Late plasticity for language in a child's non-dominant hemisphere: a pre- and post-surgery fMRI study

The ability of the right hemisphere to sustain the acquisition or the recovery of language after extensive damage to the left hemisphere has been essentially related to the age at the time of injury. Better language abilities are acquired when the insult occurs in early childhood (perinatal insults) compared with later occurrence. However, while previous studies have described the neuropsychological pattern of language development in typical cases, the neural bases of such plasticity remain unexplored. Non-invasive functional MRI (fMRI) is a unique tool to assess the neural correlates of brain plasticity through repeated studies, but the technique has not been widely used in children because of methodological limitations. Plasticity of language was studied in a boy who developed intractable epilepsy related to Rasmussen's syndrome of the left hemisphere at age 5 years 6 months, after normal language acquisition. The first fMRI study at age 6 years 10 months showed left lateralization of language networks during a word fluency task. After left hemispherotomy at age 9 years, the child experienced profound aphasia and alexia, with rapid recovery of receptive language but slower and incomplete recovery of expressive language and reading. Postoperative fMRI at age 10 years 6 months showed a shift of language-related networks to the right during expressive and receptive tasks. Right activation was seen mainly in regions that could not be detected preoperatively, but mirrored those previously found in the left hemisphere (inferior frontal, temporal and parietal cortex), suggesting reorganization in a pre-existing bilateral network. In addition, neuropsychological data of this case support the hypothesis of innately more bilateral distribution of receptive than expressive language. This first serial fMRI study illustrates the great plasticity of the child's brain and the ability of the right hemisphere to take over some expressive language functions, even at a relatively late age. It also suggests a limit for removal of the dominant hemisphere beyond the age of 6 years, a classical limit for the critical period of language acquisition.