Neurological bases of behavioral development in infancy.

This article presents selected psychological competences that emerge in children during the first 2 years, together with correlated structural, biochemical and physiological changes in the brain. Major behavioral events of the 1st year are the disappearance of the neonatal reflexes, the improvement of recognition and working memory and the appearance of the universal fears of strangers and of separation from the caretaker. These behaviors are correlated in time with changes in the brain that allow the increased ability of the cortex to inhibit brainstem reflexes, with processes in the prefrontal cortex and hippocampus that facilitate the formation, storage and retrieval of memories, and with strengthened connections between the cortex and limbic system. Behavioral events of the 2nd year include the explosion of language and the emergence of self-awareness, both of which depend on the capacity for inference. The emergence of these capabilities is correlated with the intensified connectivity of the two hemispheres, the maturation of the prefrontal cortex and cortical-subcortical network.

Neurobiological bases of behavioral development in the second year.

We discuss selected psychological competences that develop and become noticeable between one and two years of age and are temporally correlated to structural, biochemical and physiological changes in the brain. The psychological competences are: Language development, a sense of "right" and "wrong", self-awareness, and the ability to make inferences. The accompanying changes in the brain involve the prefrontal cortex, language-related cortical areas, hippocampus, cerebellum, basal ganglia and an increase in the connectivity of the network. Of special interest are the maturational changes in layers III-IV of the prefrontal cortex. Layer III is the origin and target of callosal and commissural axons linking the two hemispheres and the target of associational axons linking ipsilateral areas within each hemisphere. Layer IV, the target for axons from the mediodorsal nucleus of the thalamus, conveys information from other associational cortices, cerebellum, basal ganglia, and the reticular and limbic systems. In the second year, intensive dendritic growth and synaptogenesis in these layers increase the linking of these two layers and form a neural basis for a more efficient convergence and integration of information from the two hemispheres, which are functionally asymmetric. It is our hypothesis that these changes, together with the maturational changes in the cortico-subcortical network, are a basis for the observed emergence of the psychological competences. We are aware that temporal correlations cannot prove firm causal relationships. However, knowledge of these correlations is useful in generating specific hypotheses that can be tested directly.

Neurobiological bases of behavioral development in the first year.

This review summarizes the temporal relations between selected psychological milestones in the first year of the human infant and theoretically relevant developmental neurobiological changes in the brain, supplemented where appropriate, with evidence from the non-human primate. The disappearance of the palmar grasp reflex and the decrease in endogenous smiling and spontaneous crying, which occur at 2-3 months, are correlated to emergent cortical inhibition of brainstem circuits. In addition, the improved ability to recognize an event experienced in the immediate past (recognition memory) is related to growth of the hippocampus and adjacent structures at this age. The behavioral developments at 7-10 months include an enhanced ability to retrieve stored representations of the past and to compare past and present (working memory), along with the emergence of the universal fears of strangers and separation from the caretaker. These milestones are correlated in time with maturational changes in the prefrontal and rhinal cortices and hippocampal formation, the integration of the limbic system and increased responsiveness of the hypothalamus-pituitary-adrenal axis. Knowledge of age-dependent correlations of brain and behavioral maturation is a basis for the investigation of causal relationships between brain development and behavior. A close collaboration of pediatricians, psychologists and neuroscientists is, therefore, necessary.

Structural and neurobehavioral delay in postnatal brain development of preterm infants.

Postnatal brain development of healthy prematurely born infants was assessed to study possible influence of premature birth and early extrauterine environment on structural, biochemical, and functional brain development. Myelination and differentiation of gray and white matter were studied by in vivo magnetic resonance (MR) imaging (MRI), changes in cerebral metabolism by 1HMR spectroscopy (MRS), and changes in early human neurobehavior by the assessment of preterm infant's behavior (APIB). The stage of intrauterine and extrauterine brain development in prematurely born infants at term was compared with the stage of mainly intrauterine brain development in a group of full-term infants. Eighteen preterm infants unremarkable with respect to neurologic and medical status were studied at approximately 2 wk of postnatal age [gestational age (GA) 1: 32.5 +/- 1.2 wk] and again at term (GA 2: 40.0 +/- 1.1 wk). For comparison a group of 13 full-term born infants (GA T: 40.6 +/- 2.1 wk) were studied by MR and six by APIB. When GA 2 to GA 1 was compared, significant maturational changes were found with MRI in gray and white matter and myelination, with 1H MRS in the concentration of N-acetylaspartate and with all scores of APIB. In preterm infants at term (GA 2) compared with full-term infants (GA T) significantly less gray and white matter differentiation and myelination was observed as well as significantly poorer performance in four neurobehavioral parameters (autonomic reactivity, motoric reactivity, state organization, attentional availability). We conclude that MRI and 1H MRS can be used to study postnatal brain development in preterm infants. Structural and biochemical maturation is accompanied by functional maturation as shown with the neurobehavior assessment. Preterm infants at term compared with full-term infants show a structural as well as a functional delay in brain development assessed at 40 wk of postconceptional age.

The dynamics of brain concentrations of phenylalanine and its clinical significance in patients with phenylketonuria determined by in vivo 1H magnetic resonance spectroscopy.

Cerebral concentrations of phenylalanine (PHE) were measured by means of quantitative in vivo 1H MR spectroscopy in 8 adult patients treated early for phenylketonuria type I. A 1.5-Tesla routine magnetic resonance scanner, localization sequence with short echo time (20 ms), and a fully automated data processing scheme were used. Baseline plasma PHE concentrations were 1.04 (0.70-1.39) mmol/L PHE with concurrent brain PHE concentrations of 0.27 (0.13-0.41) mmol/kg of wet weight resulting in a plasma/brain ratio of 4.12. Plasma and brain concentrations correlated significantly (Kendall tau b = 0.91, p < 0.01). During an oral load with a single dose of 100 mg L-PHE per kg of body weight in four patients, plasma levels steeply increased. Concurrent brain PHE increase was less steep, was significantly delayed, and still continued up to 20 h postload. Despite the proven rise in plasma and brain concentrations of PHE, neuropsychologic examinations revealed no impairment of attentional and fine motor abilities from preload up to 20 h postload.

Identification and quantitation of phenylalanine in the brain of patients with phenylketonuria by means of localized in vivo 1H magnetic-resonance spectroscopy.

Localized proton MR spectroscopy was used to identify phenylalanine (PHE) and to quantitate its cerebral concentration in patients with type I phenylketonuria (PKU). Data acquisition was optimized for the detection of low-concentration metabolites, using a short TE (20 ms) double Hahn-echo localization sequence for large volumes within the head coil and for smaller volumes using a surface coil. Previously described methods to quantitate localized MR spectra were extended to cover the case of low-concentration metabolites, unevenly distributed in three brain compartments and measured in difference spectra only. PHE content was determined in difference spectra of four PKU patients with respect to normals and in one patient before and after an oral load of L-PHE. PHE concentrations of 0.3 to 0.6 mmol/kg brain tissue were obtained, resulting in a concentration gradient for PHE between blood and brain tissue of 2.4 to 3.0. No significant changes were found for the abundant metabolites in gray or white matter. Previously reported MRI changes were confirmed to be due to increased cerebro-spinal-fluid-like spaces.

In vivo proton magnetic resonance spectroscopy in a case of Reye's syndrome.

A case of a 14-year-old boy with Reye's syndrome (RS) and complete neurologic recovery is presented. 1H magnetic resonance spectroscopy was performed on days 1 (admission to ICU), 8 and 62: During the acute phase of RS substantial cerebral metabolic imbalances were observed and their normalization monitored. The spectra from day 1 featured extremely high glutamine content (approximately 18 mmol/kg excess) and low concentrations of choline compounds pounds (approximately 1 mmol/kg deficit). Also some excess lactate was present. The subsequent spectra demonstrated the return to an almost normal brain metabolite profile.

Regional metabolic assessment of human brain during development by proton magnetic resonance spectroscopy in vivo and by high-performance liquid chromatography/gas chromatography in autopsy tissue.

To study the course of regional metabolite concentrations during early brain development, we measured in vivo metabolites [N-acetyl-aspartate (NAA), choline-containing compounds, and myoinositol (M-Ino)] in the precentral area of the cerebrum by short echo-time single volume proton magnetic resonance spectroscopy and compared in vivo established spectroscopic data with classic chromatographic data (HPLC) on age-corresponding autopsy tissue in different regions of the brain. In autopsy tissue, regional (frontal lobe, precentral area, basal ganglia, thalamus) and age-dependent differences of the concentration of creatine, NAA, and M-Ino were determined. In vivo measurement of NAA by proton magnetic resonance spectroscopy shows a significant increase of NAA by increasing postconceptional age. M-Ino shows a weak correlation and a nonsignificant decrease with increasing postconceptional age. Choline shows no age-dependent changes. Creatine concentrations measured by HPLC in different regions of the developing brain at autopsy showed an age-dependent increase that was identical for the left and right side and similar for the precentral area and frontal lobe and more pronounced for the basal ganglia and thalamus. Comparison of the results obtained by the two methods shows agreement for the age-dependent changes and the absolute concentration of M-Ino. NAA determined in autopsy tissue by HPLC is significantly lower than that measured in vivo by proton magnetic resonance spectroscopy. A comparison of the concentrations measured by HPLC in frontal lobe, basal ganglia, and thalamus with the results obtained from the precentral area showed significant regional differences in all measured metabolites. These results define important age-dependent changes detected with both methods and further indicate limitations of both methods that have to be considered when presenting absolute concentration values.

In vivo measurement of phenylalanine in human brain by proton nuclear magnetic resonance spectroscopy.

Disorders of the CNS are the major causes of morbidity and mortality observed in untreated subjects with phenylketonuria (PKU). A method to measure cerebral concentrations of phenylalanine (Phe) in vivo would greatly enhance the ability to investigate both the pathophysiology and the efficacy of therapy of this aminoacidopathy. Twelve image-guided localized proton nuclear magnetic resonance spectroscopic studies were performed in seven subjects with PKU using pulse sequences optimized to detect the aromatic protons of Phe. Ten control studies were also performed using a 2.1-Tesla Bruker Biospec spectrometer. Plasma Phe was measured at the time of the spectroscopic examination in the PKU patients. A Phe signal was observed in all 12 studies performed on the group with PKU, and in five studies cerebral Phe concentrations were measured to be 480 to 780 mumol/g. Plasma Phe concentrations were 0.7 to 3.3 mM (10.8 to 54.8 mg/dL) in the subjects with PKU. Human cerebral Phe concentrations can be measured noninvasively using proton nuclear magnetic resonance spectroscopy. A simultaneous measure of Phe and several other cerebral metabolites is obtained with this innovative technology. Adaptations of this technique can be used to investigate PKU and other neurometabolic disorders with modifications of current clinical magnetic resonance imaging systems.

Retarded development of neurons and oligodendroglia in rat forebrain produced by hyperphenylalaninemia results in permanent deficits in myelin despite long recovery periods.

The severe hypomyelination seen in the CNS of untreated phenylketonuria (PKU) patients has been suggested to be the result of a defect in the process of myelination itself. Using chronic hyperphenylalaninemia (HPA) in rats as a model of PKU we have previously shown, by immunohistochemistry, that axonal maturation as well as myelination was severely retarded. In the present study we have used image analysis techniques to quantitate changes in myelin basic protein (MBP) and 200-kDa neurofilament protein (NF-H) immunostaining in the corpus callosum and cerebral cortical grey matter of HPA rats. No difference in the density of MBP+ myelin was observed in the corpus callosum after 24 days HPA treatment although the width of the tract was much reduced. In contrast there was a deficit in NF-H immunostaining. Large deficits in both myelin and axonal maturity were seen in the cortical grey matter. Following a 6-week recovery period, despite recovery in the corpus callosum, large deficits in both MBP and NF-H were still seen in all cortical layers. Deficits in NF-H immunostaining were two to three times greater than those for MBP. On increasing the recovery period to 18 weeks significant deficits in myelin remained in layers I-III of the cortical grey matter whereas NF-H immunostaining had returned to normal levels in all layers. Our data suggest a primary effect of HPA on neuronal development, in particular axonal maturation, with a secondary hypomyelination and show that permanent deficits in myelinated axons in outer cortical layers can result when myelination is severely inhibited during a critical developmental period.

Compound heterozygosity for metachromatic leukodystrophy and arylsulfatase A pseudodeficiency alleles is not associated with progressive neurological disease.

Several allelic mutations at the arylsulfatase A (ASA) locus cause substantial deficiencies of this lysosomal enzyme. Depending on the genetically determined degree of the deficiency, the clinical outcome may be very different--either metachromatic leukodystrophy (MLD), a lethal lysosomal storage disorder affecting the nervous system, or, more frequently, the so-called pseudodeficiency (PD), which has no apparent clinical consequence. Because of compound heterozygosity for MLD and PD, 1/1,000 individuals in the population have low residual enzyme activities, which are intermediate between those of MLD patients and those of PD homozygous normal individuals. In order to assess whether PD/MLD compound heterozygotes bear a health risk, we examined clinically and biochemically 16 individuals with this genotype. Of these subjects, two had neurological symptoms and two showed lesions, without clinical symptoms, in magnetic resonance imaging of the brain. None of these symptoms was progressive, nor did they resemble those of MLD. Nerve conduction velocities were normal in these probands, and they secreted only low amounts of sulfatide in the urine. We conclude that the observed neurological symptoms are unrelated to the ASA genotype and that PD/MLD compound heterozygotes are not at an increased risk for developing progressive nervous system diseases.

Short echo time proton MR spectroscopic imaging.

Proton spectroscopic imaging at short TEs (20-30 ms) in human brain requires volume preselection inside the brain to suppress overwhelming lipid and water signals from surrounding tissue. In this article we discuss limitations of conventional volume preselection using stimulated echoes that lead to spectral contamination from surrounding tissue. Improved volume preselection was obtained by adding a complete outer volume suppression (presaturation). The performance of the method is illustrated on normal volunteers and on clinical cases with brain tumors and multiple sclerosis (MS) plaques. In normal human brain, we detected resonances with short T2 values and complex J-coupling, including rather broad methyl/methylene resonances in the chemical shift range between 0 and 2 ppm. Spectroscopic images obtained on patients with intracranial tumors and on one patient with several MS plaques demonstrate the possibility of detecting regional distributions of increased methyl/methylene resonances between 0 and 2 ppm in brain lesions.

Hartnup syndrome, progressive encephalopathy and allo-albuminaemia. A clinico-pathological case study.

Clinical, biochemical, neuropathological and neurochemical findings in a case of Hartnup syndrome are reported. After initially normal development, the affected girl suffered progressive neuropsychiatric decline with statomotor and mental retardation and intractable seizures and died at the age of 2 years. Postmortem neuropathological and neurochemical investigations showed a combination of extensive neuronal degeneration and cerebral dysmyelination. Pathogenetic hypotheses and the relationship between neuropsychiatric disease and Hartnup syndrome are discussed. Additionally, a fast type bisalbuminaemia present in the girl and her mother is described.

Disturbed myelinogenesis and recovery in hyperphenylalaninemia in rats: an immunohistochemical study.

Chronic hyperphenylalaninemia (HPA) in rats has been used as an experimental model of the human inborn error of metabolism phenylketonuria (PKU). Impaired brain development in PKU and HPA is reflected in reduced myelin formation. We have used immunohistochemistry, with antibodies to cell-specific antigenic markers, to investigate the cellular basis of the hypomyelination in the corpus callosum and cerebral cortex of rats made hyperphenylalaninemic from Postnatal Days 3-17. The rats were then allowed to recover until Day 59. No effects were seen on the number and differentiation pattern of ganglioside GD3-expressing glial progenitors. Myelin basic protein and 2'3'-cyclic nucleotide 3'-phosphohydrolase (CNP) immunostaining demonstrated a reduction in myelin formation in the corpus callosum and subcortical white matter at 12 and 17 days postnatal. However, numbers of CNP+ oligodendrocytes appeared normal throughout development. No reactive astrogliosis was seen at any stage. The intensity of axonal neurofilament immunostaining was reduced in the corpus callosum at 17 days. In layers II and III of the cortical gray matter there was an increase in the cell packing density and a concomitant decrease in cell body size. Myelination in the corpus callosum was rapid during the recovery period with no difference noted at Day 59. Axonal neurofilament staining also returned to normal in the corpus callosum. However, recovery became increasingly incomplete away from the corpus callosum into the cortical gray matter. Our data suggest a primary effect of HPA on axonal maturation with hypomyelination consequential upon this.

Magnetic resonance in preterm and term newborns: 1H-spectroscopy in developing human brain.

Localized proton magnetic resonance spectra were recorded from human cerebellum in vivo with a 1.5-T magnet. The spectra from healthy adults and preterm and term babies showed resonances from N-acetylaspartate, creatine and phosphocreatine, choline-containing compounds such as phosphocholine and glycerophosphocholine, taurine, and inositol. The age-dependent changes of in vivo molar concentrations of N-acetylaspartate, choline, taurine, and inositol were estimated in preterm babies, babies at term, and adults. The range of postconceptional age in the studied babies was 31 to 45 wk. Taking the biochemically measured creatine concentrations in age-corresponding autopsy material as an internal standard, the in vivo concentrations of the other metabolites were calculated from the proton spectra. N-acetylaspartate showed an increase from 1.9 mM in preterm babies to 3.1 mM in term babies and to 6.5 mM in adult brain. Taurine was noted to increase from 1.1 mM in preterm infants to 2.3 mM in term infants and did not decrease significantly in adult brain. Choline and inositol concentrations did not change significantly throughout the studied age groups. These new data on in vivo, localized 1H-spectroscopy show that it is a sensitive method for studying early metabolic brain development in humans.

Prenatal stroke suggested by intrauterine ultrasound and confirmed by magnetic resonance imaging.

Cerebral infarction is rare in premature newborns and is most commonly the result of arterial embolization from the placenta. A focal echodense area was identified on prenatal cranial ultrasonography (US) in a premature infant (34 weeks of gestation). After birth, cerebral infarction was confirmed by magnetic resonance imaging (MRI). The clinical findings, imaging findings and pathogenesis are discussed. New diagnostic methods such as MRI show to be a useful approach in the neonatal period facilitating recognition of cerebrovascular accidents also in low-birth-weight infants.

Neurological function of immature babies after surfactant replacement therapy.

Surfactant replacement therapy in patients with neonatal respiratory distress syndrome (RDS) is a new therapeutic approach. There is now convincing evidence that the incidence and severity of RDS can be reduced. Surfactant (CUROSURF) was intratracheally applied to a group of fifteen intubated preterm infants with severe RDS (29 +/- 2.1 weeks of gestation and 1204 +/- 301 g birth weight) at 9.1 +/- 2.5 hours of life. For detection of potential neurological risk we performed serial ultrasound examinations (US), serial measurements of Creatine-Kinase Isoenzyme levels (CK-BB) looking for the presence of human antibodies to different brain antigens (BSA) as markers for neonatal cerebral injury. Using these diagnostic methods, there was no evidence of any negative influence of surfactant therapy on cerebral function of treated preterm infants.

N-acetyl-L-aspartate is a major source of acetyl groups for lipid synthesis during rat brain development.

The function of N-acetyl-L-aspartate (NAA), a predominant substance in the CNS, has not yet been determined. To investigate the possible function of NAA as a lipid precursor [14C]-N-acetyl-L-aspartate (NAA) or [14C]-acetate (AcA) was injected intracerebrally into 8, 15- and 22-day-old rats. These time points were selected because NAA concentration and the activity of the NAA synthetizing enzyme L-aspartate-N-acetyltransferase (ANAT) were low in 8-day-old rats, intermediate in 15-day-old rats and high in 22-day-old rats. During an incubation period of 4 h the radioactive acetyl group of NAA is incorporated into the lipid fraction in amounts of 42.9 to 65.7% of recovered total radioactivity, increasing with the age of the rats. In contrast, radioactivity incorporated from AcA is constant for all three ages. With NAA as precursor only 7.2-9.4% of the recovered total radioactivity is incorporated into the protein fraction. With AcA as precursor 27.0-18.1% of recovered radioactivity is incorporated into the protein fraction, the amounts decreasing with age. Taking into account that in vivo NAA concentration in the brain is much higher than the AcA concentration, NAA is clearly the more efficient precursor for lipid synthesis than AcA. Further, we compared NAA and AcA as lipid precursors by analyzing the radioactivity in single lipid fractions, expressed as normalized specific incorporation or normalized incorporation. The measured differences between NAA and AcA in normalized specific and normalized incorporation of acetyl groups imply that NAA is not simply degraded to AcA before incorporated into lipids. We conclude that NAA is a major source of acetyl groups for lipid synthesis during rat brain development.