Stacy J. Suskauer

Neuroimaging in pediatric traumatic brain injury: current and future predictors of functional outcome.

Although neuroimaging has long played a role in the acute management of pediatric traumatic brain injury (TBI), until recently, its use as a tool for understanding and predicting long-term brain-behavior relationships after TBI has been limited by the relatively poor sensitivity of routine clinical imaging for detecting diffuse axonal injury (DAI). Newer magnetic resonance-based imaging techniques demonstrate improved sensitivity to DAI. Early research suggests that these techniques hold promise for identifying imaging predictors and correlates of chronic function, both globally and within specific neuropsychological domains. In this review, we describe the principles of new, advanced imaging techniques including diffusion weighted and diffusion tensor imaging, susceptibility weighted imaging, and (1)H-magnetic resonance spectroscopy. In addition, we summarize current research demonstrating their early success in establishing relationships between imaging measures and functional outcomes after TBI. With the ongoing research, these imaging techniques may allow earlier identification of possible chronic sequelae of tissue injury for each child with TBI, thereby facilitating efficacy and efficiency in delivering successful rehabilitation services.

Examining acute rehabilitation outcomes for children with total functional dependence after traumatic brain injury: a pilot study.

Objective:To examine in a pilot cohort factors associated with functional outcome at discharge and 3-month follow-up after discharge from inpatient rehabilitation in children with severe traumatic brain injury (TBI) who entered rehabilitation with the lowest level of functional skills. Participants:Thirty-nine children and adolescents (3–18 years old) who sustained a severe TBI and had the lowest possible rating at rehabilitation admission on the Functional Independence Measure for Children (total score = 18). Methods:Retrospective review of data collected as part of routine clinical care. Results:At discharge, 59% of the children were partially dependent for basic activities, while 41% remained dependent for basic activities. Initial Glasgow Coma Scale score, time to follow commands, and time from injury to rehabilitation admission were correlated with functional status at discharge. Time to follow commands and time from injury to rehabilitation admission were correlated with functional status at 3-month follow-up. Changes in functional status during the first few weeks of admission were associated with functional status at discharge and follow-up. Conclusions:Even children with the most severe brain injuries, who enter rehabilitation completely dependent for all daily activities, have the potential to make significant gains in functioning by discharge and in the following few months. Assessment of functional status early in the course of rehabilitation contributes to the ability to predict outcome from severe TBI.

Corpus Callosum Segment Circumference Is Associated With Response Control in Children With Attention-Deficit Hyperactivity Disorder (ADHD)

Response control is impaired in attention-deficit hyperactivity disorder (ADHD). Given the corpus callosum’s role in response control, we compared callosal morphology in 64 children with ADHD and 64 typically developing children, aged 7 to 13 years, and investigated the relationships between callosal morphology and response control. Area and circumference of 5 callosal segments (genu, rostral body, midbody, isthmus, and splenium) were normalized for cerebral volume and examined for correlation with mean reaction time, intrasubject variability, and/or commission error rate from a go/no-go task. There were no between-group differences in segment areas or circumferences. Reaction time correlated with midbody circumference for boys with ADHD and isthmus circumference for girls with ADHD. For the entire cohort, rostral body circumference correlated with intrasubject variability. Impaired response control in ADHD is associated with anomalies in frontal interhemispheric connections. Future studies examining callosal shape will illuminate the anatomic basis of correlations between callosal segment circumference and response control.

Time to follow commands remains the most useful injury severity variable for predicting WeeFIM® scores 1 year after paediatric TBI

Abstract Objective: To investigate the relationship between injury severity variables, particularly time to follow commands (TFC) and long-term functional outcomes in paediatric traumatic brain injury (TBI). Methods and procedure: Participants included 40 children with moderate-to-severe TBI discharged from inpatient rehabilitation. Measures of severity were initial Glasgow Coma Scale score, TFC, duration of Post Traumatic Amnesia (PTA) and total duration of impaired consciousness (TFC + PTA). Functional outcome was measured by age-corrected Functional Independence Measure for Children (WeeFIM®) scores at 1-year after discharge. Results: Correlations indicated that injury severity variables (TFC, PTA and TFC + PTA) were all associated with functional outcome. Regression analyses revealed that TFC and TFC + PTA similarly accounted for 49% or 47% of the variance, respectively, in total WeeFIM® score. Thirty-seven of 40 children had good outcome; of the three children with TFC >26 days, two had poor outcome. Conclusion: PTA and TFC + PTA do not provide a benefit over TFC alone for prediction of long-term outcome and TFC is identified earlier in the recovery course. TFC remains an important predictor of functional outcome 1-year after discharge from inpatient rehabilitation after paediatric TBI.

Neuropsychological Features and Risk Factors in Children With Sturge-Weber Syndrome: Four Case Reports

Sturge-Weber Syndrome (SWS) is a rare neurocutaneous disorder involving facial capillary malformation (port-wine birthmark) and vascular malformation of the brain that is frequently associated with epilepsy, stroke-like episodes, cognitive deficits, motor impairment, and/or visual field cut. The four cases presented here (ages 8–9, two females) illustrate the broad range of physiologic involvement and associated neuropsychological functioning in SWS, and argue against the idea of a “typical” SWS neuropsychological presentation. Rather, we highlight a preliminary collection of disease status/severity factors thought to impact neuropsychological presentation in SWS, including degree of cortical involvement (unilateral versus bilateral; posterior only versus posterior/anterior), age at time of seizure onset, extent of seizure control, history of stroke-like episodes, and magnitude of neurologic decline/deficit. We discuss the need for broad-based assessment in this medical population, as various impairment combinations (e.g., perceptual, language, executive) create unique presentations as well as the need for individualized intervention.

Hemiparesis is a clinical correlate of general adaptive dysfunction in children and adolescents with Sturge-Weber syndrome.

This study sought to identify neurologic correlates of adaptive functioning in individuals with Sturge-Weber syndrome. A total of 18 children, adolescents, and young adults with Sturge-Weber syndrome with brain involvement were recruited from our Sturge-Weber center. All underwent neurologic examination (including review of clinical brain magnetic resonance imaging) and neuropsychological assessment. Neuropsychological assessment included measures of intellectual ability and standardized parent report of adaptive functioning. Overall, Full Scale IQ and ratings of global adaptive functioning were both lower than the population-based norms (P < .05). Negative correlations were identified between adaptive functioning ratings, clinician ratings of cortical abnormality, and ratings of neurologic status. Hemiparesis (minimal versus prominent) was the only individual component of the rating scales that differentiated between individuals with nonimpaired and impaired adaptive functioning scores. Information obtained during neurological examination of children and adolescents with Sturge-Weber syndrome particularly hemiparetic status is useful for identifying children who may need additional intervention.

Physiatric findings in individuals with Sturge-Weber syndrome.

Suskauer SJ, Trovato MK, Zabel TA, Comi AM: Physiatric findings in individuals with Sturge-Weber syndrome.Sturge-Weber syndrome is a rare neurocutaneous disorder that often results in functional impairment caused by motor (typically hemiparesis) and cognitive deficits. A retrospective chart review of physiatric evaluation of 30 individuals, aged 4 mos to 55 yrs (median age, 2.4 yrs), with Sturge-Weber syndrome with brain involvement was conducted for the purpose of summarizing physiatric findings and recommendations in this cohort. Presence or absence of motor, cognitive, and behavioral concerns and need for orthoses, spasticity management, and therapy services were noted. Hemiparesis was common, but the need for intervention for spasticity was rare. Cognitive and behavioral concerns were noted frequently, meriting additional evaluation. Case vignettes are presented to highlight (1) a child with repeated functional setbacks in association with increased seizure frequency who, with seizure control, demonstrated return to functional baseline and subsequent further skill development and (2) a child with Sturge-Weber syndrome who made functional gains with constraint-induced movement therapy.

Functional outcomes in children with abusive head trauma receiving inpatient rehabilitation compared with children with nonabusive head trauma.

OBJECTIVE To compare clinical features and functional outcomes of age- and sex-matched children with abusive and nonabusive head trauma receiving inpatient rehabilitation. STUDY DESIGN Children with abusive head trauma (n = 28) and age- and sex-matched children with nonabusive head trauma (n = 20) admitted to an inpatient pediatric rehabilitation unit from 1995-2012 were studied. Acute hospitalization and inpatient rehabilitation records were retrospectively reviewed for pertinent clinical data: initial Glasgow Coma Scale score, signs of increased intracranial pressure, neuroimaging findings, and presence of associated injuries. Functional status at admission to and discharge from inpatient rehabilitation was assessed using the Functional Independence Measure for Children. Outcome at discharge and outpatient follow-up were described based on attainment of independent ambulation and expressive language. RESULTS Children with abusive and nonabusive head trauma had similar levels of injury severity, although associated injuries were greater in those with abusive head trauma. Functional impairment upon admission to inpatient rehabilitation was comparable, and functional gains during inpatient rehabilitation were similar between groups. More children with nonabusive than with abusive head trauma attained independent ambulation and expressive language after discharge from rehabilitation; the difference was no longer significant when only children aged >12 months at injury were examined. There was variability in delay to obtain these skills and in the quality of gained skills in both groups. CONCLUSIONS Despite more associated injuries, children with abusive head trauma make significant functional gains during inpatient rehabilitation, comparable with an age- and sex-matched sample with nonabusive head trauma. Key functional skills may be gained by children in both groups following discharge from inpatient rehabilitation.

Preliminary evaluation of the Cognitive and Linguistic Scale: a measure to assess recovery in inpatient rehabilitation following pediatric brain injury.

ObjectiveA preliminary investigation of the psychometric properties of the Cognitive and Linguistic Scale (CALS), a measure of cognitive and linguistic recovery following brain injury in children and adolescents. ParticipantsOne hundred children and adolescents (aged 2–19 years) with acquired or traumatic brain injury were included. MethodsThe CALS was administered at inpatient rehabilitation admission and discharge. ResultsInternal consistency and interrater reliability were high. Factor analysis revealed 2 factors (basic responding, higher-level cognitive skills). Correlations with the Functional Independence Measure for Children (WeeFIM) ranged from 0.51 to 0.89; highest correlation was between WeeFIM cognitive domain and CALS total score. CALS scores improved significantly between admission and discharge. ConclusionOn the basis of these preliminary analyses, the CALS is a promising measure to track cognitive and linguistic recovery in children and adolescents with brain injury during inpatient rehabilitation.

Cerebral Blood Flow after Mild Traumatic Brain Injury: Associations between Symptoms and Post-Injury Perfusion

Arterial spin labeling (ASL) has emerged as a technique for assessing mild traumatic brain injury (mTBI), as it can noninvasively evaluate cerebrovascular physiology. To date, there is substantial variability in methodology and findings of ASL studies of mTBI. While both increased and decreased perfusion are reported after mTBI, more consistency is emerging when perfusion is examined with regard to symptomology. We evaluated 15 teenage athletes two and six weeks after sports-related concussion (SRC group) using pseudo-continuous ASL. We acquired comparison data from 15 matched controls from a single time point. At each time point, we completed whole-brain contrasts to evaluate differences between the SRC group and controls in relative cerebral blood flow (rCBF). Cluster-level findings directed region of interest (ROI) analyses to test for group differences in rCBF across the left dorsal anterior cingulate cortex (ACC) and left insula. Finally, we evaluated ROI rCBF and symptomology in the SRC group. At two weeks post-injury, the SRC group had significantly higher rCBF in the left dorsal ACC and left insula than controls; at six weeks post-injury, elevated rCBF persisted in the SRC group in the left dorsal ACC. Perfusion in the left dorsal ACC was higher in athletes reporting physical symptoms six weeks post-injury compared with asymptomatic athletes and controls. Overall, these findings are inconsistent with reports of reduced rCBF after mTBI but coherent with studies that report increased perfusion in persons with greater or persistent mTBI-related symptomology. Future work should continue to assess how CBF perfusion relates to symptomology and recovery after mTBI.