HEMIPLEGIA OF EARLY ONSET AND THE FACULTY OF SPEECH WITH SPECIAL REFERENCE TO THE EFFECTS OF HEMISPHERECTOMY

Is an earlier onset of focal epilepsy associated with atypical language lateralization? A systematic review, meta-analysis and new data

Right and bilateral language representation is common in focal epilepsy, possibly reflecting the influence of epileptogenic lesions and/or seizure activity in the left hemisphere. Atypical language lateralization is assumed to be more likely in cases of early seizure onset, due to greater language plasticity in childhood. However, evidence for this association is mixed, with most research based on small samples and heterogenous cohorts. In this preregistered meta-analysis we examined the association between age at seizure onset and fMRI-derived language lateralization in individuals with focal epilepsy. The pooled effect size demonstrated a correlation between an earlier onset and rightward language lateralization in the total sample (r = 0.1, p = .005, k = 58, n = 1240), with no difference in the correlation between age at seizure onset and language lateralization between left and right hemisphere epilepsy samples (Q=62.03, p = .302). In exploratory analyses of the individual participant data (n = 1157), we demonstrated strong evidence that a logarithmic model fits the data better than a linear (BF=350) or categorical model with 6 years of age as a cut-off (BF=36). These findings indicate that there is a small but significant relationship between age at seizure onset and language lateralization. The relationship was consistent with theories of language plasticity proposing an exponential decline in plasticity over early childhood. However, given that this effect was subtle and only found in larger sample sizes, an early age at seizure onset would not serve as a good indicator of atypical language lateralization on the individual patient level.

Functional and structural brain asymmetries in language processing

The lateralization of language to the left hemisphere of the human brain constitutes one of the classic examples of asymmetry in biology. At the same time, it is also commonly understood that damage to the left hemisphere does not lead to a complete loss of all linguistic abilities. These seemingly contradictory findings indicate that neither our cognitive capacity for language nor its neural substrates are monolithic. This chapter reviews the functional and structural lateralization of the neural substrates of different aspects of language as revealed in the past decades by neuroimaging research. Most aspects of language processing indeed tend to be functionally lateralized to the left hemisphere in the adult human brain. Nevertheless, both hemispheres exhibit a certain equipotentiality with regard to some aspects of language processing, especially with regard to processing meaning and sound. In contrast, the so-called "core language network" in the left hemisphere constitutes a functional and structural asymmetry: This network (i) is crucial for a core aspect of language processing, namely syntax, which refers to the generation of hierarchically structured representations of utterances linking meaning and sound, (ii) matures in accordance with a genetically determined biologic matrix, and (iii) its emergence may have constituted a prerequisite for the evolution of the human language capacity.

Is an earlier onset of focal epilepsy associated with atypical language lateralization? A systematic review, meta-analysis and new data

Right and bilateral language representation is common in focal epilepsy, possibly reflecting the influence of epileptogenic lesions and/or seizure activity in the left hemisphere. Atypical language lateralization is assumed to be more likely in cases of early seizure onset, due to greater language plasticity in childhood. However, evidence for this association is mixed, with most research based on small samples and heterogenous cohorts. In this preregistered meta-analysis we examined the association between age at seizure onset and fMRI-derived language lateralization in individuals with focal epilepsy. The pooled effect size demonstrated a correlation between an earlier onset and rightward language lateralization in the total sample (r=0.1, p=.005, k=58, n=1240), with no difference in the correlation between left and right hemisphere epilepsy samples (Q=62.03, p=.302). In exploratory analyses of the individual participant data (n=1157), we demonstrated strong evidence that a logarithmic model fits the data better than a linear (BF=350) or categorical model with 6 years of age as a cut-off (BF=36). These findings indicate that there is a small but significant relationship between age at seizure onset and language lateralization. The relationship was consistent with theories of language plasticity proposing an exponential decline in plasticity over early childhood. However, given that this effect was subtle and only found in larger sample sizes, an early age at seizure onset would not serve as a good indicator of atypical language lateralization on the individual patient level.

Trends and Most-Cited Articles on Hemispheric Surgery: A Bibliometric Analysis and Historical Review

INTRODUCTION

Hemispheric surgery is a multistep, highly effective, and radical surgical procedure in the treatment of drug-resistant epilepsy due to extensive unilateral hemispheric disease. The procedure ranges from a resective procedure (hemispherectomy) to disconnection (hemispherotomy) and has developed substantially over the last century from morbid to elegant, minimally invasive, and routinely practiced procedures. Bearing in mind the numerous articles that have been published on hemispherectomy and hemispherotomy, we aimed to highlight the top 100 cited and impactful articles to create familiarity with the topic. We anticipate that this will be a helpful guide for clinicians and academics navigating the literature on this subject.

METHODS

A Scopus title-based search on the top 100 most-cited articles on "hemispherectomy" and "hemispherotomy" was performed in September 2023 with no restrictions. The top 100 most-cited articles were then retrieved. The article title, first author, first author's specialty, country of origin, first author's institution at the time of publication, journal of publication, year of publication, citation count, and citations per year were collected. The Google Scholar database citation count for each paper was added for correlation and comprehensive coverage.

RESULTS

The top 100 most-cited articles were cited 92 times per paper on average. The publication dates ranged from 1949 to 2016. The most frequently cited article "Clinical outcomes of hemispherectomy for epilepsy in childhood and adolescence" with 307 citations was published by A.M. Devlin et al. (2003) in the journal Brain. The USA was the highest publishing country (41 articles). The highest-publishing journal was Neurology. The most prolific first authors were A. Smith, J. Schramm, and J. Villemure, each with four publications. The institution with the most contributions was McGill University and its affiliated Health Centers, with nine publications in total. Neurosurgery was the most common specialty among the first authors. Most of the included studies were cohort studies or case series.

CONCLUSION

We identified the top 100 cited articles on hemispherectomy and hemispherotomy using the Scopus database and supplemented our results with Google Scholar. We highlighted the most prominent authors, institutions, countries, journals, and study designs and illuminated the historical development of hemispherectomy and hemispherotomy procedures, in addition to landmark and currently trending papers.

Expanding the emergentist Account:Reply to open peer commentaries

Emergentism provides a framework for understanding how language learning processes vary across developmental age and linguistic levels, as shaped by core mechanisms and constraints from cognition, entrenchment, input, transfer, social support, motivation, and neurology. As our commentators all agree, this landscape is marked by intense variability arising from the complexity. These mechanisms interact in collaborative and competitive ways during actual moments of language use. To better understand these interactions and their effects, we need much richer longitudinal data regarding both input and output during actual contexts of usage. We believe that modern technology can eventually provide this data (Flege & Bohn, 2021) in ways that will allow us to more fully populate an emergent landscape.

Implications of age at lesion onset for neuropsychological outcomes: A systematic review focusing on focal brain lesions

Theories of the relation between age at lesion onset and outcomes posit different views of the young brain: resilient and plastic (i.e., the so-called "Kennard Principle"), or vulnerable (i.e., the Early Vulnerability Hypothesis). There is support for both perspectives in previous research and questions about the "best" or "worst" times to sustain brain injury remain. Here, we present a systematic review investigating the influence of age at focal brain lesion onset on cognitive functioning. This systematic review identifies and qualitatively synthesizes empirical studies from 1985 to 2021 that investigated age at lesion onset as a variable of interest associated with neuropsychological outcomes. A total of 45 studies were identified from PubMed, PsycINFO, and CINAHL databases. Almost all studies indicated that brain injury earlier in the developmental period predicts worse cognitive outcomes when compared to onset either later in the developmental period or in adulthood. More specifically, the overwhelming majority of studies support an "earlier is worse" model for domains of intellect, processing speed, attention and working memory, visuospatial and perceptual skills, and learning and memory. Relatively more variability in outcomes exists for domains of language and executive functioning. Outcomes for all domains are influenced by various other age and injury variables (e.g., lesion size, lesion laterality, chronicity, a history of epilepsy). Continued interdisciplinary understanding and communication about the influence of age at lesion onset on neuropsychological outcomes will aid in promoting the best possible outcomes for patients.

Dichotic listening deficits in children with hearing loss

PURPOSE

This correlational study compared dichotic listening among children with significant hearing loss to typically developing children and children clinically assessed for auditory processing disorder.

METHOD

Recorded versions of two dichotic tests were delivered under earphones or in the sound field for children using amplification. Individual ear scores and interaural asymmetry were compared to normative data. Matched deficit patterns from both tests were identified, ranked for severity of deficit, and compared across groups. Relationships between dichotic scores and factors related to amplification were investigated in the children with hearing loss.

RESULTS

Dichotic scores were significantly poorer among children with hearing loss without the large interaural asymmetries seen in children assessed clinically for auditory processing problems. Device type and age of implantation had no effect on scores; non-dominant ear scores on the digits test were significantly correlated to age of device use in the left ear and duration of device use in the right ear. Non-dominant ear scores with digits were also significantly correlated with bilateral word recognition.

CONCLUSIONS

Poor dichotic perception in children with significant hearing losses may be related to the use of recorded test materials, immature skills in attention and working memory, or other factors that contribute to development of vocabulary and language. These weaknesses may interfere with successful mainstream educational placement in these children. Assessment of dichotic performance in this population could lead to deficit-specific interventions that may improve outcomes and enhance educational opportunities for children with hearing loss.

Language and developmental plasticity after perinatal stroke

The mature human brain is lateralized for language, with the left hemisphere (LH) primarily responsible for sentence processing and the right hemisphere (RH) primarily responsible for processing suprasegmental aspects of language such as vocal emotion. However, it has long been hypothesized that in early life there is plasticity for language, allowing young children to acquire language in other cortical regions when LH areas are damaged. If true, what are the constraints on functional reorganization? Which areas of the brain can acquire language, and what happens to the functions these regions ordinarily perform? We address these questions by examining long-term outcomes in adolescents and young adults who, as infants, had a perinatal arterial ischemic stroke to the LH areas ordinarily subserving sentence processing. We compared them with their healthy age-matched siblings. All participants were tested on a battery of behavioral and functional imaging tasks. While stroke participants were impaired in some nonlinguistic cognitive abilities, their processing of sentences and of vocal emotion was normal and equal to that of their healthy siblings. In almost all, these abilities have both developed in the healthy RH. Our results provide insights into the remarkable ability of the young brain to reorganize language. Reorganization is highly constrained, with sentence processing almost always in the RH frontotemporal regions homotopic to their location in the healthy brain. This activation is somewhat segregated from RH emotion processing, suggesting that the two functions perform best when each has its own neural territory.

Plasticity of the language system in children and adults

The language system is perhaps the most unique feature of the human brain's cognitive architecture. It has long been a quest of cognitive neuroscience to understand the neural components that contribute to the hierarchical pattern processing and advanced rule learning required for language. The most important goal of this research is to understand how language becomes impaired when these neural components malfunction or are lost to stroke, and ultimately how we might recover language abilities under these circumstances. Additionally, understanding how the language system develops and how it can reorganize in the face of brain injury or dysfunction could help us to understand brain plasticity in cognitive networks more broadly. In this chapter we will discuss the earliest features of language organization in infants, and how deviations in typical development can-but in some cases, do not-lead to disordered language. We will then survey findings from adult stroke and aphasia research on the potential for recovering language processing in both the remaining left hemisphere tissue and in the non-dominant right hemisphere. Altogether, we hope to present a clear picture of what is known about the capacity for plastic change in the neurobiology of the human language system.

How does hemispheric specialization contribute to human-defining cognition?

Uniquely human cognitive faculties arise from flexible interplay between specific local neural modules, with hemispheric asymmetries in functional specialization. Here, we discuss how these computational design principles provide a scaffold that enables some of the most advanced cognitive operations, such as semantic understanding of world structure, logical reasoning, and communication via language. We draw parallels to dual-processing theories of cognition by placing a focus on Kahneman's System 1 and System 2. We propose integration of these ideas with the global workspace theory to explain dynamic relay of information products between both systems. Deepening the current understanding of how neurocognitive asymmetry makes humans special can ignite the next wave of neuroscience-inspired artificial intelligence.

The neural basis of language development: Changes in lateralization over age

We have long known that language is lateralized to the left hemisphere (LH) in most neurologically healthy adults. In contrast, findings on lateralization of function during development are more complex. As in adults, anatomical, electrophysiological, and neuroimaging studies in infants and children indicate LH lateralization for language. However, in very young children, lesions to either hemisphere are equally likely to result in language deficits, suggesting that language is distributed symmetrically early in life. We address this apparent contradiction by examining patterns of functional MRI (fMRI) language activation in children (ages 4 through 13) and adults (ages 18 through 29). In contrast to previous studies, we focus not on lateralization per se but rather on patterns of left-hemisphere (LH) and right-hemisphere (RH) activation across individual participants over age. Our analyses show significant activation not only in the LH language network but also in their RH homologs in all of the youngest children (ages 4 through 6). The proportion of participants showing significant RH activation decreases over age, with over 60% of adults lacking any significant RH activation. A whole-brain correlation analysis revealed an age-related decrease in language activation only in the RH homolog of Broca's area. This correlation was independent of task difficulty. We conclude that, while language is left-lateralized throughout life, the RH contribution to language processing is also strong early in life and decreases through childhood. Importantly, this early RH language activation may represent a developmental mechanism for recovery following early LH injury.

Novel linguistic evaluation of prefrontal synthesis (LEPS) test measures prefrontal synthesis acquisition in neurotypical children and predicts high-functioning versus low-functioning class assignment in individuals with autism

In order to grasp the difference between "the cat on the mat" and "the mat on the cat," understanding the words and the grammar is not enough. Rather it is essential to visualize the cat and the mat together to appreciate their relations. This type of imagination, which involves juxtaposition of mental objects is conducted by the prefrontal cortex and is therefore called Prefrontal Synthesis (PFS). PFS acquisition has a strong experience-dependent critical period putting children with language delay in danger of never acquiring PFS and, consequently, not mastering complex language comprehension. In typical children, the timeline of PFS acquisition correlates with vocabulary expansion. Conversely, atypically developing children may learn many words but never acquire PFS. In these individuals, intelligence tests based on vocabulary assessment may miss the profound deficit in PFS. Accordingly, we developed a test specific for PFS - Linguistic Evaluation of Prefrontal Synthesis or LEPS - and administered it to 50 neurotypical children, age 4.1 ± 1.3 years and to 23 individuals with impairments, age 16.4 ± 3.0 years. All neurotypical children older than 4 years received the LEPS score 7/10 or greater indicating good PFS ability. Among individuals with impairments only 39% received the LEPS score 7/10 or greater. LEPS was 90% correct in predicting high-functioning vs. low-functioning class assignment in individuals with impairments.

Language evolution to revolution: the leap from rich-vocabulary non-recursive communication system to recursive language 70,000 years ago was associated with acquisition of a novel component of imagination, called Prefrontal Synthesis, enabled by a mutation that slowed down the prefrontal cortex maturation simultaneously in two or more children – the Romulus and Remus hypothesis

There is an overwhelming archeological and genetic evidence that modern speech apparatus was acquired by hominins by 600,000 years ago. On the other hand, artifacts signifying modern imagination, such as (1) composite figurative arts, (2) bone needles with an eye, (3) construction of dwellings, and (4) elaborate burials arose not earlier than 70,000 years ago. It remains unclear (1) why there was a long gap between acquisition of modern speech apparatus and modern imagination, (2) what triggered the acquisition of modern imagination 70,000 years ago, and (3) what role language might have played in this process. Our research into evolutionary origin of modern imagination has been driven by the observation of a temporal limit for the development of a particular component of imagination. Modern children not exposed to recursive language in early childhood never acquire the type of active constructive imagination called Prefrontal Synthesis (PFS). Unlike vocabulary and grammar acquisition, which can be learned throughout one’s lifetime, there is a strong critical period for the development of PFS and individuals not exposed to recursive language in early childhood can never acquire PFS as adults. Their language will always lack understanding of spatial prepositions and recursion that depend on the PFS ability. In a similar manner, early hominins would not have been able to learn recursive language as adults and, therefore, would not be able to teach recursive language to their children. Thus, the existence of a strong critical period for PFS acquisition creates an evolutionary barrier for behavioral modernity. An evolutionary mathematical model suggests that a synergistic confluence of three events (1) a genetic mutation that extended the critical period by slowing down the prefrontal cortex development simultaneously in two or more children, (2) invention of recursive elements of language, such as spatial prepositions, by these children and (3) their dialogic communications using these recursive elements, resulted in concurrent conversion of a non-recursive communication system of their parents to recursive language and acquisition of PFS around 70,000 years ago.

Bilateral parietal activations for complex visual-spatial functions: Evidence from a visual-spatial construction task

In this paper, we examine brain lateralization patterns for a complex visual-spatial task commonly used to assess general spatial abilities. Although spatial abilities have classically been ascribed to the right hemisphere, evidence suggests that at least some tasks may be strongly bilateral. For example, while functional neuroimaging studies show right-lateralized activations for some spatial tasks (e.g., line bisection), bilateral activations are often reported for others, including classic spatial tasks such as mental rotation. Moreover, constructive apraxia has been reported following left- as well as right-hemisphere damage in adults, suggesting a role for the left hemisphere in spatial function. Here, we use functional neuroimaging to probe lateralization while healthy adults carry out a simplified visual-spatial construction task, in which they judge whether two geometric puzzle pieces can be combined to form a square. The task evokes strong bilateral activations, predominantly in parietal and lateral occipital cortex. Bilaterality was observed at the single-subject as well as at the group level, and regardless of whether specific items required mental rotation. We speculate that complex visual-spatial tasks may generally engage more bilateral activation of the brain than previously thought, and we discuss implications for understanding hemispheric specialization for spatial functions.

Functional outcomes following lesions in visual cortex: Implications for plasticity of high-level vision

Understanding the nature and extent of neural plasticity in humans remains a key challenge for neuroscience. Importantly, however, a precise characterization of plasticity and its underlying mechanism has the potential to enable new approaches for enhancing reorganization of cortical function. Investigations of the impairment and subsequent recovery of cognitive and perceptual functions following early-onset cortical lesions in humans provide a unique opportunity to elucidate how the brain changes, adapts, and reorganizes. Specifically, here, we focus on restitution of visual function, and we review the findings on plasticity and re-organization of the ventral occipital temporal cortex (VOTC) in published reports of 46 patients with a lesion to or resection of the visual cortex early in life. Findings reveal that a lesion to the VOTC results in a deficit that affects the visual recognition of more than one category of stimuli (faces, objects and words). In addition, the majority of pediatric patients show limited recovery over time, especially those in whom deficits in low-level vision also persist. Last, given that neither the equipotentiality nor the modularity view on plasticity was clearly supported, we suggest some intermediate possibilities in which some plasticity may be evident but that this might depend on the area that was affected, its maturational trajectory as well as its structural and functional connectivity constraints. Finally, we offer suggestions for future research that can elucidate plasticity further.

Language plasticity after hemispherotomy of the dominant hemisphere in 3 patients: Implication of non-linguistic networks

The neural networks involved in language recovery following hemispherotomy of the dominant hemisphere after language acquisition in children remain poorly known. Twelve hemispherotomized children (mean age at surgery: 11.3years) with comparable post-operative neuropsychological patterns underwent multi-task language functional MRI. Three of them had recovered from an initial postoperative aphasia i.e., hemispherotomy was performed on the language-dominant hemisphere. Our main results revealed (1) perisylvian activations in all patients after either left or right hemispherotomy; (2) no differences in activations between groups regarding the side of hemispherotomy; (3) additional activations in pre-frontal (3/3) and hippocampal/parahippocampal and occipito-parietal (2/3) areas, when comparing language activation in each of the three subjects with hemispherotomy of the language-dominant hemisphere to the group of 9 non-dominant hemispherotomized patients. These neural networks support the stronger engagement of learning and memory during language recovery in a hemisphere that was not initially actively subserving language.

Laterality of Cognitive Functions in Achieving Hemiplegic Children

7 left and 7 right children with infantile hemiplegia were compared with 7 physically normal children on the Wechsler Intelligence Scale for Children and Reitan-Indiana Neurological Tests. Although the brain-injured children are achieving satisfactorily in school and no differences were found among the three groups on the Wide Range Achievement Test, the left hemiplegics were poorer than the normals in visuo-perceptual performance and the right hemiplegics poorer than the normals in verbal intelligence. The results suggest that even in educationally advanced children, compensation for early, asymmetrical brain damage is not complete. Recommendations were made for early assessment of asymmetrical cognitive abilities and differential instructional procedures.

Right hemisphere dominance for language in a woman with schizophrenia and a porencephalic cyst of the left hemisphere

A large left hemisphere porencephalic cyst was incidentally found in a 48-year-old woman (MS) with a Diagnostic and Statistical Manual (DSM)-5 diagnosis of schizophrenia. The encephaloclastic characteristics of the cyst indicated that it was acquired between the 22nd and 24th gestational weeks, after the major waves of neuronal migration had tapered off. The cyst destroyed the left temporal and occipital lobes, and the inferior parietal lobule. Surprisingly, MS had no evidence of aphasia, alexia, agraphia, or ideational apraxia; in contrast, cognitive functions dependent on the integrity of the right hemisphere were severely impaired. To test the hypothesis that the development of language in MS took place at the expense of functions that are normally carried out by the right hemisphere, we investigated MS's correlates of oral comprehension with fMRI as a proxy for auditory comprehension and other cognitive functions strongly lateralized to the posterior left hemisphere, such as ideational praxis and reading. Comprehension of spoken language engaged the homologous of Wernicke's area in the right planum temporale. Porencephaly may represent a natural model of neuroplasticity supervening at predictable epochs of prenatal development.

Language and affective facial expression in children with perinatal stroke

Children with perinatal stroke (PS) provide a unique opportunity to understand developing brain-behavior relations. Previous research has noted distinctive differences in behavioral sequelae between children with PS and adults with acquired stroke: children fare better, presumably due to the plasticity of the developing brain for adaptive reorganization. Whereas we are beginning to understand language development, we know little about another communicative domain, emotional expression. The current study investigates the use and integration of language and facial expression during an interview. As anticipated, the language performance of the five and six year old PS group is comparable to their typically developing (TD) peers, however, their affective profiles are distinctive: those with right hemisphere injury are less expressive with respect to affective language and affective facial expression than either those with left hemisphere injury or TD group. The two distinctive profiles for language and emotional expression in these children suggest gradients of neuroplasticity in the developing brain.

The role of domain-general cognitive control in language comprehension

What role does domain-general cognitive control play in understanding linguistic input? Although much evidence has suggested that domain-general cognitive control and working memory resources are sometimes recruited during language comprehension, many aspects of this relationship remain elusive. For example, how frequently do cognitive control mechanisms get engaged when we understand language? And is this engagement necessary for successful comprehension? I here (a) review recent brain imaging evidence for the neural separability of the brain regions that support high-level linguistic processing vs. those that support domain-general cognitive control abilities; (b) define the space of possibilities for the relationship between these sets of brain regions; and (c) review the available evidence that constrains these possibilities to some extent. I argue that we should stop asking whether domain-general cognitive control mechanisms play a role in language comprehension, and instead focus on characterizing the division of labor between the cognitive control brain regions and the more functionally specialized language regions.

Age, plasticity, and homeostasis in childhood brain disorders

It has been widely accepted that the younger the age and/or immaturity of the organism, the greater the brain plasticity, the young age plasticity privilege. This paper examines the relation of a young age to plasticity, reviewing human pediatric brain disorders, as well as selected animal models, human developmental and adult brain disorder studies. As well, we review developmental and childhood acquired disorders that involve a failure of regulatory homeostasis. Our core arguments are as follows:

Is a lone right hemisphere enough? Neurolinguistic architecture in a case with a very early left hemispherectomy

We studied the linguistic profile and neurolinguistic organization of a 14-year-old adolescent (EB) who underwent a left hemispherectomy at the age of 2.5 years. After initial aphasia, his language skills recovered within 2 years, with the exception of some word finding problems. Over the years, the neuropsychological assessments showed that EB's language was near-to-normal, with the exception of lexical competence, which lagged slightly behind for both auditory and written language. Moreover, EB's accuracy and speed in both reading and writing words and non-words were within the normal range, whereas difficulties emerged in reading loan words and in tasks with homophones. EB's functional magnetic resonance imaging (fMRI) patterns for several linguistic and metalinguistic tasks were similar to those observed in the dominant hemisphere of controls, suggesting that his language network conforms to a left-like linguistic neural blueprint. However, a stronger frontal recruitment suggests that linguistic tasks are more demanding for him. Finally, no specific reading activation was found in EB's occipitotemporal region, a finding consistent with the surface dyslexia-like behavioral pattern of the patient. While a lone right hemisphere may not be sufficient to guarantee full blown linguistic competences after early hemispherectomy, EB's behavioral and fMRI patterns suggest that his lone right hemisphere followed a left-like blueprint of the linguistic network.

Homotopic language reorganization in the right hemisphere after early left hemisphere injury

To determine the areas involved in reorganization of language to the right hemisphere after early left hemisphere injury, we compared fMRI activation patterns during four production and comprehension tasks in post-surgical epilepsy patients with either left (LH) or right hemisphere (RH) speech dominance (determined by Wada testing) and healthy controls. Patient groups were carefully matched for IQ, lesion location and size. RH patients' activation across all tasks was greatest in right hemisphere areas homotopic to areas activated by LH and control participants. Differences in right vs. left dominant hemisphere activation were limited to homologous areas typically activated by language tasks, supporting the hypothesis that language localization following transfer to the RH is the mirror-image of localization in the absence of transfer. The similarity of these findings to those in patients with larger, peri-sylvian lesions suggests that these areas in both hemispheres may be uniquely predisposed to subserve various language functions.

Some evidence of bilateral speech representation in sinistrals

The information provided by pre and post-operative surface EEG, cortical EEG, cortical stimulation, intracarotid barbiturization, psychometric testing and ictal semiology are integrated in order to define the speech regions. The three patients described are predominantly left handed and left cerebral hemisphere dominant, all with right hemisphere epilepsy. All are considered to have bi-lateral speech representation to account for dysphasia during cortical stimulation in all three and ictal or post ictal dysphasia in the first two and post-operative dysphasia in the first and third. Some of the evidence that supports the possibility of bi-lateral speech representation is discussed.

Speech and oral motor profile after childhood hemispherectomy

Hemispherectomy (disconnection or removal of an entire cerebral hemisphere) is a rare surgical procedure used for the relief of drug-resistant epilepsy in children. After hemispherectomy, contralateral hemiplegia persists whereas gross expressive and receptive language functions can be remarkably spared. Motor speech deficits have rarely been examined systematically, thus limiting the accuracy of postoperative prognosis. We describe the speech profiles of hemispherectomized participants characterizing their intelligibility, articulation, phonological speech errors, dysarthric features, and execution and sequencing of orofacial speech and non-speech movements. Thirteen participants who had undergone hemispherectomy (six left, seven right; nine with congenital, four with acquired hemiplegia; operated between four months and 13 years) were investigated. Results showed that all participants were intelligible but showed a mild dysarthric profile characterized by neuromuscular asymmetry and reduced quality and coordination of movements, features that are characteristic of adult-onset unilateral upper motor neuron dysarthria, flaccid-ataxic variant. In addition, one left and four right hemispherectomy cases presented with impaired production of speech and non-speech sequences. No participant showed evidence of verbal or oral dyspraxia. It is concluded that mild dysarthria is persistent after left or right hemispherectomy, irrespective of age at onset of hemiplegia. These results indicate incomplete functional re-organization for the control of fine speech motor movements throughout childhood, and provide no evidence of hemispheric differences.

On the biological basis of human laterality: I. Evidence for a maturational left–right gradient

In this paper, we consider human handedness and cerebral lateralization in a general biological context, and attempt to arrive at some conclusions common to the growth of human laterality and of other structural asymmetries. We suggest that many asymmetries appear to be under the influence of a left-right maturational gradient, which often seems to favor earlier or more rapid development on the left than on the right. If the leading side is damaged or restricted, this gradient may be reversed so that growth occurs with the opposite polarity. A mechanism of this sort appears to underlie the phenomenon of situs inversus viscerum et cordis, and the same principle may help explain the equipotentiality of the two sides of the human brain with respect to the representation of language in the early years of life. However we must also suppose that the leading side normally exerts an inhibitory influence on the lagging side, for otherwise one would expect language ultimately to develop in both halves of the brain. Examples of an inhibitory influence of this kind can also be found in other biological asymmetries; for instance, in the crab Alpheus heterochelis, one claw is normally greatly enlarged relative to the other, but if the larger claw is removed the smaller one is apparently released from its inhibitory influence and grows larger.

This last example is particularly interesting because it suggests a mechanism comparable to that proposed by Annett to account for the distribution of handedness in the human population. She argued, in effect, that there is a “right shift” factor among the majority of the population, but that among a minority who lack this factor handedness is determined at random. If it is supposed that cerebral lateralization is also determined at random among this recessive minority, the model can be extended to provide a reasonable fit to the data on the correlation between handedness and cerebral lateralization. However this genetic model (or any other) still fails to account for the near-binomial distribution of handedness among twins and among nontwin siblings. We suggest that right-handedness and leftcerebral dominance for language are manifestations of an underlying gradient which is probably coded in the cytoplasm rather than in the genes. We must leave open the question as to whether departures from this pattern are due to a recessive gene which effectively cancels the asymmetry to environmental influences, or to both genetic and cytoplasmic factors.

Language after hemispherectomy in childhood: contributions from memory and intelligence

After hemispherectomy (removal or disconnection of an entire cerebral hemisphere) in childhood for treatment of intractable epilepsy, gross speech and language functions are often rescued. Whether more complex functions, such as syntactic processing, are selectively impaired, remains controversial. Here we present a cross-sectional study of expressive and receptive language functions in 30 patients who have undergone hemispherectomy (17 left, 13 right). The patients had developed epilepsy-induced pathology either during the pre/perinatal period (19 cases), or after a period of normal development (11 cases; onset range=20 months to 10 years). The patients were assessed at least 1 year post surgery on tests of receptive vocabulary, expressive and receptive grammar, instruction comprehension, and semantic association. Measures of verbal and nonverbal intelligence, short-term verbal memory, and working memory were also obtained. Principal component analysis revealed that two core components could be extracted from the five language measures, one reflecting receptive vocabulary abilities, and the other a composite of the other four measures. Regression analyses revealed that the best predictor of the composite language score was the short-term verbal memory score with some contribution from verbal intelligence, while the only predictor of receptive vocabulary was verbal intelligence. The results suggest that during childhood the lone left and right hemispheres have a similar potential for developing an adequate level of receptive vocabulary. However, congenital pathology affecting either hemisphere, and postnatal damage to the left hemisphere result in substantial language deficits that are reflected also in limitations in short-term verbal memory, and, to a lesser extent, in verbal intelligence.

[Hemispheric specialisation versus inter-hemispheric communication]

The first part of this article covers the main discoveries that led to the concept of hemispheric specialisation, from Egyptian antiquity to present times, through the pivotal XIXth century period that saw the attribution of specific cognitive functions to the left and right hemispheres. Next, this dichotomous conception of cerebral function, attributing a given process to a hemisphere and hypothesising callosal transmission, is discussed in the light of recent studies on language comprehension. Present day knowledge suggesting an alternative to the structuralist view of hemispheric specialisation in the form of dynamic, complementary sharing of labour, and of cooperation through transcortical neural networks, is then considered. Finally, the role of the corpus callosum in interhemispheric communication is briefly covered. An emphasis is placed on the diversity of this structure that is at the origin of highly different functions (fibre size, homotopic vs heterotopic connections). Ultimately, we contrast the view of a corpus callosum serving as an information transmitting channel with that of a fibre tract co-activating the non-engaged hemisphere and preparing it for potential stimulation. In this manner, the corpus callosum minimises disparities in the distribution of attention between the two hemispheres.

Pediatric functional magnetic resonance imaging (fMRI): issues and applications

Functional magnetic resonance imaging (fMRI) represents a useful tool for studying brain functions and the neural basis of cognition in healthy children and in those in disease states. Functional magnetic resonance imaging is a relatively new use of existing magnetic resonance imaging technology that allows scientists and practitioners to observe the brain at work. It is based on the observation that local increases in blood flow are related to neural activity. This review considers principles of functional magnetic resonance imaging, issues relevant to imaging children, and research using functional magnetic resonance imaging to examine cognitive processing in pediatric populations. The focus is specifically on language studies to review strengths, limitations, and practical applications of this technology with children. Future directions for functional magnetic resonance imaging are presented.

Psychiatric outcome of localized head injury in children

Previous studies have shown a high prevalence of psychiatric disturbance in children with brain injury. Studies on localized lesions have suggested that injury to the young organism carries a better prognosis for recovery of function than injury at a later age. The present study was designed to investigate these phenomena systematically. A representative sample of children (n = 98) who had been hospitalized for treatment of a compound depressed fracture, associated with a dural tear and visible damage to the underlying cortex, was identified from the records of neurosurgical units throughout the United Kingdom. The children were aged between 3 months and 12 years at the time of injury and between 5 and 15 years at the time of examination. The interval between injury and examination varied but the sample was designed to include only children who had been injured at least two years before examination. The children were examined neurologically and psychometrically, a detailed account of their current psychiatric state was obtained from one or both parents, and their mental state was assessed in a standard psychiatric examination. Preliminary data are presented which relate psychiatric, educational and intellectual status at the time of examination to site and severity of injury, age at injury, and to a number of psychosocial variables.

Recovery of function after brain injury in man

Late after-effects of cerebral trauma are difficult to study because patients tend to be seen for persisting symptoms, and not simply for their lesions. We have tried to avoid this bias by recalling periodically, over the years, 520 men with known brain injuries incurred in World War II or in Korea or Vietnam. These men are seen irrespective of clinical need and all undergo intensive behavioural and neurological assessment, which still continues. For such groups, recovery is impressive, though one third shows persistent intellectual loss. In addition, some tasks reveal specific deficits enduring unchanged, after th first 2-3 yr, for the 20-30 yr of follow-up (e.g. visual field defects, certain auditory discrimination losses, trouble on various complex perceptual tasks). These lasting deficits are linked to the site and size of focal injury, often representing remnants of more severe initially-present disorders. The extent of recovery is correlated with age at the time of trauma, the youngest faring best. Extension of such studies to cases of early brain damage (birth to five years), as indicated by hemiparesis, shows the familiar 'escape' of language after early left-hemisphere lesions but this is achieved at a price, the price being borne by non-verbal functions that normally depend on the integrity of the right hemisphere.

Language related reorganization in adult brain with slow growing glioma: fMRI prospective case-study

One possible mechanism for language plasticity in cases of lesions in left dominant hemisphere is the recruitment of homologous region in the unaffected non-dominant hemisphere. The potential of the right hemisphere to carry out such plasticity is expressed by the functional outcome of patients with lesions in the left hemisphere acquired at childhood prior to language acquisition. Whether lesions in the dominant hemisphere acquired in adulthood can result in functional recovery of language by means of recruitment of the non-dominant hemisphere is undetermined. We describe a 28-year-old, right-handed male diagnosed with a left temporo-frontal glioma. It was decided to manage him expectantly due to the low level of suspicion of malignancy and the close proximity of the lesion to critical language function centers. Language functional MRI (fMRI) tests were performed twice within the ensuing 2 years before surgical intervention. Regional brain activation was measured within the temporal and frontal lobes. Laterality index (LI) was calculated based on the corresponding number of activated voxels. The main finding is that over time, prior to resection of the enlarged tumor, the inferior frontal gyrus (IFG) changed from being strongly left lateralized in the first fMRI exam to being bilateral in the second fMRI exam, mainly due to larger activation in the right hemisphere. By that time, although the patient was not aphasic, his language performance was significantly below average. These findings suggest that a slow growing tumor in an adult language-related area might result in a functional reorganization by recruiting the right hemisphere. However, the contribution of such reorganization to the preservation of language performance remains equivocal.

The Bilingual Brain: Human Evolution and Second Language Acquisition

For the past half-century, psycholinguistic research has concerned itself with two mysteries of human cognition: (1) that children universally acquire a highly abstract, computationally complex set of linguistic rules rapidly and effortlessly, and (2) that second language acquisition (SLA) among adults is, conversely, slow, laborious, highly variable, and virtually never results in native fluency. We now have a decent, if approximate, understanding of the biological foundations of first language acquisition, thanks in large part to Lenneberg's (1964, 1984) seminal work on the critical period hypothesis. More recently, the elements of a promising theory of language and evolution have emerged as well (see e.g. Bickerton, 1981 , 1990 ; Leiberman, 1984, 1987). I argue here that the empirical foundations of an evolutionary theory of language are now solid enough to support an account of bilingualism and adult SLA as well. Specifically, I will show that evidence from the environment of evolutionary adaptation of paleolithic humans suggests that for our nomadic ancestors, the ability to master a language early in life was an eminently useful adaptation. However, the ability to acquire another language in adulthood was not, and consequently was not selected for propagation.

The validity of Barlow's 1877 case of acquired childhood aphasia: case notes versus published reports

In 1877, Barlow described a ten-year-old boy with right hemiplegia and aphasia, quick recovery of language function, and subsequent left hemiplegia and aphasia, who was shown to have symmetrical left and right Broca's area lesions at autopsy. The report of this case motivated many writers in the second half of the nineteenth century to develop theories on localization, laterality, equipotentiality and development of specialization, recovery of function, and the role of the right hemisphere (see Finger et al., 2003, for review). This paper presents an analysis of the original archived case notes that have recently come to light. Examination reveals discrepancies in significant details of the history of the case and raises questions about the degree of impairment and recovery throughout his illness as reported in the published article. Consideration of these differences between the presentation of the case in the British Medical Journal publication and the documentation in the original patient records raises issues about the validity of this case as evidence for the many arguments it was to support that have persisted to the present.

Does functional neuroimaging solve the questions of neurolinguistics?

Neurolinguistic research has been engaged in evaluating models of language using measures from brain structure and function, and/or in investigating brain structure and function with respect to language representation using proposed models of language. While the aphasiological strategy, which classifies aphasias based on performance modality and a few linguistic variables, has been the most stable, cognitive neurolinguistics has had less success in reliably associating more elaborately proposed levels and units of language models with brain structure. Functional imaging emerged at this stage of neurolinguistic research. In this review article, it is proposed that the often-inconsistent superfluity of outcomes arising from functional imaging studies of language awaits adjustment at both "ends" of the process: model and data. Assumptions that our current language models consistently and reliably represent implicit knowledge within human cerebral processing are in line for major revision; and the promise of functional brain imaging to reveal any such knowledge structures must incorporate stable correlates of the imaging signal as dependent variable.

Lateralization of the frontal lobe functions elicited by a cognitive bias task is a fundamental process. Lesion study

Cognitive neuroscience researchers have hypothesized that context-dependent and context-independent response selection is associated with the left and right frontal lobe, respectively, in right-handed adult males. Patients with left frontal lobe lesions show context-independent reasoning in a cognitive bias task (CBT), while those with right frontal lesions show context-dependent reasoning. Young children show more context-independent responses in a modified CBT (mCBT), while adolescents and adults show more context-dependent responses. We investigated the cognitive bias of right-handed children with unilateral frontal lobe lesions/epileptic foci to explore the plasticity of lateralization in the frontal lobes. The study included eight children with left frontal lobe lesions/epileptic foci (LLF) and four children with right frontal lobe lesions/epileptic foci (RLF). Twenty-three right-handed age-matched males served as controls. A computer presented version of the original card-choice task that was simplified and modified for children was used (mCBT). Simple visual stimuli differed dichotomously in shape, color, number, and shading. A target object presented alone was followed by two choices from which subjects made selection based on preference. Considering all four characteristics, the degree of similarity between the target and the subjects' choice was scored for 30 trials. A high score indicated a context-dependent response selection bias and a low score indicated a context-independent bias. The RLF subjects had a higher converted score (mean: 26.8+/-2.2), while LLF subjects showed a lower converted score (mean: 7.75+/-6.3). There were highly significant differences between LLF subjects and the other groups (P<0.001 vs. controls or RLF subjects). No significant correlations were observed between the converted scores and the age at onset, time since insult, or IQ in either LLF or RLF subjects. These findings suggest that the lateralization of frontal lobe function elicited by mCBT is fundamental and independent of language lateralization, rather than secondary to it. Furthermore, these findings also indicate that the timetable for the development of lateralized frontal lobe functions depends upon biologic factors.

The Cognitive Outcome of Hemispherectomy in 71 Children

PURPOSE

Long-term neuropsychological outcome was studied in 71 patients who underwent hemispherectomy for severe and intractable seizures at The Johns Hopkins Hospital between 1968 and 1997 and who agreed to participate. Seizures were due to cortical dysplasias (n = 27), Rasmussen syndrome (n = 37), or vascular malformations or strokes (n = 7). Both presurgical and follow-up results are available and reported for 53 patients.

METHODS

Patients and caretakers were interviewed, and patients were administered standard measures of intelligence, receptive and expressive language, visual-motor skills, adaptive/developmental functioning, and behavior.

RESULTS

Mean age at surgery was 7.2 years. At follow-up, on average 5.4 years after surgery, 65% are seizure free, 49% are medication free, and, of those responding, none rated quality of life as worse than before surgery. Mean IQ was in the 70s for Rasmussen and vascular patients and in the 30s for cortical dysplasia patients. Language and visual-motor skills were consistent with IQ. For Rasmussen patients only, language was significantly more impaired for left than for right hemispherectomy, both before surgery and at follow-up. Adaptive skills were mildly impaired, with greatest impairment in the physical domain. Cognitive measures typically changed little between surgery and follow-up, with IQ change <15 points for 34 of 53 patients; of the remainder, 11 declined and eight improved. Behavior was free of major problems, but social interactions and activities were limited.

CONCLUSIONS

The most significant predictor of cognitive skills at follow-up was etiology, with dysplasia patients scoring lowest in intelligence and language but not in visual-motor skills. Regardless of etiology, most patients showed only moderate change in cognitive performance at follow-up.

Speech and non-speech processing in hemispherectomised children: an event-related potential study

Although hemispherectomy is now used as a radical treatment for intractable seizures in a number of centres, there have been limited electrophysiological studies investigating post-procedure auditory-speech processing and recovery or reorganisation. We therefore recorded auditory event-related potentials (ERPs) evoked by pure tones and syllables employing a 51-channel electrode array concentrated over the functional hemisphere in 17 patients (nine males, mean age 14.2 years) who had undergone hemispherectomy for intractable seizures; eight of the patients had congenital brain damage and nine had sustained their initial insult at an age of 1 year or older. For comparison, recordings were made from 10 controls (five males, mean age 13.5 years). Responses from patients consisted of five small amplitude components restricted to the functional hemisphere whose scalp polarity was opposite to the ERPs observed in control subjects. The topography of the auditory ERPs in the patients was localised to the centro-temporal regions of the functional hemisphere in comparison to the midline distribution observed in control subjects. As in the control subjects, the latencies of the components evoked by tones were shorter than those evoked by syllables in both left and right hemispherectomised children. In addition, further analysis of the N1 and P2 component revealed increased syllable latencies in left hemispherectomised children only. The results of this study suggest that the left hemisphere alone may be more efficient at processing both pure tones and syllables compared to the right or both together.