Application of 7 tesla magnetic resonance imaging for pediatric neurological disorders: Early clinical experience

Ultra-high field magnetic resonance imaging (MRI) has been introduced for use in pediatric developmental neurology. While higher magnetic fields have certain advantages, optimized techniques with specific considerations are required to ensure rational and safe use in children and those with pediatric neurological disorders (PNDs). Here, we summarize our initial experience with clinical translational studies that utilized 7 tesla (T)-MRI in the fields of developmental neurology. T2-reversed images and three-dimensional anisotropy contrast imaging enabled the depiction of targeted pathological brain structures with better spatial resolution. Diffusion imaging and susceptibility-weighted imaging enabled visualization of intracortical, subcortical, and intratumoral microstructures in vivo within highly limited scan times appropriate for patients with PNDs. 7T-MRI appears to have significant potential to enhance the depiction of the structural and functional properties of the brain, particularly those associated with atypical brain development.

Non-Epileptic Paroxysmal Events in Infants: stucture, manifestation and risk factors

During 3 years we observed in specialized neurological department of St. Olga Children’s City Hospital 708 babies aged up to 42 months with different paroxysmal disorders. Non-epileptic paroxysmal events (NEPE) were diagnosed in 98 cases. These disorders were qualified (according to ILAE criteria) as differentiated and undifferentiated NEPE. In most cases neurophysiological assessment data, neurovisualization data, and neurological status of infants with NEPE and babies from comparison group varied marginally. It was shown that NEPE development correlated with perinatal factors, and with infants’ developmental diseases (functional gastrointestinal disorders, iron deficiency states, chronic or persistent infections). The obtained data was interpreted according to the developmental neurology principles (optimality concept, in particular).

Cognitive Decline in Patients with Chronic Hydrocephalus and Normal Aging: ‘Growing into Deficits'

Background/Aim: To explore the theory of ‘growing into deficits', a concept known from developmental neurology, in a series of cases with chronic hydrocephalus (CH). Methods: Patients were selected from the Amsterdam Dementia Cohort and underwent extensive dementia screening. Results: Twelve patients with CH were selected, in whom Alzheimer's disease was considered unlikely, based on biomarker information and follow-up. Mean Mini-Mental State Examination score was 24 (range 7-30). Most patients were functioning on a level of mild dementia [Clinical Dementia Rating score of 0.5 in 8/11 (66.7%) patients]. On neuropsychological examination, memory and executive functions, as well as processing speed were most frequently impaired. Conclusion: In our opinion, the theory of ‘growing into deficits' shows a parallel with the clinical course of CH and normal aging when Alzheimer's disease was considered very unlikely, because most of these patients were functioning well for a very large part of their lives. The altered cerebrospinal fluid dynamics might make the brain more vulnerable to aging-related changes, leading to a faster cognitive decline in CH patients compared to healthy subjects, especially in case of concomitant brain damage such as traumatic brain injury or meningitis.

Tongue mobility in patients with cerebral palsy

Background/Aim. In children with cerebral palsy speech is a big problem. Speech of these children is more or less understandable, depending on the degree of reduced mobility of articulatory organs. Reduced mobility is affected by inability to control facial grimacing and poor muscle strength when performing targeted movements. The aim of this study was to determine the mobility of tongue in patients with cerebral palsy. Methods. The study included a sample of 34 children - patients with cerebral palsy who had been treated in the Special Hospital for the Cerebral Palsy and Developmental Neurology in Belgrade. The patients were divided according to the determined diagnosis into two groups: Quadriparesis spastica (n = 11) and Morbus Little (n = 16). The children, aged 8-12 years, had preserved intelectual abilities, and all of them had preserved hearing. The study was conducted during the period from January to September 2009. The functional state of articulatory organs in both groups was tested by the C-test that examines the anatomic structure and mobility of the articulatory organs. Results. Our research showed that both groups of the patients had impaired functional state of the tongue - the most mobile articulatory organ. Also, the research showed that the functional state of the tongue was worse in children diagnosed with Quadriparesis spastica. A statistically significant correlation between the diagnosis and the functional state of the tongue, the tongue test performance and the retention of the tongue in a given position was found (r = 0.594, p < 0.005; r = 0.816, p < 0.01 and r = 0.738, p < 0.001, respectively). Conclusion. A large percentage of children with cerebral palsy were not able to establish control over the position of articulatory organs, especially the tongue, and its retention in a given position, all of which affect the quality of speech.

Clinical approach to developmental neurology

The objectives and principles of neurological history and examination in children are the same as those in adults. This chapter therefore, will not provide an all-encompassing description of the neurological assessment of children, but highlights where the approach must differ substantially from that used in adults. Further it aims to provide a practical and useful approach to the examination of children, who may be preverbal and certainly will show less stamina for cooperation than adults. Of course as children get older, the examination can become more conventional and systematized. By adolescence the examination can be the same as the adult examination.The first and overriding factor for success is to be flexible and to make observations when the opportunity arises rather than to wait for abnormalities to arise during the course of a more systematic approach. Nonetheless a systematic approach to recording these results is essential, so as to bring together related observations made disparately in time. The history is of paramount importance in guiding the examination. Since it is unlikely that you will be able to complete a full examination, it is important to prioritize the observations needed in light of a differential diagnosis before you begin examining. Rather than rushing straight into the examination it is rewarding to gain a young child’s confidence by playing briefly with them. Also, instead of insisting on examining the child on a couch, it helps to become adept at examining young children on their parent’s or caretaker’s knee. Finally, no matter how cooperative a child is, potentially disturbing investigations should be left until last, including tendon reflexes or examination of the tongue, fundi, and ears. Otherwise all subsequent cooperation from the child may be lost after these examinations.The examination room environment is the key to a successful neurological examination and requires careful thought. There should be sufficient space to accommodate families and for the children to play. The room needs to be friendly and conducive to encouraging play. It needs to be equipped with carefully selected toys, pictures, pencils and paper, and books of interest to children over a wide age range. Observation of the child’s play whilst you are taking a history from the parents or caregivers will allow assessment of the child’s motor skills and developmental stage. Their use of play material can yield important clues to the nature of a deficit, by revealing ataxia, weakness, involuntary movements, tics, or spasticity. Play also provides an opportunity to assess the child’s behaviour, for instance their impulsivity, distractibility, and attention span. Interaction of the child with parents or caregivers can be observed also. If the child participates actively in the history taking, their understanding and contribution to the session allows you to make assessments of their language and intellectual skills.