Presence of delayed myelination and macrocephaly in the sister of a patient with vacuolating leukoencephalopathy with subcortical cysts

Leukoencephalopathy with swelling and a discrepantly mild clinical course ("van der Knaap disease") is a recently identified syndrome. It is characterised by macrocephaly occurring during the first year of life, initially normal or nearly normal development, and slowly progressive ataxia and spasticity with initial preservation of intellectual functions. MRI shows diffuse abnormality in signal intensity, as well as swelling of the hemispheral white matter with subcortical cyst-like spaces in the fronto-parietal and anterior temporal areas. It is thought to have an autosomal recessive mode of inheritance, since many patients have consanguineous parents and more than one affected patient is often present within the same family. We report on two sibs: a 5-year old boy affected with "van der Knaap disease" and his macrocephalic sister whose first MRI (2 years 6 months) showed delayed myelination, which led us to suspect the same disease as her brother, however with subsequent normalisation at the second MRI (3 years 6 months).

[Leukoencephalopathy with swelling, megalencephalopathy and surprisingly mild course. A case report]

Leukoencephalopathy with swelling and a discrepantly mild clinical course is a recently identified syndrome described by van der Knaap et al. It is characterised by macrocephaly occurring during the first year of life, initially normal or nearly normal development, slowly progressive ataxia and spasticity with initial preservation of intellectual functions. MRI shows diffuse abnormality of signal intensity in the hemisphere white matter with subcortical cyst-like spaces in the fronto-parietal and anterior temporal areas. The case of a 5-year-old boy whose clinical and neuroimaging findings are consistent with this syndrome is reported. The clinical and neuroimaging findings of this case may provide further information about this new syndrome which could possibly be useful also for genetic counselling.

Anxiety of the 8th month in the preterm child

BACKGROUND

Aim of this paper was to verify whether the condition described by Spitz as anxiety of the 8th months occurs earlier in the preterm than in the child born at term.

METHODS

A prospective study was carried out on 27 subjects subdivided into three groups of 9, 8, 10 patients, respectively, according to gestational age (group I < or = 33 weeks; group II > or = 34 < or = 37 weeks; group III > or = 38 < or = 41 weeks). The cases were selected at random from the patients admitted to the Neuropsychomotor Unit of the Gaslini Institute of Genoa (Italy), from May 1, 1993 to May 22, 1998. All 27 subjects underwent regular follow-up according to the protocol adopted in the Unit.

RESULTS

It was observed that in group I (very preterm children), this type of anxiety had a much earlier onset with respect to group II (preterm children with higher gestational age) and III (children bom at term), in which time of onset was similar.

CONCLUSIONS

This observation could be ascribed i) to the peculiar organic and emotional conditions of a very preterm infant, who therefore is more "reactive", and ii) to its inborn ability to react promptly with manifestations of sudden alarm of fear within the frame work of interpersonal contacts.

[Hypotonic cerebral palsy. Which treatment?]

BACKGROUND

Aim of this study is to verify whether tonus neurophysiological and communicative-relational aspects in hypotonic subjects can be recovered by psychomotor therapy.

METHODS

This case series includes two randomized groups of children with central hypotonia observed at the Department of Child Neuropsychiatry of the Gaslini Institute of Genova from February 1992 to December 1996. The 1st group includes 6 subjects treated in a local rehabilitation service only by kinesitherapy. The 2nd group includes 6 children undergoing psychomotor treatment in our Department, where all the 12 cases underwent periodical controls.

RESULTS

Tonus physiological aspects equally improved in the two groups, whereas the improvement of the communication aspect was more marked in the second.

CONCLUSIONS

The conclusion is drawn that psychomotor therapy seems more appropriate for a global recovery of the hypotonic child.

[Recovery of the "instrument-hand" and the "communication-hand" in the hemiparetic child]

BACKGROUND

Rehabilitation techniques have always attached great importance to the recovery of hand functions in the different forms of child cerebral palsy. The human hand has complex structure and functions, and it can be defined as "instrument-hand", "expression-hand", "relation-hand" and "constant challenge to rehabilitation programmes. Among the most common techniques used today, neuromuscular facilitation allows the recovery only of the instrumental function, and cortical facilitation allows only the awareness of the motor learning. The psychomotor approach is aimed at a global recovery of the gesture, i.e. at the restoration of the movement neurophysiologic, relational and interactive aspects. Aim of this paper is to evaluate the possibility of restoring the hand communicative function in children with paresis.

METHODS

Ten patients (6 males and 4 females; age range 20 months-8 years) with hemiparesis not associated with other disorders undergoing psychomotor therapy were compared with 10 controls (5 males and 5 females) undergoing traditional therapy (generally following Bobath).

RESULTS

The communicative function of the hemiparetic hand was restored in 8 patients compared to 2 patients in the control group.

CONCLUSIONS

Even though our series includes few cases and it is not possible to draw any definitive conclusion, it is reasonable to hypothesize that the psychomotor approach is a therapeutic model able to restore the hand complex functions.

[Aplasia and hypoplasia of the optic nerve. Comparison of 2 cases]

Hypoplasia and aplasia of the optic nerve are congenital anomalies characterized respectively by a marked volume reduction (very small papilla, often identifiable only as a rosy-yellowish area from which the retinal vessels emerge) and by the absence of the optic disk (absence of the nerve and mainly of its vessels) and of the visual functions. These anomalies are often associated with malformations of the central nervous system and of the ocular structures. The defects originate in the embryonal period due to the arrested development of the mesodermal component towards the head of the optic nerve. The aim of this study is to try to interpret the different clinical manifestations of the disease by observing two cases (a female and a male) with a clinical picture of aplasia and hypoplasia of the optic nerve respectively. Both cases presented the following clinical characteristics: developmental defects of the optic nerve, severe microcephaly, positive IgG antibodies against CMV. The association of the optic nerve defect with microcephaly is due to the embryogenic origin of the optic vescicle by prosencephalon. The resulting clinical picture is probably the outcome of an interfering process that the authors have presumed in CMV intrauterine infection, after having excluded the most frequent teratogenic agents (maternal diabetes, tabagism, intake of alcohol ad drugs). Moreover, the different degree of ocular involvement and the different time of onset of the intrauterine pathogenic insult in the two cases could account for the different clinical pictures.

[From movement to gesture. Evaluation in the treatment of neuro- psychomotor disability]

Aim of this study is to evaluate whether the subjects with neuromotor deficits can achieve both the restoration of the motor function and of the intentional and communicative components of gesture. Our case series includes 20 children (10 males, 10 females) aged 8 months to 14 years. Ten had neuromotor impairment (9 cases with different features of C.P, 1 case with ataxia) (first group), the remaining cases had psychomotor delay of different degree (second group). The authors analyzed some communicative expressions, and especially the verbal message, which "accompany" the gesture. They have observed that the patients, who had disorders of the "execution" of movements, but preserved the cognitive-perceptive quality of them, could learn to use their motility for communication and socialization. This is perhaps too ambitious. However the authors think that it is worth trying to obtain this result, since they believe that the aim of rehabilitation is the patient's best adjustment.

[Psychomotor treatment of cranial injuries in childhood. Two cases of apallic syndrome]

In this paper the authors aim to assess the results of psychomotor treatment of 5 patients with cranial injuries admitted to the Division of Infantile Neuropsychiatry at Gaslini Hospital from 1983 to 1985 and to evaluate the role of this treatment in a pathology with multiple, complex functional disorders. Evolution was excellent in 3 out of 5 patients who presented level 1-3 coma with limited post-traumatic sequelae (epilepsy and dysfunction of the left side in A.D., epilepsy and learning disorders in C.F., motor impairment and learning disorders in V.D.) Effective control was achieved in epileptic patients together with a good recovery in those with learning handicaps. Only slight fine motor disorders remained in the case (A.D.) with left hemiparesis. The two cases with level 5 coma that developed into apallic syndrome both attained full postural and motor autonomy, although a slight paretic deficit remained in the left side in one case (V.A.) and vague cerebellar signs in the other (G.D.). Moreover, despite continuing residual difficulties involving concentration and instability of attention, together with slight affective and emotional problems, both girls acquired satisfactory knowledge and responsibility regarding their own psychomotor status and achieved good personal autonomy and a stable ego structure. These results appear to confirm the hypothesis that psychomotor treatment is an effective method of achieving an adequate recomposition of the psychophysical and functional unit of body, damaged by injury.

[Interference of anticonvulsants in the rehabilitation treatment]

Aim of this study is to investigate whether the adverse neuropsychiatric effects of anticonvulsant drugs can affect the results of physical therapy. The influence of these drugs on neurological and/or psychological functions is considered an important factor in conditioning the active psycho-perceptuo-motor learning of child during physical therapy. Our case series included 30 children aged 4; 20 to 23 months. Ten (6 males; 4 females) received both physical therapy and anticonvulsants (generally single-drug therapy) (first group). Ten (3 males; 7 females) received only physical therapy (second group). The third group (5 males; 5 females) received only anticonvulsant drugs. All children were followed up for 4 years. Not significant differences in any of the scores obtained with standard and neuropsychological tests were found between the 3 groups. No significant change of muscle trophism was found between the 3 groups. The changes of tonus, found in the first two groups, were not significantly different, for these groups. Our findings seem to disagree from those reported by the most recent studies and suggest that anticonvulsant therapy doesn't interfere with the efficacy of physical therapy. However, our data cannot be generalized due to limited number of patients included in our series and further studies are needed.

[Object permanence in children with neurological and psychomotor disorders]

The aim of this research was to investigate whether the development of object permanence is an available sign of the cognitive development in infants with psychomotor handicaps. Subjects consisted of 5 males, ranging in age from 12 to 33 months, with handicaps as a result of perinatal brain injury. Four were preterm infants. All of the children received psychomotor treatment. Their stage of object permanence was assessed using traditional (B-L) and non traditional test (U-H). (The children's performances on the U-H scales have an "Intrinsic validity"). Four children achieved the first stages of the development of object permanence. The acquisition of object permanence was delayed in comparison with the age-appropriated time, but it may be considered adequate in comparison with the "developmental age" (B-L). One children with severe mental and motor disorders solved no task, the findings suggest that the children with psychomotor handicaps may gain the concept of object permanence and that psychomotor treatment may assist them in the development of the concept. This performance is not age-dependent. So the acquisition of the concept of object permanence may be considered an accurate and sensitive tool for the follow-up of the sensorimotor development in the handicapped children.

[Cognitive and affective aspects of psychomotor assessment of myodystrophic children with the aim of specific treatment]

The aim of this study was to evaluate the incidence of cognitive and affective problems in the treatment of children suffering from myodystrophy. It was hypothesised that psychomotory assessment taking appropriate account of data regarding the evaluation of cognitive and affective development might allow an adequate and realistic therapeutic protocol to be defined. For this purpose the authors examined 55 myodystrophic patients aged between 6 and 10 years old during the period January 1980 and June 1993 using traditional psychomotory tests (Stanford-Binet and/or WISC in relation to the various age groups), projective tests (CAT, TAT) and graphic tests. The latter were also evaluated according to Koppitz's criterion which enabled emotional indicators (EI) to be assessed. All 55 cases were evaluated in collaboration with the 1st Pediatric Clinic of the Neuro-Psychomotory Unit of "G. Gaslini" Institute. Psychomotory treatment, which by definition is addressed to the entire person, specifically took cognitive and affective data into consideration. In fact, as observed by Johnson and Alexander, in myodystrophy functional skills are more often limited by cognitive and motivational factors than by actual menomation. The results showed that the concentration on psychological aspects in the rehabilitation of myodystrophic children allows the neuropsychological component of movement (practognosia) to be preserved for as long as possible despite the progress of instrumental deficit (anatomic degeneration). In the authors' experience and in comparison to that of other Authors, it was possible to state that a "personalized" approach allows the subjects to improve their own "presence in the world".

[The timing of the start of rehabilitative intervention with the newborn infant at neurological risk]

The few studies related to the effect of the timing of intervention of high-risk infants, ie. early vs late, have produced equivocal results. The aim of this study was to investigate whether "critical periods" for intervention exist. Among the high-risk infants (previously assigned to one of 3 random samples), who achieved follow-up at 5 yrs of age, 36 received a prescribed intervention as soon in NICU (very early treatment group: ET Gr). The other 21 infants began to receive the treatment after discharge (postdischarge treatment group: PDT Gr.). The remaining 27 received only traditional care both during hospitalization and after discharge (control group: C Gr.). Treated infants both ET Gr. and PDT Gr., exhibit significantly better neurological status than control infants, as assessed by Touwen Neurological Examination. They also scored significantly higher at standard psychological tests and have a significantly lower incidence of developmental sequelae. Insteated not significant differences of any of the measured outcomes were found between the ET Gr. and the PDT Gr. Delay in initiating intervention does not appear to reduce the benefits. Recent advances in the field of the developmental psychology have resulted in some new understandings of the early human behavior and the role of learning experiences in the developmental processes. Although learned changes in behavior occur from the earliest 2 and 4 months, when major physiologic/maturational changes are occurring (Lipsitt, 1986). Our findings are in accordance with the above statement and suggest that the crucial period for intervention is in 2 to 4 first months of life. Further studies are needed to solve the many unanswered questions in this controversial filed.

[Psychomotor management in the rehabilitation of patients with myopathy in infancy. Case studies]

The salient features are described of the psychomotor treatment given to two sisters: SA aged 11 yrs 5 months and MGA aged 9 yrs 9 months both affected with aspecific congenital myopathy and under medical treatment since they were 3 months old. These two cases were selected as examples for the following reasons: (1) they may offer the opportunity to highlight what should be the focal objective of all treatment of myopathic children whatever the syndrome involved, namely to ensure that the children retain capacities required for normal social life as long as possible and to help them retain the essential physical capabilities required for everyday life; (2) because the slower course of this type of myopathy permits the gradual implementation of a diversified treatment protocol in the various social contexts (family, school, play groups) in which these patients are able to lead a life whose limitations are scarcely visible for a long time. Experience in the treatment of these two cases confirms that the role of Psychomotor Education in the treatment of myopathy cases is essentially that of teaching the child to be aware of and responsible for its own movements as the disease progresses, while showing it how touse all its available sensomotorial instruments to counteract its muscular inadequacies which progressively damage the child's body image. Psychomotor education also provides the child with the self-assurance it needs in order to retain its autonomy within the framework of a knowledgeable and motivated family.

[Rehabilitative treatment of severe sensory disorders. Description of 2 cases]

The aim of the work has been to verify the efficacy of a psychomotor rehabilitative treatment undertaken at a late age in two children with multiple handicaps: sensorial (visual and hearing impairment), motor (apostural-akinetic stage) and relational (autistic behavior).

METHODS

Salvatore C, and Ivan S., admitted to the "G. Gaslini" Institute after discharge from an Institution for homeless infants, were affected by prenatal rubella sequelae. They were taken in charge at age 11 and 24 months.

TREATMENT

manipulation and body-to-body interaction to reassure the children, relieve their feelings of fright and reduce the stereotyped behaviour; stimulation of the acquisition of the body-image; strengthening of the unimpaired sensorial skills and of the residual auditory and visual possibilities; postural and motor stimulation, following the autogenetic development; stimulation to achieve spatial organization and orientation; adjusting of interventional and relation modalities common to all the persons interacting with the children.

RESULTS

we obtained a significant reduction of stereotyped behaviour and progressive improvement of the active research of productive interaction with the environment in both children; Salvatore C. was able to walk with little aid after one year of treatment; furthermore he reached a lively and organized motility, supported by a motivational drive. Ivan S. was able to walk with bilateral help after 4 months of treatment; the cognitive development improved at a slower pace; the child became able to reach for objects but used them only in stereotyped or elementary activities. From this observation it seems possible to confirm our hypothesis that psychomotor education is useful even if undertaken lately and in the absence of a supporting family.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effects of early rehabilitative treatment on neurological development and cognitive and perceptual-motor functions of preterm infants at risk]

Longterm effects of early rehabilitative treatment are evaluated in 37 premature infants at neurological risk. The late neurological and psychomotor development of this group of children (experimental group) is compared with that of another 35 at risk premature infants (control group), who received only conventional follow-up care. The two groups do not differ in birth-weight, gestational age, sex and neonatal disorders. At 6 years of age the children of the experimental group have a significantly better neurological status and score higher than the control group, on mean mental indices. They also have lower incidence of neurodevelopmental sequelae (learning disabilities and behaviour problems). However children both in the experimental group and the control group have poor visual-motor integration. Similar results are found also in children, who were low-risk premature infants and who have normal intelligence. Our data suggest that a prescribed early rehabilitative treatment for high-risk preterm infants appears enhance the quality of late development. Treated children have the greatest improvement in all measured outcomes at 6 years (included neurological status, motor and overall development), but do not achieve the same level of neurological and behavioral development as full-term control children. One might question whether the latter finding indicate limited efficacy of early treatment or rather the need to consider separate series of norms for the preterm infant in assessing its outcome. This question requires additional follow-up studies.

[Collateral transient behavioural changes during ACTH therapy in infantile generalized epilepsy (author's transl)]

ACTH therapy induces transient behaviour disturbances (irritability, restlessness or drowsiness and apathy), parallel to the EEG. changes. These behaviour abnormalities have a positive relationship with cortisolemic levels and clinical results. A clear relationship between ACTH therapy and pseudoatrophic CT findings can be observed.