Aphasia owing to subcortical brain infarcts in childhood

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.

[Formula: see text] Post-stroke acquired childhood aphasia. A scoping review

Aphasia has a great impact on children's lives, with stroke being its most common and studied etiology. However, our knowledge about this disorder is limited, the studies on this topic are sparse, and a consensus regarding its definition is lacking. In particular, the interpretation of this condition varied over time: from the rigid description of the so-called "standard doctrine" to the adoption of adult models for post-stroke aphasia. Therefore, this review provides a critical overview of childhood aphasia after stroke, focusing on its epidemiology, definition, diagnosis, and clinical manifestation. The scoping review approach was adopted, following PRISMA-ScR guidelines. PubMed, Web of Science, and PsycInfo databases were searched for related peer-review papers in English. Forty-six records were identified; the majority were single cases and case series, only a few were reviews and observational studies. Epidemiologic data are scarce; a few studies report that aphasia affects about one-third of children post-stroke. Despite terminological differences, there is an overall agreement on the definition of post-stroke aphasia in children as a language disorder acquired after the age of two. Approaches for the diagnosis and evaluation vary widely, including both assessments for developmental language disorders and tests for aphasia in adults. The clinical manifestations described in children are numerous and varied, similar to those found in adults, in contrast with the "standard doctrine." This review highlights the need for further studies to improve the knowledge of this condition, develop validated and specific assessment tools, and standardize clinical management.

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.

Language and Cognitive Outcomes Following Ischemic Stroke in Children With Monolingual and Bilingual Exposure

Aim: Although many children who experience ischemic stroke come from bilingual backgrounds, it is unclear whether bilingual exposure affects poststroke development. Our research evaluates bilingual and monolingual exposure on linguistic/cognitive development poststroke across 3 stroke-onset groups. Method: An institutional stroke registry and medical charts were used to gather data on 237 children across 3 stroke-onset groups: neonatal, <28 days; first-year, 28 days to 12 months; and childhood, 13 months to 18 years. The Pediatric Stroke Outcome Measure (PSOM), administered several times poststroke, was used to evaluate cognition and linguistic development. Results: Similar cognitive outcomes were observed across language groups. However, an interaction effect with stroke-onset group was observed, with monolinguals in the first-year group having worse productive language outcomes as compared to bilinguals. Interpretation: Overall, no detrimental effects of bilingualism were found on children's poststroke cognition and linguistic development. Our study suggests that a bilingual environment may facilitate language development in children poststroke.

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.

Characterizing language outcomes following childhood basal ganglia stroke

The basal ganglia are important for movement and executive function, but its contribution to language is less understood. This study explored language outcomes associated with childhood basal ganglia stroke. A detailed language coding scheme, which examined expressive and receptive language, verbal fluency, narrative discourse, pragmatic/applied language, and academics, was developed from qualitative and quantitative data acquired from neuropsychological testing and reports. Overall intellectual functioning and verbal comprehension was in the average range. Twelve participants had psychological diagnoses, including Learning Disorder. No one had a Language Disorder diagnosis. Among the 18 children who did not receive a diagnosis, many exhibited language issues in the mild to severe range according to our coding scheme. These children had higher-order language difficulties in verbal fluency, narrative, and pragmatic language rather than overt expressive difficulties noted in Diagnostic and Statistical Manual (DSM) diagnostic criteria. There was an association between infarct size and ESL/immersion education, math performance, and presence of a psychological diagnosis. Psychological diagnosis was also associated with literacy skills. The results highlight that language issues following basal ganglia stroke may not be fully captured by standardized neuropsychological tests and psychological diagnoses. Findings reinforce the need to integrate quantitative and qualitative findings when examining language functioning.

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.

Predictors of Cognitive and Academic Outcome following Childhood Subcortical Stroke

Childhood arterial ischemic stroke often involves basal ganglia and thalamus but little is known about neuropsychological outcomes in this group. We examined intellectual ability, academics, attention, executive function, and psychological diagnoses in children and adolescents (6-20 years of age) with childhood stroke involving the basal ganglia (n = 32) or thalamus (n = 12). Intellectual ability was age-appropriate but working memory was significantly lower than expected. Compared to the normative mean, the stroke group exhibited significantly weaker performance in reading comprehension, math fluency, attention, and greater challenges with executive function. Children with basal ganglia stroke had weaker working memory and were more likely to receive diagnoses of Attention Deficit Hyperactivity Disorder and Anxiety Disorder than those with thalamic stroke. Lesion size was most important in predicting working memory ability, whereas age at stroke and age at test were important in predicting academic ability.

Subcortical Aphasia After Stroke

Objective

To evaluate the types and severity of subcortical aphasia after stroke and to determine the predictors of the degree of aphasic impairment.

Methods

Medical records of 38 patients with post-stroke subcortical aphasia (19 males; mean age, 61.7±13.8 years) were reviewed retrospectively with respect to the following tests: the Korean version of the Western Aphasia Battery (K-WAB), the Korean version of the Modified Barthel Index (K-MBI), and the Fugl-Meyer Index (FMI). The severity of aphasia was evaluated by the aphasia quotient (AQ) and the language quotient (LQ).

Results

Anomic aphasia was the most frequent type of aphasia (n=15, 39.5%), and the lesion most frequently observed in subcortical aphasia was located in the basal ganglia (n=19, 50.0%). Patients with lesions in the basal ganglia exhibited the lowest scores on the FMI for the upper extremities (p=0.04). Severity of aphasia was significantly correlated with the K-MBI (Pearson correlation coefficient: γ=0.45, p=0.01 for AQ and γ=0.53, p=0.01 for LQ) and FMI scores for the lower extremities (γ=0.43, p=0.03 for AQ and γ=0.49, p=0.05 for LQ). In a multivariate logistic regression analysis, K-MBI remained the only explanatory variable closely associated with aphasia severity.

Conclusion

This study showed the general characteristics of post-stroke subcortical aphasia, and it revealed that K-MBI was an associated and explanatory factor for aphasia severity.

Language Representation Following Left MCA Stroke in Children and Adults: An fMRI Study

BACKGROUND

In this case series, functional magnetic resonance imaging was used to examine brain networks that mediate different aspects of language function in 4 young adults (17-22 years) with a history of left middle cerebral artery (MCA) stroke in childhood (40 years of age). Although it is widely believed that altered lateralization patterns are more likely to occur following early brain injuries compared with later brain injuries, the presumed plasticity of the young brain has been challenged in recent years, particularly in the domain of language.

METHODS

We explored this issue by contrasting the brain activation patterns of individuals with childhood left MCA stroke and adult left MCA stroke while performing two language tasks: verb generation and picture-word matching. Importantly, both groups showed significant recovery of language function, based on standard clinical indicators.

RESULTS

Controls showed left lateralized activation for both tasks, although much more pronounced for verb generation. Adult stroke patients also showed left lateralization for both tasks, though somewhat weaker than controls. Childhood stroke patients exhibited significantly weaker lateralization than the adult group for verb generation, but there was no significant group difference for picture-word matching.

CONCLUSIONS

These preliminary findings suggest that successful reorganization of language function is more likely to involve bilateral recruitment following left MCA stroke in childhood than in adulthood. Of importance, although childhood stroke patients had primarily subcortical lesions, there were substantial alterations in cortical activation patterns.

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.

Language impairment associated with arachnoid cysts: recovery after surgical treatment

Supporting data from the literature, we observe that large arachnoid cysts may affect cognitive function. Neuropsychologic assessment plus magnetic resonance imaging allowed for documentation of associations between left temporal arachnoid cysts, language impairment, and other cognitive dysfunctions. Significant cognitive improvements were evident soon after cysto-peritoneal shunting. These observations reinforce the rationale for neuropsychologic assessments of patients with developmental delay and arachnoid cysts, and support the potential benefit of surgical decompression for arachnoid cysts associated with neurologic deficits, even if surgery is performed well after the occurrence of neurologic deficits.

Neural bases of childhood speech disorders: lateralization and plasticity for speech functions during development

Current models of speech production in adults emphasize the crucial role played by the left perisylvian cortex, primary and pre-motor cortices, the basal ganglia, and the cerebellum for normal speech production. Whether similar brain-behaviour relationships and leftward cortical dominance are found in childhood remains unclear. Here we reviewed recent evidence linking motor speech disorders (apraxia of speech and dysarthria) and brain abnormalities in children and adolescents with developmental, progressive, or childhood-acquired conditions. We found no evidence that unilateral damage can result in apraxia of speech, or that left hemisphere lesions are more likely to result in dysarthria than lesion to the right. The few studies reporting on childhood apraxia of speech converged towards morphological, structural, metabolic or epileptic anomalies affecting the basal ganglia, perisylvian and rolandic cortices bilaterally. Persistent dysarthria, similarly, was commonly reported in individuals with syndromes and conditions affecting these same structures bilaterally. In conclusion, for the first time we provide evidence that longterm and severe childhood speech disorders result predominantly from bilateral disruption of the neural networks involved in speech production.

Long-term cognitive outcomes after pediatric stroke

This study assessed neurocognitive and neurologic outcomes of children with neonatal and childhood strokes. Twenty-one children with neonatal (mean age, 6.86 years) and 10 children with childhood (mean age, 8.21 years) strokes, identified via the Estonian Pediatric Stroke Database (1995-2006), participated. A developmental neuropsychologic assessment was used for neurocognitive outcomes, and the Paediatric Stroke Outcome Measure for neurologic outcomes. Neuromotor impairment was evident in 62% of children with neonatal strokes, and in 70% of children with childhood strokes. Compared with control subjects, children with strokes exhibited worse attention, language, memory, and sensorimotor functions. The sensorimotor domain comprised the most impaired neurocognitive area, whereas executive functions remained intact in both stroke groups. A well-preserved executive function may account for the normal range of intelligence in children with strokes. More severe impairment in neurocognitive skills was evident after neonatal strokes, and the visuospatial domain was more impaired than in children from the childhood group. Prognoses were worse after left hemisphere strokes associated with epilepsy. Our results on emerging neurocognitive deficits in several areas underline the importance of neuropsychologic testing and the follow-up of children with pediatric strokes.

Language and focal brain lesion in childhood

Childhood ischemic strokes can lead to problems like hemiplegias, epilepsies, cognitive changes (memory and mathematical solutions), and language ability (reading, writing, and aphasias). The purpose of this study was to evaluate language and its aspects in children with unilateral ischemic stroke and associate them with the age during the event, injured side, and occurrence of epilepsy. Thirty-two children between 8 months and 19 years of age were evaluated. Among them, 21 (65%) had a change in their language skills, there being a connection between age and the time of injury (P < .05). The most impaired aspects were their phonology, semantics, and syntax. In this sample, there was a persistent change in the semantic aspect, which is an alert for the early detection of learning and future development problems.

Arterial ischemic stroke in children--recent advances

Childhood stroke syndromes are an important cause of mortality and morbidity. This paper focuses on the recent advances in arterial ischaemic stroke beyond the neonatal period. Vascular risk factors are identified in the majority of children and guide both acute and longer term treatments, as well as determining prognosis. Contrary to popular belief many children have residual impairments encompassing a wide range of domains. National and international collaborations are facilitating an increase in the understanding of childhood stroke and have the eventual aim of conducting trials of potential therapeutic interventions.