Thomas G. Burns

Surgical Treatment of Epilepsy in Children Caused by Focal Cortical Dysplasia

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

CHOA Concussion Consensus Establishing a Uniform Policy for Academic Accommodations

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

Regionally Specific Cortical Thinning in Children with Sickle Cell Disease

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

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

Background: To date, few studies have delineated clear sex-based differences in symptom resolution after a sports-related concussion (SRC), and equivocal results have been identified in sex-based differences on baseline assessments. Purpose: To assess whether female athletes displayed prolonged recovery and more symptoms at baseline and after an SRC compared with male athletes. Study Design: Cohort study; Level of evidence, 3. Methods: The current study assessed 135 male and 41 female athletes (10-18 years old) who participated in high-impact sports in metropolitan Atlanta middle and high schools. All athletes completed a baseline assessment and at least 1 postconcussion assessment from the Immediate Post-Concussion Assessment and Cognitive Testing battery. Longitudinal hierarchical linear modeling was employed to examine individual-level variables and their associations with adolescents’ rates of recovery in concussive symptoms after controlling for age and number of prior concussions. Results: Aggregate symptoms were rated as higher in female athletes compared with male athletes at baseline (mean ± SD: females, 13.49 ± 11.20; males, 4.88 ± 8.74; F(1,175) = 10.59, P < .001) and immediately after a concussion (females: 16.75 ± 18.08; males: 10.58 ± 14.21; F(1,175) = 3.99, P = .05). There were no group differences in the slope of recovery between male and female athletes, indicating generally similar trajectories of change for both groups. Post hoc analyses revealed higher baseline levels of migraine and neuropsychological symptoms in female athletes. Conclusion: Although female athletes in the current study reported increased symptoms, identical recovery patterns were observed in both sexes, suggesting that sex-based differences in concussion recovery are better explained by increased symptom frequency among female athletes when compared with their male counterparts.

Mullen Scales of Early Learning: The Utility in Assessing Children Diagnosed With Autism Spectrum Disorders, Cerebral Palsy, and Epilepsy

A group of 47 patients diagnosed with neurodevelopmental disorders were compared to 47 age-, gender-, and racially matched typically developing children to examine the frequency of impairment across domains of the Mullen Scales of Early Learning (MSEL). The MSEL is a comprehensive measure of cognitive functioning designed to assess infants and preschool children between the ages of birth to 68 months. In the neurodevelopmental group, the sample was composed of children 2 to 4 years of age who were diagnosed with autism spectrum disorders (ASD; n = 19), cerebral palsy (CP; n = 14), and epilepsy (EPI; n = 14). A sample of 47 matched controls, taken from the normative sample of the MSEL, was used as a comparison group. Each one of the clinical groups comprising the neurodevelopmental sample demonstrated statistically significant delays across domains relative to the respective matched control group (p < .001). Children failed to demonstrate a “signature” profile for a diagnosis of ASD, CP, or EPI. The clinical sensitivity of the MSEL and the need for obtaining specific intervention services for children diagnosed with these conditions are presented. Finally, these results are discussed within the context of the clinical sensitivity of the MSEL in working with these clinical populations.

Performance of children with epilepsy and normal age-matched controls on the WISC-III.

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

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

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

Wechsler Individual Achievement Test-III: What is the ‘Gold Standard’ for Measuring Academic Achievement?

The Wechsler Individual Achievement Test-Second Edition (WIAT-II) has traditionally competed with other popular achievement measures such as the Woodcock-Johnson Test of Achievement-Third Edition (...

White Matter Integrity Dissociates Verbal Memory and Auditory Attention Span in Emerging Adults with Congenital Heart Disease.

White matter disruptions have been identified in individuals with congenital heart disease (CHD). However, no specific theory-driven relationships between microstructural white matter disruptions and cognition have been established in CHD. We conducted a two-part study. First, we identified significant differences in fractional anisotropy (FA) of emerging adults with CHD using Tract-Based Spatial Statistics (TBSS). TBSS analyses between 22 participants with CHD and 18 demographically similar controls identified five regions of normal appearing white matter with significantly lower FA in CHD, and two higher. Next, two regions of lower FA in CHD were selected to examine theory-driven differential relationships with cognition: voxels along the left uncinate fasciculus (UF; a tract theorized to contribute to verbal memory) and voxels along the right middle cerebellar peduncle (MCP; a tract previously linked to attention). In CHD, a significant positive correlation between UF FA and memory was found, r(20)=.42, p=.049 (uncorrected). There was no correlation between UF and auditory attention span. A positive correlation between MCP FA and auditory attention span was found, r(20)=.47, p=.027 (uncorrected). There was no correlation between MCP and memory. In controls, no significant relationships were identified. These results are consistent with previous literature demonstrating lower FA in younger CHD samples, and provide novel evidence for disrupted white matter integrity in emerging adults with CHD. Furthermore, a correlational double dissociation established distinct white matter circuitry (UF and MCP) and differential cognitive correlates (memory and attention span, respectively) in young adults with CHD.

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

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