Radiosurgery versus open surgery for mesial temporal lobe epilepsy: The randomized, controlled ROSE trial.

OBJECTIVE: To compare stereotactic radiosurgery (SRS) versus anterior temporal lobectomy (ATL) for patients with pharmacoresistant unilateral mesial temporal lobe epilepsy (MTLE). METHODS: This randomized, single-blinded, controlled trial recruited adults eligible for open surgery among 14 centers in the USA, UK, and India. Treatment was either SRS at 24 Gy to the 50% isodose targeting mesial structures, or standardized ATL. Outcomes were seizure remission (absence of disabling seizures between 25 and 36 months), verbal memory (VM), and quality of life (QOL) at 36-month follow-up. RESULTS: A total of 58 patients (31 in SRS, 27 in ATL) were treated. Sixteen (52%) SRS and 21 (78%) ATL patients achieved seizure remission (difference between ATL and SRS = 26%, upper 1-sided 95% confidence interval = 46%, P value at the 15% noninferiority margin = .82). Mean VM changes from baseline for 21 English-speaking, dominant-hemisphere patients did not differ between groups; consistent worsening occurred in 36% of SRS and 57% of ATL patients. QOL improved with seizure remission. Adverse events were anticipated cerebral edema and related symptoms for some SRS patients, and cerebritis, subdural hematoma, and others for ATL patients. SIGNIFICANCE: These data suggest that ATL has an advantage over SRS in terms of proportion of seizure remission, and both SRS and ATL appear to have effectiveness and reasonable safety as treatments for MTLE. SRS is an alternative to ATL for patients with contraindications for or with reluctance to undergo open surgery.

Cortical spatio-temporal dynamics underlying phonological target detection in humans.

Selective processing of task-relevant stimuli is critical for goal-directed behavior. We used electrocorticography to assess the spatio-temporal dynamics of cortical activation during a simple phonological target detection task, in which subjects press a button when a prespecified target syllable sound is heard. Simultaneous surface potential recordings during this task revealed a highly ordered temporal progression of high gamma (HG, 70-200 Hz) activity across the lateral hemisphere in less than 1 sec. The sequence demonstrated concurrent regional sensory processing of speech syllables in the posterior superior temporal gyrus (STG) and speech motor cortex, and then transitioned to sequential task-dependent processing from prefrontal cortex (PFC), to the final motor response in the hand sensorimotor cortex. STG activation was modestly enhanced for target over nontarget sounds, supporting a selective gain mechanism in early sensory processing, whereas PFC was entirely selective to targets, supporting its role in guiding response behavior. These results reveal that target detection is not a single cognitive event, but rather a process of progressive target selectivity that involves large-scale rapid parallel and serial processing in sensory, cognitive, and motor structures to support goal-directed human behavior.

Gamma knife radiosurgery for mesial temporal lobe epilepsy.

Many patients with mesial temporal lobe epilepsy continue to have seizures despite medical therapy. For these patients, one recourse is surgical resection of the mesial temporal lobe, with its attendant risks. Noninvasive treatment with Gamma Knife radiosurgery is under active investigation as a possible alternative to open surgery. Accumulated evidence from multiple studies shows radiosurgery to be comparable in outcomes to surgical resection. A definitive randomized, controlled trial, the Radiosurgery or Open Surgery for Epilepsy (ROSE) trial, is currently underway, and further investigation of this promising treatment is crucial in our advancement of alternative therapies to treat refractory epilepsy.

Single-trial speech suppression of auditory cortex activity in humans.

The human auditory cortex is engaged in monitoring the speech of interlocutors as well as self-generated speech. During vocalization, auditory cortex activity is reported to be suppressed, an effect often attributed to the influence of an efference copy from motor cortex. Single-unit studies in non-human primates have demonstrated a rich dynamic range of single-trial auditory responses to self-speech consisting of suppressed, nonsuppressed and excited auditory neurons. However, human research using noninvasive methods has only reported suppression of averaged auditory cortex responses to self-generated speech. We addressed this discrepancy by recording electrocorticographic activity from neurosurgical subjects performing auditory repetition tasks. We observed that the degree of suppression varied across different regions of auditory cortex, revealing a variety of suppressed and nonsuppressed responses during vocalization. Importantly, single-trial high-gamma power (γ(High), 70-150 Hz) robustly tracked individual auditory events and exhibited stable responses across trials for suppressed and nonsuppressed regions.

Categorical speech representation in human superior temporal gyrus.

Speech perception requires the rapid and effortless extraction of meaningful phonetic information from a highly variable acoustic signal. A powerful example of this phenomenon is categorical speech perception, in which a continuum of acoustically varying sounds is transformed into perceptually distinct phoneme categories. We found that the neural representation of speech sounds is categorically organized in the human posterior superior temporal gyrus. Using intracranial high-density cortical surface arrays, we found that listening to synthesized speech stimuli varying in small and acoustically equal steps evoked distinct and invariant cortical population response patterns that were organized by their sensitivities to critical acoustic features. Phonetic category boundaries were similar between neurometric and psychometric functions. Although speech-sound responses were distributed, spatially discrete cortical loci were found to underlie specific phonetic discrimination. Our results provide direct evidence for acoustic-to-higher order phonetic level encoding of speech sounds in human language receptive cortex.

Thalamic deep brain stimulation for essential tremor: relation of lead location to outcome.

OBJECTIVE: Thalamic deep brain stimulation (DBS) is commonly used to treat essential tremor, but the optimal lead location within the thalamus has not been systematically evaluated. We examined the relation of lead location to clinical outcome in a series of essential tremor patients treated by thalamic DBS. METHODS: Fifty-seven leads in 37 patients were studied. Lead locations were measured by postoperative magnetic resonance imaging. Contralateral arm tremor was assessed in the DBS-on and DBS-off states using the Fahn-Tolosa-Marin tremor rating scale, with a mean follow-up of 26 months. Lead locations were statistically correlated, using analysis of variance, with percent improvement in tremor resulting from DBS activation. RESULTS: Improvement in tremor score was significantly correlated with lead location in both the anteroposterior and lateral dimensions. In the plane of the commissures, the optimal electrode location was determined statistically to be 6.3 mm anterior to the posterior commissure and 12.3 mm lateral to the midline, or 10.0 mm lateral to the third ventricle. CONCLUSION: Optimal electrode location for thalamic DBS in essential tremor corresponds to the anterior margin of the ventralis intermedius nucleus. Leads located greater than 2 mm (in the plane of the commissures) from the optimal coordinates are more likely to be associated with poor tremor control than leads within 2 mm of the optimal location. The incidence of true physiological tolerance to the antitremor effect of thalamic DBS (defined as poor tremor control in spite of lead location within 2 mm of the optimal site) was found to be 9%.