Perinatal cerebral white matter injuries influence early communication and language development

Transcription

1 Perinatal cerebral white matter injuries influence early communication and language development Blazenka Brozovic University of Zagreb Department of Speech and Language Pathology Developmental Neurolinguistic Lab Croatian Institute for Brain Research

2 Perinatal brain lesions TIMING OF THE PERINATAL BRAIN INJURY Sustained during perinatal period : during pregnancy, delivery or within first 7 days after birth (term date). INCIDENCE Incidence is inversely proportional to gestational age and birth weight.

3 Highest risk between 23 and 32 weeks of gestational age (GA). Preterm infants (< 32 wks GA) Low birth weight (< 1500 gms) 20%-50% 30%-40% Term neonates (> 37 wks GA)??? 5%-20% Nonsymptomatic, noncomplicated, clinically silent

4 PERINATAL RISK FACTORS Complex multifactorial ethiology Premature birth Low birth weight Hypoxia, Ischemia, Asphyxia Disturbances of the cerebral blood flow Perinatal infections, Inflammation Hypotension / Hypertension Intrinsic vulnerability of cerebral white matter of premature infant (Volpe et al 2003). Increasing probability of PERINATAL BRAIN DAMAGE

5 PERIVENTRICULAR WHITE MATTER INJURY (NEAR THE LATTERAL VENTRICLES) PREDILECTION SITE DEPENDS ON TIMING (Brain maturation stage)

6 GA < 35 weeks Germinal matrix (periventricular white matter) GA > 35 weeks Cortex and subcortical white matter Volpe, JJ. 2009, Lancet Neurology, 8(1):

7 HAEMORRHAGIC LESIONS, Peri-intraventricular haemorrhage PVH-IVH Grade I-IV II I II US - Parasagittal sonogram US - Parasagittal sonogram Grade 1 Subependymal germinal matrix haemorrhage (H). Castillo & Mukherji, 1996, Lippincott-Raven Publ.) Grade 2 Blood in the caudothalamic notch ( ) region with extension into the adjacent frontal horn (v) of lateral ventricle, but without ventricular dilatation.

8 HAEMORRHAGIC LESIONS, Peri-intraventricular haemorrhage PVH-IVH Grade I-IV III IV IV Posljedice US- Coronal sonogram Grade 3 Clot (c) filling most of the right lateral ventricle. Hydrocephalus. Coronal section of brain Grade 4 Periventricular venous haemorrhagic infarction. Castillo & Mukherji, 1996,

9 HYPOXIC- ISCHAEMIC LESIONS Periventricular leukomalacia PVL Grade I-III Posljedice Volpe, JJ Lancet Neurology, 8(1): US- Coronal sonogram (A) & right parasagittal sonogram (B) Extensive cysts, more on the right than on the left side. On day 24 in a preterm infant, born at 28 weeks gestation. Pierrat at al., Arch Dis Child Fetal Neonatal Ed 84(3): F

10 White matter hyperintensity White matter thinning

11 Ventricular enlargement (ventriculomegaly) & thinning of the white matter Gray matter changes

12 Thinning of the corpus callosum (thinning of the white matter)

13 AIM To explore the neurodevelopmental implications of early periventricular ischaemic (PVL) and hemorrhagic lesions (PVH) on the development of early communication and language skills.

14 SUBJECTS Age 2-3 years N 30 (7 female, 23 male) Perinatal brain lesions (PBL) N 30 (7 female, 23 male) Normal neurodevelopment (ND) Preterm N 10 Term N 20 Hypoxic-ischemic N 3 Hemorrhage N 10 Hypoxia/Hemorrhage N 17 Both sided N 29 L side N 1 PVH gr. I. - II. N 27 PVH gr. II. N 1 PVL gr. III. N 1

15 INSTRUMENTS AND TASKS 1. Data collection 2. Formal assessment 3. Semi structured play with parent * Reynell Developmental Language Scales * Peabody Picture Vocabulary Test PPVT-IIIB * Articulation Test * (MacArthur-Bates Communicative Development Inventories (CDI) * Naming Test * Lexical and morphosyntactic analysis of 100 utterances (collected during 20 min. interaction) The Pragmatics Profile of Everyday Communication Skills in Children (modified) (Dewart, H., Summers, S., 1995.) * Assessment of communicative functions and forms * Analysis of gestures used in 20 min interaction Medical and developmental history, psy. developmental ass.

16 SPEECH Articulation L A N G U A G E Phonology Morphosyntax Semantics Pragmatics COMMUNICATION Brozović, 1998.

17 OUTCOME COMMUNICATION, SPEECH AND LANGUAGE 90% 80% 70% 83% ND PBL 60% 50% 50% 40% 30% 20% 20% 30% 17% 32% LANGUAGE IMPAIRMENT 10% 0% Appropriate Uredan communicative razvoj speech and language development/ No need for SLT referral Selektivne izgovorne teškoće (vjerojatna th. kasnije) Speech impairment (SLT referral) 17% COMMUNICATION AND LANGUAGE DELAY/DISORDER Odstupanje u komunikacijskom ili jezično-govornom razvoju Communication speech and language delay/disorder (SLT referral)

18 RESULTS COMMUNICATIVE FUNCTIONS ND PBL 80% 60% 40% 20% 0%

19 RESULTS COMMUNICATIVE FUNCTIONS Percentage of subjects who acquired certain communicative function. 1. IMAGINATIVE 2. EXPRESSION OF EMOTIONS 3. INFORMATIVE 4. ANSWERING WITH EXPLANATIONS 5. REQUESTING HELP 6 QUESTIONING 7 PERSONAL 8 COMMENTING 9.GREETINGS 10. NAMING 11. REQUESTING REPETITION 12. ATTENTION DIRECTING TO SOMETHING INTERESTING 13. REJECTING/REFUSING 14. REQUESTING OBJECTS 15. ATTENTION DIRECTING TO SELF 16. INSTRUMENTAL 17. REGULATORY 18. INTERACTIONAL p=0,040 p=0,010 p=0,010 p=0,010 p=0,006 p=0,001 p=0,002 Imaginativna Izražavanje osjećaja Informativna Odgovara objašnjavanjem Traži pomoć Heuristička Personalna Komentiranje Pozdravljanje Imenovanje Traži ponavljanje Odbijanje Traži predmet Pozornost na zanimljivost Pozornost na sebe Instrumentalna Regulacijska Interakcijska 37% 63% 70% 77% 80% 80% 80% 97% 97% 87% 90% 93% 97% 97% ND PBL 0% 20% 40% 60% 80%

20 RESULTS EXPRESSIVE FORM (SIGNAL, GESTURE, WORD, SENTENCE) Sentence (p=0,000), Word (p=0,003), Gesture (p=0,021) Naming Test (p=0,002) COMMUNICATIVE FORM ND PBL 30 27,67 SIGNAL GESTURE 3,9% 20 18,30 6,0% UR WORD 5,0% 21,0% POM 10 SENTENCE 69,0% 95,0% 0% 20% 40% 60% 80% 0 Imenovanje riječima Number of words

21 Number of gestures RESULTS GESTURES, WORDS, COMPREHENSION 2,6 reprezentacijske geste 1,7 1,2 ABOVE AVERAGE 0,4 BELOVE iznadprosječni prosječni -1 do -2 do -2 COMPREHENSION

22 RESULTS LANGUAGE COMPREHENSION Group differences on comprehension variables. Reynell (p= 0,001) Peabody (p= 0,010) z score Reynell z score Peabody 7% 17% više od -2 Above average -1 do -2 3% 17% Above average 43% 67% prosječni Average iznadprosječni 50% 67% Average više od -2-1 do -2 27% 23% 17% - 1 to - 2 SD - 2SD to - 3SD 47% 17% prosječni - 1 to - 2 SD iznadprosječni - 2SD to - 3SD POM PBL REYNELL Reynell UR ND POM PBL PEABODY Peabody UR ND

23 PERINATAL WHITE MATTER LESIONS General developmental delay is not frequently present but there is often an early presence of different types of communication, speech and language impairments. Even after small lesions (Grades I-II). Slower development of communication skills and/or presence of communication disorder. Speech disorders (speech apraxia, disarthria and other articulation and phonological disorders); Language delay or impairment (phonology, morphosyntax, semantics, pragmatics).

24 RECCOMENDATIONS Long-term developmental follow-up for infants with PBL Supporting early development and preventing communication and language delay and impairment Early intervention Prevention of additional disabilities (reading disorders, school failure, learning disability, behaviour disorders)

25 How to explain the complexity of cognitive, sensory and motor deficit? Judaš et al., AJNR 26: Lesions of periventricular WM crossroads of associative, commissural and projection fibers could explain the frequency and complexity of deficits. White matter segments (von Monakov 1905): 1. Central white matter - corpus callosum & PV associative fibers 2. Corona radiata 3. Centrum semiovale 4. Giral white matter 5. Cortical white matter

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