Language and focal brain lesion in childhood

Predictors of neurocognitive outcome in pediatric ischemic and hemorrhagic stroke

This clinical study examined the impact of eight predictors (age at stroke, stroke type, lesion size, lesion location, time since stroke, neurologic severity, seizures post-stroke, and socioeconomic status) on neurocognitive functioning following pediatric stroke. Youth with a history of pediatric ischemic or hemorrhagic stroke (n = 92, ages six to 25) underwent neuropsychological testing and caregivers completed parent-report questionnaires. Hospital records were accessed for medical history. Spline regressions, likelihood ratios, one-way analysis of variance, Welch's t-tests, and simple linear regressions examined associations between predictors and neuropsychological outcome measures. Large lesions and lower socioeconomic status were associated with worse neurocognitive outcomes across most neurocognitive domains. Ischemic stroke was associated with worse outcome in attention and executive functioning compared to hemorrhagic stroke. Participants with seizures had more severe executive functioning impairments than participants without seizures. Youth with cortical-subcortical lesions scored lower on a few measures than youth with cortical or subcortical lesions. Neurologic severity predicted scores on few measures. No differences were found based on time since stroke, lesion laterality, or supra- versus infratentorial lesion. In conclusion, lesion size and socioeconomic status predict neurocognitive outcome following pediatric stroke. An improved understanding of predictors is valuable to clinicians who have responsibilities related to neuropsychological assessment and treatments for this population. Findings should inform clinical practice through enhanced appraisals of prognosis and the use of a biopsychosocial approach when conceptualizing neurocognitive outcome and setting up support services aimed at fostering optimal development for youth with stroke.

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 children and adolescents: Analysis of electrophysiological and behavioral assessment findings of auditory processing

PURPOSE

This study aimed to analyze the auditory processing behavior of children and adolescents diagnosed with stroke and compare it with that of typically developing individuals.

METHODS

This was an analytical cross-sectional study involving 48 participants aged between 7 and 17 years with adequate schooling for age and grade, allocated equally to two groups: Stroke (SG) and Control Groups (CG). For the SG, cases identified between 2003 and 2018 were considered. In the CG, school-aged participants with typical development were randomized. After screening for differential audiological assessment and confirmation of auditory pathway integrity at the brainstem level, binaural analyses of the auditory processing behavior were conducted using the Dichotic Digit Test (DDT), Frequency Pattern Test (FPT), and electrophysiological assessment (P300). The Shapiro-Wilk test for normality was conducted, followed by the T and Mann-Whitney tests, with a 95 % confidence level and significance offset at p < 0.05, using the SPSS software (IBM®, v. 22.) RESULTS: The CG performed better in terms of auditory processing. These differences were significant (p < 0.0001) for the binaural integration of DDT, FPT humming and Labeling, and P300 latency. The P300 results were similar; however, with a greater amplitude in the SG.

CONCLUSION

This study showed that children and adolescents with stroke performed worse in electrophysiological and behavioral tests of auditory processing assessed using the auditory evoked potentials. These data reinforce the hypothesis that stroke-related lesions compromise the neural mechanisms underlying auditory processing.

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.

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.

Functional outcomes in children related to self-care, mobility, and social function after stroke in early childhood: a cohort study

ABSTRACT Background: Stroke has been increasingly recognized as an important morbidity and mortality factor in neonates and children. Children have different and more diverse risk factors than adults, commonly related to an underlying disease. Stroke may compromise functional capacity in children. Few studies have focused on functional outcomes related to activities and participation. Objectives: To investigate post-stroke functionality of children related to self-care, mobility, and social function. Methods: We assessed the functional outcome of 14 children younger than 7.5 years who suffered a stroke in early childhood through the use of the Pediatric Evaluation of Disability Inventory (PEDI). Results: The average age of the sample at assessment was 3.6 ± 1.4 years (2 - 6 years). The average scores in the PEDI functional domains of self-care, mobility, and social function were, respectively, 37.6 ± 15.4, 36.2 ± 15.4, and 48.7 ± 11.1. Children showed age-appropriate functional outcomes in the PEDI functional domains: 71.4% of them in self-care and mobility and 92.9% in social function. Children with bilateral injuries (p = 0.05) and longer hospital stays (r = -0.79, p = 0.001) showed the worst scores in PEDI's social function domains. Conclusions: Overall, our sample of preschool children showed age-appropriate functional outcomes on self-care, mobility, and social function domains after stroke. However, children with bilateral injuries and longer hospital stays showed the worst scores in social function domains. We recommend focusing on functional rehabilitation to promote activities and participation and to monitor the development of children's social skills after stroke.

Central auditory processing: behavioral and electrophysiological assessment of children and adolescents diagnosed with stroke

INTRODUCTION

Central auditory processing refers to the efficiency and effectiveness with which the central nervous system uses auditory information: it may be altered in neurological disorders and brain injuries, such as strokes. However, despite evidence of probable alterations in the pediatric population, functional abilities and post-stroke limitations are still not well documented in the literature.

OBJECTIVE

To analyze the findings of the electrophysiological and behavioral evaluations of central auditory processing of children and adolescents diagnosed with stroke from a reference outpatient clinic, as well as to investigate possible associations with the variables: type and location of the stroke and age group.

METHODS

The present study is characterized as comparative cross-sectional. The sample, for convenience, included individuals aged 7-18 years divided into two groups: study group, composed of individuals with a diagnosis of stroke, and control group, composed of individuals with typical development. The evaluation consisted of the following procedures: anamnesis, basic audiological evaluation, behavioral evaluation of the auditory processing disorder (dichotic digit test, dichotic consonant-vowel, synthetic sentence identification/pediatric speech intelligibility, gaps in noise, pitch pattern sequence, masking level difference), and electrophysiological evaluation (P300 and mismatch negativity).

RESULTS

Nineteen children and adolescents were included in the study group. The control group was composed of 19 children and adolescents with typical development. In the comparison between the groups, a worse performance is observed for the study group in all the evaluated tests, behavioral and electrophysiological. In the behavioral evaluation of central auditory processing, there was a statistical difference for all tests, except for masking level difference and dichotic digit test, binaural separation step on the left. In the electrophysiological evaluation, there was a statistical difference in the latency of mismatch negativity and P300. No associations were found between the behavioral and electrophysiological findings and the location of the stroke and age group variables.

CONCLUSION

Children and adolescents diagnosed with stroke present a worse performance in the electrophysiological and behavioral evaluations of central auditory processing when compared to a control group.

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.

Pharmacotherapy of Traumatic Childhood Aphasia: Beneficial Effects of Donepezil Alone and Combined With Intensive Naming Therapy

At present, language therapy is the only available treatment for childhood aphasia (CA). Studying new interventions to augment and hasten the benefits provided by language therapy in children is strongly needed. CA frequently emerges as a consequence of traumatic brain injury and, as in the case of adults, it may be associated with dysfunctional activity of neurotransmitter systems. The use of cognitive-enhancing drugs, alone or combined with aphasia therapy, promotes improvement of language deficits in aphasic adults. In this study we report the case of a 9-year-old right-handed girl, subject P, who had chronic anomic aphasia associated with traumatic lesions in the left temporal-parietal cortex. We performed a single-subject, open-label study encompassing administration of the cholinergic agent donepezil (DP) alone during 12 weeks, followed by a combination of DP and intensive naming therapy (INT) for 2 weeks and thereafter by a continued treatment of DP alone during 12 weeks, a 4-week washout period, and another 2 weeks of INT. Four comprehensive language and neuropsychological evaluations were performed at different timepoints along the study, and multiple naming evaluations were performed after each INT in order to assess performance in treated and untreated words. Structural magnetic resonance imaging (MRI) was performed at baseline. MRI revealed two focal lesions in the left hemisphere, one large involving the posterior inferior and middle temporal gyri and another comprising the angular gyrus. Overall, baseline evaluation disclosed marked impairment in naming with mild-to-moderate compromise of spontaneous speech, repetition, and auditory comprehension. Executive and attention functions were also affected, but memory, visuoconstructive, and visuoperceptive functions were preserved. Treatment with DP alone significantly improved spontaneous speech, auditory comprehension, repetition, and picture naming, in addition to processing speed, selective, and sustained attention. Combined DP-INT further improved naming. After washout of both interventions, most of these beneficial changes remained. Importantly, DP produced no side effects and subject P attained the necessary level of language competence to return to regular schooling. In conclusion, the use of DP alone and in combination with INT improved language function and related cognitive posttraumatic deficits in a child with acquired aphasia. Further studies in larger samples are warranted.

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.

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.

Processing verbal morphology in patients with congenital left-hemispheric brain lesions

The goal of this study was to test whether children, teenagers and adults with congenital left-hemispheric brain lesions master the regularities of German verbal inflectional morphology. Thirteen patients and 35 controls without brain damage participated in three experiments. A grammaticality judgment task, a participle inflection task and a nonce-verb inflection task revealed significant differences between patients and controls. In addition, a main effect of verb type could be observed as patients and controls made more mistakes with irregular than with regular verbs. The findings indicate that the congenitally damaged brain not only has difficulties with complex syntactic structures during language development, as reported by earlier studies, but also has persistent deficits on the morphological level. These observations suggest that the plasticity of the developing brain cannot fully compensate for congenital brain damage which affects regions associated with language functions.

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.