Jeff Russ, MD, PhD
Perinatal stroke is all too common, occurring in up to 1 in 1,100 term infants, considering all-comers with different etiologies and clinical courses.1,2 In particular, perinatal arterial ischemic stroke, which occurs in one out of every 3,000 to 5,000 term births,1,3 or periventricular venous infarction, which occurs in one out of every 6,000 term births,1 typically disrupts unilateral cortical and subcortical motor pathways, often leading to hemiparetic cerebral palsy (CP).4 Since the etiology of these disorders is heterogeneous, prevention remains elusive, and thus treatment strategies rely on harnessing neuroplasticity to regain function through neurorehabilitation. However, novel strategies for rehabilitation are often tested in adult stroke patients, overlooking a young population with enhanced neuroplasticity that would benefit greatly from additional modes of functional recovery.
In their article published in Stroke, Jadavji et al. take a step toward modernizing pediatric neurorehabilitation practices by exploring the feasibility of a non-invasive brain-computer interface (BCI) in pediatric patients with hemiparetic CP. Twenty-one patients between nine and eighteen years old with disabling hemiparetic CP and MRI-confirmed perinatal arterial or venous stroke were recruited to learn and operate an EEG-controlled goal-oriented system. Patients were asked to complete two tasks: either move a mouse on a computer screen toward a red circle or drive a remote-controlled car on the floor toward a finish line. To complete either task, the patients were asked to employ one of two mental imagery strategies: either imagine moving the object toward its target or imagine opening and closing one’s hands. Changes in electrographic signal during these mental imagery epochs were communicated to the BCI-linked mouse or toy car to initiate movement. The patients’ facility with these tasks was compared to that of twenty-four neurotypical control subjects.
Jadavji et al. found that 43% of patients were able to achieve competency across all four combinations of imagery strategies and goal-oriented tasks, but that 95% of patients became competent in at least one of the four combinations. Moreover, patients achieved comparable ability to utilize the brain-computer interface as their control subject peers. Despite the authors’ prior study5 showing enhanced performance for the car over the cursor, and for the goal-imagining strategy over the hand movement strategy in control subjects, patients with hemiparetic CP in the current study demonstrated equal mastery across scenarios. Finally, while age, sex, and arterial versus venous stroke did not impact skill acquisition, patients with a right-sided lesion gained higher proficiency with the BCI than those with a left-sided lesion.
Incorporating a BCI strategy into current rehabilitation techniques for children with CP is a welcome frontier to supplement existing therapeutic strategies for improving motor function. Current strategies include physical and occupational therapy, constraint-induced movement therapy (temporarily immobilizing the functional limbs to encourage use of the paretic limbs), and medical and surgical approaches for ameliorating spasticity and contractures. One can imagine, however, that manipulating a racecar or controlling a video game with one’s mind offers a science fiction–like activity that is likely more engaging and fun for pediatric patients (adult patients, too), encouraging their participation in rehabilitation activities or offering a method for circumventing the limited function of an affected limb. Use of a BCI could be limited in some CP patients with developmental delay or intellectual disability, but the potential for this technology is broad, and further studies will elucidate the boundaries of its functional contexts.
In sum, much like a thought-controlled toy car, the results of Jadavji et al. accelerate the options for pediatric rehabilitation toward a finish line of an array of high-tech tools to complement strategies for functional recovery after perinatal stroke.
- Dunbar M, Mineyko A, Hill M, Hodge J, Floer A, Kirton A. Population based birth prevalence of disease-specific perinatal stroke. Pediatrics, 2020; 146(5):e2020013201.
- Clive B, Vincer M, Ahmad T, Khan N, Afifi J, El-Naggar W. Epidemiology of neonatal stroke: a population-based study. Pediatr Child Health 2020; 25(1):20-25.
- Sorg AL, von Kries R, Klemme M, Gerstl L, Felderhoff-Muser U, Dzietko M. Incidence estimates of perinatal arterial ischemic stroke in preterm- and term-born infants: a national capture-recapture calculation corrected surveillance study. Neonatology 2021; 1-7.
- Grunt S, et al. Incidence and outcomes of symptomatic neonatal arterial ischemic stroke. Pediatrics 2015; 135(5):e1220-1228.
- Zhang J, Jadavji Z, Zewdie E, Kirton A. Evaluating if children can use simple brain computer interfaces. Front Hum Neurosci 2019; 13:24.