30(3):178–86. [14] Schmahmann JD, Sherman JC. The cerebellar cognitive affective syndrome. Brain 1998;121:561–79. [15] Levisohn L, Cronin-Golomb A, Schmahmann JD. Neuropsychological consequences of cerebellar tumor resection in children: cerebellar cognitive affective syndrome in a pediatric population. Brain 2000;123:1041–50. [16] Shergill SS, Brammer MJ, Fukuda R, Williams SC, Murray RM, McGuire PK. Engagement of brain areas implicated in processing inner speech in people with auditory hallucinations. Br J Psychiatry 2003;182:525–31.
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
Case Report
Visual and auditory hallucinations revealing cerebellar extraventricular neurocytoma: uncommon presentation for uncommon tumor in uncommon location Gentian Kaloshi, M.D., Ph.D. a,⁎, Valbona Alikaj, M.D. b, Arben Rroji, M.D. c, Gjergji Vreto, M.D., Ph.D. c, Mentor Petrela, M.D., Ph.D. a a b c
Department of Neurosurgery, School of Medicine, University of Tirana, Albania Department of Psychiatry, Child and Adolescent Psychiatry Service, School of Medicine, University of Tirana, Albania Department of Radiology, School of Medicine, University of Tirana, Albania
a r t i c l e
i n f o
Article history: Received 20 January 2013 Revised 14 March 2013 Accepted 16 March 2013 Keywords: Psychiatric disorders Cerebellum Extraventricular neurocytoma IDH mutation
a b s t r a c t Objective: Visual and auditory hallucinations in relation to a cerebellar tumor are rarely reported in children. Primary origin of extraventricular neurocytoma (EVN) in the cerebellum is very rare. Clinical Presentation: We report on a case of a cerebellar EVN in a 13-year-old girl with the initial symptoms of psychiatric manifestations for more than 2 months. Magnetic resonance imaging of the brain revealed a patchy enhanced tumor in the paramedian left cerebellar region. No obstructive hydrocephalus was noted. Intervention: Total surgical removal of the tumor was performed. The tumor was initially diagnosed as an oligodendroglioma. After special immunohistochemical studies, the final definitive diagnosis was an EVN without isocitrate dehydrogenase mutation. Conclusion: EVNs located in the cerebellum are extremely rare. We discuss the clinical symptoms and histological–immunohistochemical features of this rare tumor in that rare location. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Auditory and visual hallucinations involve perceiving sounds and figures without auditory and/or visual stimulus. This may be associated with psychotic disorders such as schizophrenia or mania. The emergence of such psychiatric disorders has been reported in individual with cerebellar lesions (stroke, abscesses, megacisterna magna, Dandy–Walker and tumors) [1]. Extraventricular neurocytoma (EVN) are rare neurocytoma arising outside their stereotypic location within ventricular system. Since the first cases described on 1997 [2], there is a growing evidence of this probable underdiagnosed tumor, recently added in the World Health Organization (WHO) classification [3]. Cerebellum is a very rare location. Thus, we report on such unique case in a 13-year-old girl manifesting auditory hallucinations due to cerebellar EVN. 2. Case presentation This 13-year-old girl came at our intention for a 2-year history of frequent psychotic manifestations with visual and auditory hallucinations. On admission, she complained/told the examiner of auditory ⁎ Corresponding author. Department of Neurosurgery, School of Medicine, University of Tirana, Tirana, Albania. Tel.: +355 42 36 26 41; fax: +355 42 36 26 41. E-mail address: [email protected] (G. Kaloshi). 0163-8343/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2013.03.011
hallucinations heard like male and female voices arguing with each other or talking about the patient. She also reported visual hallucinations of human forms of his family or other familiar persons that were experienced as the source of auditory hallucinations referred as living in a parallel environment. Furthermore, the girl believed these complex visual/auditory experiences to be real, being often emotionally jarred by their occurrence. Neurological examination found only a mild left dysmetria in association with puerile attitude and spasmodic laughter. She showed psychomotor slowing with minimal spontaneous speech. Formal bedside cognitive tests were not performed because of her illiteracy. An electroencephalogram (EEG) performed at another institution reportedly showed no paroxistic abnormalities. A following brain MRI confirmed the presence of heterogeneous lesion with multiple foci of contrast enhancement highly difficult to differentiate a definite radiological diagnosis (Fig 1A). Subsequently, the patient underwent the operation through a suboccipital median craniectomy. A partially cystic lesion, grey– yellow hue, with a few necrotic foci was seen and then removed. Her postoperative course was uneventful. MRI of control confirmed the total removal of the tumor (Fig 1B). First hematoxylin and eosin examination was suggestive of an anaplastic oligodendroglioma. A second histological opinion confirmed the presence of a cerebellar tissue infiltrated by a monomorphic population of oligodendrogliallike cells with sparse nuclear polymorphism. Microcystic formations
680.e2
G. Kaloshi et al. / General Hospital Psychiatry 35 (2013) 680.e1–680.e3
were noted. A frank astrocytic proliferation was noted positive for glial fibrillary acidic protein (GFAP) on some fields. Calcifications and vascular proliferations were present. Cells were positive for synaptophysin and negative for isocitrate dehydrogenase 1 (IDH1). Rare mitosis were observed (b1 per 10HPF). Cell proliferation index valued by Ki67 was about 1%. These findings were highly suggestive of a lowgrade glioneuronal neoplasm, EVN. Postoperative MRI confirmed the macroscopically total removal of the tumor, as showed by the last MRI of control (Fig 1C). One year after the operation, the patient still experienced the same visual and auditory hallucinations even if in a decreased frequency. 3. Discussion Visual and/or auditory hallucinations are an important symptom, often but not always explained by a psychiatric disease. Experience in the evaluation and management of hallucinations is important. Alternative conditions causing visual or auditory hallucinations should be ruled out. Assessment should focus on temporal features, potential underlying psychiatric illness and medication. For example, complex visual hallucinations associated with spasmodic laughing may occur with vascular pseudobulbar paralysis (peduncular hallucinosis) as well as with epileptic fits. As a mixed glial and neuronal tumor, like gangliogliomas and dysembryoplastic neuroepithelial tumors, EVN would express some abnormal hyperexcitability underlying a likely intrinsic propensity to epileptic fits. However, the EEG of
our patient was devoid of epileptiform features. Furthermore, our patient did not significantly improve after the lesionectomy contrarily of the reported effectiveness of the removal of glioneuronal tumors on seizure outcome [4]. The clinical presentation in this case consisted of pathologic visual and auditory hallucinations and an initial working hypothesis of schizophrenia. However, atypical neurologic symptoms, headaches and mild left dysmetria prompted additional investigations. Computed tomography and MRI of the brain revealed a cerebellar EVN, confirmed by histopathological examination. The typical neurocytoma is a rare low-grade neuroepithelial tumor located in the supratentorial ventricular system (lateral ventricles in 77% and third ventricle 21% of the cases). In 1997, Giangaspero et al. reported the first cases of a tumor that mimicked central neurocytoma but was located in the extraventricular area [2]. Despite histological similarities, different locations and genetic abnormalities (such as the presence of 1p/19q codeletion) [5,6] prompted the recognition of EVN as a separate entity from its intraventricular/central counterpart in the recent 2007 WHO classification [3]. In a recently published report, EVNs were immunohistochemically characterized by the absence of p53 overexpression, a-internexin positivity, O 6-methylguanine–DNA methyltransferase promoter methylation and IDH1/IDH2 mutation [7]. With the strong positivity for synaptophysin and lack of expression for IDH1 mutation, our case demonstrated that cerebellar EVN presented the same characteristics of other “triple negative” EVNs. The presence of GFAP positivity (as in our case) represents a potential
Fig. 1. MRI axial T2 weighted and T1 weighted with contrast at presentation (A), immediately after operation (B) and 1 year after (C).
G. Kaloshi et al. / General Hospital Psychiatry 35 (2013) 680.e1–680.e3
glial differentiation. Thus, these above-mentioned remnant cells would have capacity of potential neuronal and glial differentiation. On the other hand, it has been shown that combined losses of 1p and 19q, the genetic hallmark of oligodendroglioma, were not observed in cerebellar oligodendroglioma [8]. Do these differentiations represent different stages of the same progenitor cell or different processes? To date, there are not sufficient data to discern. It has been suggested that IDH mutations occur early in the development of a glioma from a stem cell that can give rise to both astrocytes and oligodendrocytes [9]. Taken together, we can speculate that the neuronal differentiation toward neurocytoma occurs more prematurely than glial differentiation. Most likely, the intrinsic characteristics of progenitor cell location may play a crucial role in promoting these differentiations. Intracerebellar EVNs are exceedingly rare. A large review of the literature found only three cases of EVN in cerebellum [10–12]. Patients usually presented with symptoms not related to tumor location (neck pain). Our patient presented with complex visual/ auditory hallucinations. Characterizing these hallucinations as secondary to an acquired cerebellar lesion is challenging. In last decades, in addition to motor and coordination function, the cerebellum has been also implicated in several psychiatric disorders with the cortico–cerebellar–thalamic– cortical circuit receiving a particular interest [13]. Schmahmann et al. used the term “cerebellar cognitive affective syndrome” describing a characteristic constellation of cognitive impairments, affecting executive, visual–spatial, linguistic and behavioral functions in adult patients with acquired cerebellar lesions [14]. This syndrome has been also documented to occur in children [15]. An increasing number of neuropsychological, neurophysiological and neuroimaging studies have contributed to identify the specific regions where the psychiatric patients differed from the normal volunteers. It has been shown that lesions of the posterior lobe resulted in more cognitive dysfunction [14]. Another study found an attenuation of the BOLD fMRI response in the cerebellum in patients with a history of prominent hallucinations. In their study, when the rate of inner speech generation was increased, the BOLD response was correspondingly reduced in hemispheric cerebellar areas [16]. However, the exact mechanism of the cerebellar involvement in cognitive processes is not well understood. In our case, the posterior and hemispheric location of the tumor and the absence of personal and familial psychiatric history lead us to believe that complex auditory/visual hallucinations and cerebellar lesion was closely related. This association has rarely been reported in children. In conclusion, clinical symptoms and abnormal neurological examination within a constellation suggestive of a psychiatric or
680.e3
psychosomatic syndrome should warrant directed additional investigations, to detect less obvious causes of pathologic hallucinations such as cerebellar lesions.
Acknowledgment We express our gratitude to Professor F. Giangaspero, the pioneer of EVN, for his invaluable help in reviewing and confirming the pathological diagnosis of our case.
References [1] Pollak L, Klein C, Rabey JM, Schiffer J. Posterior fossa lesions associated with neuropsychiatric symptomatology. Int J Neurosci 1996;87(3–4):119–26. [2] Giangaspero F, Cenacchi G, Losi L, et al. Extraventricular neoplasms with neurocytoma features. A clinicopathological study of 11 cases. Am J Surg Pathol 1997;21:206–12. [3] Figarella-Branger D, Soylemezoglu F, Burger P. Central neurocytoma and extraventricular neurocytoma. In: Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, editors. Who Rodriguez et al. Page 6 Brain Pathol. Classification of Tumours of the Central Nervous System. Lyon, France: International Agency For Research On Cancer; 2007. p. 106–9. [4] Giulioni M, Rubboli G, Marucci G. Seizure outcome of epilepsy surgery in focal epilepsies associated with temporomesial glioneuronal tumors: lesionectomy compared with tailored resection. J Neurosurg 2009;111:1275–82. [5] Leenstra JL, Rodriguez FJ, Frechette CM, Giannini C, Stafford SL, Pollock BE, et al. Central neurocytoma: management recommendations based on a 35-year experience. Int J Radiat Oncol Biol Phys 2007;67:1145–54. [6] Perry A, Fuller CE, Banerjee R, Brat DJ, Scheithauer BW. Ancillary FISH analysis for 1p and 19q status: preliminary observations in 287 gliomas and oligodendroglioma mimics. Front Biosci 2003;8:a1–9. [7] Clinicopathological and genetic characteristics of extraventricular neurocytomas. Jae Kyung Myung,1 Hwa Jin Cho, Chul-Kee Park, Chun Kee Chung, Seung Hong Choi, Seung-Ki Kim4 and Sung-Hye Park Neuropathology 2012 DOI: 10.1111/j.1440-1789.2012.01330.x. [8] Miwa T, Hirose Y, Sasaki H, Ikeda E, Yoshida K, Kawase T. Genetic characterization of adult infratentorial gliomas. J Neurooncol 2009;91(3):251–5. [9] Sanson M, Marie Y, Paris S, et al. Isocitrate dehydrogenase 1 codon 132 mutation is an important prognostic biomarker in gliomas. J Clin Oncol 2009;27:4150–4. [10] Enam SA, Rosenblum ML, Ho KL. Neurocytoma in the cerebellum. Case report. J Neurosurg 1997;87:100–2. [11] Ogiwara H, Dubner S, Bigio E, Chandler J. Neurocytoma of the cerebellum. Surg Neurol Int 2011;2:36. [12] Ahmad F, Rosenblum MK, Chamyan G, Sandberg DI. Infiltrative brainstem and cerebellar neurocytoma: case report. J Neurosurg Pediatr 2012;5:418–22. [13] Konarski JZ, McIntyre RS, Grupp LA, Kennedy SH. Is the cerebellum relevant in the circuitry of neuropsychiatric disorders? J Psychiatry Neurosci 2005;30(3):178–86. [14] Schmahmann JD, Sherman JC. The cerebellar cognitive affective syndrome. Brain 1998;121:561–79. [15] Levisohn L, Cronin-Golomb A, Schmahmann JD. Neuropsychological consequences of cerebellar tumor resection in children: cerebellar cognitive affective syndrome in a pediatric population. Brain 2000;123:1041–50. [16] Shergill SS, Brammer MJ, Fukuda R, Williams SC, Murray RM, McGuire PK. Engagement of brain areas implicated in processing inner speech in people with auditory hallucinations. Br J Psychiatry 2003;182:525–31.