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Das S, Mishra K, Ganju L, Singh S. Intranasally delivered small interfering RNA-mediated suppression of scavenger receptor Mac-1 attenuates microglial phenotype switching and working memory impairment following hypoxia. Neuropharmacology 2018; 137:240-255. [DOI: 10.1016/j.neuropharm.2018.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 04/22/2018] [Accepted: 05/02/2018] [Indexed: 01/06/2023]
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Schiller R, IJsselstijn H, Hoskote A, White T, Verhulst F, van Heijst A, Tibboel D. Memory deficits following neonatal critical illness: a common neurodevelopmental pathway. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:281-289. [PMID: 30169299 DOI: 10.1016/s2352-4642(17)30180-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 10/31/2017] [Accepted: 10/31/2017] [Indexed: 01/03/2023]
Abstract
Over the past decade, evidence has emerged that children growing up after neonatal critical illness, irrespective of underlying diagnosis, are at risk of memory impairment and academic problems. These difficulties are manifest even when intelligence is within the normal range. In this Review, we propose a common neurodevelopmental pathway following neonatal critical illness by showing that survivors of preterm birth, congenital heart disease, and severe respiratory failure share an increased risk of long-term memory deficits and associated hippocampal alterations. Rather than a consequence of underlying diagnosis, we suggest that this shared vulnerability is probably related to common conditions associated with neonatal critical illness, including hypoxia, neuroinflammation, stress, exposure to anaesthetics, or a complex interplay of these factors at different postconceptional ages. Future work should be aimed at improvement of early identification of patients at risk and evaluation of intervention modalities, such as exercise or cognitive training.
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Affiliation(s)
- Raisa Schiller
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands; Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Hanneke IJsselstijn
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Aparna Hoskote
- Cardiac Intensive Care, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Tonya White
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Netherlands
| | - Frank Verhulst
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands; Department of Clinical Medicine at the Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Arno van Heijst
- Department of Neonatology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.
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IJsselstijn H, Hunfeld M, Schiller RM, Houmes RJ, Hoskote A, Tibboel D, van Heijst AFJ. Improving Long-Term Outcomes After Extracorporeal Membrane Oxygenation: From Observational Follow-Up Programs Toward Risk Stratification. Front Pediatr 2018; 6:177. [PMID: 30013958 PMCID: PMC6036288 DOI: 10.3389/fped.2018.00177] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/30/2018] [Indexed: 01/02/2023] Open
Abstract
Since the introduction of extracorporeal membrane oxygenation (ECMO), more neonates and children with cardiorespiratory failure survive. Interest has therefore shifted from reduction of mortality toward evaluation of long-term outcomes and prevention of morbidity. This review addresses the changes in ECMO population and the ECMO-treatment that may affect long-term outcomes, the diagnostic modalities to evaluate neurological morbidities and their contributions to prognostication of long-term outcomes. Most follow-up data have only become available from observational follow-up programs in neonatal ECMO-survivors. The main topics are discussed in this review. Recommendations for long-term follow up depend on the presence of neurological comorbidity, the nature and extent of the underlying disease, and the indication for ECMO. Follow up should preferably be offered as standard of care, and in an interdisciplinary, structured and standardized way. This permits evaluation of outcome data and effect of interventions. We propose a standardized approach and recommend that multiple domains should be evaluated during long-term follow up of neonates and children who needed extracorporeal life support.
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Affiliation(s)
- Hanneke IJsselstijn
- Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, Netherlands
| | - Maayke Hunfeld
- Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, Netherlands
| | - Raisa M Schiller
- Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, Netherlands
| | - Robert J Houmes
- Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, Netherlands
| | - Aparna Hoskote
- Department of Cardiac Intensive Care, Great Ormond Street Institute of Child Health, University College London and Great Ormond Street Hospital for Children, London, United Kingdom
| | - Dick Tibboel
- Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, Netherlands
| | - Arno F J van Heijst
- Department of Neonatology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
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The 1-Year Follow-Up Clinic for Neonates and Children After Respiratory Extracorporeal Membrane Oxygenation Support: A 10-Year Single Institution Experience. Pediatr Crit Care Med 2017; 18:1047-1054. [PMID: 28922267 DOI: 10.1097/pcc.0000000000001304] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To establish the effectiveness of a "1-year extracorporeal membrane oxygenation follow-up clinic" and to characterize any neurodevelopmental concerns identified. DESIGN Single-center retrospective cohort of respiratory extracorporeal membrane oxygenation survivors over 10 years. SETTING Nationally commissioned center for neonatal and pediatric (> 28 d of life) respiratory extracorporeal membrane oxygenation. PATIENTS Children attending the follow-up clinic 1 year after receiving respiratory extracorporeal membrane oxygenation between 2003 and 2013. INTERVENTIONS Standardized follow-up 1 year after extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS In 10 years, 290 children received extracorporeal membrane oxygenation, 194 (67%) survived; all were offered 1-year follow-up, and 98 (51%) attended the clinic. Among these, 51 of 98 (52%) had meconium aspiration syndrome, and 74 of 98 (75%) were on veno-arterial extracorporeal membrane oxygenation with a median (interquartile range) duration of 6 days (4-8 d). Neurodevelopmental problems were identified in 30 of 98 (30%). The specific abnormalities noted included neurologic (seizures, motor, or vision abnormalities) (n = 8), hearing with/without language delay (n = 8), and behavioral problems (as reported by parents) (n = 6), with eight of 30 (27%) having difficulties spanning these domains. An acute neurologic event on extracorporeal membrane oxygenation was found to be the only risk factor for neurodevelopmental concerns (p = 0.006 with odds ratio 5.4 [95% CI, 1.63-17.92]). Despite having neither a cardiac arrest nor an acute neurologic event documented, 18 of 74 (24.3%), 95% CI (15.1-35.7), had neurodevelopmental concerns at 1-year follow-up. Among the nonattenders, 30 (15%) had local follow-up, and 66 (34%) were lost to follow-up. CONCLUSIONS All extracorporeal membrane oxygenation survivors need follow-up either at the extracorporeal membrane oxygenation center or in their community, as evidenced by the 1-year follow-up data. Our 1-year extracorporeal membrane oxygenation follow-up clinic provides an opportunity to engage with families, identify neurodevelopmental concerns, and signpost to appropriate services. Of concern, one third of survivors are lost to follow-up, some with an acute neurologic event on extracorporeal membrane oxygenation, a significant risk factor. A consensus-based standardized national follow-up program is vital.
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Abstract
OBJECTIVES Survivors of critical illness in early life are at risk of long-term-memory and attention impairments. However, their neurobiologic substrates remain largely unknown. DESIGN A prospective follow-up study. SETTING Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands. PATIENTS Thirty-eight school-age (8-12 yr) survivors of neonatal extracorporeal membrane oxygenation and/or congenital diaphragmatic hernia with an intelligence quotient greater than or equal to 80 and a below average score (z score ≤ -1.5) on one or more memory tests. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Intelligence, attention, memory, executive functioning, and visuospatial processing were assessed and compared with reference data. White matter microstructure and hippocampal volume were assessed using diffusion tensor imaging and structural MRI, respectively. Global fractional anisotropy was positively associated with selective attention (β = 0.53; p = 0.030) and sustained attention (β = 0.48; p = 0.018). Mean diffusivity in the left parahippocampal region of the cingulum was negatively associated with visuospatial memory, both immediate (β = -0.48; p = 0.030) and delayed recall (β = -0.47; p = 0.030). Mean diffusivity in the parahippocampal region of the cingulum was negatively associated with verbal memory delayed recall (left: β = -0.52, p = 0.021; right: β = -0.52, p = 0.021). Hippocampal volume was positively associated with verbal memory delayed recall (left: β = 0.44, p = 0.037; right: β = 0.67, p = 0.012). Extracorporeal membrane oxygenation treatment or extracorporeal membrane oxygenation type did not influence the structure-function relationships. CONCLUSIONS Our findings indicate specific neurobiologic correlates of attention and memory deficits in school-age survivors of neonatal extracorporeal membrane oxygenation and congenital diaphragmatic hernia. A better understanding of the neurobiology following critical illness, both in early and in adult life, may lead to earlier identification of patients at risk for impaired neuropsychological outcome with the use of neurobiologic markers.
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Intracranial Hemorrhage and Extracorporeal Membrane Oxygenation: Chicken or the Egg? Crit Care Med 2017; 45:1781-1783. [PMID: 28915173 DOI: 10.1097/ccm.0000000000002632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Effect of temperature on FAD and NADH-derived signals and neurometabolic coupling in the mouse auditory and motor cortex. Pflugers Arch 2017; 469:1631-1649. [PMID: 28785802 DOI: 10.1007/s00424-017-2037-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/03/2017] [Accepted: 07/13/2017] [Indexed: 12/13/2022]
Abstract
Tight coupling of neuronal metabolism to synaptic activity is critical to ensure that the supply of metabolic substrates meets the demands of neuronal signaling. Given the impact of temperature on metabolism, and the wide fluctuations of brain temperature observed during clinical hypothermia, we examined the effect of temperature on neurometabolic coupling. Intrinsic fluorescence signals of the oxidized form of flavin adenine dinucleotide (FAD) and the reduced form of nicotinamide adenine dinucleotide (NADH), and their ratios, were measured to assess neural metabolic state and local field potentials were recorded to measure synaptic activity in the mouse brain. Brain slice preparations were used to remove the potential impacts of blood flow. Tight coupling between metabolic signals and local field potential amplitudes was observed at a range of temperatures below 29 °C. However, above 29 °C, the metabolic and synaptic signatures diverged such that FAD signals were diminished, but local field potentials retained their amplitude. It was also observed that the declines in the FAD signals seen at high temperatures (and hence the decoupling between synaptic and metabolic events) are driven by low FAD availability at high temperatures. These data suggest that neurometabolic coupling, thought to be critical for ensuring the metabolic health of the brain, may show temperature dependence, and is related to temperature-dependent changes in FAD supplies.
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58
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Growing Up After Critical Illness: Verbal, Visual-Spatial, and Working Memory Problems in Neonatal Extracorporeal Membrane Oxygenation Survivors. Crit Care Med 2017; 44:1182-90. [PMID: 26937861 DOI: 10.1097/ccm.0000000000001626] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess neuropsychologic outcome in 17- and 18-year-old neonatal extracorporeal membrane oxygenation survivors. DESIGN A prospective longitudinal follow-up study. SETTING Follow-up program at the Erasmus MC-Sophia Children's Hospital in Rotterdam, The Netherlands. PATIENTS Thirty adolescents 17 or 18 years old, treated between 1991 and 1997, underwent neuropsychologic assessment. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Attention, memory, executive functioning, visual-spatial functions, social-emotional functioning, and behavior were assessed with validated instruments, and data were compared with reference data. Included predictors for analysis of adverse outcome were diagnosis, age at start extracorporeal membrane oxygenation, convulsions, and use of antiepileptics. Adolescents' performance (expressed as mean [SD] z score) was significantly lower than the norm on short-term and long-term verbal memory (z score = -1.40 [1.58], p = 0.016; z score = -1.54 [1.67], p = 0.010, respectively), visual-spatial memory (z score = -1.65 [1.37], p = 0.008; z score = -1.70 [1.23], p = 0.008, respectively), and working memory (32% vs 9% in the norm population). Parents reported more problems for their children regarding organization of materials (z score = -0.60 [0.90]; p = 0.03) and behavior evaluation (z score = -0.53 [0.88]; p = 0.05) on a questionnaire. Patients reported more withdrawn/depressed behavior (z score = -0.47 [0.54]; p = 0.02), somatic complaints (z score = -0.43 [0.48]; p = 0.03), and social problems (z score = -0.41 [0.46]; p = 0.04). Patients reported more positive feelings of self-esteem and an average health status. CONCLUSIONS Adolescents treated with neonatal extracorporeal membrane oxygenation are at risk of verbal, visual-spatial, and working memory problems. Future research should focus on 1) the longitudinal outcome of specific neuropsychologic skills in adolescence and adulthood; 2) identifying risk factors of neuropsychologic dysfunction; 3) evaluating to what extent "severity of illness" is responsible for acquired brain injury; and 4) effects of timely cognitive rehabilitation.
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Wright KL, Kirwan CB, Gale SD, Levan AJ, Hopkins RO. Long-term cognitive and neuroanatomical stability in patients with anoxic amnesia: A Case Report. Brain Inj 2017; 31:709-716. [PMID: 28350252 DOI: 10.1080/02699052.2017.1285051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Anoxia can result in selective hippocampal damage with associated impairments in declarative memory. Whilst memory impairments and brain structures are thought to be stable, there are little data regarding the effects of ageing or change over time in patients with amnesia from anoxic brain injury. METHODS To assess change over time, we compared structural magnetic resonance imaging (MRI) with data obtained over ten years previously in two well-characterized patients with amnesia (JRW and RS) who experienced an anoxic brain injury. Six healthy, age-matched control participants were recruited to compare brain volumes with the patients at Time 2. Wechsler adult intelligence scale-revised and Wechsler memory scale-revised scores were compared to scores on the same tests administered 13 and 19 years prior. RESULTS Patients with amnesia had significantly smaller hippocampal volumes than controls, but comparable medial temporal lobe and ventricular volumes. Memory, intellectual function and brain volumes were stable over time. CONCLUSION Patients with an amnesia due to anoxia have memory impairments and smaller hippocampal volumes compared to controls; however, memory, intelligence and structural volumes remain stable over time. At ages 50 and 57, they do not appear to have early age-associated cognitive decline that is sometimes observed in patients with traumatic brain injury.
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Affiliation(s)
- Kacie L Wright
- a Psychology Department , Brigham Young University , Provo , Utah , USA
| | - C Brock Kirwan
- a Psychology Department , Brigham Young University , Provo , Utah , USA.,b Neuroscience Center, Brigham Young University , Provo , Utah , USA
| | - Shawn D Gale
- a Psychology Department , Brigham Young University , Provo , Utah , USA.,b Neuroscience Center, Brigham Young University , Provo , Utah , USA
| | - Ashley J Levan
- a Psychology Department , Brigham Young University , Provo , Utah , USA
| | - Ramona O Hopkins
- a Psychology Department , Brigham Young University , Provo , Utah , USA.,b Neuroscience Center, Brigham Young University , Provo , Utah , USA.,c Department of Medicine, Pulmonary and Critical Care Division , Intermountain Medical Center , Murray , Utah , USA.,d Center for Humanizing Critical Care, Intermountain Healthcare , Murray , Utah , USA
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Schiller RM, van den Bosch GE, Muetzel RL, Smits M, Dudink J, Tibboel D, Ijsselstijn H, White T. Neonatal critical illness and development: white matter and hippocampus alterations in school-age neonatal extracorporeal membrane oxygenation survivors. Dev Med Child Neurol 2017; 59:304-310. [PMID: 27873310 DOI: 10.1111/dmcn.13309] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2016] [Indexed: 11/30/2022]
Abstract
AIM To examine the neurobiology of long-term neuropsychological deficits after neonatal extracorporeal membrane oxygenation (ECMO). METHOD This cross-sectional study assessed white matter integrity and hippocampal volume of ECMO survivors (8-15y) and healthy children (8-17y) using diffusion tensor imaging (DTI) and structural magnetic resonance imaging (MRI) respectively. Neuropsychological outcome was evaluated in ECMO survivors. Included clinical predictors of white matter integrity: age start ECMO, ECMO duration, highest oxygenation index before ECMO, highest mean airway pressure, and mechanical ventilation duration. RESULTS ECMO survivors (n=23) had lower global fractional anisotropy than healthy children (n=54) (patients=0.368; comparison group=0.381; p=0.018), but similar global mean diffusivity (p=0.410). ECMO survivors had lower fractional anisotropy in the left cingulum bundle (ECMO survivors=0.345; comparison group=0.399; p<0.001) and higher mean diffusivity in a region of the left parahippocampal cingulum (patients=0.916; comparison group=0.871; p<0.001). Higher global mean diffusivity predicted worse verbal memory in ECMO survivors (n=17) (β=-0.74, p=0.008). ECMO survivors (n=23) had smaller bilateral hippocampal volume than healthy children (n=43) (left, p<0.001; right, p<0.001) and this was related to worse verbal memory (left, β=0.65, p=0.018; right, β=0.71, p=0.006). INTERPRETATION Neonatal ECMO survivors are at risk for long-term brain alterations, which may partly explain long-term neuropsychological impairments. Neuroimaging may contribute to better risk stratification of long-term impairments.
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Affiliation(s)
- Raisa M Schiller
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Gerbrich E van den Bosch
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ryan L Muetzel
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marion Smits
- Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
| | - Jeroen Dudink
- Department of Radiology, Erasmus MC, Rotterdam, The Netherlands.,Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Hanneke Ijsselstijn
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Tonya White
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
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Muñoz-López M, Hoskote A, Chadwick MJ, Dzieciol AM, Gadian DG, Chong K, Banks T, de Haan M, Baldeweg T, Mishkin M, Vargha-Khadem F. Hippocampal damage and memory impairment in congenital cyanotic heart disease. Hippocampus 2017; 27:417-424. [PMID: 28032672 PMCID: PMC5363353 DOI: 10.1002/hipo.22700] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 12/20/2016] [Accepted: 12/20/2016] [Indexed: 11/17/2022]
Abstract
Neonatal hypoxia can lead to hippocampal atrophy, which can lead, in turn, to memory impairment. To test the generalizability of this causal sequence, we examined a cohort of 41 children aged 8‐16, who, having received the arterial switch operation to correct for transposition of the great arteries, had sustained significant neonatal cyanosis but were otherwise neurodevelopmentally normal. As predicted, the cohort had significant bilateral reduction of hippocampal volumes relative to the volumes of 64 normal controls. They also had significant, yet selective, impairment of episodic memory as measured by standard tests of memory, despite relatively normal levels of intelligence, academic attainment, and verbal fluency. Across the cohort, degree of memory impairment was correlated with degree of hippocampal atrophy suggesting that even as early as neonatal life no other structure can fully compensate for hippocampal injury and its special role in serving episodic long term memory. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Mónica Muñoz-López
- Cognitive Neuroscience & Neuropsychiatry Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Aparna Hoskote
- Cardiac Intensive Care Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Martin J Chadwick
- Cognitive Neuroscience & Neuropsychiatry Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Anna M Dzieciol
- Cognitive Neuroscience & Neuropsychiatry Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - David G Gadian
- Developmental Imaging and Biophysics Section, UCL Institute of Child Health, London, United Kingdom
| | - Kling Chong
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Tina Banks
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Michelle de Haan
- Cognitive Neuroscience & Neuropsychiatry Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Torsten Baldeweg
- Cognitive Neuroscience & Neuropsychiatry Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Mortimer Mishkin
- Laboratory of Neuropsychology, National Institute of Mental Health, Bethesda, Maryland
| | - Faraneh Vargha-Khadem
- Cognitive Neuroscience & Neuropsychiatry Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,Department of Neuropsychology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
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62
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ERP evidence of preserved early memory function in term infants with neonatal encephalopathy following therapeutic hypothermia. Pediatr Res 2016; 80:800-808. [PMID: 27529810 DOI: 10.1038/pr.2016.169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 07/01/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Neonatal encephalopathy (NE) carries high risk for neurodevelopmental impairments. Therapeutic hypothermia (TH) reduces this risk, particularly for moderate encephalopathy (ME). Nevertheless, these infants often have subtle functional deficits, including abnormal memory function. Detection of deficits at the earliest possible time-point would allow for intervention during a period of maximal brain plasticity. METHODS Recognition memory function in 22 infants with NE treated with TH was compared to 23 healthy controls using event-related potentials (ERPs) at 2 wk of age. ERPs were recorded to mother's voice alternating with a stranger's voice to assess attentional responses (P2), novelty detection (slow wave), and discrimination between familiar and novel (difference wave). Development was tested at 12 mo using the Bayley Scales of Infant Development, Third Edition (BSID-III). RESULTS The NE group showed similar ERP components and BSID-III scores to controls. However, infants with NE showed discrimination at midline leads (P = 0.01), whereas controls showed discrimination in the left hemisphere (P = 0.05). Normal MRI (P = 0.05) and seizure-free electroencephalogram (EEG) (P = 0.04) correlated positively with outcomes. CONCLUSION Infants with NE have preserved recognition memory function after TH. The spatially different recognition memory processing after early brain injury may represent compensatory changes in the brain circuitry and reflect a benefit of TH.
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63
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Sukhanova IA, Sebentsova EA, Levitskaya NG. The acute and delayed effects of perinatal hypoxic brain damage in children and in model experiments with rodents. NEUROCHEM J+ 2016. [DOI: 10.1134/s1819712416040127] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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64
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Dzieciol AM, Bachevalier J, Saleem KS, Gadian DG, Saunders R, Chong WKK, Banks T, Mishkin M, Vargha-Khadem F. Hippocampal and diencephalic pathology in developmental amnesia. Cortex 2016; 86:33-44. [PMID: 27880886 PMCID: PMC5264402 DOI: 10.1016/j.cortex.2016.09.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 06/10/2016] [Accepted: 09/18/2016] [Indexed: 01/01/2023]
Abstract
Developmental amnesia (DA) is a selective episodic memory disorder associated with hypoxia-induced bilateral hippocampal atrophy of early onset. Despite the systemic impact of hypoxia-ischaemia, the resulting brain damage was previously reported to be largely limited to the hippocampus. However, the thalamus and the mammillary bodies are parts of the hippocampal-diencephalic network and are therefore also at risk of injury following hypoxic-ischaemic events. Here, we report a neuroimaging investigation of diencephalic damage in a group of 18 patients with DA (age range 11-35 years), and an equal number of controls. Importantly, we uncovered a marked degree of atrophy in the mammillary bodies in two thirds of our patients. In addition, as a group, patients had mildly reduced thalamic volumes. The size of the anterior-mid thalamic (AMT) segment was correlated with patients' visual memory performance. Thus, in addition to the hippocampus, the diencephalic structures also appear to play a role in the patients' memory deficit.
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Affiliation(s)
- Anna M Dzieciol
- University College London Great Ormond Street Institute of Child Health, London, UK.
| | | | | | - David G Gadian
- University College London Great Ormond Street Institute of Child Health, London, UK
| | | | - W K Kling Chong
- Department of Radiology, Great Ormond Street Hospital for Children, London, UK
| | - Tina Banks
- Department of Radiology, Great Ormond Street Hospital for Children, London, UK
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Geva S, Cooper JM, Gadian DG, Mishkin M, Vargha-Khadem F. Impairment on a self-ordered working memory task in patients with early-acquired hippocampal atrophy. Dev Cogn Neurosci 2016; 20:12-22. [PMID: 27288821 PMCID: PMC4973808 DOI: 10.1016/j.dcn.2016.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 06/01/2016] [Accepted: 06/01/2016] [Indexed: 11/16/2022] Open
Abstract
Patients with early onset hippocampal damage were impaired on a working memory task. Impairment was evident only on those trials when memory load was intermediate. Hippocampal volume correlated with behaviour when memory load was intermediate/high. Patients showed no proactive interference. Patients showed no effect of age at injury on performance.
One of the features of both adult-onset and developmental forms of amnesia resulting from bilateral medial temporal lobe damage, or even from relatively selective damage to the hippocampus, is the sparing of working memory. Recently, however, a number of studies have reported deficits on working memory tasks in patients with damage to the hippocampus and in macaque monkeys with neonatal hippocampal lesions. These studies suggest that successful performance on working memory tasks with high memory load require the contribution of the hippocampus. Here we compared performance on a working memory task (the Self-ordered Pointing Task), between patients with early onset hippocampal damage and a group of healthy controls. Consistent with the findings in the monkeys with neonatal lesions, we found that the patients were impaired on the task, but only on blocks of trials with intermediate memory load. Importantly, only intermediate to high memory load blocks yielded significant correlations between task performance and hippocampal volume. Additionally, we found no evidence of proactive interference in either group, and no evidence of an effect of time since injury on performance. We discuss the role of the hippocampus and its interactions with the prefrontal cortex in serving working memory.
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Affiliation(s)
- Sharon Geva
- Cognitive Neuroscience and Neuropsychiatry Section, University College London Institute of Child Health, 30 Guilford Street, London WC1N 1EH, United Kingdom.
| | - Janine M Cooper
- Cognitive Neuroscience and Neuropsychiatry Section, University College London Institute of Child Health, 30 Guilford Street, London WC1N 1EH, United Kingdom.
| | - David G Gadian
- Developmental Imaging and Biophysics Section, University College London Institute of Child Health, 30 Guilford Street, London WC1N 1EH, United Kingdom.
| | - Mortimer Mishkin
- Cognitive Neuroscience and Neuropsychiatry Section, University College London Institute of Child Health, 30 Guilford Street, London WC1N 1EH, United Kingdom; Laboratory of Neuropsychology, National Institute of Mental Health, Bethesda, MD 20892, USA.
| | - Faraneh Vargha-Khadem
- Cognitive Neuroscience and Neuropsychiatry Section, University College London Institute of Child Health, 30 Guilford Street, London WC1N 1EH, United Kingdom.
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Ramon M, Miellet S, Dzieciol AM, Konrad BN, Dresler M, Caldara R. Super-Memorizers Are Not Super-Recognizers. PLoS One 2016; 11:e0150972. [PMID: 27008627 PMCID: PMC4805230 DOI: 10.1371/journal.pone.0150972] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 02/22/2016] [Indexed: 11/18/2022] Open
Abstract
Humans have a natural expertise in recognizing faces. However, the nature of the interaction between this critical visual biological skill and memory is yet unclear. Here, we had the unique opportunity to test two individuals who have had exceptional success in the World Memory Championships, including several world records in face-name association memory. We designed a range of face processing tasks to determine whether superior/expert face memory skills are associated with distinctive perceptual strategies for processing faces. Superior memorizers excelled at tasks involving associative face-name learning. Nevertheless, they were as impaired as controls in tasks probing the efficiency of the face system: face inversion and the other-race effect. Super memorizers did not show increased hippocampal volumes, and exhibited optimal generic eye movement strategies when they performed complex multi-item face-name associations. Our data show that the visual computations of the face system are not malleable and are robust to acquired expertise involving extensive training of associative memory.
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Affiliation(s)
- Meike Ramon
- University of Fribourg, Department of Psychology, Rue P.A. de Faucigny 2, 1700 Fribourg, Switzerland
- * E-mail:
| | - Sebastien Miellet
- Bournemouth University, Department of Psychology, Talbot Campus, BH12 5BB, Poole, United Kingdom
| | - Anna M. Dzieciol
- Cognitive Neuroscience and Neuropsychiatry Section, UCL Institute of Child Health, 30 Guilford Street, WC1N 1EH, London, United Kingdom
| | - Boris Nikolai Konrad
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Kapittelweg 29, 6525 EN Nijmegen, The Netherlands
| | - Martin Dresler
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Kapittelweg 29, 6525 EN Nijmegen, The Netherlands
- Max Planck Institute of Psychiatry, Kraepelinstr. 2–10, 80804 Munich, Germany
| | - Roberto Caldara
- University of Fribourg, Department of Psychology, Rue P.A. de Faucigny 2, 1700 Fribourg, Switzerland
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Hippocampal Volume Reduction in Humans Predicts Impaired Allocentric Spatial Memory in Virtual-Reality Navigation. J Neurosci 2016; 35:14123-31. [PMID: 26490854 DOI: 10.1523/jneurosci.0801-15.2015] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
UNLABELLED The extent to which navigational spatial memory depends on hippocampal integrity in humans is not well documented. We investigated allocentric spatial recall using a virtual environment in a group of patients with severe hippocampal damage (SHD), a group of patients with "moderate" hippocampal damage (MHD), and a normal control group. Through four learning blocks with feedback, participants learned the target locations of four different objects in a circular arena. Distal cues were present throughout the experiment to provide orientation. A circular boundary as well as an intra-arena landmark provided spatial reference frames. During a subsequent test phase, recall of all four objects was tested with only the boundary or the landmark being present. Patients with SHD were impaired in both phases of this task. Across groups, performance on both types of spatial recall was highly correlated with memory quotient (MQ), but not with intelligence quotient (IQ), age, or sex. However, both measures of spatial recall separated experimental groups beyond what would be expected based on MQ, a widely used measure of general memory function. Boundary-based and landmark-based spatial recall were both strongly related to bilateral hippocampal volumes, but not to volumes of the thalamus, putamen, pallidum, nucleus accumbens, or caudate nucleus. The results show that boundary-based and landmark-based allocentric spatial recall are similarly impaired in patients with SHD, that both types of recall are impaired beyond that predicted by MQ, and that recall deficits are best explained by a reduction in bilateral hippocampal volumes. SIGNIFICANCE STATEMENT In humans, bilateral hippocampal atrophy can lead to profound impairments in episodic memory. Across species, perhaps the most well-established contribution of the hippocampus to memory is not to episodic memory generally but to allocentric spatial memory. However, the extent to which navigational spatial memory depends on hippocampal integrity in humans is not well documented. We investigated spatial recall using a virtual environment in two groups of patients with hippocampal damage (moderate/severe) and a normal control group. The results showed that patients with severe hippocampal damage are impaired in learning and recalling allocentric spatial information. Furthermore, hippocampal volume reduction impaired allocentric navigation beyond what can be predicted by memory quotient as a widely used measure of general memory function.
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Abstract
Which specific memory functions are dependent on the hippocampus is still debated. The availability of a large cohort of patients who had sustained relatively selective hippocampal damage early in life enabled us to determine which type of mnemonic deficit showed a correlation with extent of hippocampal injury. We assessed our patient cohort on a test that provides measures of recognition and recall that are equated for difficulty and found that the patients' performance on the recall tests correlated significantly with their hippocampal volumes, whereas their performance on the equally difficult recognition tests did not and, indeed, was largely unaffected regardless of extent of hippocampal atrophy. The results provide new evidence in favor of the view that the hippocampus is essential for recall but not for recognition.
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Sex differences in cell genesis, hippocampal volume and behavioral outcomes in a rat model of neonatal HI. Exp Neurol 2015; 275 Pt 2:285-95. [PMID: 26376217 DOI: 10.1016/j.expneurol.2015.09.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 08/27/2015] [Accepted: 09/06/2015] [Indexed: 12/11/2022]
Abstract
Hypoxia-ischemia (HI) of the brain in near-term and term infants is a leading cause of infant mortality and lifelong disability but current therapeutic approaches remain limited. Males consistently display greater vulnerability to the deleterious consequences of HI in both humans and animal models. Neurogenesis increases after neonatal HI and offers a potential therapeutic target for recovery. The steroid hormone estradiol has been extensively explored as a neuroprotectant in adult models of stroke but with mixed results. Less consideration has been afforded to this naturally occurring agent in the developing brain, which has unique challenges from the adult. Using a model of term HI in the rat we have explored the impact of this insult on cell genesis in the hippocampus of males and females and the ability of estradiol treatment immediately after insult to restore function. Both short-term (3 days) and long-term (7 days) post-injury were assessed and revealed that only females had markedly increased cell genesis on the short-term but both sexes were increased long-term. A battery of behavioral tests revealed motor impairment in males and compromised episodic memory while both sexes were modestly impaired in spatial memory. Juvenile social play was also depressed in both sexes after HI. Estradiol therapy improved behavioral performance in both sexes but did not reverse a deficit in hippocampal volume ipsilateral to the insult. Thus the effects of estradiol do not appear to be via cell death or proliferation but rather involve other components of neural functioning.
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Skirrow C, Cross JH, Harrison S, Cormack F, Harkness W, Coleman R, Meierotto E, Gaiottino J, Vargha-Khadem F, Baldeweg T. Temporal lobe surgery in childhood and neuroanatomical predictors of long-term declarative memory outcome. ACTA ACUST UNITED AC 2014; 138:80-93. [PMID: 25392199 PMCID: PMC4285190 DOI: 10.1093/brain/awu313] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
See Berg (doi:10.1093/brain/awu320) for a scientific commentary on this article. In a long-term follow-up study of children who underwent temporal lobe surgery for treatment of epilepsy, Skirrow et al. identify no significant pre-to-post-surgery memory losses, but instead robust improvements in memory functions supported by the unoperated temporal lobe. The integrity of remaining temporal lobe structures places constraints on long-term memory outcomes. The temporal lobes play a prominent role in declarative memory function, including episodic memory (memory for events) and semantic memory (memory for facts and concepts). Surgical resection for medication-resistant and well-localized temporal lobe epilepsy has good prognosis for seizure freedom, but is linked to memory difficulties in adults, especially when the removal is on the left side. Children may benefit most from surgery, because brain plasticity may facilitate post-surgical reorganization, and seizure cessation may promote cognitive development. However, the long-term impact of this intervention in children is not known. We examined memory function in 53 children (25 males, 28 females) who were evaluated for epilepsy surgery: 42 underwent unilateral temporal lobe resections (25 left, 17 right, mean age at surgery 13.8 years), 11 were treated only pharmacologically. Average follow-up was 9 years (range 5–15). Post-surgical change in visual and verbal episodic memory, and semantic memory at follow-up were examined. Pre- and post-surgical T1-weighted MRI brain scans were analysed to extract hippocampal and resection volumes, and evaluate post-surgical temporal lobe integrity. Language lateralization indices were derived from functional magnetic resonance imaging. There were no significant pre- to postoperative decrements in memory associated with surgery. In contrast, gains in verbal episodic memory were seen after right temporal lobe surgery, and visual episodic memory improved after left temporal lobe surgery, indicating a functional release in the unoperated temporal lobe after seizure reduction or cessation. Pre- to post-surgical change in memory function was not associated with any indices of brain structure derived from MRI. However, better verbal memory at follow-up was linked to greater post-surgical residual hippocampal volumes, most robustly in left surgical participants. Better semantic memory at follow-up was associated with smaller resection volumes and greater temporal pole integrity after left temporal surgery. Results were independent of post-surgical intellectual function and language lateralization. Our findings indicate post-surgical, hemisphere-dependent material-specific improvement in memory functions in the intact temporal lobe. However, outcome was linked to the anatomical integrity of the temporal lobe memory system, indicating that compensatory mechanisms are constrained by the amount of tissue which remains in the operated temporal lobe. Careful tailoring of resections for children undergoing epilepsy surgery may enhance long-term memory outcome.
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Affiliation(s)
- Caroline Skirrow
- 1 Cognitive Neuroscience and Neuropsychiatry Section, Developmental Neurosciences Programme, Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK 2 Great Ormond Street Hospital NHS Trust, Great Ormond Street, WC1N 3JH, UK
| | - J Helen Cross
- 2 Great Ormond Street Hospital NHS Trust, Great Ormond Street, WC1N 3JH, UK 3 Clinical Neurosciences Section, Developmental Neurosciences Programme, Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
| | - Sue Harrison
- 1 Cognitive Neuroscience and Neuropsychiatry Section, Developmental Neurosciences Programme, Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK 2 Great Ormond Street Hospital NHS Trust, Great Ormond Street, WC1N 3JH, UK
| | - Francesca Cormack
- 4 Cognition and Brain Sciences Unit, 15 Chaucer Road, Cambridge, CB2 7EF, UK
| | - William Harkness
- 2 Great Ormond Street Hospital NHS Trust, Great Ormond Street, WC1N 3JH, UK
| | - Rosie Coleman
- 1 Cognitive Neuroscience and Neuropsychiatry Section, Developmental Neurosciences Programme, Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK 2 Great Ormond Street Hospital NHS Trust, Great Ormond Street, WC1N 3JH, UK
| | - Ellen Meierotto
- 1 Cognitive Neuroscience and Neuropsychiatry Section, Developmental Neurosciences Programme, Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK 5 Abteilung für Psychiatrie und Psychotherapie, Universitätsklinik Freiburg, Hugstetter Strasse 55, 29106 Freiburg, Germany
| | - Johanna Gaiottino
- 1 Cognitive Neuroscience and Neuropsychiatry Section, Developmental Neurosciences Programme, Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
| | - Faraneh Vargha-Khadem
- 1 Cognitive Neuroscience and Neuropsychiatry Section, Developmental Neurosciences Programme, Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK 2 Great Ormond Street Hospital NHS Trust, Great Ormond Street, WC1N 3JH, UK
| | - Torsten Baldeweg
- 1 Cognitive Neuroscience and Neuropsychiatry Section, Developmental Neurosciences Programme, Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK 2 Great Ormond Street Hospital NHS Trust, Great Ormond Street, WC1N 3JH, UK
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Rosenbaum RS, Gao F, Honjo K, Raybaud C, Olsen RK, Palombo DJ, Levine B, Black SE. Congenital absence of the mammillary bodies: a novel finding in a well-studied case of developmental amnesia. Neuropsychologia 2014; 65:82-7. [PMID: 25301386 DOI: 10.1016/j.neuropsychologia.2014.09.047] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 09/24/2014] [Accepted: 09/26/2014] [Indexed: 11/24/2022]
Abstract
Individuals with developmental amnesia experience compromised development of episodic memory for details of personal life events, believed to relate to changes to the hippocampus after birth. Here we report the very rare discovery of aplasia of the mammillary bodies, hypogenesis of the fornix, and abnormal hippocampal shape and orientation in H.C., a well-documented case of selectively compromised episodic memory development who is the subject of numerous published empirical articles. These anatomical abnormalities are highly suggestive of disrupted extended hippocampal system development very early in gestation, despite an original diagnosis of developmental amnesia and assumed perinatal hypoxia. These findings provide a unique window into the normal function of the mammillary bodies, fornices, and related anterior nuclei of the thalamus bilaterally. The results also encourage re-examination of the pathological basis of developmental amnesia in other cases reported in the literature.
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Affiliation(s)
- R Shayna Rosenbaum
- Department of Psychology, York University, Toronto, Ontario, Canada M3J 1P3; Rotman Research Institute Baycrest Health Sciences, Toronto, Ontario, Canada M6A 2E1.
| | - Fuqiang Gao
- LC Campbell Cognitive Neurology Research Unit, Brain Science Research Program, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada M4N 3M5
| | - Kie Honjo
- LC Campbell Cognitive Neurology Research Unit, Brain Science Research Program, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada M4N 3M5
| | - Charles Raybaud
- Division of Neuroradiology, Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada M5T 1W7
| | - Rosanna K Olsen
- Rotman Research Institute Baycrest Health Sciences, Toronto, Ontario, Canada M6A 2E1
| | - Daniela J Palombo
- Rotman Research Institute Baycrest Health Sciences, Toronto, Ontario, Canada M6A 2E1; Department of Psychology, University of Toronto, Toronto, Ontario, Canada M5S 3G3
| | - Brian Levine
- Rotman Research Institute Baycrest Health Sciences, Toronto, Ontario, Canada M6A 2E1; Department of Psychology, University of Toronto, Toronto, Ontario, Canada M5S 3G3; Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada M4N 3M5
| | - Sandra E Black
- Rotman Research Institute Baycrest Health Sciences, Toronto, Ontario, Canada M6A 2E1; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada M5T 1W7; Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada M4N 3M5
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