Electrocortical Stimulation Mapping Research Articles

Human brain mapping using co-registered fUS, fMRI and ESM during awake brain surgeries: A proof-of-concept study

Accurate, depth-resolved functional imaging is key in both understanding and treatment of the human brain. A new sonography-based imaging technique named functional Ultrasound (fUS) uniquely combines high sensitivity with submillimeter-subsecond spatiotemporal resolution available in large fields-of-view. In this proof-of-concept study we show that: (A) fUS reveals the same eloquent regions as found by fMRI while concomitantly visualizing in-vivo microvascular morphology underlying these functional hemodynamics and (B) fUS-based functional maps are confirmed by Electrocortical Stimulation Mapping (ESM), the current gold-standard in awake neurosurgical practice. This unique cross-modality experiment was performed using motor, visual and language-related functional tasks in patients undergoing awake brain tumor resection. The current work serves as an important milestone towards further maturity of fUS as well as a novel avenue to increase our understanding of hemodynamics-based functional brain imaging.

P15.07.B FUNCTIONAL BRAIN MAPPING DURING AWAKE TUMOR RESECTIONS USING ESM-FMRI CO-REGISTERED FUNCTIONAL ULTRASOUND (FUS)-IMAGING

Abstract BACKGROUND Neurosurgical resection of brain tumors resembles a balancing act between maximing extent of tumor resection (efficacy) and minimizing the risk of post-operative neurological deficits (safety). Given the difficulty of this trade-off, it is surprising how limited the neurosurgeon’s intra-operative tools are. To this day, neurosurgeons still resect brain tumors without any form of real-time volumetric functional imaging. Functional Ultrasound (fUS) shows great potential as a next-generation intra-operative functional imaging technique, combining submillimeter-subsecond spatiotemporal resolution, high-depth penetration and large fields of view. In previous work we have successfully shown fUS’ ability to map out hemodynamics-based functional brain activity during language and motor tasks during awake tumor resections. However, there has been no study comparing fUS-acquired functional maps and its gold standard counterpart of BOLD-fMRI imaging or Electrocortical Stimulation Mapping (ESM). Here we present our first results of concomitant ESM-, fMRI- and fUS-imaging in the same human subjects. MATERIAL AND METHODS In N = 3 patients undergoing awake surgery for tumor removal, we performed paired functional testing with pre-operative fMRI and intra-operative fUS and ESM. Using conventional linear ultrasound arrays (GE L8-18I-D (7.8 MHz) and GE 9L-D Logiq 9 (5.3 MHz)) interfaced with our experimental system (Vantage-256, Verasonics), we could acquire fUS-images up to 8 cm in depth with a PRF up to 800 Hz. Building on clinically available neuro-navigation software with optical tracking (Brainlab), we co-registered our intra-operative fUS-maps and ESM-hotspots to pre-operative MRI/CT-data in real-time to study spatiotemporal overlap. RESULTS In motor, language and visual tasks, we were able to demonstrate consistent spatial overlap between the fUS-based and ESM- and fMRI-based functional regions. Our fUS functional maps presented with unprecedented mesoscopic-scale precision (400 µm), even at depths of over > 5 cm. In contrast to fMRI and ESM, fUS was also able to concomitantly visualize the in-vivo microvascular morphology underlying the functional hemodynamics. The current results were only obtainable after we developed a powerful study pipeline including pre-operative fMRI-imaging and ROI-planning, intra-operative integration of experimental Doppler-data and co-registered functional analyses. CONCLUSION The work presented here is the first-ever, in-human comparison between ESM-, fMRI- and fUS-based functional data, serving as a significant milestone towards further clinical maturity of fUS as a new intra-operative tool to improve the safety and efficacy of neurosurgical brain tumor resections. Disclosure: This work was supported by the NWO-Groot grant of The Dutch Organization for Scientific Research (NWO) (Grant no. 108845).

Apraxia of speech with phonological alexia and agraphia following resection of the left middle precentral gyrus: illustrative case.

Apraxia of speech is a disorder of speech-motor planning in which articulation is effortful and error-prone despite normal strength of the articulators. Phonological alexia and agraphia are disorders of reading and writing disproportionately affecting unfamiliar words. These disorders are almost always accompanied by aphasia. A 36-year-old woman underwent resection of a grade IV astrocytoma based in the left middle precentral gyrus, including a cortical site associated with speech arrest during electrocortical stimulation mapping. Following surgery, she exhibited moderate apraxia of speech and difficulty with reading and spelling, both of which improved but persisted 6 months after surgery. A battery of speech and language assessments was administered, revealing preserved comprehension, naming, cognition, and orofacial praxis, with largely isolated deficits in speech-motor planning and the spelling and reading of nonwords. This case describes a specific constellation of speech-motor and written language symptoms-apraxia of speech, phonological agraphia, and phonological alexia in the absence of aphasia-which the authors theorize may be attributable to disruption of a single process of "motor-phonological sequencing." The middle precentral gyrus may play an important role in the planning of motorically complex phonological sequences for production, independent of output modality.

Evaluating syntactic comprehension during awake intraoperative cortical stimulation mapping.

Electrocortical stimulation mapping (ECS) is widely used to identify essential language areas, but sentence-level processing has rarely been investigated. While undergoing awake surgery in the dominant left hemisphere, 6 subjects were asked to comprehend sentences varying in their demands on syntactic processing. In all 6 subjects, stimulation of the inferior frontal gyrus disrupted comprehension of passive sentences, which critically depend on syntactic processing to correctly assign grammatical roles, without disrupting comprehension of simpler tasks. In 4 of the 6 subjects, these sites were localized to the pars opercularis. Sentence comprehension was also disrupted by stimulation of other perisylvian sites, but in a more variable manner. These findings suggest that there may be language regions that differentially contribute to sentence processing and which therefore are best identified using sentence-level tasks. The functional consequences of resecting these sites remain to be investigated.

Electrically stimulated auras as a potential biomarker of the epileptogenic zone

Electrocortical stimulation mapping (ESM) is often performed in patients undergoing stereoelectroencephalography (SEEG) prior to epilepsy surgery, with the goal of identifying functional cortex and preserving it postoperatively. ESM may also evoke a patient’s typical seizure semiology. The purpose of this study was to determine whether the sites at which typical auras are evoked during ESM are associated with other known clinical and electrophysiologic biomarkers of the epileptogenic zone: the seizure onset zone (SOZ), the early spread zone (ES), and high-frequency oscillations (HFOs). We found that the sites at which auras were provoked were not consistently associated with known biomarkers (p = 0.09). We conclude that evoked auras during ESM may reflect electrical spread rather than true epileptogenicity, and that a larger study is needed to assess their potential value as independent epileptic biomarkers.

The Relationship Between Stimulation Current and Functional Site Localization During Brain Mapping.

Gliomas are often in close proximity to functional regions of the brain; therefore, electrocortical stimulation (ECS) mapping is a common technique utilized during glioma resection to identify functional areas. Stimulation-induced seizure (SIS) remains the most common reason for aborted procedures. Few studies have focused on oncological factors impacting cortical stimulation thresholds. To examine oncological factors thought to impact stimulation threshold in order to understand whether a linear relationship exists between stimulation current and number of functional cortical sites identified. We retrospectively reviewed single-institution prospectively collected brain mapping data of patients with dominant hemisphere gliomas. Comparisons of stimulation threshold were made using t-tests and ANOVAs. Associations between oncologic factors and stimulation threshold were made using multivariate regressions. The association between stimulation current and number of positive sites was made using a Poisson model. Of the 586 patients included in the study, SIS occurred in 3.92% and the rate of SIS events differed by cortical location (frontal 8.5%, insular 1.6%, parietal 1.3%, and temporal 2.8%; P=.009). Stimulation current was lower when mapping frontal cortex (P=.002). Stimulation current was not associated with tumor plus peritumor edema volume, world health organization) (WHO grade, histology, or isocitrate dehydrogenase (IDH) mutation status but was associated with tumor volume within the frontal lobe (P=.018). Stimulation current was not associated with number of positive sites identified during ECS mapping (P=.118). SISs are rare but serious events during ECS mapping. SISs are most common when mapping the frontal lobe. Greater stimulation current is not associated with the identification of more cortical functional sites during glioma surgery.

Spatial-Temporal Functional Mapping Combined With Cortico-Cortical Evoked Potentials in Predicting Cortical Stimulation Results.

Functional human brain mapping is commonly performed during invasive monitoring with intracranial electroencephalographic (iEEG) electrodes prior to resective surgery for drug­ resistant epilepsy. The current gold standard, electrocortical stimulation mapping (ESM), is time ­consuming, sometimes elicits pain, and often induces after discharges or seizures. Moreover, there is a risk of overestimating eloquent areas due to propagation of the effects of stimulation to a broader network of language cortex. Passive iEEG spatial-temporal functional mapping (STFM) has recently emerged as a potential alternative to ESM. However, investigators have observed less correspondence between STFM and ESM maps of language than between their maps of motor function. We hypothesized that incongruities between ESM and STFM of language function may arise due to propagation of the effects of ESM to cortical areas having strong effective connectivity with the site of stimulation. We evaluated five patients who underwent invasive monitoring for seizure localization, whose language areas were identified using ESM. All patients performed a battery of language tasks during passive iEEG recordings. To estimate the effective connectivity of stimulation sites with a broader network of task-activated cortical sites, we measured cortico-cortical evoked potentials (CCEPs) elicited across all recording sites by single-pulse electrical stimulation at sites where ESM was performed at other times. With the combination of high gamma power as well as CCEPs results, we trained a logistic regression model to predict ESM results at individual electrode pairs. The average accuracy of the classifier using both STFM and CCEPs results combined was 87.7%, significantly higher than the one using STFM alone (71.8%), indicating that the correspondence between STFM and ESM results is greater when effective connectivity between ESM stimulation sites and task-activated sites is taken into consideration. These findings, though based on a small number of subjects to date, provide preliminary support for the hypothesis that incongruities between ESM and STFM may arise in part from propagation of stimulation effects to a broader network of cortical language sites activated by language tasks, and suggest that more studies, with larger numbers of patients, are needed to understand the utility of both mapping techniques in clinical practice.

Deep Learning Provides Exceptional Accuracy to ECoG-Based Functional Language Mapping for Epilepsy Surgery.

The success of surgical resection in epilepsy patients depends on preserving functionally critical brain regions, while removing pathological tissues. Being the gold standard, electro-cortical stimulation mapping (ESM) helps surgeons in localizing the function of eloquent cortex through electrical stimulation of electrodes placed directly on the cortical brain surface. Due to the potential hazards of ESM, including increased risk of provoked seizures, electrocorticography based functional mapping (ECoG-FM) was introduced as a safer alternative approach. However, ECoG-FM has a low success rate when compared to the ESM. In this study, we address this critical limitation by developing a new algorithm based on deep learning for ECoG-FM and thereby we achieve an accuracy comparable to ESM in identifying eloquent language cortex. In our experiments, with 11 epilepsy patients who underwent presurgical evaluation (through deep learning-based signal analysis on 637 electrodes), our proposed algorithm obtained an accuracy of 83.05% in identifying language regions, an exceptional 23% improvement with respect to the conventional ECoG-FM analysis (∼60%). Our findings have demonstrated, for the first time, that deep learning powered ECoG-FM can serve as a stand-alone modality and avoid likely hazards of the ESM in epilepsy surgery. Hence, reducing the potential for developing post-surgical morbidity in the language function.

Brain Stimulation Can Help Us Understand Music and Language

Language and music are important ways that we communicate with each other. Talking out loud and playing a guitar may seem pretty different, but did you know that they use many of the same brain areas? Did you know that researchers have been able to study the language and music functions of the brain during brain surgery? In this article, you will learn about a procedure called electrocortical stimulation mapping (ESM), which is a procedure used during brain surgery to figure out which parts of the brain are important for speaking and playing an instrument.

Functional Ultrasound (fUS) During Awake Brain Surgery: The Clinical Potential of Intra-Operative Functional and Vascular Brain Mapping.

Background and PurposeOncological neurosurgery relies heavily on making continuous, intra-operative tumor-brain delineations based on image-guidance. Limitations of currently available imaging techniques call for the development of real-time image-guided resection tools, which allow for reliable functional and anatomical information in an intra-operative setting. Functional ultrasound (fUS), is a new mobile neuro-imaging tool with unprecedented spatiotemporal resolution, which allows for the detection of small changes in blood dynamics that reflect changes in metabolic activity of activated neurons through neurovascular coupling. We have applied fUS during conventional awake brain surgery to determine its clinical potential for both intra-operative functional and vascular brain mapping, with the ultimate aim of achieving maximum safe tumor resection.MethodsDuring awake brain surgery, fUS was used to image tumor vasculature and task-evoked brain activation with electrocortical stimulation mapping (ESM) as a gold standard. For functional imaging, patients were presented with motor, language or visual tasks, while the probe was placed over (ESM-defined) functional brain areas. For tumor vascular imaging, tumor tissue (pre-resection) and tumor resection cavity (post-resection) were imaged by moving the hand-held probe along a continuous trajectory over the regions of interest.ResultsA total of 10 patients were included, with predominantly intra-parenchymal frontal and temporal lobe tumors of both low and higher histopathological grades. fUS was able to detect (ESM-defined) functional areas deep inside the brain for a range of functional tasks including language processing. Brain tissue could be imaged at a spatial and temporal resolution of 300 μm and 1.5–2.0 ms respectively, revealing real-time tumor-specific, and healthy vascular characteristics.ConclusionThe current study presents the potential of applying fUS during awake brain surgery. We illustrate the relevance of fUS for awake brain surgery based on its ability to capture both task-evoked functional cortical responses as well as differences in vascular characteristics between tumor and healthy tissue. As current neurosurgical practice is still pre-dominantly leaning on inherently limited pre-operative imaging techniques for tumor resection-guidance, fUS enters the scene as a promising alternative that is both anatomically and physiologically informative.

Intraoperative Use of Functional MRI for Surgical Decision Making after Limited or Infeasible Electrocortical Stimulation Mapping.

Functional magnetic resonance imaging (fMRI) is becoming widely recognized as a key component of preoperative neurosurgical planning, although intraoperative electrocortical stimulation (ECS) is considered the gold standard surgical brain mapping method. However, acquiring and interpreting ECS results can sometimes be challenging. This retrospective study assesses whether intraoperative availability of fMRI impacted surgical decision-making when ECS was problematic or unobtainable. Records were reviewed for 191 patients who underwent presurgical fMRI with fMRI loaded into the neuronavigation system. Four patients were excluded as a bur-hole biopsy was performed. Imaging was acquired at 3 Tesla and analyzed using the general linear model with significantly activated pixels determined via individually determined thresholds. fMRI maps were displayed intraoperatively via commercial neuronavigation systems. Seventy-one cases were planned ECS; however, 18 (25.35%) of these procedures were either not attempted or aborted/limited due to: seizure (10), patient difficulty cooperating with the ECS mapping (4), scarring/limited dural opening (3), or dural bleeding (1). In all aborted/limited ECS cases, the surgeon continued surgery using fMRI to guide surgical decision-making. There was no significant difference in the incidence of postoperative deficits between cases with completed ECS and those with limited/aborted ECS. Preoperative fMRI allowed for continuation of surgery in over one-fourth of patients in which planned ECS was incomplete or impossible, without a significantly different incidence of postoperative deficits compared to the patients with completed ECS. This demonstrates additional value of fMRI beyond presurgical planning, as fMRI data served as a backup method to ECS.

Real-life speech production and perception have a shared premotor-cortical substrate

Motor-cognitive accounts assume that the articulatory cortex is involved in language comprehension, but previous studies may have observed such an involvement as an artefact of experimental procedures. Here, we employed electrocorticography (ECoG) during natural, non-experimental behavior combined with electrocortical stimulation mapping to study the neural basis of real-life human verbal communication. We took advantage of ECoG’s ability to capture high-gamma activity (70–350 Hz) as a spatially and temporally precise index of cortical activation during unconstrained, naturalistic speech production and perception conditions. Our findings show that an electrostimulation-defined mouth motor region located in the superior ventral premotor cortex is consistently activated during both conditions. This region became active early relative to the onset of speech production and was recruited during speech perception regardless of acoustic background noise. Our study thus pinpoints a shared ventral premotor substrate for real-life speech production and perception with its basic properties.

Neuropsychology Within a Tertiary Care Epilepsy Center

Epilepsy is a prevalent condition characterized by variations in its clinical presentation, etiology, and amenability to treatment. Through history, neuropsychologists have played a significant role in performing research studies on changes in language, memory, and executive functioning in patients with epilepsy, including those undergoing surgical treatment for medically refractory seizures. These studies provided a foundation for establishing neuropsychologists as critical members of interdisciplinary clinical teams specializing in evaluation and treatment of epilepsy. This article describes a number of elements of specialized neuropsychological practice that have evolved over the years within a tertiary care epilepsy center. Through diagnostic interview and objective testing, the neuropsychologist is able to provide a more complete and objective understanding of a patient's cognitive and behavioral functioning than what is obtained by other clinicians through brief office visits. While assessment of cognition, mood, and behavior is the most commonly provided service to patients with epilepsy from all age groups, there are many instances when neuropsychologists in surgical settings are called to perform more specialized procedures, including the intracarotid amytal (Wada) procedure, electrocortical stimulation mapping of language eloquent brain regions, and functional brain imaging procedures. While working as a neuropsychologist on an interdisciplinary epilepsy care team requires specialized knowledge and clinical training, it is extremely satisfying due to the diversity of the patient population and the particular challenges resulting from the often unique manner that cognition and behavior can be affected in patients with epilepsy across the lifespan.

Critical Language Areas Show Increased Functional Connectivity in Human Cortex.

Electrocortical stimulation (ECS) mapping is routinely used to identify critical language sites before resective neurosurgery. The precise locations of these sites are highly variable across patients, occurring in the frontal, temporal, and parietal lobes-it is this variability that necessitates individual patient mapping. But why these particular anatomical sites are so privileged in each patient is unknown. We hypothesized that critical language sites have greater functional connectivity with nearby cortex than sites without critical functions, since they serve as central nodes within the language network. Functional connectivity across language, motor, and cleared sites was measured in 15 patients undergoing electrocortiographic (ECoG) mapping for epilepsy surgery. Critical language sites had significantly higher connectivity than sites without critical functions (P = 0.001), and this also held for motor sites (P = 0.022). These data support the hypothesis that critical language sites are highly connected within the local cortical network, perhaps explaining why their disruption with ECS leads to transient disturbances in language function. It is our hope that improved understanding of the mechanisms of ECS will permit improved surgical planning and perhaps contribute to the understanding of normal language physiology.

Spatial-temporal functional mapping of language at the bedside with electrocorticography.

Editors' Note: In WriteClick this week, Dr. Nirenberg responds to “Augmentation and impulsive behaviors in restless legs syndrome: Coexistence or association?” with the hypothesis that augmentation in restless legs syndrome may be a forme fruste of dopamine agonist withdrawal syndrome. Authors Djamshidian et al. report no association between augmentation and medication nonadherence, but agree with monitoring these patients closely for addictive behaviors. In reference to “Spatial-temporal functional mapping of language at the bedside with electrocorticography,” Drs. Babajani-Feremi et al. and authors Wang et al. discuss the use of high-gamma electrocorticography, electrocortical stimulation mapping, …

Clinical Impact and Implication of Real-Time Oscillation Analysis for Language Mapping

We developed a functional brain analysis system that enabled us to perform real-time task-related electrocorticography (ECoG) and evaluated its potential in clinical practice. We hypothesized that high gamma activity (HGA) mapping would provide better spatial and temporal resolution with high signal-to-noise ratios. Seven awake craniotomy patients were evaluated. ECoG was recorded during language tasks using subdural grids, and HGA (60-170 Hz) maps were obtained in real time. The patients also underwent electrocortical stimulation (ECS) mapping to validate the suspected functional locations on HGA mapping. The results were compared and calculated to assess the sensitivity and specificity of HGA mapping. For reference, bedside HGA-ECS mapping was performed in 5 epilepsy patients. HGA mapping demonstrated functional brain areas in real time and was comparable with ECS mapping. Sensitivity and specificity for the language area were 90.1% ± 11.2% and 90.0% ± 4.2%, respectively. Most HGA-positive areas were consistent with ECS-positive regions in both groups, and there were no statistical between-group differences. Although this study included a small number of subjects, it showed real-time HGA mapping with the same setting and tasks under different conditions. This study demonstrates the clinical feasibility of real-time HGA mapping. Real-time HGA mapping enabled simple and rapid detection of language functional areas in awake craniotomy. The mapping results were highly accurate, although the mapping environment was noisy. Further studies of HGA mapping may provide the potential to elaborate complex brain functions and networks.

Passive language mapping combining real-time oscillation analysis with cortico-cortical evoked potentials for awake craniotomy.

OBJECTIVE Electrocortical stimulation (ECS) is the gold standard for functional brain mapping; however, precise functional mapping is still difficult in patients with language deficits. High gamma activity (HGA) between 80 and 140 Hz on electrocorticography is assumed to reflect localized cortical processing, whereas the cortico-cortical evoked potential (CCEP) can reflect bidirectional responses evoked by monophasic pulse stimuli to the language cortices when there is no patient cooperation. The authors propose the use of "passive" mapping by combining HGA mapping and CCEP recording without active tasks during conscious resections of brain tumors. METHODS Five patients, each with an intraaxial tumor in their dominant hemisphere, underwent conscious resection of their lesion with passive mapping. The authors performed functional localization for the receptive language area, using real-time HGA mapping, by listening passively to linguistic sounds. Furthermore, single electrical pulses were delivered to the identified receptive temporal language area to detect CCEPs in the frontal lobe. All mapping results were validated by ECS, and the sensitivity and specificity were evaluated. RESULTS Linguistic HGA mapping quickly identified the language area in the temporal lobe. Electrical stimulation by linguistic HGA mapping to the identified temporal receptive language area evoked CCEPs on the frontal lobe. The combination of linguistic HGA and frontal CCEPs needed no patient cooperation or effort. In this small case series, the sensitivity and specificity were 93.8% and 89%, respectively. CONCLUSIONS The described technique allows for simple and quick functional brain mapping with higher sensitivity and specificity than ECS mapping. The authors believe that this could improve the reliability of functional brain mapping and facilitate rational and objective operations. Passive mapping also sheds light on the underlying physiological mechanisms of language in the human brain.

Spatial-temporal functional mapping of language at the bedside with electrocorticography.

To investigate the feasibility and clinical utility of using passive electrocorticography (ECoG) for online spatial-temporal functional mapping (STFM) of language cortex in patients being monitored for epilepsy surgery. We developed and tested an online system that exploits ECoG's temporal resolution to display the evolution of statistically significant high gamma (70-110 Hz) responses across all recording sites activated by a discrete cognitive task. We illustrate how this spatial-temporal evolution can be used to study the function of individual recording sites engaged during different language tasks, and how this approach can be particularly useful for mapping eloquent cortex. Using electrocortical stimulation mapping (ESM) as the clinical gold standard for localizing language cortex, the average sensitivity and specificity of online STFM across 7 patients were 69.9% and 83.5%, respectively. Moreover, relative to regions of interest where discrete cortical lesions have most reliably caused language impairments in the literature, the sensitivity of STFM was significantly greater than that of ESM, while its specificity was also greater than that of ESM, though not significantly so. This study supports the feasibility and clinical utility of online STFM for mapping human language function, particularly under clinical circumstances in which time is limited and comprehensive ESM is impractical.

High density EEG: Could it be useful for language localization?

In patients with pharmacoresistant epilepsy, pre-surgical planning requires precise localization of both the epileptic zone and the eloquent cortical areas. In some patients, electrode implantation is necessary to achieve this goal. Electrocortical stimulation (ECS) of the individual contacts has been established as the gold-standard for individual cortical localization of critical brain regions. However, ECS is not suitable for all patients. Therefore, to overcome the limitations of ECS, non-invasive and invasive functional mapping approaches based mainly on functional magnetic resonance imaging (fMRI) and subdural electrocorticographic recordings (ECoG) have been developed. Although fMRI is frequently used as a complementary tool for surgical planning, less is known about the use of high density electroencephalography (EEG). Very few high density EEG studies have shown consistent results for language lateralization. Here, we will discuss our experience with 256-channel EEG in language localization in the individual brain.

Electrocorticographic language mapping with a listening task consisting of alternating speech and music phrases

ObjectiveElectrocorticographic (ECoG) mapping of high gamma activity induced by language tasks has been proposed as a more patient friendly alternative for electrocortical stimulation mapping (ESM), the gold standard in pre-surgical language mapping of epilepsy patients. However, ECoG mapping often reveals more language areas than considered critical with ESM. We investigated if critical language areas can be identified with a listening task consisting of speech and music phrases. MethodsNine patients with implanted subdural grid electrodes listened to an audio fragment in which music and speech alternated. We analysed ECoG power in the 65–95Hz band and obtained task-related activity patterns in electrodes over language areas. We compared the spatial distribution of sites that discriminated between listening to speech and music to ESM results using sensitivity and specificity calculations. ResultsOur listening task of alternating speech and music phrases had a low sensitivity (0.32) but a high specificity (0.95). ConclusionsThe high specificity indicates that this test does indeed point to areas that are critical to language processing. SignificanceOur test cannot replace ESM, but this short and simple task can give a reliable indication where to find critical language areas, better than ECoG mapping using language tasks alone.