Capturing neuroplastic changes after bimanual intensive rehabilitation in children with unilateral spastic cerebral palsy: A combined DTI, TMS and fMRI pilot study.

Intensive rehabilitation interventions have been shown to be efficacious in improving upper extremity function in children with unilateral spastic cerebral palsy (USCP). These interventions are based on motor learning principles and engage children in skillful movements. Improvements in upper extremity function are believed to be associated with neuroplastic changes. However, these neuroplastic changes have not been well-described in children with cerebral palsy, likely due to challenges in defining and implementing the optimal tools and tests in children. Here we documented the implementation of three different neurological assessments (diffusion tensor imaging-DTI, transcranial magnetic stimulation-TMS and functional magnetic resonance imaging-fMRI) before and after a bimanual intensive treatment (HABIT-ILE) in two children with USCP presenting differential corticospinal developmental reorganization (ipsilateral and contralateral). The aim of the study was to capture neurophysiological changes and to document the complementary relationship between these measures, the potential measurable changes and the feasibility of applying these techniques in children with USCP. Independent of cortical reorganization, both children showed increases in activation and size of the motor areas controlling the affected hand, quantified with different techniques. In addition, fMRI provided additional unexpected changes in the reward circuit while using the affected hand.

Classification of non-demented patients attending a memory clinic using the new diagnostic criteria for Alzheimer's disease with disease-related biomarkers.

BACKGROUND: New diagnostic criteria for predemential Alzheimer's disease (AD) advocate the use of biomarkers. However, the benefit of using biomarkers has not been clearly demonstrated in clinical practice. OBJECTIVE: To investigate whether a combination of biomarkers may be helpful in classifying a population of non-demented patients attending a Memory Clinic. METHODS: Sixty non-demented patients were compared with 31 healthy elderly subjects. All subjects underwent a neuropsychological examination, brain 3T magnetic resonance imaging, [F18]-fluorodeoxyglucose and [F18]-flutemetamol positron emission tomography. According to their performance on memory, language, executive, and visuo-spatial domains, the patients were classified as mild cognitive impairment (amnestic, non-amnestic, single, or multiple domain) or subjective cognitive impairment. Patients were then classified according to the National Institute on Aging-Alzheimer's Association (NIA-AA) criteria, using the normalized mean hippocampal volume (Freesurfer), [F18]-FDG PALZAD, and [F18]-flutemetamol standard uptake value ratio (SUVr) (cut-off at the 10th percentile of controls). The standard of truth was the clinical status at study entry (patient versus control). RESULTS: The sensitivity/specificity of the clinical classification was 65/84%. The NIA-AA criteria were applicable in 85% of patients and 87% of controls. For biomarkers the best sensitivity (72%) at a fixed specificity of 84% was achieved by a combination of the three biomarkers. The clinical diagnosis was reconsidered in more than one third of the patients (42%) as a result of including the biomarker results. CONCLUSIONS: Application of the new NIA-AA AD diagnostic criteria based on biomarkers in an unselected sample of non-demented patients attending a Memory Clinic was useful in allowing for a better classification of the subjects.

Neural correlates of the numerical distance effect in children.

In number comparison tasks, the performance is better when the distance between the numbers to compare increases. It has been shown that this so-called numerical distance effect (NDE) decreases with age but the neuroanatomical correlates of these age-related changes are poorly known. Using functional magnetic resonance imaging (fMRI), we recorded the brain activity changes in children aged from 8 to 14 years while they performed a number comparison task on pairs of Arabic digits and a control color comparison task on non-numerical symbols. On the one hand, we observed developmental changes in the recruitment of frontal regions and the left intraparietal sulcus (IPS), with lower activation as age increased. On the other hand, we found that a behavioral index of selective sensitivity to the NDE was positively correlated with higher brain activity in a right lateralized occipito-temporo-parietal network including the IPS. This leads us to propose that the left IPS would be engaged in the refinement of cognitive processes involved in number comparison during development, while the right IPS would underlie the semantic representation of numbers and its activation would be mainly affected by the numerical proximity between them.

Extensive left temporal pole damage does not impact on theory of mind abilities.

The temporal poles (TPs) are among the brain regions that are often considered as the brain network sustaining our ability to understand other people's mental states or "Theory of Mind" (ToM). However, so far the functional role of the left and right TPs in ToM is still debated, and it is even not clear yet whether these regions are necessary for ToM. In this study, we tested whether the left TP is necessary for ToM by assessing the mentalizing abilities of a patient (C.M.) diagnosed with semantic dementia. Converging evidence from detailed MRI and (18)F-fluoro-2-deoxy-d-glucose PET examinations showed a massive atrophy of the left TP with the right TP being relatively unaffected. Furthermore, C.M.'s atrophy encompassed most regions of the left TP usually activated in neuroimaging studies investigating ToM. Given C.M.'s language impairments, we used a battery of entirely nonverbal ToM tasks. Across five tasks encompassing 100 trials, which probed the patient's ability to attribute various mental states (intentions, knowledge, and beliefs), C.M. showed a totally spared performance. This finding suggests that, despite its consistently observed activation in neuroimaging studies involving ToM tasks, the left TP is not necessary for ToM reasoning, at least in nonverbal conditions and as long as its right counterpart is preserved. Implications for understanding the social abilities of patients with semantic dementia are discussed.

Partly reversible central auditory dysfunction induced by cerebral vasospasm after subarachnoid hemorrhage.

The authors describe a rare case of central auditory dysfunction induced by cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). A 55-year-old woman who was admitted after aneurysmal SAH developed cerebral vasospasm on Day 3 affecting mainly the right middle cerebral artery (MCA) and partly the left MCA. The vasospasm became refractory to conventional therapy and was ultimately improved by intraarterial infusion of nimodipine in the right MCA and angioplasty. Severe auditory dysfunction was apparent from Day 10 as the patient was not reactive to speech or environmental sounds. Brain MRI on Day 17 demonstrated infarcted areas mainly in the right hippocampus, medial occipital lobe, and thalamus. The patient underwent further examination using audiometry, speech testing, auditory evoked potentials, functional MRI, and cerebral PET. The initial diagnosis was extended nonverbal agnosia and total pure word deafness. The central auditory dysfunction improved over 6 months, with persisting hyperacusis, tinnitus, and amusia. Central auditory dysfunction is a rare complication after SAH. While cortical deafness may be associated with bilateral lesions of the temporal cortex, partly reversible central auditory dysfunction was observed in this patient after prominently unilateral right temporal lesions. The role of the interthalamic connections can be discussed, as well as the possibility that a less severe vasospasm on the left MCA could have transiently impaired the left thalamocortical auditory pathways.

Right occipital cortex activation correlates with superior odor processing performance in the early blind.

Using functional magnetic resonance imaging (fMRI) in ten early blind humans, we found robust occipital activation during two odor-processing tasks (discrimination or categorization of fruit and flower odors), as well as during control auditory-verbal conditions (discrimination or categorization of fruit and flower names). We also found evidence for reorganization and specialization of the ventral part of the occipital cortex, with dissociation according to stimulus modality: the right fusiform gyrus was most activated during olfactory conditions while part of the left ventral lateral occipital complex showed a preference for auditory-verbal processing. Only little occipital activation was found in sighted subjects, but the same right-olfactory/left-auditory-verbal hemispheric lateralization was found overall in their brain. This difference between the groups was mirrored by superior performance of the blind in various odor-processing tasks. Moreover, the level of right fusiform gyrus activation during the olfactory conditions was highly correlated with individual scores in a variety of odor recognition tests, indicating that the additional occipital activation may play a functional role in odor processing.

Cerebral embolization during percutaneous valve implantation does not occur during balloon inflation valvuloplasty: prospective diffusion-weighted brain MRI study.

BACKGROUND AND AIM OF THE STUDY: The study aim was to define the timing of cerebral embolization events during transcatheter aortic valve implantation (TAVI), and to determine if events were more closely associated with valve implantation or with balloon inflation. METHODS: Between January 2008 and November 2011, a total of 114 patients underwent TAVI at the author's institution. Of these patients, 44 had previously undergone imaging before and after TAVI, and were included in the study (26 transfemoral (TF); 18 transapical (TA)). Eleven patients who had only balloon valvuloplasty (BV) during the same period were included, as were 22 patients who had open aortic valve replacement (AVR), as controls. All 77 patients underwent neurological examination, and all had cerebral MRIs before and after their procedures. RESULTS: Fifty of the 77 patients who underwent postprocedural MRI had new cerebral lesions, as follows: 24/26 (92%) in TF patients; 17/18 (94%) in TA patients; 3/11 (27%) in BV patients; and 6/22 (27%) in AVR patients (TF and TA versus BV and AVR, p < 0.0001). The mean number and volume of embolic lesions per patient were respectively 5.4/438 mm3 for TF, 11.6/3414 mm3 for TA, 0.7/46 mm3 for BV, and 0.4/48 mm3 for AVR (TF versus TA and BV versus AVR, p = NS; TF and TA versus BV and AVR, p < 0.0001). No association was found between either the EuroSCORE or patient age and the number of events. CONCLUSION: In the present study, an incidence of silent cerebral embolic lesions after TAVI was identified which was significantly higher than that for BV or AVR. This indicated an association of embolism with valve implantation rather than with balloon inflation.

Immediate post-operative MRI suggestive of the site and timing of glioblastoma recurrence after gross total resection: a retrospective longitudinal preliminary study.

OBJECTIVES: To retrospectively identify morphological and physiological post-operative magnetic resonance imaging (MRI) characteristics predictive of glioblastoma recurrences after gross total resection (gross-TR). METHODS: Resection margins of 24 glioblastoma were analysed immediately post-operatively (MRI ≤ 2 h) and early post-operatively (24 h ≤ MRI ≤ 48 h), and subdivided into areas with and without subtle contrast enhancement previously considered non-specific. On follow-up MRI, tumour regrowth areas were subdivided according to recurrence extent (focally/extended) and delay (≤6 and ≥12 months). Co-registration of pre-operative, immediately post-operative and early post-operative MRI with the first follow-up MRI demonstrating recurrence authorised their morphological (contrast enhancements) and physiological (rCBV) characterisation. RESULTS: Morphologically, on immediately post-operative MRI, micro-nodular and frayed enhancements correlate significantly with early recurrences (≤6 months). After gross-TR the absence of these enhancements is associated with a significant increase in progression-free survival (61 vs 15 weeks respectively) and overall survival (125 vs 51 weeks respectively). Physiologically, areas with a future focal recurrence have a trend toward higher rCBV than other areas. CONCLUSION: Immediately post-operative topography of micro-nodular and frayed enhancements is suggestive of recurrence location and delay. Absence of such enhancements is associated with a fourfold increase in progression-free survival and a 2.5-fold increase in overall survival. KEY POINTS: • Immediately post-operative MRI reveals contrast enhancement after glioblastoma gross total resection. • Immediately post-operative micro-nodular and frayed enhancement correlate with early recurrence. • Absence of micro-nodular/frayed enhancement is associated with 61 weeks' progression-free survival. • Absence of micro-nodular/frayed enhancement is associated with 125 weeks' overall survival.

The neural network sustaining crossmodal integration is impaired in alcohol-dependence: an fMRI study.

INTRODUCTION: Crossmodality (i.e., the integration of stimulations coming from different sensory modalities) is a crucial ability in everyday life and has been extensively explored in healthy adults. Still, it has not yet received much attention in psychiatry, and particularly in alcohol-dependence. The present study investigates the cerebral correlates of crossmodal integration deficits in alcohol-dependence to assess whether these deficits are due to the mere accumulation of unimodal impairments or rather to specific alterations in crossmodal areas. METHODS: Twenty-eight subjects [14 alcohol-dependent subjects (ADS), 14 paired controls] were scanned using fMRI while performing a categorization task on faces (F), voices (V) and face-voice pairs (FV). A subtraction contrast [FV-(F+V)] and a conjunction analysis [(FV-F) ∩ (FV-V)] isolated the brain areas specifically involved in crossmodal face-voice integration. The functional connectivity between unimodal and crossmodal areas was explored using psycho-physiological interactions (PPI). RESULTS: ADS presented only moderate alterations during unimodal processing. More centrally, in the subtraction contrast and conjunction analysis, they did not show any specific crossmodal brain activation while controls presented activations in specific crossmodal areas (inferior occipital gyrus, middle frontal gyrus, superior parietal lobule). Moreover, PPI analyses showed reduced connectivity between unimodal and crossmodal areas in alcohol-dependence. CONCLUSIONS: This first fMRI exploration of crossmodal processing in alcohol-dependence showed a specific face-voice integration deficit indexed by reduced activation of crossmodal areas and reduced connectivity in the crossmodal integration network. Using crossmodal paradigms is thus crucial to correctly evaluate the deficits presented by ADS in real-life situations.

Brain plasticity and cortical correlates of osseoperception revealed by punctate mechanical stimulation of osseointegrated oral implants during fMRI.

PURPOSE: Our aim was to unveil the cortical neural correlates of osseoperception, i.e. the tactile sensation perceived when loading a bone-anchored implant, by taking oral implants as a model. This was performed in a cross-sectional observational study with 9 volunteering patients and 10 age-matched controls. For each patient, functional magnetic resonance imaging (fRMI) recordings were made during punctate mechanical stimulation of either teeth or osseointegrated implants in the maxillary incisor area. MATERIALS AND METHODS: During fMRI recordings, 1 Hz punctate tactile stimuli were applied either on a maxillary left central incisor, canine tooth or central incisor implant. A block design paradigm was used to stimulate, in 9 patients, maxillary left central incisor implants (I21-p) and maxillary left canines (T23-p). In 10 control subjects, maxillary left central incisors and canines (T21-c, T23-c) were stimulated. Random effect group analyses were performed for each stimulated site, and differences in cortical activity elicited when loading teeth or implants were examined using ANOVA. RESULTS: As a group, patients activated somatosensory area S2 bilaterally for both I21 and T23, while controls activated S1 and S2 bilaterally for T21 and T23. At an individual level, S1 was activated by 4/9 implants, mainly on the ipsilateral side. The stimulated implants activated a larger bilateral cortical network outside the somatosensory areas: in parietal, frontal and insular lobes, the main clusters being located in the inferior frontal gyri. Stimulation of T23 in patients resulted in an activation pattern intermediate between that of the implants and that of natural teeth. CONCLUSION: This study demonstrates that punctate mechanical stimulation of oral implants activates both primary and secondary cortical somatosensory areas. It also suggests that brain plasticity occurs when extracted teeth are replaced by endosseous implants. This cortical activation may represent the underlying mechanism of osseoperception.

Associative encoding deficits in amnestic mild cognitive impairment: a volumetric and functional MRI study.

BACKGROUND: Previous functional MRI studies have shown increased hippocampus activation in response to item encoding in amnestic mild cognitive impairment (aMCI). Recent behavioral studies suggested that associative memory could be more impaired than item memory in aMCI. So far, associative encoding has not been evaluated separately from item encoding in functional MRI studies. METHODS: We conducted a volumetric and functional MRI study investigating associative encoding in 16 aMCI and 16 elderly controls while controlling for item encoding. RESULTS: We confirmed the presence of associative memory impairment in aMCI even after controlling for item memory differences between groups. Associative memory but not item memory correlated with hippocampus volume in aMCI. Such a correlation was not observed in elderly controls. The left anterior hippocampus activation in response to successful associative encoding was decreased in aMCI, even after correction for hippocampus atrophy. CONCLUSION: Associative memory impairment in aMCI appears to be related to hippocampus atrophy and left anterior hippocampus hypoactivation.

Magnetic resonance imaging evaluation of cerebral embolization during percutaneous aortic valve implantation: comparison of transfemoral and trans-apical approaches using Edwards Sapiens valve.

OBJECTIVE: Cerebral embolization during trans-catheter aortic valve implantation (TAVI) has not been assessed clearly in the literature. Therefore, we compared the rate of cerebral embolisms with diffusion-weighted magnetic resonance imaging (DWI) in transfemoral (TF) and trans-apical (TA) approaches. METHOD: Eighty patients benefited from TAVI between January 2008 and June 2010. Out of these, 35 were included in the study. Twenty-one were TF (group 1) and 14 TA (group 2). During the same period, 285 patients benefited from a conventional aortic valve surgery (aortic valve replacement (AVR)). Thirteen of these were also analyzed and considered as the control group (group 3). We systematically performed a DWI the day before the procedure and 48 h after. DWI studies were blindly analyzed by a neuroradiologist, and all patients had a clinical neurological assessment before and after the procedure, according the National Institutes of Health Stroke Scale (NIHSS). RESULTS: Thirty-two patients in the TAVI group had new cerebral lesions: 19 in the TF group and 13 in the trans-apical group (p=NS). Mean number of embolic lesions per patient was 6.6 in group I and 6.0 in group II (p=NS). Mean volume of embolic lesions was 475.0 mm³ in group I and 2170.5 mm³ in group II (p=NS). In group III, one patient had one new cerebral lesion (p<0.05 vs TAVI) of 36.5 mm³ (p=NS vs TAVI). All patients were neurologically asymptomatic. CONCLUSIONS: The incidence of silent cerebral embolic lesions after TAVI is significantly higher compared with the standard surgical AVR. The number of emboli is similar in the TF and TA groups but the volume tended to be higher in the TA group. However, there is no clinical impact of those lesions.

Development of a fully automated system for delivering odors in an MRI environment.

We describe the development and evaluation of a computer-controlled system for delivering odors in a magnetic resonance imaging (MRI) environment. The system allows a timely presentation of different odors in synchrony with MRI sequences and participant's inspiration phase. The rise/fall time of odor deliverance has been optimized to generate prompt and strong stimulations. Equipped with a user-friendly programming interface, the system can be used reliably in a wide range of experimental paradigms. We have paid particular attention to developing a portable system that is relatively easy, rapid, and inexpensive to replicate. The equipment has been tested in a 3-Tesla MRI in a boxcar paradigm, in which stimulation conditions alternated with rest periods (no stimulation). The experiment demonstrated the good functioning of the device and its efficiency in producing the expected activation in the olfactory cortex; it also revealed some methodological and technical aspects to be improved.

Increased olfactory bulb volume and olfactory function in early blind subjects.

It has been shown that the volume of the olfactory bulb (OB) changes with function. The aim of this study was to investigate whether the OB volume and the olfactory function in early blind (EB) subjects increase compared with controls. Psychophysical testing of olfactory performances and OB volumetric measurements assessed by an MRI scan were studied. Quantitative olfactory function expressed in the odor discrimination and odor-free identification scores was higher in EB subjects compared with controls. The mean of right, left and total OB volume was 65.40, 75.48, and 140.89 mm, respectively for the EB subjects and 54.47, 52.11, and 106.60 mm, respectively for the controls, with these differences being significant. EB subjects have superior olfactory abilities and presented with significantly higher OB volume than the sighted controls. OB plasticity may explain this compensatory mechanism between visual deprivation and enhanced olfactory perception.

A manually controlled new device for punctuate mechanical stimulation of teeth during functional magnetic resonance imaging studies.

AIM: To design a simple and affordable device that could apply standardized mechanical punctuate stimuli to trigger the periodontal mechanoreceptors during functional magnetic resonance imaging (fMRI). MATERIAL AND METHODS: A new manually controlled device using von Frey monofilaments was tested on a phantom and on eight volunteers. Four block design paradigms with different timing were compared. Teeth 11, 12, 13, 21, 22, 23 and the thumb were stimulated. RESULTS: The device did not induce any artefacts in MR images. The most efficient protocol included an epoch duration of 24 s and stimuli delivered at 1 Hz. When stimulating the teeth, activations of the primary (S1) and secondary (S2) somatosensory areas were consistently obtained, either on the ipsilateral, contra-lateral or both sides. Stimulation of the thumb led to activations of the contra-lateral S1 area and either ipsilateral or contra-lateral S2 area. CONCLUSION: The use of this innovative tool should allow to perform fMRI studies aimed to unveil the neural correlates of periodontal neural receptors, and to understand their plasticity induced by tooth loss and their eventual replacement by endosseous oral implants.

Neural correlates of symbolic number comparison in developmental dyscalculia.

Developmental dyscalculia (DD) is a deficit in number processing and arithmetic that affects 3-6% of schoolchildren. The goal of the present study was to analyze cerebral bases of DD related to symbolic number processing. Children with DD aged 9-11 years and matched children with no learning disability history were investigated using fMRI. The two groups of children were controlled for general cognitive factors, such as working memory, reading abilities, or IQ. Brain activations were measured during a number comparison task on pairs of Arabic numerals and a color comparison task on pairs of nonnumerical symbols. In each task, pairs of stimuli that were close or far on the relevant dimension were constituted. Brain activation in bilateral intraparietal sulcus (IPS) was modulated by numerical distance in controls but not in children with DD. Moreover, although the right IPS responded to numerical distance only, the left IPS was influenced by both numerical and color distances in control children. Our findings suggest that dyscalculia is associated with impairment in areas involved in number magnitude processing and, to a lesser extent, in areas dedicated to domain-general magnitude processing.

Outcome of transsphenoidal surgery for Cushing's disease: a high remission rate in ACTH-secreting macroadenomas.

OBJECTIVE: Although numerous studies have shown that transsphenoidal surgery is the best initial treatment for Cushing disease offering 59-95% of success, fewer information is available on the long-term outcome in the subgroup of patients harboring ACTH-secreting macroadenomas. The aims of this study were to analyze our 10-year experience with transsphenoidal surgery in Cushing's disease and to examine whether remission rates were different between micro- and macroadenomas. PATIENTS AND METHODS: Forty consecutive patients with proven Cushing's disease (28 microadenomas, 12 macroadenomas [diameter: 10-25 mm], 3 patients with no visible adenoma at MRI) underwent transsphenoidal surgery (TSS) assisted by neuronavigation in our center between 1996 and 2007. The diagnosis was made using standard endocrinological criteria including bilateral inferior petrosal sinus sampling (BIPSS) with CRH stimulation in all patients with discordant or equivocal biochemical and radiological testing. Morning serum cortisol was measured during the first week postoperatively, and a complete endocrine evaluation was made in all patients at 6-8 weeks. Remission at follow-up was defined as a normal postoperative 24-h urinary free cortisol (UFC) or continued need for glucocorticoid hormone replacement after TSS. RESULTS: Overall, 32/40 patients (80%) were in remission after one or more TSS. Interestingly, a very good remission rate (92%) was observed in the subset of macroadenomas, similar to that found in the group of microadenomas (84%, NS), while no post-surgical remission was observed in the 3 patients with no visible adenoma at MRI (p<0.01). Of the 8 patients not in remission after repeated TSS surgery, 3 underwent radiation therapy and three had bilateral adrenalectomy, allowing remission of their hypercortisolism. There was minor morbidity and no death. CONCLUSION: While our overall results are in accordance with other published series, we show here that ACTH-secreting pituitary macroadenomas are usually not associated with a bad outcome, in contrast with patients with no visible adenoma at preoperative MRI.

Domain-specific reorganization of semantic processing after extensive damage to the left temporal lobe.

We investigated with fMRI the cortical correlates of recovery of semantic processing in a patient (DL) with left temporal damage. Names of animals, plant, and artifacts (semantic conditions) and reversed words (baseline condition) were auditorily presented to the patient and nine control subjects in a category monitoring task. Data analyses showed large differences between the patterns of domain-specific semantic activation observed in DL and the control subjects, which could be attributed to a cortical reorganization compensating for the damaged part of the semantic processing system in DL. Such reorganization relied on three main mechanisms, first, upholding of a subset of the structurally intact domain-specific regions, second, functional changes (both decreases and increases) of the domain specificity in several structurally intact regions that are normally engaged in the domain-specific network and, third, recruitment of supplementary domain-specific areas. Thus, in DL, animal-specific processing engaged supplementary areas in the left lingual gyrus and right cuneus, which correspond to animal-specific regions usually engaged in more demanding semantic tasks whereas the supplementary areas recruited for artifact-specific processing within the left superior/middle occipital lobe and right angular gyrus probably are endowed with a related but not domain-specific, semantic function. In contrast, no supplementary area contributed to plant-specific processing in DL. These findings suggest that the pattern of cortical reorganization consecutive to damage to the semantic processing network depends on the particular domain-specific function sustained by the damaged areas and the capacity of the remaining areas to assume this function.

Refractory High Intracranial Pressure following Intraventricular Hemorrhage due to Moyamoya Disease in a Pregnant Caucasian Woman.

Intraventricular hemorrhage during pregnancy is usually followed by a poor recovery. When caused by moyamoya disease, ischemic or hemorrhagic episodes may complicate the management of high intracranial pressure. A 26-year-old Caucasian woman presented with generalized seizures and a Glasgow Coma Score (GCS) of 3 during the 36th week of pregnancy. The fetus was delivered by caesarean section. The brain CT in the mother revealed bilateral intraventricular hemorrhage, a callosal hematoma, hydrocephalus and right frontal ischemia. Refractory high intracranial pressure developed and required bilateral ventricular drainage and intensive care treatment with barbiturates and hypothermia. Magnetic resonance imaging and cerebral angiography revealed a moyamoya syndrome with rupture of the abnormal collateral vascular network as the cause of the hemorrhage. Intracranial pressure could only be controlled after the surgical removal of the clots after a large opening of the right ventricle. Despite an initially low GCS, this patient made a good functional recovery at one year follow-up. Management of refractory high intracranial pressure following moyamoya related intraventricular bleeding should require optimal removal of ventricular clots and appropriate control of cerebral hemodynamics to avoid ischemic or hemorrhagic complications.

Corticospinal dysgenesis and upper-limb deficits in congenital hemiplegia: a diffusion tensor imaging study.

OBJECTIVES: Precision grasping critically relies on the integrity of the corticospinal tract as evidenced in congenital hemiplegia by the correlation found between corticospinal dysgenesis and hand-movement deficits. Therefore, corticospinal dysgenesis could be used to anticipate upper-limb deficits in young infants with congenital hemiplegia. However, most studies have quantified corticospinal dysgenesis by measuring the cross-sectional area of cerebral peduncles on T1 MRI, a measure biased by other structures present in the peduncles. The purpose of this study was to evaluate the extent to which this may have hampered the conclusions of previous studies. We also aimed to investigate the relationship between upper-limb deficits and a more accurate measure of corticospinal dysgenesis to provide a tool for anticipating upper-limb deficits in infants with congenital hemiplegia. METHODS: To address this issue, we measured corticospinal tract areas in 12 patients with congenital hemiplegia and 12 matched control subjects by using the diffusion tensor imaging technique. Corticospinal dysgenesis was quantified by computing a symmetry index between the area of the contralateral and ipsilateral corticospinal tracts. This value was then compared with that resulting from the conventional MRI method. RESULTS: The symmetry indexes gathered with these 2 methods were highly correlated, although the diffusion tensor imaging symmetry indexes were significantly smaller. This indicates that, in patients with congenital hemiplegia, the conventional MRI measurement has led to a systematic underestimate of corticospinal dysgenesis. These 2 estimates of corticospinal dysgenesis were also correlated with upper-limb impairments and disabilities. Although the symmetry index computed from peduncle measurements was correlated solely with deficits in stereognosis, the diffusion tensor imaging index correlated with stereognosis, digital and manual dexterities, and ABILHAND-Kids, a measure of manual ability in daily life activities. CONCLUSIONS: The diffusion tensor imaging symmetry index provides a useful prognostic tool for anticipating upper-limb deficits and their consequences in daily life activities.