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OBJECTIVE In pediatric hydrocephalus, shunts tend to result in smaller postoperative ventricles compared with those following an endoscopic third ventriculostomy (ETV). The impact of the final treated ventricle size on neuropsychological and quality-of-life outcomes is currently undetermined. Therefore, the authors sought to ascertain whether treated ventricle size is associated with neurocognitive and academic outcomes postoperatively. METHODS This prospective cohort study included children aged 5 years and older at the first diagnosis of hydrocephalus at 8 Hydrocephalus Clinical Research Network sites from 2011 to 2015. The treated ventricle size, as measured by the frontal and occipital horn ratio (FOR), was compared with 25 neuropsychological tests 6 months postoperatively after adjusting for age, hydrocephalus etiology, and treatment type (ETV vs shunt). Pre- and posttreatment grade point average (GPA), quality-of-life measures (Hydrocephalus Outcome Questionnaire [HOQ]), and a truncated preoperative neuropsychological battery were also compared with the FOR. RESULTS Overall, 60 children were included with a mean age of 10.8 years; 17% had ≥ 1 comorbidity. Etiologies for hydrocephalus were midbrain lesions (37%), aqueductal stenosis (22%), posterior fossa tumors (13%), and supratentorial tumors (12%). ETV (78%) was more commonly used than shunting (22%). Of the 25 neuropsychological tests, including full-scale IQ (q = 0.77), 23 tests showed no univariable association with postoperative ventricle size. Verbal learning delayed recall (p = 0.006, q = 0.118) and visual spatial judgment (p = 0.006, q = 0.118) were negatively associated with larger ventricles and remained significant after multivariate adjustment for age, etiology, and procedure type. However, neither delayed verbal learning (p = 0.40) nor visual spatial judgment (p = 0.22) was associated with ventricle size change with surgery. No associations were found between postoperative ventricle size and either GPA or the HOQ. CONCLUSIONS Minimal associations were found between the treated ventricle size and neuropsychological, academic, or quality-of-life outcomes for pediatric patients in this comprehensive, multicenter study that encompassed heterogeneous hydrocephalus etiologies.

To assess relatively long-term (ie, 1 year) neurocognitive outcomes of patients undergoing carotid artery stent (CAS) placement with cerebral protection.Sixty-two patients (19 symptomatic; mean age, 73 years) with significant carotid stenosis (or = 70% for symptomatic patients,or = 80% for asymptomatic patients) underwent CAS placement with embolic protection. Cognitive function was assessed prospectively with use of a battery of standardized tests administered at baseline (1-5 days before CAS endovascular therapy) and at 3, 6, and 12 months after CAS placement. Diffusion-weighted imaging (DWI) was performed before the procedure and within 24 hours after CAS placement.Results of statistical modeling across occasions of measurement indicated significant main effects of occasion for the Dementia Rating Scale (DRS)-2 concept formation (P.001), memory (P = .029), and total scores (P = .001); the DRS-2 total age- and education-corrected Mayo Older Americans Normative Studies score (P.001); and the North American Adult Reading Test IQ score (P = .003). The vast majority of patients showed improvement or no change relative to baseline DRS-2 total scores at all time points. No significant relationship between DWI outcomes and cognition scores over time was found. Age influenced improvement on cognitive tests, whereas baseline symptom status did not.Revascularization with a carotid stent and neuroprotection, at a minimum, left cognitive function unchanged in patients receiving a CAS, and in many instances improved it. The preliminary findings of this prospective pilot study should be confirmed with a larger, controlled trial.

✓ The authors present a method of incorporating preoperative noninvasive functional brain mapping data into the frameless stereotactic magnetic resonance (MR) imaging dataset used for image-guided resection of brain lesions located near eloquent cortex. They report the use of functional (f)MR imaging and magnetic source (MS) imaging for preoperative mapping of eloquent cortex in difficult cases of brain tumor resection such as those in which there are large expansive masses or in which reoperations are required and the anatomy is distorted from prior treatments. To correlate methods of preoperative and intraoperative mapping localization directly, the authors have developed techniques of importing preoperative MS and fMR imaging data into an image-guided frameless stereotactic computer workstation. The data appear as a seamless overlay on the same preoperative volumetric MR imaging dataset used for stereotactic guidance during the operation. Intraoperatively identified functional locations mapped by cortical stimulation are recorded as digitally registered points. This approach should prove useful in assessing the accuracy and reliability of various preoperative functional brain mapping techniques.

This study compared the ventricle-to-brain ratio (VBR) of the day-of-injury (DOI) computerized tomogram (CT) in traumatic brain-injured (TBI) patients with post-injury (2 months or greater) magnetic resonance (MR) VBRs in the same patients and in medical control subjects. The DOI VBR did not differ significantly from the medical controls, but both (DOI and medical control VBR) differed significantly from post-injury VBR. Additionally, a case study is presented wherein MR imaging studies were obtained prior to TBI so that a direct comparison of pre-injury to DOI to post-injury changes could be made. In this case the pre-injury and DOI VBRs were within approximately 9% of each other. In contrast, the post-injury VBR demonstrated over a 100% increase in comparison to either the pre-injury or DOI scan. This case and another case are illustrated using three-dimensional image analysis to represent ventricular change over time. These cases, along with the similarity of the DOI VBR with the medical controls, suggests that the DOI VBR can be utilized as an estimate or index of pre-injury ventricle/brain morphology. This will permit the use of DOI CT data for within-subject designs in TBI research that examines the course of degenerative changes over time.

Fornix-to-brain ratios (FBR) based on postinjury magnetic resonance (MR) studies were calculated on a group of 27 female traumatic brain injury (TBI) patients and 18 female medical controls by taking the widest aspect of the fornix at the level of the anterior horns and third ventricle and determining a fornix surface area. The FBR was significantly reduced in the TBI group (FBR = 0.1121) as compared to the normal control group (FBR = 0.1766). Despite these significant FBR findings indicating prominent atrophic changes of the fornix in TBI patients, the FBR did not relate systematically to neuropsychological outcome. These findings clearly indicate fornix vulnerability in TBI and that current quantitative MR methods are sensitive enough to detect such changes. However, fornix degeneration constitutes only one of many contributing factors to the anatomic basis of TBI-induced cognitive disturbances, as fornix atrophy did not relate systematically to neuropsychological outcome.

We present a case of right hemispheric dominance for sign language but left hemispheric dominance for reading, in a left-handed deaf patient with epilepsy and left mesial temporal sclerosis. Atypical language laterality for ASL was determined by preoperative fMRI, and congruent with ASL modified WADA testing. We conclude that reading and sign language can have crossed dominance and preoperative fMRI evaluation of deaf patients should include both reading and sign language evaluations.

The current study investigated ways to improve the ecological validity of the neuropsychological assessment of executive functioning through the formal assessment of compensatory strategies and environmental cognitive demands. Results indicated that the group of executive functioning tests (i.e., Trail Making Test, Wisconsin Card Sorting Test, Stroop, and Controlled Oral Word Association Test) accounted for 18-20% of the variance in everyday executive ability as measured by the Dysexecutive Questionnaire and Brock Adaptive Functioning Questionnaire. The addition of extra-test variables significantly increased the variance in everyday executive ability accounted for. The current study adds to the literature on the ecological validity of executive functioning assessment by highlighting the importance of extra-test variables when trying to understand the complex relationship between cognitive testing and real world performance.

Of all of the advances in clinical neuroscience, the advent of brain imaging represents one of the most significant, particularly for assessment of pediatric neurologic disorders. Prior to brain imaging, only inferences of structural brain integrity could be made from behavior, development, and standard physical neurologic examinations of the child. These measures continue to be important in the diagnostic process, but now the brain can be viewed in vivo. This chapter will overview some major categories where brain imaging provides critical information relative to brain structure and function in pediatric neuropsychology. First is a basic review of some underlying assumptions in pediatric neuro-imaging, followed by an overview of some major childhood categories wherein neuroimaging provides useful diagnostic information that can be integrated with neuropsychological assessment and/or consultation. We feel that it is critical for neuropsychologists to have more familiarity with neuroimaging procedures and interpretation in the assessment, development of treatment strategies, and clinical feedback involving parents, school, and other healthcare professionals. For more detailed exposition of pediatric neuroimaging per se, the reader is referred to Barkovich (1995), Osborn and Boyer (1994) and Wolpert and Barnes (1992).