Results Of Cortical Stimulation Research Articles

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.

SEEG-guided radiofrequency thermocoagulation of epileptic foci in the paediatric population: Feasibility, safety and efficacy

PurposeFocal epilepsy in children may be refractory to pharmacological treatment and surgical resection may be an appropriate option. When invasive electroencephalogram is required in the presurgical evaluation, depth electrodes can be used to create focal lesions in the epileptogenic zone using radiofrequency thermocoagulation (RFTC), to disrupt the epileptogenic zone. MethodsThis study aimed to assess the efficacy and safety of RFTC in a paediatric population of 46 patients. ResultsThe mean age of onset was 3.3 years and the mean age at SEEG was 8.2 years. MRI lesions were identified in 71.7% of the series, among them 60% of malformation of cortical development. 43.5% of the patients were seizure free at 1 month, 26.1% were responders. The mean duration of improvement was 6.8 months. 8 children were seizure free for >8 months and among them, 6 are currently seizure free for 8–24 months. 5 patients had functional deficits post-procedures, transient in 4 patients and prolonged in one of whom. 3/5 were anticipated following the results of cortical stimulation. Multivariate analysis found 3 independent criteria linked to RFTC efficiency one month after RFTC: frequency of the seizures before RFTC, age and number of contacts used. ConclusionRFTC is a safe method for the paediatric population providing important predictive information for surgical resection. An improvement in seizure frequency, often transient, is seen in 2/3 of our patients. RTFC could be useful as a palliative technique for children with an epileptogenic zone overlapping with eloquent areas, with minimal risk of sequelae.

Navigated Brain Stimulation for Preoperative Cortical Mapping in Paretic Patients: Case Report of a Hemiplegic Patient

Navigated brain stimulation (NBS) is an emerging technology that can be used for preoperative mapping of the motor cortex. It combines conventional transcranial magnetic stimulation with neuronavigation and achieves high precision by taking into account all relevant physical factors. In contrast to functional imaging technologies, NBS does not rely on voluntary patient movements for cortical mapping. Thus, NBS can be used even on patients with severe motor impairment. This article presents the case of a hemiplegic elderly woman with a brain tumor in the motor cortex. Preoperative NBS surprisingly demonstrated intact corticospinal tracts in the hemiplegic patient. The results modified the surgical strategy. Direct cortical stimulation was performed intraoperatively. The direct cortical stimulation results were in agreement with the preoperative NBS findings, and the clinical success of the surgery exceeded expectations. NBS can be used for preoperative mapping in plegic patients. Even more important, this case report discusses why tumor resection surgery based on NBS may sometimes lead to substantially better clinical outcomes than surgery planned according to functional imaging technologies.

Awake Craniotomy and Intraoperative Magnetic Resonance Imaging

Intraoperative magnetic resonance imaging (iMRI) has been reported to augment radical brain tumor resection. "Awake craniotomy" is a technique to conserve function during brain tumor surgery. We report on the combination of these 2 techniques, with special emphasis on potential adverse effects, caveats, and patient preparation. Thirty-four patients had 38 awake craniotomies with cortical stimulation within an integrated MRI-operating room with a 1.5-T unit. Thirty-two lesions were left hemispheric, 6 on the right side. Preparation for iMRI per patient amounted to 20 to 25 minutes, in addition to scan time. The procedure was well tolerated by all patients. Thirty-two stated that they would undergo this procedure again, if necessary. Four underwent a second "awake" surgery in the iMRI for recurrent disease. Intraoperative MRI had no adverse effect, such as seizures. Cortical stimulation could be performed without restrictions outside the 5-gauss line. The combination of iMRI and awake craniotomy is demanding but well tolerated by patients. Careful preoperative evaluation is essential to ensure compliance. There is no adverse effect through iMRI on the awake patient or the results of cortical stimulation. Since the introduction of the iMRI in our department in 2005, all awake craniotomies were done in this setting. The implementation of these 2 techniques into our procedures is demanding, and necessitates thorough preparation but has broadened our basis for surgical decision making. However, to substantiate our positive perception, more clinical data are being compiled.

Speech arrest with stimulation may not reliably predict language deficit after epilepsy surgery

The authors present a patient in whom electrical cortical stimulation of the posterior temporal cortex induced speech arrest, comprehension deficits, and other language-related impairments. This area was ultimately resected because of persistence of a severe seizure disorder. No postoperative aphasia was observed despite the cortical stimulation results, and the patient is since seizure free. These findings question the well-established principle that corticography directly reflects local cortical functions in all patients.

Localising and lateralising value of ictal piloerection

Background: Piloerection is a rare clinical symptom described during seizures. Previous reports suggested that the temporal lobe is the ictal onset zone in many of these cases. One case series...

Corticothalamic inhibition in the thalamic reticular nucleus.

Mutual inhibition between the GABAergic cells of the thalamic reticular nucleus (RTN) is important in regulating oscillations in the thalamocortical network, promoting those in the spindle range of frequencies over those at lower frequencies. Excitatory inputs to the RTN from the cerebral cortex are numerically large and particularly powerful in inducing spindles. However, the extent to which corticothalamic influences can engage the inhibitory network of the RTN has not been fully explored. Focal electrical stimulation of layer VI in the barrel cortex of the mouse thalamocortical slice in vitro resulted in prominent di- or polysynaptic inhibitory postsynaptic currents (IPSCs) in RTN cells under the experimental conditions used. The majority of cortically induced responses consisted of mixed PSCs in which the inhibitory component predominated or of large IPSCs alone, implying inhibition of neighboring cells by other, cortically excited RTN cells. Within the mixed PSCs, fixed and variable latency components could commonly be identified. IPSCs could be blocked by application of ionotropic glutamate receptor antagonists or of GABA(A) receptor antagonists, also indicating their dependence on corticothalamic excitation triggering disynaptic or polysynaptic inhibition. Spontaneous GABA(A) receptor-dependent IPSCs were routinely observed in the RTN and, taken together with the results of cortical stimulation, indicate the existence of a substantial network of intrareticular inhibitory connections that can be effectively recruited by the corticothalamic system. These results suggest activation of cortical excitatory inputs triggers the propagation of inhibitory currents within the RTN and support the view that activation of the RTN from the somatosensory cortex, although focused by the topography of the corticothalamic projection, is capable of disynaptically engaging the whole inhibitory network of the RTN, by local and probably by reentrant GABA(A) receptor-based synapses, thus spreading the corticothalamic influence throughout the RTN.

Comparative localization of auditory comprehension using functional magnetic resonance imaging and cortical stimulation

The authors have previously described a functional magnetic resonance (fMR) imaging procedure for the localization of auditory comprehension in which focal activation of posterior temporal and inferior frontal regions of the left hemisphere was reliably demonstrated. Because this past study was conducted in neurologically normal volunteers, it was not possible to determine whether the activated regions were critical to the performance of language tasks; that is, whether the fMR imaging activations provided a rate measure of language processing. A direct comparison of fMR imaging language activation with cortical stimulation must be completed before the tool can be used with confidence in presurgical planning. Here the authors report a series of 33 consecutive patients who underwent dominant hemisphere resection in which fMR image mapping of auditory comprehension was performed at the Yale neurosurgical program. In 23 of the 33 patients reliable fMR imaging activation was shown. In 16 of these 23 patients language mapping was performed using either intra- or extraoperative cortical stimulation. Cortical stimulation failed to localize language areas in two of the 16 patients. Electrical stimulation that was performed in close proximity to the fMR image activations interfered with auditory comprehension, object naming, or speech production in 12 of the remaining 14 patients. Five of the 10 cases in which evocation reliable fMR imaging activation failed were attributable to technical problems and/or patient head movement. Cortical stimulation results and fMR imaging findings were consistent in all but two patients. However, the spatial extent of the activation produced by fMR imaging and the spatial extent of stimulation-induced language disruption that was caused by direct cortical stimulation did not always correspond. Problems in defining the extent of activation by both methods are discussed.

Magnetoencephalographic mapping of the language-specific cortex.

In this paper the authors introduce a novel use of magnetoencephalography (MEG) for noninvasive mapping of language-specific cortex in individual patients and in healthy volunteers. The authors describe a series of six experiments in which normative MEG data were collected and the reliability, validity, and topographical accuracy of the data were assessed in patients who had also undergone the Wada procedure or language mapping through intraoperative cortical stimulation. Findings include: 1) receptive language-specific areas can be reliably activated by simple language tasks and this activation can be readily recorded in short MEG sessions; 2) MEG-derived maps of each individual are reliable because they remain stable over time and are independent of whether auditory or visual stimuli are used to activate the brain; and 3) these maps are also valid because they concur with results of the Wada procedure in assessing hemispheric dominance for language and with the results of cortical stimulation in identifying the precise topography of receptive language regions within the dominant hemisphere. Although the MEG mapping technique should be further refined, it has been shown to be efficacious by correctly identifying the language-dominant hemisphere and specific language-related regions within this hemisphere. Further development of the technique may render it a valuable adjunct for routine presurgical planning in many patients who harbor tumors or have epilepsy.

Magnetoencephalographic mapping of the language-specific cortex

Object In this paper the authors introduce a novel use of magnetoencephalography (MEG) for noninvasive mapping of language-specific cortex in individual patients and in healthy volunteers. Methods The authors describe a series of six experiments in which normative MEG data were collected and the reliability, validity, and topographical accuracy of the data were assessed in patients who had also undergone the Wada procedure or language mapping through intraoperative cortical stimulation. Conclusions Findings include: 1) receptive language-specific areas can be reliably activated by simple language tasks and this activation can be readily recorded in short MEG sessions; 2) MEG-derived maps of each individual are reliable because they remain stable over time and are independent of whether auditory or visual stimuli are used to activate the brain; and 3) these maps are also valid because they concur with results of the Wada procedure in assessing hemispheric dominance for language and with the results of cortical stimulation in identifying the precise topography of receptive language regions within the dominant hemisphere. Although the MEG mapping technique should be further refined, it has been shown to be efficacious by correctly identifying the language-dominant hemisphere and specific language-related regions within this hemisphere. Further development of the technique may render it a valuable adjunct for routine presurgical planning in many patients who harbor tumors or have epilepsy.

Nonlagged relay cells and interneurons in the cat lateral geniculate nucleus: receptive-field properties and retinal inputs.

Simultaneous recording in the cat's retina and lateral geniculate nucleus (LGN) was used to find excitatory inputs to LGN cells. These recordings, correlated with measurements of LGN cell receptive-field properties, suggested new functional subdivisions of LGN cells. Distinctions between lagged and nonlagged cells were described before (Mastronarde, 1987a,b; Mastronarde et al., 1991), classification of nonlagged cells is examined here. The XS-type relay cells described before (Mastronarde, 1987a,b) each had detectable excitatory input from only one retinal X cell. Cells that received significant input from more than one retinal X cell were of three kinds: relay cells with pure X input (XM); relay cells with mixed X and Y input (X/Y); and cells that could not be antidromically activated from visual cortex (XI). In the series of relay cells, XS-XM-X/Y-Y, cells had progressively larger receptive-field centers, lower spatial resolution, and faster and more Y-like responses to various stimuli. XI cells resembled XM and X/Y cells in some respects but tended to have higher maintained firing rates, more sustained responses, and weaker surround suppression of the center response. The distinctness of XS, XM, X/Y, XI, and Y from each other was examined with a modification of discriminant analysis that allowed cells to lack measurements for some parameters. Any given pair of categories could be distinguished reliably with only three parameters, although less so for X/Y-Y. In particular, XI cells were distinguishable from relay cells by properties other than the results of cortical stimulation, thus supporting the identity of XI cells as a separate class of X interneurons. Two discontinuities in the behavior of retinal input suggest that XM cells are a separate class from XS and X/Y cells: (1) LGN X cells received either no detectable input from any of the retinal X cells adjacent to their main input, or an easily detectable amount from several such cells; and (2) cells received either no Y input or a certain minimum amount. No such discontinuity in input underlies the distinction between X/Y and Y cells. LGN Y cells were also heterogeneous. Those with substantial input from more than one retinal Y cell had larger receptive fields and a greater preference for fast-moving stimuli than did Y cells dominated by a single input. Three Y cells could not be antidromically activated. They tended to differ from Y relay cells and resemble X interneurons in several ways.(ABSTRACT TRUNCATED AT 400 WORDS)

Intracarotid Amobarbital (Wada) Test for Language Dominance: Correlation with Results of Cortical Stimulation

Eighty-eight patients had bilateral intracarotid amobarbital (Wada) testing to determine hemispheric dominance for language in preparation for epilepsy surgery, as well as unilateral extraoperative cortical electrical stimulation using subdural electrode arrays. In none of the patients with left dominance by Wada testing were language areas found with right-sided stimulation, but two patients with right dominance by Wada testing had language areas mapped on the left side. These findings suggest that left dominance by Wada testing is strong evidence for exclusive lateralization of language function in the left hemisphere, but there is concern about the ability of the Wada test to exclude the possibility of some left-sided language function despite apparent right-sided dominance. Patients with left dominance on Wada testing do not need cortical stimulation before extensive right temporal lobectomy, but we believe that patients with right or bilateral dominance on Wada testing should have cortical stimulation for localization of language areas if extensive left or right temporal or frontal resection is planned.

Drug effects on the results of minimal cortical stimulation

The effects were investigated of a number of anticonvulsants upon the spread of depression and “convulsoid activity” induced by minimal cortical stimulation. Pentobarbital decreased the wave frequency of the convulsoid activity, increased the threshold of stimulation for Leão's spreading depression and decreased the rate of propagation of this phenomenon. In small doses it “improved” the pattern in between stimulation (interim pattern). Phenobarbital had a similar, although less pronounced effect on the convulsoid activity and on the interim pattern as Pentobarbital. It did not influence the threshold or rate of spread of Leão's depression. Mebaral curtailed the convulsoid activity in small doses. Tridione had no effect on any of the results of cortical stimulation investigated. Mesantoin suppressed the convulsoid activity in rather small doses. Dilantin slowed down the wave frequency of the convulsoid activity, but did not suppress this phenomenon even in relatively large doses. It did not effect the threshold or rate of spread of Leão's depression. The interim pattern deteriorated after the administration of Dilantin.