A longitudinal evaluation of a penetrating traumatic brain injury: Theories of plasticity and vulnerability

Penetrating traumatic brain injury (TBI) is uncommon in infancy. The consequences may be devastating, especially when the injury is extensive and affects eloquent areas of the brain. There is the potential for neuropsychological dysfunction that may impact the individual's development and well-being into adulthood. In the context of early brain injury, the developing brain is both remarkably resilient and vulnerable. The present case study describes a patient who experienced a penetrating TBI at 9 days of age, subsequently developed intractable seizures, and underwent left hemispherectomy. Neuropsychological testing at ages 5, 10, 11, and 19 years are presented alongside fMRI and Wada testing. While the patient initially developed cognitive functions in the low-average range by age 5, scores on neuropsychological assessments began to decrease thereafter. This case is discussed with attention to vulnerability and plasticity theories. It highlights the ability of the brain to reorganize and allow the development of functions that would normally be sub-served by damaged areas and the limits of plasticity. Further, this case illustrates the vulnerability of the early brain to insult, the potential to grow into deficits, and the need to consider a variety of factors when predicting outcomes for cases of pediatric brain injury.

Differential antiseizure medication sensitivity of the Affective Reactivity Index: A randomized controlled trial in new-onset pediatric focal epilepsy

BACKGROUND

Irritability is a adverse effect of many antiseizure medications (ASMs), but there are no validated measures currently available to characterize this behavioral risk. We examined both child and parent/guardian versions of the Affective Reactivity Index (ARI), a validated measure developed for application in adolescent psychiatry, to determine its sensitivity to ASM-related irritability. We hypothesized irritability increases associated with levetiracetam (LEV) but not lamotrigine (LTG) or oxcarbazepine (OXC).

METHOD

The ARI was administered to 71 child and parent/guardian pairs randomized to one of three common ASMs (LEV, LTG, OXC) used to treat new-onset focal (localization-related) epilepsy. Subjects were recruited as part of a prospective multicenter, randomized, open-label, parallel group design. The ARI was administered at baseline prior to treatment initiation and again at 3 months after ASM initiation.

RESULTS

There was a significant increase in ARI ratings for both child and parent/guardian ratings for LEV but not LTG or OXC when assessed 3 months after treatment initiation. When examined on the individual subject level using a criterion of at least a 3-point ARI increase, there was an increase associated with LEV for child ratings but not parent/guardian scores.

CONCLUSION

Both child and parent/guardian versions of the ARI appear sensitive to medication-induced irritability associated with LEV on both the group and individual levels. The findings extend the applicability of ARI from characterizing the presence of clinical irritability as a psychiatric diagnostic feature to a more modifiable aspect of behavior change related to medication management and support its use in clinical trial applications.

Effects of Developmental Age on Symptom Reporting and Neurocognitive Performance in Youth After Sports-Related Concussion Compared to Control Athletes

There is increased necessity to focus research on school-aged athletes with sports-related concussion (SRC). This study assessed differences in symptom reporting and neurocognitive performance in youth athletes who sustained a sports-related concussion. A total of 1345 concussed and 3529 nonconcussed athletes (ages 8-21) completed the Immediate Post-concussive Assessment and Cognitive Testing (ImPACT). Analyses of covariance were conducted in order to assess differences in neurocognitive performance and symptom reporting between the sports-related concussion and control groups across age ranges. Longitudinal hierarchical linear modeling was employed to examine age and its relationship with rates of sports-related concussion recovery in neurocognitive performance. Results revealed athletes aged 13 to 15 had significantly lower neurocognitive performance scores compared to same-aged athletes without a history of sports-related concussion. With respect to the hierarchical linear modeling results, age was identified as a unique predictor of symptom recovery, particularly for ages 8 to 12. Results provide a better understanding of typical symptom reporting and neurocognitive outcomes for younger athletes across different ages.

Assessment of Sleep Quantity and Sleep Disturbances During Recovery From Sports-Related Concussion in Youth Athletes

OBJECTIVE

To determine the relation between sleep quantity and sleep disturbances on symptoms and neurocognitive ability during the acute phase (<7d) and after sports-related concussion (SRC; >21d).

DESIGN

Prospective inception cohort study.

SETTING

General community setting of regional middle and high schools.

PARTICIPANTS

A sample (N=971) including youth athletes with SRC (n=528) and controls (n=443) (age, 10-18y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Athletes completed the Immediate Post-Concussion Assessment and Cognitive Testing battery. Partial correlation analyses and independent t tests were conducted to assess sleep quantity the night before testing. Multivariate analysis of covariance was used to assess sleep disturbances and their interaction with age.

RESULTS

Less sleep quantity was correlated with greater report of cognitive (P=.001) and neuropsychological (P=.024) symptoms specific to prolonged recovery from SRC. Sleep disturbances significantly affect each migraine, cognitive, and neuropsychological symptoms (P<.001). A significant interaction was found between sleep disturbances and age (P=.04) at >21 days post-SRC.

CONCLUSIONS

Findings emphasize that the continued presence of low sleep quantity and sleep disturbances in youth athletes with SRC should be a specific indicator to health professionals that these athletes are at an increased risk of protracted recovery. Further research should identify additional factors that may interact with sleep to increase the risk of protracted recovery.

Differences in Activation and Deactivation in Children with Sickle Cell Disease Compared with Demographically Matched Controls

BACKGROUND AND PURPOSE

Declines in both functional activation and functional connectivity have been reported in patients with sickle cell disease. In this study, we derived the functional and default mode responses to a word stem paradigm in age-, ethnicity-, and background-matched subjects with sickle cell disease and control groups, with the aim of testing whether both networks were similarly attenuated and whether the changes were related to physiologic parameters that characterize sickle cell disease.

MATERIALS AND METHODS

Both the functional and default mode responses were obtained from age- and background-matched controls and the sickle cell population by using a visually presented word stem paradigm on a 3T scanner.

RESULTS

We observed an attenuated response to both activation and deactivation in the sickle cell disease group. There were no significant differences in the activation response between the 2 groups for the contrast control > sickle cell disease; however, significant differences were observed in the medial parietal cortex, the auditory cortex, and the angular gyrus for the default mode. For the sickle cell group, a significant correlation between the activation z scores and the physiologic parameters was observed; for the deactivation, the results were not significant but the trend was similar.

CONCLUSIONS

The results indicate that the physiologic parameters modulate the activation in the expected fashion, but that the effect was weaker for deactivation. Given that significant differences between the 2 groups were only seen for deactivation, additional factors must modulate the deactivation in sickle cell disease.

Quality Improvement in Concussion Care: Influence of Guideline-Based Education

OBJECTIVE

To evaluate the potential impact of a concussion management education program on community-practicing pediatricians.

STUDY DESIGN

We prospectively surveyed 210 pediatricians before and 18 months after participation in an evidence-based, concussion education program. Pediatricians were part of a network of 38 clinically integrated practices in metro-Atlanta. Participation was mandatory for at least 1 pediatrician in each practice. We assessed pediatricians' self-reported concussion knowledge, use of guidelines, and comfort level, as well as self-reported referral patterns for computed tomography (CT) and/or emergency department (ED) evaluation of children who sustained concussion.

RESULTS

Based on responses from 120 pediatricians participating in the 2 surveys and intervention (response rate, 57.1%), the program had significant positive effects from pre- to postintervention on knowledge of concussions (-0.26 to 0.56 on -3 to +1 scale; P < .001), guideline use (0.73-.06 on 0-6 scale; P < .01), and comfort level in managing concussions (3.76-4.16 on 1-5 scale; P < .01). Posteducation, pediatricians were significantly less likely to self-report referral for CT (1.64-1.07; P < .001) and CT/ED (4.73-3.97; P < .01), but not ED referral alone (3.07-3.09; P = ns).

CONCLUSIONS

Adoption of a multifaceted, evidence-based, education program translated into a positive modification of self-reported practice behavior for youth concussion case management. Given the surging demand for community-based youth concussion care, this program can serve as a model for improving the quality of pediatric concussion management.

Development of user-friendly and interactive data collection system for cerebral palsy

Cerebral palsy (CP) is a permanent motor disorder that appears in early age and it requires multiple tests to assess the physical and mental capabilities of the patients. Current medical record data collection systems, e.g., EPIC, employed for CP are very general, difficult to navigate, and prone to errors. The data cannot easily be extracted which limits data analysis on this rich source of information. To overcome these limitations, we designed and prototyped a database with a graphical user interface geared towards clinical research specifically in CP. The platform with MySQL and Java framework is reliable, secure, and can be easily integrated with other programming languages for data analysis such as MATLAB. This database with GUI design is a promising tool for data collection and can be applied in many different fields aside from CP to infer useful information out of the vast amount of data being collected.

Sex-Based Differences as a Predictor of Recovery Trajectories in Young Athletes After a Sports-Related Concussion

BACKGROUND

To date, few studies have delineated clear sex-based differences in symptom resolution after a sports-related concussion (SRC), and equivocal results have been identified in sex-based differences on baseline assessments.

PURPOSE

To assess whether female athletes displayed prolonged recovery and more symptoms at baseline and after an SRC compared with male athletes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The current study assessed 135 male and 41 female athletes (10-18 years old) who participated in high-impact sports in metropolitan Atlanta middle and high schools. All athletes completed a baseline assessment and at least 1 postconcussion assessment from the Immediate Post-Concussion Assessment and Cognitive Testing battery. Longitudinal hierarchical linear modeling was employed to examine individual-level variables and their associations with adolescents' rates of recovery in concussive symptoms after controlling for age and number of prior concussions.

RESULTS

Aggregate symptoms were rated as higher in female athletes compared with male athletes at baseline (mean ± SD: females, 13.49 ± 11.20; males, 4.88 ± 8.74; F(1,175) = 10.59, P < .001) and immediately after a concussion (females: 16.75 ± 18.08; males: 10.58 ± 14.21; F(1,175) = 3.99, P = .05). There were no group differences in the slope of recovery between male and female athletes, indicating generally similar trajectories of change for both groups. Post hoc analyses revealed higher baseline levels of migraine and neuropsychological symptoms in female athletes.

CONCLUSION

Although female athletes in the current study reported increased symptoms, identical recovery patterns were observed in both sexes, suggesting that sex-based differences in concussion recovery are better explained by increased symptom frequency among female athletes when compared with their male counterparts.

Wechsler Intelligence Scale for Children-V: Test Review

Changes from the fourth edition of the Wechsler Intelligence Scale for Children (WISC) to the fifth edition are discussed, with particular emphasis on how the electronic administration facilitated assessment. The hierarchical organization and conceptualization of primary indices have been adjusted, based on recent theory and research on the construct of intelligence. Changes also include updates to psychometric properties and consideration of cultural bias. The scoring program allows intelligence scores to be linked statistically to achievement measures to aid in diagnoses of learning disabilities. Electronic assessment was clunky at times but overall delivered on its promise of quicker and more accurate administration and scoring.

Neurocognitive improvements following endovascular repair of vein of Galen malformation in a child

Cognitive regression is a well-described presentation of vein of Galen aneurysmal malformations (VGAMs) in childhood. However, it remains unclear whether successful treatment of the malformation can reverse cognitive regression. Here, the authors present the case of a 5-year-old girl with a VGAM that was treated with staged endovascular embolization procedures. Comprehensive neurocognitive assessments were completed before intervention and approximately 6 years after initial presentation. There were significant age-matched improvements in this child's neurocognitive profile over this period. The authors believe that timely and successful treatment of VGAM in children may not only stabilize the associated cognitive deterioration but, in some cases, may ameliorate these deficits. Details of this case and a discussion of neurocognitive deficits related to VGAM are presented.

Pediatric sports specific return to play guidelines following concussion

PURPOSE/BACKGROUND

In 2010, the American Academy of Pediatrics officially adopted the recommended return to play guidelines proposed by the International Conference on Concussion in Sport. The guidelines include a six-step process that provides structure to guide an athlete who is recovering from a concussion in a gradual return to play (RTP) by allowing participation in increasingly difficult physical activities. Unfortunately, the guidelines fail to take into account the variability that occurs within different sports and the resulting challenges medical professionals face in making sure each athlete is able to withstand the rigors of their specific sport, without return of symptoms. Therefore, the purpose of this clinical commentary is to expand upon the current general consensus guidelines for treatment of concussed pediatric athletes and provide sport specific RTP guidelines.

DESCRIPTION OF TOPIC

The intention of the sport specific guidelines is to maintain the integrity of the current six-step model, add a moderate activity phase highlighted by resistance training, and to provide contact and limited contact drills specific to the athlete's sport and/or position. The drills and activities in the proposed seven-step programs are designed to simulate sport specific movements; the sports include: football, gymnastics, cheerleading, wrestling, soccer, basketball, lacrosse, baseball, softball, and ice hockey. These activities will provide sports specific challenges to each athlete while simultaneously accomplishing the objectives of each stage of the RTP progression. The final RTP determination should occur with documented medical clearance from a licensed healthcare provider who has been trained in the evaluation and management of concussions.

DISCUSSION/RELATION TO CLINICAL PRACTICE

There have been significant strides in the management and care of concussed athletes. However, there continues to be a lot of confusion among, athletes, parents, and coaches regarding the proper management of an athlete with a concussion, particularly in the pediatric population. In an effort to eliminate ambiguity and help further promote adherence to the RTP guidelines, the authors developed several sports-specific RTP guidelines.

LEVEL OF EVIDENCE

5.

CHOA concussion consensus: establishing a uniform policy for academic accommodations

Concussion research generally centers on physical challenges, though aspects such as social functioning and returning to school also warrant attention in pediatric populations. Restoring academic performance postconcussion remains a challenge. Here we provide recommendations addressing a uniform policy for pediatric concussion patients in academic institutions. Tools that may minimize difficulty with academic re-entry include independent educational evaluations, individualized educational programs (IEPs), student support teams (SSTs), letters of academic accommodation, time off, and 504 Plans. Recognition and treatment is crucial for symptom relief and prevention of functional disruption, as is specialist referral during the acute window. We recommend early intervention with a letter of academic accommodation and SST and suggest that 504 Plans and IEPs be reserved for protracted or medically complicated cases. Students with concussion should be observed for anxiety and depression because these symptoms can lead to prolonged recovery, decreased quality of life, and other social challenges.

Mining Association Rules for Neurobehavioral and Motor Disorders in Children Diagnosed with Cerebral Palsy

Children diagnosed with cerebral palsy (CP) appear to be at high risk for developing neurobehavioral and motor disorders. The most common disorders for these children are impaired visual-perception skills and motor planning. Besides, they often have impaired executive functions, which can contribute to problematic emotional adjustment such as depression. Additionally, literature suggests that the tendency to develop these cognitive impairments and emotional abnormalities in pediatric CP is influenced by age and IQ. Because there are many other medical co-morbidities that can occur with CP (e.g., seizures and shunt placement), prediction of what percentages of patients will incur cognitive impairment and emotional abnormality is a difficult task. The purpose of this study was to investigate the associations between possible factors mentioned above, and neurobehavioral and motor disorders from a clinical database of pediatric subjects diagnosed with CP. The study resulted in 22 rules that can predict negative outcomes. These rules reinforced the growing body of literature supporting a link between CP, executive dysfunction, and subsequent neurobehavioral problems. The antecedents and consequents of some association rules were single factors, while other statistical associations were interactions of factor combinations. Further research is needed to include children's comprehensive treatment and medication history in order to determine additional impacts on their neurobehavioral and motor disorders.

White matter damage in asymptomatic patients with sickle cell anemia: screening with diffusion tensor imaging

BACKGROUND AND PURPOSE

Ischemic injury to the brain is a common complication of SCA. To better understand the neurologic impact of SCA, TBSS were applied to DTI data to investigate white matter injuries in pediatric patients with SCA.

MATERIALS AND METHODS

TBSS comparisons of a range of anisotropy and diffusion measures were carried out between age- and background-matched population groups: patients with SCA with no visible lesions, patients with SCA with mild gliosis, and normal controls.

RESULTS

TBSS analysis revealed that both SCA populations exhibited reduced anisotropy and increased diffusivity compared with normal controls in multiple brain regions, including the corpus callosum and centrum semiovale. Furthermore, the results suggest that the severity of SCA is positively correlated with the white matter changes in the corpus callosum.

CONCLUSIONS

The study demonstrates that TBSS is a viable technique in detecting subtle white matter damage in patients with SCA whose conventional anatomic MR imaging scans show no, or minimal, abnormalities and has the potential to evaluate the neurologic impact of the treatment of SCA.

Age association of language task induced deactivation induced in a pediatric population

Task-induced deactivation (TID) potentially reflects the interactions between the default mode and task specific networks, which are assumed to be age dependent. The study of the age association of such interactions provides insight about the maturation of neural networks, and lays out the groundwork for evaluating abnormal development of neural networks in neurological disorders. The current study analyzed the deactivations induced by language tasks in 45 right-handed normal controls aging from 6 to 22 years of age. Converging results from GLM, dual regression and ROI analyses showed a gradual reduction in both the spatial extent and the strength of the TID in the DMN cortices as the brain matured from kindergarten to early adulthood in the absence of any significant change in task performance. The results may be ascribed to maturation leading to either improved multi-tasking (i.e. reduced deactivation) or reduced cognitive demands due to greater experience (affects both control and active tasks but leads to reduced overall difference). However, other effects, such as changes in the DMN connectivity that were not included in this study may also have influenced the results. In light of this, researchers should be cautious when investigating the maturation of DMN using TID. With a GLM analysis using the concatenated fMRI data from several paradigms, this study additionally identified an age associated increase of TID in the STG (bilateral), possibly reflecting the role of this area in speech perception and phonological processing.

Adaptor protein complex-4 (AP-4) deficiency causes a novel autosomal recessive cerebral palsy syndrome with microcephaly and intellectual disability

BACKGROUND

Cerebral palsy is a heterogeneous group of neurodevelopmental brain disorders resulting in motor and posture impairments often associated with cognitive, sensorial, and behavioural disturbances. Hypoxic-ischaemic injury, long considered the most frequent causative factor, accounts for fewer than 10% of cases, whereas a growing body of evidence suggests that diverse genetic abnormalities likely play a major role.

METHODS AND RESULTS

This report describes an autosomal recessive form of spastic tetraplegic cerebral palsy with profound intellectual disability, microcephaly, epilepsy and white matter loss in a consanguineous family resulting from a homozygous deletion involving AP4E1, one of the four subunits of the adaptor protein complex-4 (AP-4), identified by chromosomal microarray analysis.

CONCLUSION

These findings, along with previous reports of human and mouse mutations in other members of the complex, indicate that disruption of any one of the four subunits of AP-4 causes dysfunction of the entire complex, leading to a distinct 'AP-4 deficiency syndrome'.

Higher order factor structure of the WISC-IV in a clinical neuropsychological sample

A confirmatory factor analysis was conducted examining the higher order factor structure of the WISC-IV scores for 344 children who participated in neuropsychological evaluations at a large children's hospital. The WISC-IV factor structure mirrored that of the standardization sample. The second order general intelligence factor (g) accounted for the largest proportion of variance in the first-order latent factors and in the individual subtests, especially for the working memory index. The first-order processing speed factor exhibited the most unique variance beyond the influence of g. The results suggest that clinicians should not ignore the contribution of g when interpreting the first-order factors.

Carbonic anhydrase-inhibiting medications and the intracarotid amobarbital procedure in children

The intracarotid amobarbital procedure (IAP) is routinely conducted as part of the presurgical evaluation of pediatric patients with epilepsy. The aim of the present study was to investigate the possibility that anesthetization failures are the result of interactions of carbonic anhydrase-inhibiting (CAI) medications with sodium amobarbital. An archival review of 81 cases conducted between 1999 and 2008 was performed across two pediatric epilepsy centers. chi(2) analysis was used to assess whether CAI medications interfered with the outcome of these procedures. Of 81 patients, 85.2% had conclusive findings. All of the remaining 14.8% with anesthetization failures were taking CAI medications at the time of the procedure. However, 53.8% of patients taking CAI medications had conclusive results. This suggests that these medications may interact with sodium amobarbital, raising the possibility of anesthetization failures in children prescribed CAI medications.

Regionally specific cortical thinning in children with sickle cell disease

Sickle cell disease (SCD) is a chronic disease with a significant rate of neurological complications in the first decade of life. In this retrospective study, cortical thickness was examined in children with SCD who had no detectable abnormalities on conventional magnetic resonance imaging/magnetic resonance angiography. Regional differences in cortical thickness from SCD were explored using age-matched healthy controls as comparison. A comparison analysis was done for SCD (n = 28) and controls (n = 29) based on age (5-11; 12-21 years), due to the age-dependent variation in cortex maturation. Distinct regions of thinning were found in SCD patients in both age groups. The number, spatial extent, and significance (P < 0.001) of these areas of thinning were increased in the older SCD group. Regions of interest (ROIs) were defined on the areas of highly significant thinning in the older group and then mapped onto the younger cohort; a multiparametric linear regression analysis of the ROI data demonstrated significant (P < 0.001) cortical thinning in SCD subjects, with the largest regions of thinning in the precuneus and the posterior cingulate. The regionally specific differences suggest that cortical thickness may serve as a marker for silent insults in SCD and hence may be a useful tool for identifying SCD patients at risk for neurological sequelae.

Performance of Children with Epilepsy and Normal Age-Matched Controls on the WISC-III

Research findings regarding the effects of childhood epilepsy on general intelligence have produced variable results. The aim of this study was to investigate the effects of epilepsy, age of seizure onset, and Antiepileptic Drugs (AED) on intellectual ability as assessed by the Wechsler Intelligence Scale for Children, 3rd Edition (WISC-III; Wechsler, 1991). This study included children with epilepsy assessed with the WISC-III who achieved either a Full Scale, Verbal Scale, or Performance Scale IQ score >or= 70. A clinical sample of children diagnosed with epilepsy (n = 32) were age- and gender-matched with subjects from the normative standardization sample for the WISC-III, yielding a total sample of 64 subjects. Comparison using a MANOVA revealed significant differences across WISC-III Index standard scores (p = 0.0005) and subtest scaled scores (p = 0.0013), with control participants performing better than epileptic participants. Secondary analyses were also conducted considering monotherapy (n = 14) versus polytherapy (n = 11), and age of seizure onset (<6 years, n = 12; 6 > years, n = 15). MANOVA comparisons revealed no significant differences between groups across WISC-III Index standard scores.

A Comparison of Children with Epilepsy to an Age- and IQ-Matched Control Group on the Children's Memory Scale

Past research has found that children with epilepsy exhibit decreased memory skills. In addition, some studies have found that children with epilepsy obtain significantly lower IQ scores than controls. In an effort to examine whether children with epilepsy have specific memory weaknesses versus global cognitive difficulties, the present study compared the performance of 62 children (age range = 6-16 years). Thirty-one children with epilepsy were compared to 31 age- and IQ-matched controls on the Children's Memory Scale (CMS) to determine whether differences in memory skills persist when IQ is matched. An independent t-test comparing index and scaled scores was performed. The results indicated that with the exception of the Word Pairs subtest (p < .01), children with epilepsy did not differ significantly on the CMS subtests when IQ was matched. This suggests that list-learning paradigms may be particularly sensitive to memory impairments in children with epilepsy and/or that children with epilepsy have more global cognitive impairments.

Relationship of surgical approach to neurodevelopmental outcomes in hypoplastic left heart syndrome

OBJECTIVE

Two strategies for surgical management are used for infants with hypoplastic left heart syndrome (HLHS), primary heart transplantation and the Norwood procedure. We sought to determine how these 2 surgical approaches influence neurodevelopmental outcomes at school age.

METHODS

A multicenter, cross-sectional study of neurodevelopmental outcomes among school-aged children (>8 years of age) with HLHS was undertaken between July 2003 and September 2004. Four centers enrolled 48 subjects, of whom 47 completed neuropsychologic testing. Twenty-six subjects (55%) had undergone the Norwood procedure and 21 (45%) had undergone transplantation, with an intention-to-treat analysis. The mean age at testing was 12.4 +/- 2.5 years. Evaluations included the Wechsler Abbreviated Scale of Intelligence, Clinical Evaluation of Language Fundamentals, Wechsler Individual Achievement Test, and Beery-Buktenica Developmental Test of Visual-Motor Integration.

RESULTS

The mean neurocognitive test results were significantly below population normative values. The mean full-scale IQ for the entire cohort was 86 +/- 14. In a multivariate model, there was no association of surgical strategy with any measure of developmental outcome. A longer hospital stay, however, was associated significantly with lower verbal, performance, and full-scale IQ scores. Aortic valve atresia was associated with lower math achievement test scores.

CONCLUSIONS

Neurodevelopmental deficits are prevalent among school-aged children with HLHS, regardless of surgical approach. Complications that result in prolonged hospitalization at the time of the initial operation are associated with neurodevelopmental status at school age.

Surgical treatment of epilepsy in children caused by focal cortical dysplasia

Focal cortical dysplasia (FCD) is a congenital disorder of neuronal migration that is increasingly recognized as a common cause of seizures in children, occurring in 20-30% of all surgically treated cases of epilepsy in the pediatric population. Advances in neuroimaging have contributed to recognition of FCD. We report 15 children (9 female, 6 male) with FCD and surgically treated intractable epilepsy. In 9 cases, a surgical strategy of anatomic (frameless stereotactic) grid placement and physiologic (electrocorticography) resection was employed. Postoperative MRI scans were obtained, the pathologic specimen was graded according to the Brannstrom system, and seizure outcome was defined using the Engel classification. There were no deaths and no permanent morbidity. After, on average, 4 years since treatment, 10 children are seizure free, 2 are 2A, 2 are 2B and 1 is 3A. Predictors of good outcome are an MRI-defined lesion and increased cortical disorganization (higher Brannstrom grade). Subtotal resection did not preclude a seizure-free outcome.

A randomized, double-blind, placebo-controlled trial of single-dose intravenous secretin as treatment for children with autism

OBJECTIVE

To determine whether a single injection of intravenous secretin results in measurable improvements in socialization and/or communication skills in children with autism.

STUDY DESIGN

Sixty subjects with autism were randomly selected and assigned to either treatment or placebo group. Subjects in the treatment group received 2.0 clinical units of secretin per kilogram of body weight as a single intravenous dose. Subjects in the placebo group received normal saline solution. Neurodevelopmental and behavioral assessments were performed for all subjects before injection and at 3 and 6 weeks after injection.

RESULTS

Assessment of language skills and parents' behavioral assessments revealed no significant differences between the treatment and placebo groups. Raters' assessments of severity of autistic symptoms did not differ for the 2 groups at 6 weeks after injection. A marginally statistically significant improvement in autistic behaviors was seen in the treatment group at 3 weeks after injection (P =.051).

CONCLUSIONS

A single dose of intravenous secretin does not appear to have significant effects on either parents' perception of autistic behaviors or language skills at 6 weeks after injection. Transient, marginally significant improvements in autistic behaviors may occur in some children.

Scheduled feeding and 24-hour rhythms of N-acetylserotonin and melatonin in rats

Male rats, kept under a lighting condition of 14-h light, 10-h dark, were subjected to scheduled feeding regimens. Food was available either in the early light phase or the early dark phase. The 24-h rhythms of serum corticosterone and of N-acetylserotonin (NAS) and melatonin (MT) in the pineal and serum were determined. It was found that whereas serum corticosterone and NAS rhythms responded to the feeding schedules, the rhythms of pineal NAS and of serum and pineal MT remained synchronized with the light-dark cycle. These findings indicated that the pineal was not the major source of circulating NAS. Whereas environmental lighting was the dominant "Zeitgeber" for the NAS rhythms in the pineal and the MT rhythms in the pineal and serum, for serum NAS rhythm, food presentation was the stronger Zeitgeber.

Behavioral effects of 5-hydroxy-N-acetyltryptophan, a putative synthetic precursor of N-acetylserotonin

1. Adult male rats were injected with either 5-hydroxy-N-acetyltryptophan (5-OHNAT), a synthetic putative precursor of N-acetylserotonin, or 5-hydroxytryptophan (5-HTP), the serotonin precursor, and behavioral effects were observed. Pretreatment consisted of carbidopa and nialamide. 2. The behavioral effects of systemic injections of 5-OHNAT and 5-HTP were qualitatively similar i.e. head weaving, forepaw treading, etc., but the effect of 5-OHNAT was appreciably delayed in onset. 3. 5-OHNAT loading may cause an increase in central nervous system 5-HT via initial deacetylation to 5-HTP. Alternatively, 5-OHNAT may cause a delayed increase in brain NAS and the "serotonin syndrome" may reflect increased conversion of 5-HT to NAS.