This presentation provides a general introduction to neuroanatomy after cerebral hemispherectomy, a procedure where half the brain is removed to stop intractable epilepsy that originates from one side of the brain. Topics include potential of the remaining hemisphere, cortical plasticity, clinical presentation of hemiparesis due to innervation by only the ipsilateral corticospinal tract, life span impairments. Various case studies discussed. Presented at the Combined Section Meeting of the American Physical Therapy Association February 2014 By: Dr. Stella de Bode, Ph.D. Chief Science Officer, The Brain Recovery Project Nisha Pagan, PT, DPT, NCS, PCS, Owner Wholehearted Pediatric Physical Therapy

1. When One Hemisphere Innervates
Both Body Sides
Combined Sections Meeting 2014
Las Vegas, Nevada, February 3 – 6, 2014
A Look at Children Status Post
Hemispherectomy
Dr. Nisha Pagan, PT, DPT, NCS, PCS
Whole Hearted Pediatric Physical Therapy
Dr. Stella DeBode, PhD
Brain Recovery Project Foundation
Department of Radiology and Neurosurgery at UCLA

2. Dr. Stella de Bode, PhD
• Research focus: Manipulating cortical plasticity to help individuals
after cerebral hemispherectomy achieve their maximum potential
• Doctorate in Applied Linguistics and Neuroanatomy from UCLA.
Fifteen years of experience working with children post-
hemispherectomy
• Current affiliations: Brain Recovery Project Foundation, a non-
profit research foundation and UCLA, Dept of Radiology and
Neurosurgery
2

3. Acknowledgements
Dr. Stacy Fritz, PT, PhD:
• Program Director & Associate Professor at University of
South Carolina Rehabilitation
• Examining Differences in Outcomes for Intensive Mobility
Training (IMT) Compared to Locomotor Training in Chronic
Stroke (PI)
• Compared IMT effects for individuals with chronic
impairments & disabilities from stroke to a therapy of equal
dosage and task intensity
3

4. Acknowledgements
Dr. Stella DeBode, PhD
Dr. Stacy Fritz, PT, PhD
Gary Mathern, MD
Investigated cortical plasticity and effects utilizing IMT with
children with cerebral hemispherectomy
4

5. Dr. Nisha Pagan, PT, DPT, NCS, PCS
• Working since 2001 with various diagnoses from NY to AK to CA
• USC/Rancho Los Amigos Neurology Residency (2005)
• USC Post Professional Doctoral Physical Therapy (2007)
• Intervention therapist providing repeat bout of IMT (2011)
5

6. Repeat bout of IMT
• The Effect of Chronic Hemiparesis on the Cortical Motor
Maps in Individuals after Cerebral Hemispherectomy
• UCLA Institutional Review Board (IRB)
• Intensive Mobility Training (IMT) at Precision Rehab
• Functional brain images before and after 2 week period
6

7. Acknowledgements
Permission to disclose pictures and clinically
relevant information for educational purposes was
obtained by all patients and families.
7

8. Learning Objectives:
• What is a cerebral hemispherectomy?
• Who and why do individuals undergo this procedure?
• How do patients with only an ipsilateral corticospinal tract
(CST) present clinically, in the upper extremity and lower
extremity?
• What is Intensive Mobility Training (IMT)?
• Review the life span of children and young adults with
cerebral hemispherectomy through a case study approach.
8

9. Course Content: Presenter Dr. Stella DeBode, PhD
• Various etiologies leading to cerebral hemispherectomy
• The effect of seizures before surgery and brain atrophy after
• Types of cerebral hemispherectomy (anatomical vs functional)
• Differences with upper extremity and lower extremity motor
innervation
• Presurgical Organization of corticospinal tract (CST)
9

10. Presenter Nisha Pagan, PT, DPT, NCS, PCS
• Acute and Chronic Precautions
• Examination and Clinical Presentation
• Therapeutic Options UE/LE and Intensive Mobility Training
(IMT)
• Outcome Measures
• Case examples of different etiologies across the life span
utilizing IMT 10

11. Our Audience?
Who has worked with an individual with a cerebral
hemispherectomy?
11

12. What is Cerebral Hemispherectomy?
Cerebral Hemispherectomy is the partial or complete
removal and disconnection of one cerebral hemisphere
of the brain.
Surgical techniques differ in how much tissue is
removed and how to perform this removal, but in all
techniques the deceased cerebral hemisphere is
rendered completely functionally and anatomically
disconnected from the remaining “good” hemisphere.
12

13. What is Cerebral Hemispherectomy?
Cerebral Hemispherectomy is the partial or complete
removal and/or disconnection of one cerebral
hemisphere of the brain.
“Cerebral” means that deep subcortical structures
remain intact although some centers are now starting to
remove parts of Basal Ganglia.
13

14. Why Cerebral Hemispherectomy?
• Life-threatening
• Anti-epileptic drugs, AED, resistant seizures
Prevalence: 16-20% of all pediatric seizure-related
surgeries in the US (Harvey et al 2008).
Seizures, clinical and subclinical, are manifestation of the
underlying disorder. In case of hemispherectomy these
underlying disorders fall into the following groups:
14

15. Disorders Leading to Cerebral
Hemispherectomy
Seizures, clinical and subclinical, are manifestation of the
underlying disorder. In case of hemispherectomy these
underlying disorders fall into the following groups:
1. Developmental (e.g., disorders of neuronal
migration)
2. Acquired (e.g. pre- and postnatal stroke)
3. Progressive (e.g. Sturge Weber Syndrome and
Rasmussen Encephalitis)
15

16. What is the status of the remaining
brain?
• The remaining hemisphere may be relatively healthy,
but there is always a danger of microscopic damage
caused by either primary insult (e.g., cortical dysplasia)
or seizures that affect both hemispheres or both.
• Post-surgical complications (e.g., hydrocephalus) may
also compromise the remaining brain

17. Example of Anatomical Hemispherectomy
17

18. Example of Functional Hemispherectomy
18

19. Neuroanatomy of an Isolated Cerebral
Hemisphere
• Corticospianal tract, the only
conscious motor control tract
from the remaining hemisphere
now innervates both sides of the
body by its ipsi- and contralateral
components
• The sequelae of the isolated
ipsilateral CST are not known
• We will describe existing evidence
drawing from population with CP,
animal models of neurobiological
substrate and functional
measures of both sides
19

20. Neuroanatomy of an Isolated Cerebral
Hemisphere
•There is a
difference in CST
innervation of the
Upper and Lower
extremities.
20

21. 21
What is the Degree of Functional Impairements
after Hemispherectomy, Affected Side?
De Bode et al., 2005
The Fugl-Meyer scores
by side (paretic &
non-paretic) in 12
children post-
hemispherectomy (5
years +).

22. What do we know about pre-surgical
organization of the corticospinal tract?
Case study: 18 y.o. male with right-sided RE, duration 6yrs (de Bode & Davis, 2007)
Non-Affected
hand
Affected foot
Non-Affected foot
Affected hand
22

23. 23
Motor Innervation from the Remaining
Hemisphere, LE
De Bode & Fritz, 2007
Similar cortical areas, M1S1 & SMA are involved in moving a paretic leg

24. 24
Motor Innervation from the Remaining
Hemisphere, UE
De Bode & Fritz, 2007
Remaining hemisphere
supporting both hands:
Red – nonaffected hand
Blue – affected hand

25. The Effects of Ipsilateral Innervation and “Sharing”
Sensorimotor Brain Representations
The effects of ipsilateral corticospinal innervation is
known from CP studies and animal models:
• In a study of UE impairments Staudt et al (2007)
found that participants with unilateral innervation
of both hands were most impaired and therapy-
resistant in comparison to those who had “normal”
bilateral and mixed (drawing from both S1M1)
representations of their hand.
25

26. The Effects of Ipsilateral Innervation and “Sharing”
Sensorimotor Brain Representations
• In other words, when the most severe impairments
in CP were associated with brain representations
that are identical to the patients after
hemispherectomy. Why? The closest answer
comes from the animal models
26

27. Animal Models
27
John Martin and colleagues, 2007-12
Bilateral immature
Critical refinement
period
Predominantly
contralateral mature
Cortex
Spinal cord

28. 28
Blockade of motor
activity on ONE side
Absence of activity-
dependent
competition
Maladaptive
laterality pattern and
functional outcome
similar to CP
Martin et al 1999; Friel & Martin, 2005; Martin, 2009
refinement
period
85%
15%
55%
45%
Animal Models: Sequelae of Hemispherectomy

29. 29
Blockade of motor
activity on ONE side
Absence of activity-
dependent
competition
Maladaptive
laterality pattern and
functional outcome
similar to CP
Martin et al 1999; Friel & Martin, 2005; Martin, 2009
Animal Models: Sequelae of Hemispherectomy
Functionally, unilateral blockade of one
hemisphere and ipsilateral
corticospinal tract “claiming” the
territory of both tracts resulted in
severe deficits in animals

30. Putting it All Together
1. Cerebral hemispherectomy often arrests seizures, but results in permanent
hemisparesis caused by the removal of S1M1 of the deceased hemisphere and
corticospinal tract of the remaining hemisphere forced to support both body sides
2. Functionally, such reorganization results in severe deficits of the UE, less deficits in
the LE and the presence of the distal-proximal gradient
3. Motor representations that are now “shared” by both body sides mean that any
therapy aiming at the paretic side would potentially affect the “strong” side. There
is one study (Dijkerman etal, 2008) suggesting that following hemispherectomy
subtle deficits are associated with the non-affected side similar to studies in
populations with CP.
4. Therapy in this population should be guided by the understanding that, in contrast
to CP, functional improvements of the affected side based on recruitment of the
contralateral hemisphere is not possible.
30

31. Cerebral Hemispherectomy:
Clinical Considerations and Application of IMT

32. Acute Stage
• Blood loss (developmental > RE and infarct)
• Level of interaction will ↓ by 48 hours due to brain swelling
• Chemical meningitis is common
• Restarted on AEDs once taking liquids by mouth
(Lam and Mathern (2010) Functional Hemispherectomy at UCLA chapter 27 in Pediatric Epilepsy Surgery:
Preoperative Assessment and Surgical Treatment edited by Oguz Cataltepe, George I. Jallo)
32

33. Acute Stage
• Discharged 7 to 14 days after surgery
• Older children walking before surgery receive inpatient rehab
• Neuro-surgeon F/U is 6 months, 12 months and then annually
• May taper AEDs 3 months after surgery
Lam and Mathern (2010)
33

34. Chronic
• Many report headaches/migraines (Lew, 2013)
• Cerebral shunt in 32% of patients (Lam & Mathern 2010)
Any signs of increased intracranial pressure, immediately
order neuro-imaging to R/O Late Acquired Hydrocephalus
34

35. Examination: history
• Etiology (i.e. developmental vs. acquired) (Van der Kolk 2012)
• Age of surgery (↑ improvements <5 years of age) (Fritz, et al 2011)
35

36. Examination: clinical presentation
• Motor:
Permanent Hemiparesis (UE>LE)
distal-proximal gradient
• Sensory
36

37. • Acquired Etiology
• Status Post Wrist
Fusion
• Note Associated
Movements in
Unaffected Hand
Example
37

38. Sensory
• Vision: Right or Left homonymous hemianopsia
www.Lighthouse.org
38

39. Sensory
• Light Touch & Proprioception
• Sensory Integration ??
• Low registration ↑↑
• Sensory sensitivity ↑↑
• Sensory avoiding ↑
39

40. Cognitive Functioning
• Limited Cognitive Function
• Decreased planning and problem solving skills
• Age-appropriate skills
40

41. Therapeutic Goals
• Family and patient centered
• Typically to keep up with their peers
• Promote the best quality of life
41

42. What is the optimal dosage?
• Tap into the brain’s amazing ability to reorganize itself
• Extended, repetitive, meaningful, skilled training
• Intensity matters--- but what is optimal?
42

43. Why provide Intensive Therapy?
• Therapists Perspective
• Parents Perspective
• Suggests rate of treatment more critical than # of treatments
Intermittent intensive physiotherapy in children with cerebral palsy: a pilot
study. Trahan and Malouin. Developmental Medicine and Child Neurology
(2002) 44: 233-239
43

44. Upper Extremity Therapy
• HABIT versus CIMT (Gordon et al 2006, 2007, 2008; de Bode 2009)
• Depends on individual functioning level, neuroanatomy & goal
• Limited research on therapy in this population
Recruitment of the contralateral hemisphere is not
possible
44

45. LE training: Intensive Mobility Training
(IMT)
Repetitive, Task-specific training in a mass practice
schedule
45

46. IMT participants:
• Incomplete spinal cord injury (ISCI)
• Parkinson’s disease
• Stroke
• Cerebral hemispherectomy (Fritz et al 2011, DeBode et al 2007)
Chronic (≥6 months) & varying ambulation skills
Feasibility of Intensive Mobility Training to Improve Gait, Balance, and Mobility in Persons With Chronic
Neurological Conditions: A Case Series. Fritz et al JNPT 2011;35: 1–7) 46

47. IMT protocol (Fritz et al 2011)
● Two weeks 10 days of therapy (3hrs a day, total 30 hours)
● 1/3 of each session in Body Weight Support Training
● 1/3 interventions aiming at improving balance
● 1/3 muscle coordination, flexibility, strengthening
TIME BASED PROTOCOL
47

48. 50 minutes of
BWST.
50 Minutes of
Balance Re-
training
50 Minutes of
Strengthening,
ROM and
Coordination
Activities
Take
initial
BP, HR,
Fatigue
and
Pain
Level.
Take
final BP,
HR,
Fatigue
and
Pain
Level.
Activities are modified based on BP, HR, fatigue, pain, frustration, interest level
and performance. Rest breaks given did not total more than 30 minutes of the 3
hour session.
48

49. Activities
• Activity list compiled and used as a template
• Always challenge the patient
↑time/distance/height, change support surface, ↓support
49

50. An example of how to utilize IMT:
Preparation Gait Training
Higher
Coordination
Skills/Activities
50

51. Treadmill guidelines
1) approach normal temporal parameters of gait
2) maintain upright trunk
3) approximate normal joint kinematics for lower extremity joints
4) avoid excessive weight bearing on the upper extremities
Berhman AL & Harkema SJ Locomotor training after human spinal cord injury:
a series of case studies. PT 2000; 80:688-700
51

52. Treadmill guidelines
• BWS used if unable to accomplish independently on TM
• Maximize bilateral limb loading without knee buckling
• Manual cues used if unable to generate the stepping motion
Berhman AL & Harkema SJ Locomotor training after human spinal cord injury:
a series of case studies. PT 2000; 80:688-700
52

53. Treadmill guidelines
Once optimal gait kinematics was achieved:
• 1st BWS was decreased as well as manual assistance
• Following speed of walking was increased
53

54. IMT Outcome measures
•Fugl Meyer LE and balance
•6 minute walk
•Timed Up and Go
•Dynamic Gait Index
•Berg Balance Scale
•Step Length
•Toe in and out
“Combined Functional Index” (CFI) was analyzed
54

55. IMT Results: 19 children status post hemispherectomy
Fritz et al 2011
55

56. 56
2006
2013
2013

57. 70
75
80
85
90
PRE 2006 POST 2006 PRE 2012 POST 2012
CFI
CFI Changes Associated with Two Therapy IMT
AC, 14-20
GM, 9-15
AS, 5-11
LE, 9-16
Drop in
scores
following 6 yrs
w/out therapy
DeBode and Pagan, unpublished
57

58. Additional Pediatric Outcome Measures
• Gross Motor Function (GMFCS - E & R © Robert Palisano, Peter
Rosenbaum, Doreen Bartlett, Michael Livingston, 2007)
• Bruininks-Oseretsky Test of Motor Proficiency, 2nd Ed (BOT™-2)
58

59. Additional Pediatric Outcome Measures
• Developmental Exams
• Bayley Scales of Infant Development (BSID-III)
• Peabody Developmental Motor Scales, Second Edition (PDMS-2)
• Developmental Assessment of Young Children, Second Edition
(DAYC-2)
59

60. Additional Pediatric Outcome Measures
Sensory Profile by Winnie Dunn, PhD, OTR, FAOTA
• Infant/Toddler
• School age
• Adolescent/Adult
60

61. Case Study: Young adult
• Infarct in utero (left hemiplegia, left hand surgery at birth)
• Intractable seizures began at 4 years and 2 months old
• At 6 years old and 3 months received a left hemispherectomy
61

62. Case Study: Young adult
• 13 years old participated in IMT for the first time in SC with Dr. Fritz
• Following PT 1x/year
• 19 years and 9 months old participated in a repeat bout of IMT
62

63. Strengths
• Motivated to work hard
• Able to articulate her goals and difficulties
• Extremely artistic
63

64. Impairments
• Mental age in Low Average (test-PPVT)
• BMI ~ 40.2 (obesity)
• Baseline blood pressure 135/84; HR 112
64

65. Impairments
• ↓ force production throughout R > L
• ↓ ROM/contractures UE > LE
• Pain in left wrist and back
65

66. Activity Limitations and Participation Level
• Attends college
• Difficulty walking across campus
• Falls a couple times of month
Fitness level, ↓ balance, pain, fear and depression →
↓ activity and participation
66

67. Goals
• Dressing (pulling up pants and zipping up jacket)
• ↓ Motor planning, Balance, UE Control
• To stand up from the floor
• ↓ Motor planning, UE/LE/trunk strength, balance, ROM
67

68. 68

69. 70
75
80
85
90
PRE 2006 POST 2006 PRE 2012 POST 2012
CFI
CFI Changes Associated with Two Therapy IMT
AC, 14-20
Drop in
scores
following 6 yrs
w/out therapy
DeBode & Pagan, unpublished
69

70. Outcomes
Gait
• Toe out decreased 15° to 6.5°
• No change in gait velocity
Balance
• Improved static balance (standing tandem, on one leg)
• Improved dynamic balance (horizontal head turns,
stepping around obstacles)
Mobility
• 6 min walk pre: 45.7% normal post: 49.6% normal
70

71. Outcomes
Flexibility
• UE mobility improved
• no LE ROM changes
Pain
• Pain decreased at back on final assessment
71

72. Bruininks-Oseretsky Test of Motor
Proficiency, 2nd Ed (BOT™-2)
72

73. Referrals Provided
• Psychologist and primary care physician
• Fitness gym within Physical Therapy clinic
• Primary PT and OT for further therapy
• Vocational Rehabilitation
• Cerebral palsy clinic
73

74. A.C 2006 Age 14
Paretic Knee
Non-paretic Knee
74

75. Repeat Bout IMT Effects Age 19Paretic Knee
Non-paretic Knee
75

76. Follow-up 5 months after IMT
• California Children’s Services approved 1x/week
therapy for 4 visits
• Followed up with UCLA referral
• Reported a fall on the stairs on college campus
76

77. Aging with a disability
• ↑ Pain
• ↓ fitness
• Surgical candidate
• Gait and mobility changes
• Functional changes?
Requires continued follow up with a team approach
77

78. Case Study: Pre-Teen
• 4 years old intractable seizures due to RE
• 4 years and 6 months old had a R hemispherectomy
• 5 years old participated in IMT in SC with Dr. Fritz
78

79. Case Study: Pre-Teen
• Monthly to twice a year PT
• Weaned off of medicine due to persistent headaches
• 11 years and 6 months old participated in a repeat bout
of IMT
79

80. Strengths
• Cheerful
• Motivated
• Cooperative
• Active
• Supportive Family
80

81. Impairments
• Mental age in Low Average (test-PPVT)
• Leg Length discrepancy found 88 cm on R, 86 on L
• ROM limitations due at knee extension and ankle df
• Spasticity at Hamstrings and plantarflexors
• Proprioception impaired as tested on foot
81

82. Activity Limitations and Participation Level
• GMFCS Level I
• Actively plays basketball
• Big brother to a 6 year old sister
Strong Compensational strategies with learned disuse on
left side with absent left protective reaction
82

83. Description of therapy
• LL discrepancy corrected
• Range of motion
• Gait re-education
• Electrical stimulation
83

84. 84

85. 70
75
80
85
90
PRE 2006 POST 2006 PRE 2012 POST 2012
CFI
CFI Changes Associated with Two Therapy IMT
AS, 5-11
Drop in
scores
following 6 yrs
w/out therapy
Pagan and DeBode
85

86. • ROM changes
• Active ankle movement
• Demonstrated fair understanding of prescribed a HEP
86

87. Pre (age equivalent) Post (age equivalent) Post 6 months
Coordination UE 8-8:2/bilateral 5:4-
5:5
UE 11:3-11:5/ bilateral
6:3-6:5
NT
Balance 5:10-5:11 16:5-16:11 5-5:1 (↓)
Running Speed and
agility
5:6-5:7 8:0-8:2 NT
Strength 7:0-7:2 11:9-11:11 7:9-7:11 (↓)
87

88. 6 month follow up
• Primary PT providing monthly consults to monitor a HEP
• Rapid decline due to Growth spurt?
• ↑ tightness at hamstrings and ankle plantarflexors
• ↑ activity however with ↑ gait deviations & compensations
88

89. Are IMT effects lasting?
What needs to be modified to maintain results?
Should IMT be provided more frequently prior to puberty?
Would an ↑ of conventional PT vs monitoring suffice?
89

90. Case Study: Toddler
• intractable seizures due to cortical dysplasia
• 2 months old 1st surgery left hemispherectomy
• 15 ½ months old required a 2nd surgery revision
• 2 hours of PT and 2 hours of OT weekly
• Nearly 22 months participated in IMT
90

91. Developmental Scores: BSID-III & DAYC
Area of Development % Delay
Cognition 36%
Receptive Communication 36%
Expressive Communication 23%
Fine Motor 41%
Gross Motor 68%
Social Emotional 45%
Adaptive Development 36%
91

92. Parent Goals
Toddler to initiate steps
↑ Hand use
Assess orthotic and equipment needs
92

93. Description of Therapy
• STM
• ROM with sensory play
• Strengthening included sit to stand and squatting
• UE play kinesiotaping
• Education/Equipment needs
93

94. Gait progress
• 1st week dragging and increase rigidity of feet
• Progressed to spontaneous stepping over treadmill
without harness
• ↓ turning of right foot
• Total time on treadmill 23 - 34 minutes
• Speed of treadmill .2-.6 mph
• Remaining time gait training overground: forward and
cruising
94

95. Changes
• Reaching out with right hand more frequently
• Sit to stand from 22 cm height with contact guard assist
• Hamstring length improved
• (R popliteal angle from 40° to 20°)
• Initiating steps forward over treadmill and over ground with
stabilization
95

96. 96

97. Follow Up 7 months after IMT
• Not creeping or crawling
• Not transitioning from sitting to quadruped
• Occasionally pulling to stand
• Began to cruise independently 3 months after IMT
• Stands without support for up to 30s
• Taking about 10 independent steps with coaxing and reassurance
97

98. Toddler case study
• IMT feasible for toddler with incorporation of sensory play
• Decrease compensational strategy within all daily activities
• Trial of equipment such as stander and orthotics
• Parents reported a faster rate of change with IMT
98

99. Conclusions:
• Long term disability at risk of ↓ function & participation
• Consider goal’s, cognitive & sensory processing abilities
99

100. Conclusion
Consider:
• the role of etiology
• previous length of time exposed to seizures
• history of therapy (including frequency, dosage and
timing throughout lifespan)
100

101. Take home messages
• More longitudinal and case by case research needs
to be collected to determine:
• the impact of therapy on functional expectations
throughout the life span;
• to determine optimal dosage and
• how to retain results
101

102. QUESTIONS???
102

103. Contact information
nishapagan@wholeheartedpediatrictherapy.com
stella.de.bode@me.com
103

104. References:
1. Cook SW, Nguyen BH, Yudovin S, Shields WD, Vinters HV, Van d Wiele BM, Harrison, RE, Mathern
GW. Cerebral hemispherectomy in pediatric patients with epilepsy: comparison of three techniques by
pathological substrate in 115 patients Journal of Neurosurgery: Pediatrics, February 2004 / Vol. 100 / No.
2 : Pages 125-141
2. Jonas, R., Nguyen, S., Hu, B., Asarnow, R. F., C., L., Curtiss, S., Shields, W. D.. Cerebral
hemispherectomy: hospital course, developmental, language, and motor outcomes. Neurology, 62, 1712-
1721. (2004)
3. Harvey AS, Cross JH, Shinnar S, Mathern BW; ILAE Pediatric Epilepsy Surgery Survey Taskforce,
Defining the spectrum of international practice in pediatric epilepsy surgery patients. Epilepsia 2008; 49
(1): 146-155
4. van der Kolk NM, Boshuisen K, van Empelen R, Koudijs SM, Staudt M, van Rijen PC, van
Nieuwenhuizen O, Braun KP Etiology-specific differences in motor function after hemispherectomy.
Epilepsy Res. 2013 Feb;103(2-3):221-30. doi: 10.1016/j.eplepsyres.2012.08.007. Epub 2012 Sep
5. Staudt M 2007 Reorganization of the developing human brain after early lesions. Dev Med Child Neurol.
2007 Aug;49(8):564.
104

105. References
6. Martin, J. H., Chakrabarty, S., & Friel, K. M. Harnessing activity-dependent plasticity to
repair the damaged corticospinal tract in an animal model of cerebral palsy. Developmental
Medicine and Child Neurology, 53(3), 9-13. (2011).
7. De Bode, S., Mathern, G. W., Bookheimer, S. & B. Dobkin Locomotor training remodels
fMRI sensorimotor cortical activations in children after cerebral hemispherectomy. J of
Neurorehabilitation and Neural Repair 21(6): 497-508(2007).
8. Fritz, S. L., Rivers, E., Merlo, A., Mathern, G. W., & de Bode, S. Intensive Mobility Training
Post Cerebral Hemispherectomy: Early Surgery Shows Best Improvements. Eur J Phys
Rehabil Med, e-pub ahead of print. (2011).
9. De Bode, S., Firestine, A., Mathern, G. & B. Dobkin. Residual Motor Control and Cortical
Representations of Function Following Hemispherectomy. Journal of Child Neurology, 1:
78-90 (2005).
10. Lew, Sean M; Matthews, Anne E; Hartman, Adam L; Haranhalli. Posthemispherectomy
hydrocephalus: Results of a comprehensive, multiinstitutional review, Neil. Epilepsia54.2
(Feb 2013): 383-389
105