Hearing preservation in acoustic neuroma surgery: middle fossa versus retrosigmoid approach.

OBJECTIVE: To compare the results of the middle fossa approach with those of the retrosigmoid approach in acoustic neuroma hearing preservation surgery. STUDY DESIGN: Retrospective review. SETTING: Tertiary care facility. PATIENTS: Patients of the otology service with acoustic neuromas and useful hearing. Fifteen intracanalicular tumors were removed via a middle fossa approach and matched with 15 intracanalicular tumors removed via the retrosigmoid approach. Four additional patients with larger tumors were operated on via the middle fossa approach and matched with patients having similar tumors removed via the retrosigmoid approach. MAIN OUTCOME MEASURES: The 1994 Committee on Hearing and Equilibrium guidelines for the evaluation of hearing preservation in acoustic neuroma were applied. Facial nerve results were graded according to the House-Brackmann grading scale 3 months postoperatively. RESULTS: In the group operated on by the middle fossa approach, the average preoperative pure-tone threshold average (PTA) was 23 dB with a word recognition score (WRS) of 79%, and the postoperative PTA averaged 49 dB with a mean WRS of 56%. In the group operated on by the retrosigmoid approach, the mean preoperative PTA was 16 dB with a WRS of 95% and a postoperative PTA value of 62 dB and WRS of 51% (hearing preservation rate of 47%). The middle fossa patients had an average change in PTA of 19 dB and an average change in WRS of 20% (hearing preservation rate of 57%). Overall, the retrosigmoid patients had an average change in PTA of 42 dB and an average change in WRS of 40%. The average change in PTA for larger tumors removed via the middle fossa approach was 32 dB, whereas all matched retrosigmoid patients lost all hearing. The rate of cerebrospinal fluid leak and facial nerve outcomes were similar between the two groups. The retrosigmoid group had a higher rate of postoperative headache. CONCLUSIONS: Compared with the retrosigmoid approach, the middle fossa approach for hearing preservation surgery yields better hearing results for intracanalicular tumors and also has a lower incidence of postoperative headache.

Location of language in the cortex: a comparison between functional MR imaging and electrocortical stimulation.

PURPOSE: To determine the accuracy of functional MR imaging in locating language areas for planning surgical resection. METHODS: Intraoperative photographs were digitized and overlaid on functional MR language maps. The sensitivity and specificity of functional MR imaging for identifying language areas were determined for five different language tasks by comparing functional MR areas of language activation with results of electrocortical stimulation. A match was considered to occur if an activated area contacted overlapped, or surrounded a language tag. The borders of the activation areas were extended by 1 and 2 cm to determine whether the number of matches changed. Language and nonlanguage tag matches were tabulated separately. RESULTS: Sensitivity/specificity for all patients and all language tasks ranged from 81%/53% for areas that touched to 92%/0% for areas separated by 2 cm. Individual language tasks were not as sensitive as a battery of language tasks combined. Location of language areas varied among subjects for a given task and among tasks for a given subject. CONCLUSION: Functional MR imaging should be considered a useful presurgical planning tool for mapping cortical language areas, because it is sensitive, it provides increased time for planning before surgery, and it is noninvasive.

Preservation of hearing and facial nerve function in resection of acoustic neuroma.

The surgical results in 78 recent cases of total removal of unilateral acoustic neuroma in which an attempt was made to preserve cochlear function have been added to the authors' previous series of 66 cases to evaluate the factors influencing the ability to preserve useful hearing. Useful hearing was defined by speech reception threshold no poorer than 70 dB and a discrimination score of at least 15%. Analysis using a logistic regression model showed that certain preoperative clinical parameters such as tumor size, speech discrimination score, and gender were significantly correlated with hearing outcome. Favorable outcome was significantly correlated with smaller tumor size, higher preoperative speech discrimination score, and male sex. From this data, an explicit formula was devised for predicting hearing outcome for an individual patient. In four cases with useful hearing preserved, there was improvement of greater than 15 percentage points in speech discrimination scores. While preoperative auditory brainstem responses were not predictive of hearing preservation, monitoring of intraoperative auditory evoked potentials was predictive of hearing outcome in selected cases. Specifically, when wave V was unchanged at the end of the operation, even if it may have been transiently lost during surgery, useful hearing was invariably preserved.

Neurosurgical applications for intraoperative stimulation.

Intraoperative neurostimulation can be most useful to the surgeon whenever the need arises to assess physiological function or identify fiber pathways and/or neuronal populations in critical areas of brain, spinal cord, or peripheral nerve. Low-level (threshold) stimulation allows for the nearest populations of axons or neuronal cell bodies (in the vicinity of the electrode tip) to be activated in the safest possible fashion. When motor pathways are being tested, attention must be paid to the control and administration of muscle relaxant drugs, which can dampen or abolish muscle responsiveness during stimulation. Peripheral nerve conduction studies can be carried out intraoperatively and may be beneficial for assessing the physiological status of a section of traumatized nerve. Cortical mapping is valuable when surgical resections near motor or speech areas in the brain are contemplated and may help the surgeon avoid significant postoperative deficits in movement or language. Intraoperative stimulation for identifying spinal motor pathways may be used to guide surgical exploration. Finally, selective intraoperative stimulation for identifying nerve fibers encased in tumor may be useful for procedures involving difficult dissections along the brachial plexus or other major nerves in the arm or leg.

Cortical mapping for defining the limits of tumor resection.

We have used cortical mapping during local anesthesia to help us define the limits of safe resection in neurosurgical patients undergoing tumor resection for lesions near language, somatosensory, or motor areas in the brain. Tumors located near the language areas in the frontal or temporal cortex were safely resected by first establishing the spatial limits for speech in these areas. In one patient with a tumor underneath the hand representation area of the right motor and sensory cortices, we also were able to define which cortical zones had to be avoided if a postoperative deficit secondary to tumor resection were to be averted. Brain swelling was not a problem; patients willingly cooperated during the cortical mapping procedure and were able to define accurately the kinds of sensory or motor changes that occurred when neurostimulation was used. It is possible safely to biopsy or resect tumors that previously might have been considered inoperable; intraoperative mapping is a useful surgical adjunct.

Excitation of visual cortex neurons by local intracortical microstimulation.

The threshold current required for the excitation of visual cortex neurons in the vicinity (approximately 1 mm) of an intracortical stimulating electrode was measured as a function of the stimulus pulse duration in the anesthetized cat. For cortical neurons with latencies of activation from 0.4 to 3.4 ms and for stimulus pulse durations from 0.02 to 0.7 ms, the threshold current for all neurons tested decreased in an exponential fashion as the pulse width was increased. Rheobase current values (ampere-threshold) were 1.2 to 516 muA (mean 160 +/- 24 muA, N = 24) and chronaxie values were 0.07 to 0.79 ms (mean 0.217 +/- 0.036 ms, N = 24). When the quantity of charge required for neuronal excitation was calculated, a quasilinear relationship was found between threshold charge and stimulus pulse width. The minimum threshold charge (coulomb-threshold) occurred for the briefest pulse widths tested and were 2 to 86 nC (mean 36.4 +/- 4.4 nC, N = 24). When the pulse energy index was calculated (threshold current squared multiplied by the pulse width), the minimum pulse energy capable of generating an evoked response (a single action potential) occurred when the pulse width was approximately 80% greater than the chronaxie. These studies demonstrate that the predictions derived from A. V. Hill's classical theory of nerve excitation are to a first approximation obeyed by visual cortex neurons. For the three parameters analyzed as a function of stimulus pulse width, the pulse current is minimized at long pulse durations, the pulse charge is minimized at short pulse durations, and the pulse energy is minimized at pulse widths of intermediate value.

Spatial computation performed by simple and complex cells in the visual cortex of the cat.

Simple and complex cells have been tested with drifting sine-wave and square-wave gratings. Despite the known differences in the response pattern of each cell type to drifting sine-wave gratings, the tuning curves for square-wave gratings for both cell types show a similar secondary response band peaking at one-third the preferred spatial frequency as determined from sine-wave studies. These results establish that both cell types respond predominantly to the third harmonic of square-wave gratings in this frequency range. At the simple cell stage, all the information required to specify the amplitude and phase for channel at a given orientation, direction and spatial frequency can be conveyed by four cells for a given subsection of visual space. At the complex cell stage, the cell's mean firing rate appears to represent the amplitude of a local Fourier coefficient, but phase information is not conveyed in the action potential code.

Intracortical microstimulation of neurons in the visual cortex of the cat.

The response of visual cortex neurons to local intracortical microstimulation was measured in the anesthetized cat. When the recording microelectrode was very close (about 20 micrometers) to the tip of the stimulating electrode, threshold currents as low as 10 micro A were capable of firing neurons. Over a 20-fold range in distance from the site of stimulation, an 80-fold increase in threshold current was observed. The mean latency of activation for 30 neurons tested with intracortical stimulation was 2.88 +/- 0.45 msec. The majority of these cells were probably synaptically activated. The mean threshold current for these neurons was 0.55 +/- 0.12 mA (N = 30). These values were significantly smaller than the thresholds found previously when stimulating electrodes were located on the pia-arachnoid surface of the visual cortex.

Phase relationships between adjacent simple cells in the visual cortex.

Adjacent simple cells recorded and "isolated" simultaneously from the same microelectrode placement were usually tuned to the same orientation and spatial frequency. The responses of the members of these "spatial frequency pairs" to drifting sine-wave gratings were cross-correlates. Within the middle range of the spatial frequency selectivity curves, the responses of the paired cells differed in phase by approximately 90 percent. This phase relationship suggests that adjacent simple cells tuned to the same spatial frequency and orientation represent paired sine and cosine filters in terms of their processing of afferent spatial inputs and truncated sine and cosine filters in terms of the output of simple cells.

Responses of complex cells in the visual cortex of the cat as a function of the length of moving slits.

(1) As a step towards specifying the spatial selectivity characteristics of complex cells with spatially periodic substructures, we have studied single cell responses to narrow slits of variable length moved across the receptive field in the preferred direction. In general, the length-response curves were linear over a considerable and sometimes full range until an optimal slit length was reached. (2) In those cells in which the rate of rise of the slit length-response functions decreased before the optimal length was reached, at least 3 factors contribute to the shape of the curve. First, the receptive field shapes of some complex cells are more ovoid or rounded than rectangular, and the summation of responses from excitatory zones of varying optimal lengths itself results in a nonlinear slit length-response function at long slit lengths. Second, central regions may contribute more to cell response than do more lateral regions along the length dimension. Third, a nonlinearity in the slit length-response curve may occur in the upper range of slit lengths as a saturation effect because discharge rates may reach 600/sec, which appears to be close to a limiting firing rate. (3) Some cells believed to be complex during preliminary receptive field testing showed weak inhibitory regions beyond the region of the optimal slit length. Many of these cells also displayed periodic average response histograms to moving slits. The extent and magnitude of the inhibition were variable from cell to cell. In terms of receptive field properties, these cells and 'regular' complex cells seem part of a continuum.

Periodic excitability changes across the receptive fields of complex cells in the striate and parastriate cortex of the cat.

1. Complex cells in cortical areas 17 and 18 of the cat have been studied in response to narrow slits and edges moving across the receptive field in the preferred direction and also to stationary slits of different widths. 2. Average response histograms, recorded as a narrow slit was moved across the receptive field, displayed a periodic series of peaks above a base line level. The response histogram for most area 17 and 18 cells contained five principal peaks; sometimes one or two weaker peaks were present at receptive field borders. The histogram for one cell located at the area 17-18 border showed thirteen distinct peaks. Periodic response patterns were also generated as an extended edge was moved across the receptive field. Plots of cell responses versus slit width for stationary slits of different widths also indicated periodic response pattern. 3. The accuracy of determining the preferred slit orientation was the single most important requirement for demonstrating the periodic response pattern. Significant changes in the appearance of the periodic pattern occurred even upon 5 degrees rotations away from the preferred orientation. 4. Average response histograms were also studied over a wide range of moving slit velocities. The number of peaks across corresponding spacings within the recewptive field remained constant over a range of velocities. Response amplitudes, however, were velocity dependent. Thus the response peaks remain associated with fixed positions within visual space independent of stimulus velocity, even though temporal as well as spatial factors may be involved in response selectivity and the periodic modulation. The most striking periodic response histograms were generated at the velocities which produced the greatest cell firing rates. Area 17 complex cells responded well to velocities of less than 0-5 degrees to 6-0 degrees/sec, but cells in area 18 generally required higher velocities, sometimes as high as 20 degrees--30 degrees/sec, for a good response. 5. Spatial frequencies for the periodic component of the receptive field for area 17 cells in the central visual area covered a range of three octaves up to 5 cycles/degree, and area 18 cells included another octave on the low frequency side. The spatial frequency of a cell was found to be roughly inversely proportional to the receptive field width. Only a small sample of area 18 cells was studied, but these cells tended to represent low spatial frequencies and to respond selectively to high velocity stimuli...