2.5-Minute Fast Brain MRI with Multiple Contrasts in Acute Ischemic Stroke.

PURPOSE: To assess the performance of a 2.5-minute multi-contrast brain MRI sequence (NeuroMix) in diagnosing acute cerebral infarctions. METHODS: Adult patients with a clinical suspicion of acute ischemic stroke were retrospectively included. Brain MRI at 3 T included NeuroMix and routine clinical MRI (cMRI) sequences, with DWI/ADC, T2-FLAIR, T2-weighted, T2*, SWI-EPI, and T1-weighted contrasts. Three radiologists (R1-3) independently assessed NeuroMix and cMRI for the presence of acute infarcts (DWI ↑, ADC = or ↓) and infarct-associated abnormalities on other image contrasts. Sensitivity, specificity, and the area under the receiver operating characteristic curve (AUC) were calculated and compared using DeLong's test. Inter- and intra-rater agreements were studied with kappa statistics. Relative DWI (rDWI) and T2-FLAIR (rT2-FLAIR) signal intensity for infarctions were semi-automatically rendered, and the correlation between methods was evaluated. RESULTS: According to the reference standard, acute infarction was present in 34 out of 44 (77%) patients (63 ± 17 years, 31 men). Other infarct-associated signal abnormalities were reported in similar frequencies on NeuroMix and cMRI (p > .08). Sensitivity for infarction detection was 94%, 100%, and 94% evaluated by R1, R2, R3, for NeuroMix and 94%, 100%, and 100% for cMRI. Specificity was 100%, 90%, and 100% for NeuroMix and 100%, 100%, and 100% for cMRI. AUC for NeuroMix was .97, .95, and .97 and .97, 1, and 1 for cMRI (DeLong p = 1, .32, .15), respectively. Inter- and intra-rater agreement was κ = .88-1. The correlation between NeuroMix and cMRI was R = .73 for rDWI and R = .83 for rT2-FLAIR. CONCLUSION: Fast multi-contrast MRI NeuroMix has high diagnostic performance for detecting acute cerebral infarctions.

Elective one-minute full brain multi-contrast MRI versus brain CT in pediatric patients: a prospective feasibility study.

BACKGROUND: Brain CT can be used to evaluate pediatric patients with suspicion of cerebral pathology when anesthetic and MRI resources are scarce. This study aimed to assess if pediatric patients referred for an elective brain CT could endure a diagnostic fast brain MRI without general anesthesia using a one-minute multi-contrast EPI-based sequence (EPIMix) with comparable diagnostic performance. METHODS: Pediatric patients referred for an elective brain CT between March 2019 and March 2020 were prospectively included and underwent EPIMix without general anesthesia in addition to CT. Three readers (R1-3) independently evaluated EPIMix and CT images on two separate occasions. The two main study outcomes were the tolerance to undergo an EPIMix scan without general anesthesia and its performance to classify a scan as normal or abnormal. Secondary outcomes were assessment of disease category, incidental findings, diagnostic image quality, diagnostic confidence, and image artifacts. Further, a side-by-side evaluation of EPIMix and CT was performed. The signal-to-noise ratio (SNR) was calculated for EPIMix on T1-weighted, T2-weighted, and ADC images. Descriptive statistics, Fisher's exact test, and Chi-squared test were used to compare the two imaging modalities. RESULTS: EPIMix was well tolerated by all included patients (n = 15) aged 5-16 (mean 11, SD 3) years old. Thirteen cases on EPIMix and twelve cases on CT were classified as normal by all readers (R1-3), while two cases on EPIMix and three cases on CT were classified as abnormal by one reader (R1), (R1-3, p = 1.00). There was no evidence of a difference in diagnostic confidence, image quality, or the presence of motion artifacts between EPIMix and CT (R1-3, p ≥ 0.10). Side-by-side evaluation (R2 + R4 + R5) reviewed all scans as lacking significant pathological findings on EPIMix and CT images. CONCLUSIONS: Full brain MRI-based EPIMix sequence was well tolerated without general anesthesia with a diagnostic performance comparable to CT in elective pediatric patients. TRIAL REGISTRATION: This study was approved by the Swedish Ethical Review Authority (ethical approval number/ID Ethical approval 2017/2424-31/1). This study was a clinical trial study, with study protocol published at ClinicalTrials.gov with Trial registration number NCT03847051, date of registration 18/02/2019.

[Conditions for performing CT and MRI scans in pregnant and lactating patients]. / Att tänka på vid neuroradiologisk diagnostik av gravida och ammande.

Many women are pregnant during several percent of their lives. Occasionally, there is a need for neuroradiological examinations during pregnancy or lactation. In our clinical work, we regularly see that female patients are being withheld relevant diagnostic scans during pregnancy, due to insufficient knowledge or an unbalanced comparison between benefits and risks. This article describes the current knowledge regarding conditions for performing CT and MRI scans in pregnant and lactating patients, including the use of contrast media. PET scans and reactions to contrast media are briefly mentioned, but interventional radiology is not discussed.

Learning Curve Analysis and Adverse Events After Implementation of Neurosurgical Laser Ablation Treatment: A Population-Based Single-Institution Consecutive Series.

OBJECTIVE AND METHODS: We conducted a retrospective review of the first 30 patients treated with stereotactic laser ablation (SLA) at our institution since the introduction of the technique in September 2019. We aimed to analyze our initial results and potential learning curve by investigating precision and lesion coverage and assessing the frequency and nature of adverse events according to the Landriel-Ibanez classification for neurosurgical complications. RESULTS: Indications were de novo gliomas (23%), recurrent gliomas (57%), and epileptogenic foci (20%). There was a trend toward improvement of lesion coverage and target deviation, and a statistically significant improvement in entry point deviation, over time. Four patients (13.3%) experienced a new neurological deficit, where three patients had transient and one patient had permanent deficits, respectively. Our results show a learning curve on precision measures over the first 30 cases. Based on our results the technique can safely be implemented at centers with experience in stereotaxy.

Fatal Acute Hemorrhagic Encephalomyelitis and Antiphospholipid Antibodies following SARS-CoV-2 Vaccination: A Case Report.

Acute hemorrhagic encephalomyelitis (AHEM) is a rare hyperacute form of acute disseminated encephalomyelitis (ADEM). The disease is characterized by fulminant inflammation and demyelination in the brain and spinal cord and is often preceded by an infection or vaccination. This case report presents a 53-year-old male with rheumatoid arthritis and ongoing treatment with methotrexate and etanercept who developed fatal AHEM following the second dose of the COVID-19 vaccine. The disease course was complicated by multiorgan thromboembolic disease and the presence of high/moderate levels of cardiolipin IgG antibodies and anti-beta-2 glycoprotein 1 IgG antibodies suggesting a possible antiphospholipid syndrome. Treatment with immunosuppressive therapies failed to improve the course. The report comprises comprehensive clinical, neuroimaging, and neuropathological findings. The case highlights diagnostic challenges in a patient with several preceding risk factors, including autoimmune disease, immunotherapy, and vaccination, with possible pathophysiological implications. The temporal association with the COVID-19 vaccination may suggest possible causality although evidence cannot be ascertained. Reporting possible adverse events following COVID-19 vaccination is important to identify at-risk populations and to accomplish control of the current pandemic.

A 78 Seconds Complete Brain MRI Examination in Ischemic Stroke: A Prospective Cohort Study.

BACKGROUND: Fast 78-second multicontrast echo-planar MRI (EPIMix) has shown good diagnostic performance for detecting infarctions at a comprehensive stroke center, but its diagnostic performance has not been evaluated in a prospective study at a primary stroke center. PURPOSE: To prospectively determine whether EPIMix was noninferior in detecting ischemic lesions compared to routine clinical MRI. STUDY TYPE: Prospective cohort study. POPULATION: A total of 118 patients with acute MRI and symptoms of ischemic stroke. FIELD STRENGTH AND SEQUENCE: A 3 T. EPIMix (echo-planar based: T1-FLAIR, T2-weighted, T2-FLAIR, T2*, DWI) and routine clinical MRI sequences (T1-weighted fast spin echo, T2-weighted PROPELLER, T2-weighted-FLAIR fast spin echo, T2* gradient echo echo-planar, and DWI spin echo echo-planar). ASSESSMENT: Three radiologists, blinded for clinical information, assessed signs of ischemic lesions (DWI↑, ADC↓, and T2/T2-FLAIR↑) on EPIMix and routine clinical MRI, with disagreements solved in consensus with a fourth reader to establish the reference standard. STATISTICAL TESTS: Diagnostic performance including sensitivity and specificity against the reference standard was evaluated. EPIMix sensitivity was tested for noninferiority compared to the reference standard using Nam's restricted maximum likelihood estimation (RMLE) Score. A P-value < 0.05 was considered statistically significant. RESULTS: Of 118 patients (mean age 62 ± 16 years, 58% males), 25% (n = 30) had MRI signs of acute infarcts. EPIMix was noninferior with 97% (95% CI 83-100) sensitivity for reader 1, 100% (95% CI 88-100) sensitivity for reader 2, and 90% (95% CI 88-98) sensitivity for reader 3 vs. 93% (95% CI 78-99) sensitivity for readers 1 and 2 and 90% (95% CI 74-98) for reader 3 on routine clinical MRI. Specificity was 99% (95% CI 94-100) for reader 1, 100% (95% CI 96-100) for reader 2, and 98% (95% CI 92-100) for reader 3 on EPIMix vs. 100% (95% CI 96-100) for all readers on routine clinical MRI. CONCLUSION: EPIMix was noninferior to routine clinical MRI for the diagnosis of acute ischemic stroke. EVIDENCE LEVEL: 2 TECHNICAL EFFICACY: Stage 2.

NeuroMix-A single-scan brain exam.

PURPOSE: Implement a fast, motion-robust pulse sequence that acquires T1 -weighted, T2 -weighted, T2* -weighted, T2 fluid-attenuated inversion recovery, and DWI data in one run with only one prescription and one prescan. METHODS: A software framework was developed that configures and runs several sequences in one main sequence. Based on that framework, the NeuroMix sequence was implemented, containing motion robust single-shot sequences using EPI and fast spin echo (FSE) readouts (without EPI distortions). Optional multi-shot sequences that provide better contrast, higher resolution, or isotropic resolution could also be run within the NeuroMix sequence. An optimized acquisition order was implemented that minimizes times where no data is acquired. RESULTS: NeuroMix is customizable and takes between 1:20 and 4 min for a full brain scan. A comparison with the predecessor EPIMix revealed significant improvements for T2 -weighted and T2 fluid-attenuated inversion recovery, while taking only 8 s longer for a similar configuration. The optional contrasts were less motion robust but offered a significant increase in quality, detail, and contrast. Initial clinical scans on 1 pediatric and 1 adult patient showed encouraging image quality. CONCLUSION: The single-shot FSE readouts for T2 -weighted and T2 fluid-attenuated inversion recovery and the optional multishot FSE and 3D-EPI contrasts significantly increased diagnostic value compared with EPIMix, allowing NeuroMix to be considered as a standalone brain MRI application.

One-Minute Multi-contrast Echo Planar Brain MRI in Ischemic Stroke: A Retrospective Observational Study of Diagnostic Performance.

BACKGROUND: Fast multi-contrast echo planar MRI (EPIMix) has comparable diagnostic performance to standard MRI for detecting brain pathology but its performance in detecting acute cerebral infarctions has not been determined. PURPOSE: To assess the diagnostic performance of EPIMix for the detection of acute cerebral infarctions. STUDY TYPE: Retrospective observational cohort. POPULATION: One hundred and seventy-two consecutive patients with a clinical suspicion of non-hyperacute ischemic stroke (January 2018 to December 2019). FIELD STRENGTH AND SEQUENCE: 1.5 T or 3 T. EPIMix ((echo-planar based: diffusion weighted (DWI), T2*-weighted, T2-weighted, T2- and T1-fluid attenuated inversion recovery (FLAIR) images) vs. standard MRI: echo-planar DWI, echo-planar T2*-weighted or susceptibility weighted, turbo spin-echo T2-weighted, T2- and T1-FLAIR turbo spin-echo sequences. ASSESSMENT: Three neuroradiologists rated EPIMix and standard MRI on two separate occasions. Incongruent assessments were resolved in consensus with the fourth reader. The ratings included the diagnostic category (acute infarct, normal, and other pathology). Congruent diagnoses together with consensus diagnoses served as the reference standard. STATISTICAL TESTS: The diagnostic performance of EPIMix and standard MRI against the reference standard was calculated by the area under the receiver operating characteristic curve (AUC) and compared by DeLong's test. Sensitivity and specificity were determined. Inter-rater agreements were evaluated by Fleiss's kappa. RESULTS: Of 172 patients (61 ± 16 years, 103 men), acute infarcts were present in 80/172 (47%), normal findings in 60/172 (35%), and other pathology in 32/172 (19%). Across readers, the AUCs were .94-.95 for EPIMix and .95-.99 for standard MRI, with overlapping 95% CI (P = .02-.18). Inter-rater agreement for EPIMix was 0.90 and for standard MRI was 0.93. The sensitivity for EPIMix and standard MRI was 88-91% and 91-98%, respectively, while the specificity was 98-100% and 98-99%, both with overlapping 95% CI. CONCLUSION: Multi-contrast echo planar MRI showed a high but marginally lower diagnostic performance compared to standard MRI for the detection and characterization of acute brain infarct. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY: Stage 2.

[Laser ablation of brain tumors now available in the Nordic countries]. / Laserablation kan användas vid intrakraniella lesioner.

Laser Interstitial Thermal Therapy (LITT) is used to treat patients with intracranial lesions such as epileptogenic foci, radiation necrosis, cavernomas and brain tumors in the United States. The approval for this treatment in Europe has first been granted in 2018, with the first treatment(s) in the Nordic countries - in the form of 3 brain tumor patients - performed at the Karolinska University Hospital in 2019. In this article we briefly describe our initial experience in the context of current literature.

Nervous System Involvement in Coronavirus Disease 2019: Results from a Retrospective Consecutive Neuroimaging Cohort.

Background Neurologic complications in coronavirus disease 2019 (COVID-19) have been described, but the understanding of their pathophysiologic causes and neuroanatomical correlates remains limited. Purpose To report on the frequency and type of neuroradiological findings in COVID-19. Materials and Methods In this retrospective study, all consecutive adult hospitalized patients with polymerase chain reaction positivity for severe acute respiratory syndrome coronavirus 2 and who underwent neuroimaging at Karolinska University Hospital between March 2 and May 24, 2020, were included. All examinations were systematically re-evaluated by 12 readers. Summary descriptive statistics were calculated. Results A total of 185 patients with COVID-19 (62 years ± 14 [standard deviation]; 138 men) underwent neuroimaging. In total, 222 brain CT, 47 brain MRI, and seven spinal MRI examinations were performed. Intra-axial susceptibility abnormalities were the most common finding (29 of 39; 74%, 95% CI: 58, 87) in patients who underwent brain MRI, often with an ovoid shape suggestive of microvascular pathology and with a predilection for the corpus callosum (23 of 39; 59%; 95% CI: 42, 74) and juxtacortical areas (14 of 39; 36%; 95% CI: 21, 53). Ischemic and macrohemorrhagic manifestations were also observed, but vascular imaging did not demonstrate overt abnormalities. Dynamic susceptibility contrast perfusion MRI in 19 patients did not reveal consistent asymmetries between hemispheres or regions. Many patients (18 of 41; 44%; 95% CI: 28, 60) had leukoencephalopathy and one patient had a cytotoxic lesion of the corpus callosum. Other findings included olfactory bulb signal abnormalities (seven of 37; 19%), prominent optic nerve subarachnoid spaces (20 of 36; 56%), and enhancement of the parenchyma (three of 20; 15%), leptomeninges (three of 20; 15%), cranial nerves (two of 20; 10%), and spinal nerves (two of four; 50%). At MRI follow-up, regression of leukoencephalopathy and progressive leptomeningeal enhancement was observed in one patient each, respectively, which is suggestive of dynamic processes. Conclusion Patients with coronavirus disease 2019 had a wide spectrum of vascular and inflammatory involvement of both the central and peripheral nervous system. © RSNA, 2020 Online supplemental material is available for this article.

Optimizing 3D EPI for rapid T1 -weighted imaging.

PURPOSE: To investigate the use of 3D EPI for rapid T1 -weighted brain imaging, focusing on the RF pulse's influence on the contrast between gray and white matter. METHODS: An interleaved 3D EPI sequence use partial Fourier and CAIPIRINHA sampling was used to acquire T1 -weighted brain volumes with isotropic resolution, low echo times, and low geometric distortions. Five different RF pulses were evaluated in terms of fat suppression performance and gray-white matter contrast. Two binomial RF pulses were compared to a single rectangular (WE-rect) RF pulse exciting only water, and two new RF pulses developed in this work, where one was an extension of the WE-rect, and the other was an SLR pulse. The technique was demonstrated in three clinical cases, where brain tumor patients were imaged before and after gadolinium administration. RESULTS: A fat-suppressed 3D EPI sequence with a phase encoding bandwidth of around 100 Hz was found to exhibit a good trade-off between geometrical distortions and scan duration. Whole-brain T1 -weighted 3D EPI images with 1.2 mm isotropic voxel size could be acquired in 24 seconds. The WE-rect, its extension, and the SLR RF pulses resulted in reduced magnetization transfer effects and provided a 20% mean increase in gray-white matter contrast. CONCLUSION: Using a high phase encoding bandwidth and RF pulses that reduce magnetization transfer effects, a fat-suppressed multi-shot 3D EPI sequence can be used to rapidly acquire isotropic T1 -weighted volumes.

Diagnostic performance of a new multicontrast one-minute full brain exam (EPIMix) in neuroradiology: A prospective study.

BACKGROUND: Clinical MRI protocols are time-consuming; hence, new faster techniques are needed. One new fast multicontrast MRI technique, called echo planar image mix (EPIMix) (including contrasts T1 -FLAIR, T2 -weighted, diffusion-weighted images [DWI], apparent diffusion coefficient [ADC], T2 *-weighted, and T2 -FLAIR images) needs to be tested. PURPOSE: To assess if EPIMix has comparable diagnostic performance as routine clinical brain MRI. STUDY TYPE: Prospective. POPULATION: A consecutive series of 103 patients' brain MRI (January 2018 to May 2018). FIELD STRENGTH/SEQUENCE: 1.5 T or 3T. EPIMix and routine clinical protocol (clinical MRI included all or some of the contrasts T1 -FLAIR, T2 -weighted, DWI, T2 *-weighted, T2 -FLAIR, 3D-FSE). ASSESSMENT: Two neuroradiologists assessed EPIMix and clinical scans and categorized the images as abnormal or normal and described diagnosis, artifacts, diagnostic confidence image quality, and comparison of imaging time. STATISTICAL TESTS: Pivot tables with diagnostic performance calculated by receiver operating characteristics (ROC) and the area under curve (AUC). Disease categorization and image quality measures were evaluated. The study protocol is published at ClinicalTrials.gov NCT03338270. RESULTS: After exclusion of 21 patients, 82 patients had a routine clinical MRI with comparable contrasts to EPIMix and were evaluated. The diagnostic performance to categorize a full brain MRI investigation as abnormal or normal was comparable between EPIMix (AUC 0.99 (95% confidence interval [CI] 0.97-1.00) and 0.99 (95% CI 0.97-1.00)) and routine clinical MRI (n = 82). Sensitivity was 95% (95% CI 88-95) and 93% (95% CI 86-98), and specificity 100% (95% CI 97-100) and 100% (95% CI 90-100). Disease categorization was congruent between EPIMix and clinical routine MRI in 90% (reader 2) and 93% (reader 1). Image quality was generally rated lower for EPIMix (P < 0.001). Imaging time was 78 seconds for EPIMix and for the same contrasts 12 minutes 29 seconds for conventional 3T MRI. DATA CONCLUSION: EPIMix has comparable diagnostic performance (disease identification and categorization) for most patients investigated in clinical routine. Level of Evidence 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:1824-1833.

Diagnostic accuracy of 11C-methionine PET in detecting neuropathologically confirmed recurrent brain tumor after radiation therapy.

OBJECTIVE: This study aims to determine the diagnostic test accuracy (DTA) of 11C-methionine (MET) PET in the discrimination between recurrent tumor and radiation-induced injury in neuropathologically confirmed cases. METHODS: A retrospective cohort of 30 patients with previously irradiated intracranial tumors (23 gliomas, 6 metastases, and 1 meningioma) was included. All patients underwent a preoperative MET PET and postoperative neuropathological analysis. Maximum and mean standardized uptake values (SUV) were obtained in the lesion, in the contralateral mirror region, and in the contralateral frontal cortex. Lesion-to-background SUV ratios (SUR mirror and SUR cortex) were then calculated. The Mann-Whitney U test was used to evaluate differences in SUV ratios between confirmed recurrent tumor and radiation injury. DTA was determined through receiver operating characteristic (ROC) analysis. RESULTS: Twenty-one patients had recurrent tumor and nine had radiation injury. The area under the ROC curve (AUC) was 0.89 for SURmaxmirror and 0.88 for SURmaxcortex. The mean (SD) of SURmaxmirror was 2.37 (0.58) in tumor recurrence and 1.57 (0.40) in radiation necrosis (P ≤ 0.001). The corresponding values for SURmaxcortex were 2.13 (0.50) and 1.45 (0.37) (P = 0.001). Clinically relevant cutoffs were SURmaxmirror ≥ 1.99 giving a specificity of 100% for tumor recurrence with a sensitivity of 76% and SURmaxcortex ≥ 1.58 giving a sensitivity and specificity of 90 and 78%, respectively. CONCLUSIONS: Based on neuropathologically confirmed cases, the DTA of SURmaxmirror and SURmaxcortex from 11C-methionine PET was high when discriminating recurrent tumor from radiation injury.

Improvements in bimanual hand function after baby-CIMT in two-year old children with unilateral cerebral palsy: A retrospective study.

The common assumption that early-onset intensive intervention positively affects motor development has rarely been investigated for hand function in children with unilateral cerebral palsy (CP). This retrospective study explored the possible impact of baby constraint-induced movement therapy (baby-CIMT) on hand function at two years of age. We hypothesized that baby-CIMT in the first year of life would lead to better bimanual hand use at two years of age than would not receiving baby-CIMT. The Assisting Hand Assessment (AHA) was administered at age 21 months (SD 2.4 months) in 72 children with unilateral CP, 31 of who received baby-CIMT. When dividing the children into four functional levels based on AHA, the proportional distribution differed between the groups in favour of baby-CIMT. Logistic regression analysis indicated that children in the baby-CIMT group were more likely than were children in the no baby-CIMT group to have a high functional level, even when controlling for the effect of brain lesion type (OR 5.83, 95% CI 1.44-23.56, p = 0.001). However, no difference was found between groups in the odds of having a very low functional level (OR 0.31, 95% CI 0.08-1.17, p = 0.084). The result shows that baby-CIMT at early age can have a positive effect. Children who received baby-CIMT were six times more likely to have a high functional level at two years of age than were children in the no baby-CIMT group.

Is outcome of constraint-induced movement therapy in unilateral cerebral palsy dependent on corticomotor projection pattern and brain lesion characteristics?

AIM: The aim of the study was to explore individual variations in outcome of hand function after constraint-induced movement therapy (CIMT) in relation to the organization of corticomotor projection and brain lesion characteristics in participants with unilateral cerebral palsy (CP). METHOD: Sixteen participants (eight males, eight females; mean age 13 y, [SD 2 y] range 10-16 y) with unilateral CP (nine right-sided; Manual Ability Classification System [MACS] level I, n=1; level II, n=15) who participated in a 2-week CIMT day camp (63 h) were included in the study. Various aspects of hand function were measured by the Jebsen-Taylor Hand Function Test (JTHFT), the Assisting Hand Assessment (AHA), and the Melbourne Assessment, both before and after the day camp. Transcranial magnetic stimulation was used to explore the corticomotor organization, and brain lesion characteristics were described by visual assessment of conventional structural magnetic resonance images. RESULTS: At a group level, the training was associated with significant improvements in JTHFT (p=0.003) and AHA (p=0.046), but not in Melbourne Assessment scores. Improvements were found in all types of corticomotor projection patterns, i.e. contralateral, mixed, and ipsilateral. There was no relationship between functional improvement and brain lesion characteristics. INTERPRETATION: Individuals with CP experience improved motor outcomes after CIMT, independent of corticomotor projection pattern and lesion characteristics.

Neuroradiology can predict the development of hand function in children with unilateral cerebral palsy.

BACKGROUND: Much variation is found in the development of hand function in children with unilateral cerebral palsy (CP). OBJECTIVE: . To explore how anatomic brain abnormalities can be used to predict the development of hand function. METHODS: A total of 32 children with unilateral CP (16 boys and 16 girls) were evaluated at least once a year by the Assisting Hand Assessment (AHA). The data collection covered an age range from 18 months to 8 years (mean time in study, 4 years and 6 months). Computerized tomography or magnetic resonance imaging of the brain were assessed for patterns of brain damage, including the location of gray and extent of white-matter damage. The children were divided into groups according to lesion characteristics, and a series of univariate models were analyzed with a nonlinear mixed-effects model. The rate and maximum limit of development were calculated. RESULTS: The highest predictive power of better development of hand function was the absence of a concurrent lesion to the basal ganglia and thalamus, independent of the basic type of brain lesion. This model predicted both the rate of increasing ability and hand function at age 8 years. Hand function was also predicted by the basic pattern of damage and by the extent of white-matter damage. The presence of unilateral or bilateral damage had no predictive value. CONCLUSIONS: Neuroradiological findings can be used to make a crude prediction of the future development of the use of the affected hand in young children with unilateral CP.

Visual field function in school-aged children with spastic unilateral cerebral palsy related to different patterns of brain damage.

AIM: To relate visual field function to brain morphology in children with unilateral cerebral palsy (CP). METHOD: Visual field function was assessed using the confrontation technique and Goldmann perimetry in 29 children (15 males, 14 females; age range 7-17y, median age 11y) with unilateral CP classified at Gross Motor Function Classification System (GMFCS) level I and Manual Ability Classification System levels I to III. The type and extent of brain lesions were determined using cerebral imaging. RESULTS: Eighteen children had subnormal visual field function. The visual fields were severely restricted in six. The underlying brain lesions were malformation (n=7), white matter damage of immaturity (WMDI; n=13), and cortical-subcortical lesions (n=9). Visual field function could be correlated with the pattern of brain damage in children with cortical-subcortical lesions or extensive lesions caused by malformation or WMDI. Total homonymous hemianopia was common in the cortical-subcortical group but rare in children with malformation or WMDI. Five children had normal visual field function despite having malformation or WMDI involving parts of the brain usually encompassing the visual system. INTERPRETATION: Visual field function may be preserved by plasticity of the immature brain in children with malformation and WMDI. Severely restricted visual fields were more often associated with lesions occurring later in the developing brain. All children with severely restricted visual fields were identified by the confrontation technique. Goldmann perimetry was a suitable method to identify relative visual field defects.

Hand function in relation to brain lesions and corticomotor-projection pattern in children with unilateral cerebral palsy.

AIM: To investigate relationships between hand function, brain lesions, and corticomotor projections in children with unilateral cerebral palsy (CP). METHOD: The study included 17 children (nine males, eight females; mean age 11.4 [SD 2.4] range 7-16 y), with unilateral CP at Gross Motor Function Classification System level I and Manual Ability Classification System level I or II. Hand function was assessed with the Box and Blocks test and Assisting Hand Assessment (AHA). Conventional structural magnetic resonance images were assessed visually for type, location, and extent of brain lesions. Single-pulse transcranial magnetic stimulation (TMS) provided information on organization of corticomotor projections. RESULTS: The most favourable hand function was seen in children who had white-matter damage of immaturity with mild white-matter loss and contralateral motor projections. Children with ipsilateral projections had the most impaired function. Nevertheless, in this subgroup a range of ability was seen (AHA 29-59%). Motor-projection patterns appeared to be influenced by lesion extent and location, but not by lesion type. INTERPRETATION: Combining information from structural magnetic resonance images and TMS can improve prediction of hand function. A wide variation in hand function was seen within all motor-projection patterns. Although the most impaired hand function was seen in the ipsilateral motor-projection group, some children in this group had fairly good ability. Such information is important for treatment planning.