Discourse plasticity in children after stroke: age at injury and lesion effects

Natural course and predictors of consciousness recovery in children with prolonged disorder of consciousness

Prolonged disorder of consciousness (DoC) is a rising challenge. Pediatric data on diagnosis and prognosis of prolonged DoC were too limited and heterogeneous, making it difficult to define the natural course and evaluate the prognosis. The present study explored the emergence from the Minimally Conscious State (eMCS) incidence at different months postinjury drawing the natural course, and detected the predictors of the incidence in children with prolonged DoC. A hospital-based prospective cohort study was conducted. Kaplan-Meier curves, as well as univariate and multivariate COX regression analysis, were performed. The study enrolled 383 pediatric DoC individuals, including 220 males (57.4%), with an average age of 3.9 (1.9-7.3) years. The median duration between onset and rehabilitation is 30.0 (21.0-46.0) days. At enrollment, the ratio of vegetative state/unresponsive wakefulness syndrome (VS/WUS) to MCS is 78.9%-21.1%. Traumatic brain injury and infection are the major etiologies (36.8% and 37.1%, respectively), followed by hypoxia cerebral injury (12.3%). For children with prolonged DoC, the cumulative incidence of eMCS at months 3, 6, 12, and 24 was 0.510, 0.652, 0.731, 0.784 VS 0.290, 0.418, 0.539, 0.603 in the traumatic VS non-traumatic subgroup, respectively. For children in a persistent vegetative state (PVS), the cumulative incidence of emergence at months in 3, 6, 12, 24, 36 and 48 was testified as 0.439, 0.591, 0.683, 0.724, 0.743 and 0.743 in the traumatic subgroup, and 0.204, 0.349, 0.469, 0.534, 0.589 and 0.620 in the non-traumatic subgroup. Participants who exhibit any of the following four demographical and/or clinical characteristics-namely, older than 4 years at onset, accepted rehabilitation within 28 days of onset, remained MCS at enrollment, or with etiology of traumatic brain injuries-had a significantly positive outcome of consciousness recovery (eMCS). Moreover, both prolongation of the central somatosensory conductive time (CCT) (level 2) and absence of N20 (level 3) independently predict a negative outcome. In children with prolonged DoC, we found that 12 months postinjury was critical to eMCS, and a preferred timepoint to define chronic vegetative state (VS). The characteristics including age, etiology, time before rehabilitation, consciousness state, and SEP results were useful predictors of conscious recovery.Trial registration Registered 06/11/2018, the registration number is chiCTR1800019330 (chictr.org.cn). Registered prospectively.

Arterial Presumed Perinatal Ischemic Stroke: A Mini Review and Case Report of Cognitive and Speech-Language Profiles in a 5-Year-Old Girl

Arterial presumed perinatal ischemic stroke is a type of perinatal stroke that emerges due to late or delayed diagnostics of perinatal or neonatal arterial ischemic stroke. It is usually recognized before one year of life due to hemiparesis. This injury may lead to cognitive, behavioral, or motor symptoms, and life-long neurodevelopmental disabilities. In this case report, we describe a five-year-old girl with a history of arterial presumed perinatal ischemic stroke in the left hemisphere, which adversely affected her cognitive and language outcomes. The girl's cognitive development has been uneven, ranging from below average to average, and she had specific language acquisition deficits in comprehension, vocabulary, morphology, use of complex syntax, and narrative structure. The obtained results point to the specificity of each child whose development is influenced not only by the timing of the brain lesion and the degree of damage, but also by the child's neurobiological capacity. In addition, we provide an updated review of the literature that includes information on epidemiology, risk factors, diagnostics, clinical manifestations, outcomes, and potential therapies. The present article highlights the importance of early intervention and systematic monitoring of children with perinatal stroke with the aim of improving the child's development.

Structural networking of the developing brain: from maturation to neurosurgical implications

Modern neuroscience agrees that neurological processing emerges from the multimodal interaction among multiple cortical and subcortical neuronal hubs, connected at short and long distance by white matter, to form a largely integrated and dynamic network, called the brain "connectome." The final architecture of these circuits results from a complex, continuous, and highly protracted development process of several axonal pathways that constitute the anatomical substrate of neuronal interactions. Awareness of the network organization of the central nervous system is crucial not only to understand the basis of children's neurological development, but also it may be of special interest to improve the quality of neurosurgical treatments of many pediatric diseases. Although there are a flourishing number of neuroimaging studies of the connectome, a comprehensive vision linking this research to neurosurgical practice is still lacking in the current pediatric literature. The goal of this review is to contribute to bridging this gap. In the first part, we summarize the main current knowledge concerning brain network maturation and its involvement in different aspects of normal neurocognitive development as well as in the pathophysiology of specific diseases. The final section is devoted to identifying possible implications of this knowledge in the neurosurgical field, especially in epilepsy and tumor surgery, and to discuss promising perspectives for future investigations.

Stroke in the Developing Brain: Neurophysiologic Implications of Stroke Timing, Location, and Comorbid Factors

BACKGROUND

Pediatric stroke, which is unique in that it represents a static insult to a developing brain, often leads to long-term neurological disability. Neuroplasticity in infants and children influences neurophysiologic recovery patterns after stroke; therefore outcomes depend on several factors including the timing and location of stroke and the presence of comorbid conditions.

METHODS

In this review, we discuss the unique implications of stroke occurring in the fetal, perinatal, and childhood/adolescent time periods. First, we highlight the impact of the developmental stage of the brain at the time of insult on the motor, sensory, cognitive, speech, and behavioral domains. Next, we consider the influence of location of stroke on the presence and severity of motor and nonmotor outcomes. Finally, we discuss the impact of associated conditions on long-term outcomes and risk for stroke recurrence.

RESULTS

Hemiparesis is common after stroke at any age, although the severity of impairment differs by age group. Risk of epilepsy is elevated in all age groups compared with those without stroke. Outcomes in other domains vary by age, although several studies suggest worse cognitive outcomes when stroke occurs in early childhood compared with fetal and later childhood epochs. Conditions such as congenital heart disease, sickle cell disease, and moyamoya increase the risk of stroke and leave patients differentially vulnerable to neurodevelopmental delay, stroke recurrence, silent infarcts, and cognitive impairment.

CONCLUSIONS

A comprehensive understanding of the interplay of various factors is essential in guiding the clinical care of patients with pediatric stroke.

Visuospatial processing skills following unilateral arterial ischemic stroke in childhood

Due to the rare occurrence of childhood stroke, its impact on later cognitive functioning remains unclear. While it is often assumed that children recover better than adults, recent studies suggest that childhood stroke can negatively affect a wide range of cognitive domains, such as attention, language, and processing speed, among others. We examined the effect of unilateral stroke on children's visuoconstructive ability and visual memory. Seventeen children with left- or right-sided arterial ischemic stroke were tested using subtests of the Hamburg-Wechsler Intelligenztest für Kinder and the Rey-Osterrieth Complex Figure (ROCF). The ROCF was evaluated both quantitatively and qualitatively with the help of two separate scoring methods. We found that lesion laterality and age at stroke impacted childhood stroke patients' ability to recall certain elements of the figure. Regarding lesion laterality, left-sided stroke patients had more difficulties recalling internal details than right-sided stroke patients. In terms of age, patients with stroke onset before the age of 5 years remembered fewer structural elements than patients with stroke onset after the age of 5 years did. Moreover, the qualitative scoring method better differentiated between individuals and between groups than the more commonly used quantitative method. The results of this study not only highlight the importance of a qualitative assessment of the ROCF but could also aid clinicians in testing stroke patients more accurately and tailoring subsequent therapy to the patient's individual needs.

Neurological and Functional Outcomes after Pediatric Stroke

Pediatric stroke results in life-long morbidity for many patients, but the outcomes can vary depending on factors such as age of injury, or mechanism, size, and location of stroke. In this review, we summarize the current understanding of outcomes in different neurological domains (eg, motor, cognitive, language) for children with stroke of different mechanisms (ie, arterial ischemic stroke, cerebral sinus venous thrombosis, and hemorrhagic stroke), but with a focus on World Health Organization International Classification for Functioning, Disability, and Health (ICF-CY) framework for measuring health and disability for children and youth. We describe outcomes for the population as a whole and certain factors that may further refine prognostication.

Mechanical Properties of the Developing Brain are Associated with Language Input and Vocabulary Outcome

The quality of language that children hear in their environment is associated with the development of language-related brain regions, in turn promoting vocabulary knowledge. Although informative, it remains unknown how these environmental influences alter the structure of neural tissue and subsequent vocabulary outcomes. The current study uses magnetic resonance elastography (MRE) to examine how children's language environments underlie brain tissue mechanical properties, characterized as brain tissue stiffness and damping ratio, and promote vocabulary knowledge. Twenty-five children, ages 5-7, had their audio and video recorded while engaging in a play session with their parents. Children also completed the Picture Vocabulary Task (from NIH Toolbox) and participated in an MRI, where MRE and anatomical images were acquired. Higher quality input was associated with greater stiffness in the bilateral inferior frontal gyrus and right superior temporal gyrus, whereas greater vocabulary knowledge was associated with lower damping ratio in the right inferior frontal gyrus. These findings suggest changes in neural tissue composition are sensitive to malleable aspects of the environment, whereas tissue organization is more strongly associated with vocabulary outcome. Notably, these associations were independent of maternal education, suggesting more proximal measures of a child's environment may be the source of differences in neural tissue structure underlying variability in vocabulary outcomes.

Language lateralization and outcome in perinatal stroke patients with different vascular types

Perinatal stroke affects child's language development and can change language lateralization. Language generation and comprehension tasks in functional magnetic resonance imaging were used to determine language lateralization in term born children with perinatal left-side arterial ischemic stroke (AIS) (n = 9, mean age (SD) 13.4 (3.1) y.) and periventricular venous infarction (PVI) (n = 12, 11.8 (2.8) y.), and in healthy right-handed controls (n = 30, 11.6 (2.6) y.). Lateralization index was calculated for the Broca and Wernicke areas and correlated with language and cognitive outcomes measured by the Kaufman Assessment Battery for Children II ed. Language outcome in children with perinatal stroke is poorer compared to healthy controls. Children with small AIS lesions and most children with PVI showed left-side language activation. Most children with large AIS lesions and one child with large PVI had language activation reorganized to the right hemisphere. Language reorganization to the unlesioned right hemisphere did not ensure normal language outcome.

Predictors of Neurological Outcome of Arterial Ischemic Stroke in Children

Stroke is an important cause of mortality and morbidity in children. The aim of the study was to evaluate long-term neurological outcome in children with arterial ischemic stroke (AIS) and explore predictive factors that affect poor outcome. Fifty-six patients aged between 1 month and 17 years who were treated at M. Iashvili Children's Central Hospital, Tbilisi, Georgia, with an onset of stroke from 2007 to 2017 were included. To explore predictive factors of outcome, the following data were collected: demographic characteristics, risk factors, he presenting signs, radiological features, and presence of stroke recurrence. Neurological status at discharge and long-term neurological outcome at least 1 year after stroke was evaluated according to Pediatric Stroke Outcome Measure subscale. The reported outcome after childhood stroke was variable with long-term neurological deficits in one-third of patients (30.4%). The neurological outcome was worse in males, in patients with multiple stroke episodes, and in those with infarctions involving a combination of cortical and subcortical areas. Pediatric AIS carries the risk of long-term morbidity, and neuroimaging has a predictive influence on outcome.

Influence of socioeconomic status on cognitive outcome after childhood arterial ischemic stroke

AIM

To determine whether socioeconomic status (SES) is a stronger predictor for cognitive outcome after childhood arterial ischemic stroke compared to clinical factors.

METHOD

We investigated perceptual reasoning, executive functions, language, memory, and attention in 18 children and adolescents (12 males, six females, median age at testing 13y 4mo, range 7y-17y 5mo) after arterial ischemic stroke; collected sociodemographic information (education of parents, household income); and used clinical information (initial lesion volume, residual lesion volume, age at stroke, time since stroke). Linear regression models were used to investigate the potential influence of SES and clinical parameters on cognitive abilities.

RESULTS

SES had a moderate effect on all cognitive outcome parameters except attention by explaining 41.9%, 37.9%, 38.0%, and 22.5% of variability in perceptual reasoning, executive functions, language, and memory respectively. Initial lesion volume was the only clinical parameter that showed moderate importance on cognitive outcome (33.1% and 25.6% of the variability in perceptual reasoning and memory respectively). Overall, SES was a stronger predictor of cognitive outcome than clinical factors.

INTERPRETATION

Future paediatric studies aiming at clinical predictors of cognitive outcome should control their analyses for SES in their study participants. The findings of the present study further point to the need for more attention to the treatment of children with low SES.

WHAT THIS PAPER ADDS

Socioeconomic status (SES) explains up to 42% of variance in cognitive outcome after childhood arterial ischemic stroke. SES is a stronger predictor of outcome than clinical factors.

Predicting Recovery and Outcome after Pediatric Stroke: Results from the International Pediatric Stroke Study

OBJECTIVE

To characterize predictors of recovery and outcome following pediatric arterial ischemic stroke, hypothesizing that age influences recovery after stroke.

METHODS

We studied children enrolled in the International Pediatric Stroke Study between January 1, 2003 and July 31, 2014 with 2-year follow-up after arterial ischemic stroke. Outcomes were defined at discharge by clinician grading and at 2 years by the Pediatric Stroke Outcome Measure. Demographic, clinical, and radiologic outcome predictors were examined. We defined changes in outcome from discharge to 2 years as recovery (improved outcome), emerging deficit (worse outcome), or no change.

RESULTS

Our population consisted of 587 patients, including 174 with neonatal stroke and 413 with childhood stroke, with recurrent stroke in 8.2% of childhood patients. Moderate to severe neurological impairment was present in 9.4% of neonates versus 48.8% of children at discharge compared to 8.0% versus 24.7% after 2 years. Predictors of poor outcome included age between 28 days and 1 year (compared to neonates, odds ratio [OR] = 3.58, p < 0.05), underlying chronic disorder (OR = 2.23, p < 0.05), and involvement of both small and large vascular territories (OR = 2.84, p < 0.05). Recovery patterns differed, with emerging deficits more common in children <1 year of age (p < 0.05).

INTERPRETATION

Outcomes after pediatric stroke are generally favorable, but moderate to severe neurological impairments are still common. Age between 28 days and 1 year appears to be a particularly vulnerable period. Understanding the timing and predictors of recovery will allow us to better counsel families and target therapies to improve outcomes after pediatric stroke. ANN NEUROL 2020;87:840-852.

Severe acquired brain injury aetiologies, early clinical factors, and rehabilitation outcomes: a retrospective study on pediatric patients in rehabilitation

Objective: Studies on pediatric severe acquired brain injury (sABI) outcomes focused mostly on single etiologies, not clarifying the independent role of clinical factors, and scantly explored inter-dependence between variables. We assessed associations of clinical factors at admission with essential outcomes, controlling for inter-dependence and sABI etiology. Methods: We reviewed the clinical records of 280 patients with traumatic and 292 with non-traumatic sABI, discharged from intensive care to pediatric neurological rehabilitation. We analyzed the distribution of clinical factors based on sABI etiology; conducted a factor analysis of variables; built multivariate models evaluating the associations of variables with death, persistent vegetative states, duration of coma, GOS outcome, length of stay. Results: We described the study sample. Factor analysis of inter-dependence between GCS, time before rehabilitation, dysautonomia, device use, produced the indicators "injury severity" and "neurological dysfunction", independent from sABI etiology, age, sex, and admittance GOS. Multivariate analyzes showed that: coma duration, GOS outcome, and length of stay, which may depend on rehabilitation courses, were directly associated with injury severity, neurological dysfunction, and patients' age; death and persistent vegetative states were also associated with etiology. Conclusion: Future studies should analyze larger cohorts and investigate mechanisms linking specific etiologies and patients' age with outcomes.

Language and cognitive outcomes after childhood stroke: Theoretical implications for hemispheric specialization

The purpose of this study was to investigate language and cognitive outcomes following severe childhood stroke, and the role of age at stroke according to lesion lateralization. We retrospectively included children consecutively admitted to a physical medicine and rehabilitation department between 1992 and 2015 following childhood stroke (age at stroke 1 month to15 years). Data collection included demographic and clinical information, results of cognitive assessments on the Wechsler Intelligence scales, detailed language assessments by speech and language therapists, and long-term academic outcome. Overall, 184 children (52% boys; mean age at assessment = 8.5 years, range .7-15.4 years) were hospitalized following ischemic (n = 79) or hemorrhagic (n = 105) stroke. After a median time since stroke of 4 months (n = 135), mean Full-Scale, Verbal, and Performance Intellectual Quotient (FSIQ, VIQ and PIQ) were 85 (SD = 19), 93 (SD = 22), and 85 (SD = 20), respectively. In language tests (n = 130) assessing lexical and syntactic expression and comprehension, 26%-53% of the children exhibited impairments (scores <2SD). After a median follow-up of 40 months, only 27% of the children were following a normal curriculum without adaptations or delay, and 27% were attending special education programs. School situation was strongly associated with language and FSIQ scores. Language and verbal IQ scores were significantly lower (p < .01) among patients with lesions in the left hemisphere as opposed to the right. After a left hemisphere lesion, language skills were not associated with age at stroke, but for right hemisphere lesions, language was more impaired among children who were younger at stroke onset. PIQ tended to correlate positively with age at stroke in left hemisphere lesions (poorer PIQ in early lesions) and negatively for right hemisphere lesions (poorer PIQ in late lesions). These findings, discussed in the light of the brain vulnerability and plasticity hypotheses, are in favor of a developmental view of hemispheric specialization.

Oligodendrocyte Progenitor Cell Proliferation and Fate after White Matter Stroke in Juvenile and Adult Mice

The incidence of stroke in children is 2.4 per 100,000 person-years and results in long-term motor and cognitive disability. In ischemic stroke, white matter (WM) is frequently injured, but is relatively understudied compared to grey matter injury. Previous research suggests that the cellular response to WM ischemic injury is different at different ages. Little is known about whether WM repair mechanisms differ in children and adults. We utilized a model of focal ischemic WM injury to determine the oligodendrocyte (OL) response to focal WM ischemic injury in juvenile and adult mice. Methods: Juvenile (21-25 days of age) versus adult (2-3 months of age) mice underwent stereotaxic injection of the potent vasoconstrictor N5-(1-iminoethyhl)-L-ornithine (L-NIO) into the lateral corpus callosum (CC). Animals were sacrificed on postoperative day 3 (acute) or 21 (chronic). Cell birth-dating was performed acutely after WM stroke with 5-ethynyl-2-deoxyuridine (EdU) injected intraperitoneally. Immunohistochemistry was performed, as well as stereology, to measure injury volume. The acute oligodendrocyte progenitor cell (OPC) proliferation and the chronic OL cell fate were determined with immunohistochemistry. Compound action potentials were measured in the CC at acute and chronic time points. Results: Acutely WM injury volume was smaller in juveniles. There was significantly greater OPC proliferation in juvenile animals (acute) compared to adults, but newly born OLs did not survive and mature into myelinating cells at chronic time points. In addition, juveniles did not have improved histological or functional recovery when compared to adults. Protecting newly born OPCs is a potential therapeutic target in children with ischemic stroke.

Speech and Language Impairments After Childhood Arterial Ischemic Stroke: Does Hemisphere Matter?

BACKGROUND

The association between left hemisphere stroke and acute speech and language impairment is well documented in adults. However, little is known about this association in childhood arterial ischemic stroke. Here we examined potential predictors of acute speech (dysarthria and apraxia) and language impairments after childhood arterial ischemic stroke, including site of lesion.

METHODS

Children with radiologically confirmed acute arterial ischemic stroke, admitted to a tertiary pediatric hospital from 2004 to 2012, were identified from an institutional registry. We examined the prevalence of dysarthria, apraxia, and language impairment within two weeks of the stroke. Associations with age at stroke event, lesion side (left, right, or bilateral), and arterial territory affected (anterior, posterior, or both) were assessed using logistic regression.

RESULTS

Sixty-two children with mean age eight years (range three to 17 years) were identified. Strokes were located in the left (32%), right (44%), or both hemispheres (24%). Dysarthria (74%) and language impairment (50%) were frequent. Verbal dyspraxia was less common (11%). There was little evidence that variables of interest, including site of lesion, were significantly associated with increased odds of dysarthria or language impairment (all P > 0.49).

CONCLUSIONS

Regardless of age, children are at high risk of communication disorders after stroke. Unlike adults, left hemisphere stroke was not associated with either speech or language impairment in our cohort, suggesting there may be bihemispheric contribution to language function. Future studies are needed to examine whether the predictors examined here determine long-term outcomes.

Atypical language representation is unfavorable for language abilities following childhood stroke

Brain plasticity has often been quoted as a reason for the more favorable outcome in childhood stroke compared to adult stroke. We investigated the relationship between language abilities and language localization in childhood stroke. Seventeen children and adolescents with left- or right-sided ischemic stroke and 18 healthy controls were tested with a comprehensive neurolinguistic test battery, and the individual neural representation of language was measured with an fMRI language paradigm. Overall, 12 of 17 stroke patients showed language abilities below average, and five patients exhibited impaired language performance. fMRI revealed increased activity in right hemisphere areas homotopic to left hemisphere language regions. In sum, seven stroke patients revealed atypical, i.e. bilateral or right lateralized language representation. Typical left hemispheric language lateralization was associated with better performance in naming and word fluency, whereas increased involvement of right homologues was accompanied by worse language outcome. In contrast, lesion lateralization or lesion volume did not correlate with language outcome or atypical language lateralization. Thus, atypical language lateralization is unfavorable for language outcome, and right homologues do not have the same cognitive capacity, even in young children.

Tracking of neurocognitive outcomes over time in children with perinatal stroke and associated complex medical conditions: a case series

Neurocognitive outcomes in children with perinatal stroke are complicated by additional neurological/medical factors. The main objective of this study was to retrospectively examine long-term neurocognitive outcomes in five children with perinatal stroke with increasingly complex comorbidities; ages 5-7 at first evaluation. Results revealed that intelligence and academic skills were significantly decreased in cases with combined perinatal stroke and comorbidities. Early language development was particularly vulnerable to disruption over time in children with increasing medical complexity. The delayed emergence of neurocognitive deficits emphasizes the need for serial assessment of neurocognitive development to identify early services and interventions.

Discourse and cognition in speakers with acquired brain injury (ABI): a systematic review

BACKGROUND

Cognitive impairment, particularly of executive functioning, has been implicated in deficits in spoken discourse production following acquired brain injury (ABI). However, due to variation in the methodologies and heterogeneity of findings across studies, the nature and extent of this association is not well understood.

AIMS

This review aims to synthesize the literature investigating associations between cognitive deficits and discourse impairment after ABI. It is reported in accordance with guidelines of The Preferred Reporting Items of Systematic Reviews and Meta-Analyses.

DATA SOURCES

Searches were conducted of a variety of databases including Medline, PsycINFO, EMBASE, CINAHL, ProQuest, Cochrane and ERIC. Additional studies were identified via reference harvesting.

ELIGIBILITY CRITERIA

Studies were included if they reported data on participants with ABI, assessed spoken discourse production and cognitive function, and performed statistical analyses to determine the association between discourse and cognitive variables. This review excluded non-English sources and those not published in peer-reviewed journals. Meta-analyses were not conducted due to variability across tools and terminology used to describe participant injury- and non-injury-related characteristics and outcomes.

RESULTS

Twenty-five observational studies were included in the review. Findings revealed significant associations between multiple cognitive functions and discourse across micro-linguistic to super-structural measures. Methodological and terminological inconsistencies were identified across studies, which limited systematic comparison of the results.

CONCLUSIONS

This review revealed present, yet heterogeneous, relationships between cognitive and discourse deficits in speakers with ABI. Associations were interpreted in light of a well-established model of discourse processing. Greater comparison across studies would have been facilitated by a standard nomenclature in relation to cognitive constructs and standardized discourse assessment. Future research should explore the influence of injury- and participant-related factors on discourse-cognitive relationships. The lack of information on conversational discourse and paediatric ABI limits the generalizability of this review to daily interaction following ABI. While applicable across the lifespan, in-depth investigation of discourse following ABI in childhood and adolescence is a priority due to complex changes in language and cognition, and the potential for impairments profoundly impact social, emotional and academic progression into adulthood. Given the centrality of remediating cognitive-communication difficulties in ABI, the interrelationships between discourse and cognition should retain a critical focus of research. This will inform clinical management and future research with this population. Findings have implications for our theoretical understanding of discourse and the nature of its breakdown in ABI.

Multimodal Outcome at 7 Years of Age after Neonatal Arterial Ischemic Stroke

OBJECTIVES

To evaluate the epileptic, academic, and developmental status at age 7 years in a large population of term-born children who sustained neonatal arterial ischemic stroke (NAIS), and to assess the co-occurrence of these outcomes.

STUDY DESIGN

A cohort study including 100 term newborns with NAIS was designed. Two infants died during the neonatal period, 13 families were lost to follow-up, and 5 families declined to participate in this evaluation. Thus, 80 families completed the 7-year clinical assessment. Epileptic status, schooling, motor abilities, global intellectual functioning, spoken language, and parental opinions were recorded. Principal component analysis was applied.

RESULTS

Rates of impaired language, cerebral palsy, low academic skills, active epilepsy, and global intellectual deficiency were 49%, 32%, 28%, 11%, and 8%, respectively. All were highly correlated. Eventually, 59% of children were affected by at least 1 of the aforementioned conditions. In 30% of cases, the viewpoints of health practitioners and parents did not match.

CONCLUSION

The prevalence of severe disabilities at 7 years after NAIS is low, but most children exhibit some impairment in developmental profile.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02511249), Programme Hospitalier de Recherche Clinique Régional (0308052), Programme Hospitalier de Recherche Clinique Interrégional (1008026), and EudraCT (2010-A00329-30).

Optimization of MRI-based scoring scales of brain injury severity in children with unilateral cerebral palsy

BACKGROUND

Several scoring systems for measuring brain injury severity have been developed to standardize the classification of MRI results, which allows for the prediction of functional outcomes to help plan effective interventions for children with cerebral palsy.

OBJECTIVE

The aim of this study is to use statistical techniques to optimize the clinical utility of a recently proposed template-based scoring method by weighting individual anatomical scores of injury, while maintaining its simplicity by retaining only a subset of scored anatomical regions.

MATERIALS AND METHODS

Seventy-six children with unilateral cerebral palsy were evaluated in terms of upper limb motor function using the Assisting Hand Assessment measure and injuries visible on MRI using a semiquantitative approach. This cohort included 52 children with periventricular white matter injury and 24 with cortical and deep gray matter injuries. A subset of the template-derived cerebral regions was selected using a data-driven region selection algorithm. Linear regression was performed using this subset, with interaction effects excluded.

RESULTS

Linear regression improved multiple correlations between MRI-based and Assisting Hand Assessment scores for both periventricular white matter (R squared increased to 0.45 from 0, P < 0.0001) and cortical and deep gray matter (0.84 from 0.44, P < 0.0001) cohorts. In both cohorts, the data-driven approach retained fewer than 8 of the 40 template-derived anatomical regions.

CONCLUSION

The equal or better prediction of the clinically meaningful Assisting Hand Assessment measure using fewer anatomical regions highlights the potential of these developments to enable enhanced quantification of injury and prediction of patient motor outcome, while maintaining the clinical expediency of the scoring approach.

Reading Development in Typically Developing Children and Children With Prenatal or Perinatal Brain Lesions: Differential School Year and Summer Growth

Summer slide, uneven growth of academic skills over the calendar year, captures the fact that the learning gains children make over the school year do not continue at the same pace over the summer, when children are typically not in school. We compared growth of reading skills during the school year and over the summer months in children with pre-or perinatal brain lesion (PL) and typically-developing (TD) children from varying socioeconomic status (SES) backgrounds as a new way to probe the role of structured environmental support in functional plasticity for reading skills in children with PL. Results showed that children with PL performed lower than TD children on both reading decoding and reading comprehension. Group differences were primarily driven by children with larger lesions and children with right hemisphere lesions (RH). For reading comprehension, children with RH showed greater growth during the school year but more slide during the summer months than both TD children and children with left hemisphere lesions, implicating a particularly strong role of structured input in supporting reading comprehension in this group. TD children from lower SES backgrounds fell behind their TD peers from higher SES backgrounds on decoding and reading comprehension, but did not show differential patterns of school year and summer growth. Overall, results highlight the importance of considering the role of a host of factors interacting at multiple levels of analyses, including biological and environmental, in influencing developmental trajectories of typically and atypically-developing children.

Age at stroke onset influences the clinical outcome and health-related quality of life in pediatric ischemic stroke survivors

AIM

Stroke in children occurs across different phases of brain development. Age at onset may affect outcome and health-related quality of life (HRQL). We evaluated the influence of age at stroke onset on the long-term neurological outcomes and HRQL of pediatric stroke survivors.

METHOD

Children with ischemic stroke were recruited into three groups according to their age at onset of stroke (presumed perinatal, neonatal, and childhood). Neurological outcomes were assessed using the Pediatric Stroke Recovery and Recurrence Questionnaire. HRQL was evaluated using proxy report versions (2-18y) of the Pediatric Quality of Life Inventory (PedsQL 4.0). A χ(2) /Fisher's exact test and multivariable logistic regression analysis was performed for the neurological outcomes. HRQL scores from the different age groups were compared using linear regression.

RESULTS

Ninety participants (presumed perinatal stroke, n=31; neonatal stroke, n=36; childhood stroke, n=23) were enrolled. Median age at the onset of stroke was 0.5 days and 3.7 years in neonatal and childhood participants respectively. Of the three groups, participants with presumed perinatal stroke demonstrated the worst global (p<0.002) and motor (p<0.001) outcomes and the lowest level of independence in daily activities (p<0.001). Parents reported the best global outcome and overall HRQL (p=0.007) after neonatal stroke.

INTERPRETATION

The age at stroke onset has important implications regarding long-term clinical outcomes and HRQL for survivors. Individuals with presumed perinatal stroke should be considered at high-risk for poor outcomes.

Visuoperceptual sequelae in children with hemophilia and intracranial hemorrhage

BACKGROUND

The goal of this study was to examine the impact of focal brain injuries on the outcomes of visual perception and visuospatial abilities in Mexican children with hemophilia who have experienced intracranial hemorrhages.

METHODS

We assessed ten boys who had hemophilia with intracranial hemorrhage (HIC), six boys who had hemophilia without intracranial hemorrhage (HH), and ten boys without hemophilia (CTL). The Verbal (VIQ), Performance IQs (PIQ), and Full Scale IQs (FSIQ) from the Wechsler Intelligence Scale for Children-Mexican Revision, Visual Perception, and Visuospatial Abilities domains, which are from a neuropsychological assessment battery for Spanish-speaking children (ENI), were employed for our analysis.

RESULTS

The results showed that the HIC group performed in the low-average range on the PIQ and FSIQ, which was lower than the HH group. The HIC group showed low performance on visual perception tests, such as line orientation, fragmented objects, and overlapping figures, compared with their matched controls.

CONCLUSIONS

The results suggest that it is not the ability to recognize objects that is impaired in the HIC group, but the ability to identify objects under less favorable conditions. Our findings may have therapeutic and rehabilitative implications for the management of children with hemophilia and early focal brain lesions.

Determinants of cognitive outcomes of perinatal and childhood stroke: A review

Our understanding of cognitive and behavioral outcomes of perinatal and childhood stroke is rapidly evolving. A current understanding of cognitive outcomes following pediatric stroke can inform prognosis and direct interventions and our understanding of plasticity in the developing brain. However, our understanding of these outcomes has been hampered by the notable heterogeneity that exists amongst the pediatric stroke population, as the influences of various demographic, cognitive, neurological, etiological, and psychosocial variables preclude broad generalizations about outcomes in any one cognitive domain. We therefore aimed to conduct a detailed overview of the published literature regarding the effects of age at stroke, time since stroke, sex, etiology, lesion characteristics (i.e., location, laterality, volume), neurologic impairment, and seizures on cognitive outcomes following pediatric stroke. A key theme arising from this review is the importance of interactive effects among variables on cognitive outcomes following pediatric stroke. Interactions particularly of note include the following: (a) age at Stroke x Lesion Location; (b) Lesion Characteristics (i.e., volume, location) x Neurologic Impairment; (c) Lesion Volume x Time Since Stroke; (d) Sex x Lesion Laterality; and (e) Seizures x Time Since Stroke. Further, it appears that these relationships do not always apply uniformly across cognitive domains but, rather, are contingent upon the cognitive ability in question. Implications for future research directions are discussed.

Contrasting pediatric and adult cerebral malaria: the role of the endothelial barrier

Malaria affects millions of people around the world and a small subset of those infected develop cerebral malaria. The clinical presentation of cerebral malaria differs between children and adults, and it has been suggested that age-related changes in the endothelial response may account for some of these differences. During cerebral malaria, parasites sequester within the brain microvasculature but do not penetrate into the brain parenchyma and yet, the infection causes severe neurological symptoms. Endothelial dysfunction is thought to play an important role in mediating these adverse clinical outcomes. During infection, the endothelium becomes activated and more permeable, which leads to increased inflammation, hemorrhages, and edema in the surrounding tissue. We hypothesize that post-natal developmental changes, occurring in both endothelial response and the neurovascular unit, account for the differences observed in the clinical presentations of cerebral malaria in children compared with adults.

Congenital brain damage: cognitive development correlates with lesion and electroencephalographic features

The purpose of this study was to assess cognitive development in 26 children with congenital focal brain lesion and unilateral spastic cerebral palsy first diagnosed and followed up for rehabilitation at our institution. Mean intelligence quotients (IQs) were correlated not only to the different features of the cerebral lesions, but also to the different types of electroencephalographic abnormalities. We also examined individual scores. We found that about 70% of the children had values of Full-Scale, Verbal, and Performance IQs within the normal range. No differences were found between left and right injured children. Different Verbal IQ-Performance IQ profiles were observed. Larger lesions and some electroencephalographic features, mainly signal slowing/attenuation as signs of structural brain damage, were significantly associated with lower intellectual abilities. The role of other factors, including genetic and environmental background variability, as well as rehabilitative treatments, on cognitive sequelae in such patients was discussed.

Der Einfluss von Schlaganfällen im Kindes- und Jugendalter auf die kognitive Entwicklung

Schlaganfälle ereignen sich im Kindesalter nur selten, haben jedoch für betroffene Kinder große Auswirkungen auch auf kognitive Fähigkeiten. Die vorliegende Studie analysiert die Intelligenzleistung von 103 Kindern nach einem Schlaganfall im Versorgungsgebiet der Arteria cerebri media. Dabei zeigt sich, dass das Alter zum Zeitpunkt der Schädigung einen großen Einfluss auf das Leistungsniveau hat. Kinder mit perinatalen Schlaganfällen schneiden in den Intelligenztestskalen insgesamt am schlechtesten ab. Dabei weist eine antikonvulsive Medikation zur Epilepsiebehandlung einen zusätzlichen Effekt auf. Ereignet sich der Schlaganfall nach dem sechsten Lebensjahr, können lateralisierte Effekte sichtbar gemacht werden: nach linkshemisphärischen Infarkten zeigen sich Sprachleistungen reduziert, rechtshemisphärische Schlaganfälle wirken sich auf visuell-räumliche Leitungen aus. Die Ergebnisse weisen auf die Notwendigkeit langfristiger neuropsychologischer Begleitung der Kinder und Jugendlichen hin.

Astrocyte precursor response to embryonic brain injury

Penetrating traumatic insult during pregnancy is a leading cause of human fetal demise; in particular, trauma to the brain may lead to devastating long-term cognitive sequelae. Perinatal brain injury involves glial precursors, but the neural mechanisms controlling astrocyte ontogeny after injury remain incompletely understood, partly due to a lack of appropriate markers and animal models. We analyzed astrocyte precursor response to injury at the beginning (E11) and peak (E15) of gliogenesis in an avian tectal model of penetrating embryonic brain trauma, without confounding maternal and sibling effects. At both ages, lateral ventricular dilatation, necrotic foci, periventricular cysts and intraventricular hemorrhages were observed distal to stab wounds two days after a unilateral stab injury to optic tecta. Neuronal (TUBB3) and oligodendrocyte precursor (PLP) markers were down-regulated, even far-removed from the wound site. In contrast, the mature astrocyte marker, GFAP, was up-regulated at the wound site, around necrotic areas and cysts, plus in usual areas of GFAP expression. Increased inflammatory response and apoptotic cell death were also confirmed in the injured tecta. Increased expression of NFIA, SOX9 and GLAST at the wound site and in the ventricular zone (VZ) of the injured tecta indicated an astroglial precursor response. However, cell division increased in the VZ only in early (E11) injury, but not later (E15), indicating that in late injury the astrogliogenesis occurring after acute injury is predominantly due to precursor differentiation rather than precursor proliferation. The inability to replenish the glial precursor pool during the critical period of vulnerability to injury may be an important cause of subsequent developmental abnormalities.

Narrative skill in children with early unilateral brain injury: a possible limit to functional plasticity

Children with pre- or perinatal brain injury (PL) exhibit marked plasticity for language learning. Previous work has focused mostly on the emergence of earlier-developing skills, such as vocabulary and syntax. Here we ask whether this plasticity for earlier-developing aspects of language extends to more complex, later-developing language functions by examining the narrative production of children with PL. Using an elicitation technique that involves asking children to create stories de novo in response to a story stem, we collected narratives from 11 children with PL and 20 typically developing (TD) children. Narratives were analysed for length, diversity of the vocabulary used, use of complex syntax, complexity of the macro-level narrative structure and use of narrative evaluation. Children's language performance on vocabulary and syntax tasks outside the narrative context was also measured. Findings show that children with PL produced shorter stories, used less diverse vocabulary, produced structurally less complex stories at the macro-level, and made fewer inferences regarding the cognitive states of the story characters. These differences in the narrative task emerged even though children with PL did not differ from TD children on vocabulary and syntax tasks outside the narrative context. Thus, findings suggest that there may be limitations to the plasticity for language functions displayed by children with PL, and that these limitations may be most apparent in complex, decontextualized language tasks such as narrative production.

Cognitive outcome following unilateral arterial ischaemic stroke in childhood: effects of age at stroke and lesion location

AIM

Plasticity in the developing brain is a controversial issue. Although language and motor function often recover remarkably well following early brain injury, recent evidence suggests that damage to the developing brain results in significant long-term neuropsychological impairment. Our aim was to investigate the relationship among age at injury, lesion location and intellectual outcome.

METHOD

Using age-appropriate Wechsler scales of intellectual ability, we explored this issue by evaluating a large group (n=145) of children (89 males, 56 females) who experienced unilateral arterial ischaemic stroke during the perinatal period (diagnosed mean 73d, SD 29d), between the ages of 1 month and 5 years (mean 2y 10mo, SD 1y 9mo), or between the ages of 6 and 16 years (mean 11y 1mo SD 3y 6mo). The mean age at assessment was 8 years (SD 3y 10mo) in the perinatal group, 7 years 5 months (SD 2y 9mo) in the 1 month to 5 years group, and 12 years 5 months (SD 3y 9mo) in the 6 to 16 years group. The mean time interval between stroke and assessment was 8 years (SD 18d) for perinatal, 4 years 6 months (SD 1y 5mo) for 1 month to 5 years, and 1 year 4 months (SD 2y 9mo) for 6 to 16 years. The relationship between age at stroke and lesion location (subcortical, cortical, or combined) as it pertains to cognitive outcome was also examined.

RESULTS

Measures of overall intelligence, verbal ability, working memory, and processing speed were significantly lower in children who had had a stroke than in the normative sample (all z>2.5, all p<0.01). The perinatal group performed more poorly than the other two groups on most cognitive measures, regardless of lesion location. The combined lesion location group performed more poorly than those with damage to either cortical or subcortical areas alone. Further investigation revealed different periods of peak vulnerability for subcortical lesions (perinatal) and cortical lesions (1mo-5y).

INTERPRETATION

Lesion location modulates the relationship between age at stroke and cognitive outcome.

Predictors of outcome following acquired brain injury in children

Acquired brain injury (ABI) in children and adolescents can result from multiple causes, including trauma, central nervous system infections, noninfectious disorders (epilepsy, hypoxia/ischemia, genetic/metabolic disorders), tumors, and vascular abnormalities. Prediction of outcomes is important, to target interventions, allocate resources, provide education to family or caregivers, and begin appropriate planning for the future. Researchers have identified several factors associated with better or worse outcomes after ABI, including variables related to the injury itself, postinjury factors related to intervention or trajectory of recovery, and preinjury or demographic factors. When examining the scientific literature, it is important to identify how "outcome" is defined, as the predictors may change depending on the outcome studied. In addition, key variables may be specific to the etiology of injury. Therefore, predictors of outcome cannot be generalized across the various etiologies of ABI, and this review will discuss predictors within the context of multiple etiologies of ABI. This article reviews the current literature on predicting outcomes after pediatric ABI, and areas in need of further research are discussed.

Self-regulation of regional cortical activity using real-time fMRI: the right inferior frontal gyrus and linguistic processing

Neurofeedback of functional magnetic resonance imaging (fMRI) can be used to acquire selective control over activation in circumscribed brain areas, potentially inducing behavioral changes, depending on the functional role of the targeted cortical sites. In the present study, we used fMRI-neurofeedback to train subjects to enhance regional activation in the right inferior frontal gyrus (IFG) to influence speech processing and to modulate language-related performance. Seven subjects underwent real-time fMRI-neurofeedback training and succeeded in achieving voluntary regulation of their right Brodmann's area (BA) 45. To examine short-term behavioral impact, two linguistic tasks were carried out immediately before and after the training. A significant improvement of accuracy was observed for the identification of emotional prosodic intonations but not for syntactic processing. This evidence supports a role for the right IFG in the processing of emotional information and evaluation of affective salience. The present study confirms the efficacy of fMRI-biofeedback for noninvasive self-regulation of circumscribed brain activity.

Pediatric stroke recovery: a descriptive analysis

OBJECTIVE

To investigate recovery patterns and potential prognostic factors of pediatric stroke.

DESIGN

Retrospective study.

SETTING

Acute rehabilitation at a university-based children's hospital.

PARTICIPANTS

Children (N=44; 25 boys, 19 girls; age range, 8mo-17y) with diagnosis of first-ever stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Functional outcomes at discharge and 1-year follow-up. Modified Brunnstrom stages, Gross Motor Function Classification System, activities of daily living (ADLs), swallowing, speech, and sphincter function were measured.

RESULTS

Recovery of swallowing function occurred earlier than other functions in the first 2 to 3 months poststroke. Less than half of the patients were able to use the affected arms and legs without assistive devices. Eleven of 32 patients who initially had poor body control became ambulatory without assistive devices. A total of 18 of 44 patients were able to walk without assistive devices. Bilateral hemisphere lesions and flaccid muscle tone of the affected extremity at stroke onset had a less favorable prognosis in terms of ambulation and ADLs. Hemorrhagic strokes without surgical complications had a better prognosis than nonhemorrhagic strokes.

CONCLUSIONS

Similar to the adult stroke population, most of the functional recovery in pediatric stroke occurs within the first 2 to 3 months after stroke, but the quality of functional recovery was better in the pediatric population. The lesion size of the stroke was found to be related to prognosis. Additional large cohort studies are suggested to understand the complex similarities and differences in recovery between pediatric and adult stroke.

Language outcome after perinatal stroke: does side matter?

The goal of this study was to examine structured language skills in children with perinatal strokes. Participants were 28 school-age children with early focal brain lesions (17 with left hemisphere [LH] damage, 11 with right hemisphere [RH] damage), and 57 controls. A standardized test of language (Clinical Evaluation of Language Fundamentals-Revised) was administered. Receptive, Expressive, and Total Language scores, as well as subtest scores, were analyzed. Control participants scored within the normal range, whereas the LH and RH groups scored significantly more poorly than did controls. There were no differences between the LH and RH groups on any of the language scores, and all scores were below the 14th percentile. Within the lesion group as a whole, scores were not related to lesion laterality, site, or severity. Results also were not accounted for by socioeconomic status or IQ. However, children who experienced seizures demonstrated significantly poorer performance than did children who did not experience seizures. Damage to either the LH or RH early in development adversely affects later language abilities, particularly on tasks with structured and complex linguistic demands. Although lesion side has little effect, the presence or absence of seizures is a major contributor to language outcome.

The revision decision: is change always good? A comparison of CELF-R and CELF-3 test scores in children with language impairment, focal brain damage, and typical development

PURPOSE

The Clinical Evaluation of Language Fundamentals (CELF) is a widely used, comprehensive test battery that assesses language in school-age children and adolescents. The CELF-R (E. Semel, E. H. Wiig, & W. Secord, 1987) was updated to the CELF-3 (E. Semel, E. H. Wiig, & W. A. Secord, 1995) in 1995. The goal of the present study was to compare scores and evaluate the diagnostic utility of the CELF-R and CELF-3 in 2 clinical populations and a typically developing control group.

METHOD

The present study compared CELF-R and CELF-3 test scores of 107 children with language impairment (LI), 54 children with early focal brain damage (FL), and 90 controls.

RESULTS

All 3 groups demonstrated significantly better performance on the CELF-3 than on the CELF-R. LI children scored in the moderately-to-severely impaired range on the CELF-R, but in the mildly-to-moderately impaired range on the CELF-3. FL children went from being mildly-to-moderately impaired on the CELF-R to within normal limits on the CELF-3. Controls went from the average range on the CELF-R to the high average range on the CELF-3.

CONCLUSION

This study is important for professionals who administer language tests and/or use language testing results to recommend appropriate school placements, additional services, and/or interventions. Although psychometric tests are frequently revised, it is not always the case that a revised version has improved diagnostic utility.

Early cognitive outcome after neonatal stroke

The purpose of this study was to assess the cognitive development of 27 children with nonhemorrhagic neonatal stroke (occurring within the first 28 days of life). The cognitive evaluation consisted of the Bayley Scales of Infant Development, administered at 12 and/or 24 months poststroke. Compared with the normative sample, children with neonatal stroke obtained significantly lower scores on the Bayley Psychomotor Development Index at 12 months poststroke and on the Bayley Mental and Psychomotor Development Indices at 24 months poststroke. Outcome did not differ based on stroke type or laterality of infarct. However, there was a trend toward higher scores on the Bayley Psychomotor Development Index at 24 months in the left hemisphere group compared to the right hemisphere group. Overall, children with neonatal stroke evidenced significant impairment within the first 2 years poststroke. Further research is required to confirm whether cognitive impairments in these children resolve, remain in the low-average range, or increase with development as more complex skills are learned.

Brain structure in prenatal stroke: quantitative magnetic resonance imaging (MRI) analysis

Neonatal stroke outcome studies demonstrate variable findings of either relatively spared intellectual function or persistent impairments. Volumetric measurement of the brain can provide more precise data on lesion-cognition outcomes. We studied 7 children with unilateral focal lesions from prenatal stroke. Whole-brain magnetic resonance imaging scans were analyzed to produce volumes of cortical gray matter, total white matter, cerebrospinal fluid, lesion, and lesion constricted fluid, and we ascertained the relationship of morphometric variables to intellectual and clinical outcome. Children with cystic encephalomalacia plus atrophy had poorer outcomes than children with atrophy or gliosis alone. These children also demonstrated the largest lesion size, smallest gray matter volume, and greatest proportion of hyperintense white matter in the affected hemisphere. Findings suggest that the type and size of the lesion, in addition to the integrity of white matter and residual cortex, may be better predictors of intellectual functioning than either of these indices alone.

Using the language characteristics of clinical populations to understand normal language development

The overall purpose of this article is to describe the speech and language abilities of children who have selected clinical conditions, not only to characterize the outcomes of those conditions, but also to understand fundamental requirements for language learning in typically developing children. This developmental cognitive neuroscience analysis conceptualizes the clinical conditions as naturalistic experimental manipulations, selectively altering factors in the language-learning situation that could not otherwise be ethically manipulated in a research study.

A SPECT study of language and brain reorganization three years after pediatric brain injury

Using single photon emission computed tomography (SPECT), we investigated brain plasticity in children 3 years after sustaining a severe traumatic brain injury (TBI). First, we assessed brain perfusion patterns (i.e., the extent of brain blood flow to regions of the brain) at rest in eight children who suffered severe TBI as compared to perfusion patterns in eight normally developing children. Second, we examined differences in perfusion between children with severe TBI who showed good versus poor recovery in complex discourse skills. Specifically, the children were asked to produce and abstract core meaning for two stories in the form of a lesson. Inconsistent with our predictions, children with severe TBI showed areas of increased perfusion as compared to normally developing controls. Adult studies have shown the reverse pattern with TBI associated with reduced perfusion. With regard to the second aim and consistent with previously identified brain-discourse relations, we found a strong positive association between perfusion in right frontal regions and discourse abstraction abilities, with higher perfusion linked to better discourse outcomes and lower perfusion linked to poorer discourse outcomes. Furthermore, brain-discourse patterns of increased perfusion in left frontal regions were associated with lower discourse abstraction ability. The results are discussed in terms of how brain changes may represent adaptive and maladaptive plasticity. The findings offer direction for future studies of brain plasticity in response to neurocognitive treatments.

Impairments of procedures for implementing complex language are due to disruption of frontal attention processes

Production of complex discourse-lengthy, open-ended utterances and narratives-requires intact basic language operations, but it also requires a series of learned procedures for construction of complex, goal-directed communications. The progression of clinical disorders from transcortical motor aphasia to dynamic aphasia to discourse impairments represents a progression of procedural deficits from basic morpho-syntax to complex grammatical structures to narrative and a progression of lesions from posterior frontal to polar and/or lateral frontal to medial frontal. Two cases of impaired utilization of language exemplify the range of impairments from clearly aphasic agrammatic, nonfluency to less and less "aphasic" and more and more executive impairments from transcortical motor aphasia to dynamic aphasia to narrative discourse disorder. The clinical phenomenology of these disorders gradually comes to be more accurately defined in the terminology of executive deficits than that of aphasia. The executive deficits are, in turn, based on impairments in various components of attention. Specific impairments in energizing attention and setting response criteria associated, respectively, with lesions in superior medial and left ventrolateral frontal regions may cause defective recruitment of the procedures of complex language assembly.

A matched lesion analysis of childhood versus adult-onset brain injury due to unilateral stroke: another perspective on neural plasticity and recovery of social functioning

BACKGROUND

The literature on neuroplasticity lacks a direct comparison of chronic neuropsychological and social outcomes following brain damage acquired in childhood versus adulthood, when lesions are matched across adults and children for size and location.

METHODS

We paired adults and children with similar unilateral stroke lesions and then compared chronic neuropsychological and social outcomes. Quantitative comparisons were conducted, as well as qualitative analyses of each subject pair, focusing on specific domains of cognitive impairment and changes in social functioning.

RESULTS

We found that learning and memory impairments were most common in both children and adults. Left hemisphere-lesioned children were normal on speech/language ratings, whereas their adult counterparts were borderline impaired. Impairments in social functioning were highly associated with hemispheric side of damage in adults, but not in children: Specifically, adults with right hemisphere lesions developed social defects much more frequently than adults with left hemisphere lesions, whereas this asymmetry was not evident in the children. Most importantly, though, was the overarching finding of a high degree of similarity between chronic neuropsychological and social function outcomes in adults and children with similarly located brain lesions due to unilateral stroke.

CONCLUSIONS

On balance, the findings suggest that lesion location and size are prepotent factors determining neuropsychological and social recovery from stroke.

Methods of constraint-induced movement therapy for children with hemiplegic cerebral palsy: Development of a child-friendly intervention for improving upper-extremity function

We delineate the methodology for constraint-induced movement therapy (CIMT) modified for children with hemiplegic cerebral palsy (CP) and describe important considerations that need to be made when testing this intervention in children. The resulting intervention evolved from piloting and testing it with 38 children with hemiplegic CP who were between the ages of 4 and 14 years. Thirty-seven successfully completed the treatment protocol. The intervention retains the 2 major elements of the adult CIMT (repetitive practice, shaping) and was constructed to be as child-friendly as possible. It involves restraining the noninvolved extremity with a sling and having the child engage in unimanual activities with the involved extremity 6 hours a day for 10 days (60 h). Specific activities are selected by considering joint movements with pronounced deficits and improvement of which interventionists believe have greatest potential. The activities are chosen to elicit repetitive practice and shaping. The intervention is conducted in groups of 2 to 3 children to provide social interaction, modeling, and encouragement. Each child is assigned to an interventionist to maintain at least a 1:1 ratio. CIMT can be modified to be child-friendly while maintaining all practice elements of the adult CIMT. The modified therapy is tolerated by most children. Further modifications will likely be required to hone in on the specific components of the intervention that are most effective before applying them to children who are most likely to benefit.