A role for retro-splenial cortex in the task-related P3 network.

OBJECTIVE: The P3 is an event-related response observed in relation to task-relevant sensory events. Despite its ubiquitous presence, the neural generators of the P3 are controversial and not well identified. METHODS: We compared source analysis of combined magneto- and electroencephalography (M/EEG) data with functional magnetic resonance imaging (fMRI) and simulation studies to better understand the sources of the P3 in an auditory oddball paradigm. RESULTS: Our results suggest that the dominant source of the classical, postero-central P3 lies in the retro-splenial cortex of the ventral cingulate gyrus. A second P3 source in the anterior insular cortex contributes little to the postero-central maximum. Multiple other sources in the auditory, somatosensory, and anterior midcingulate cortex are active in an overlapping time window but can be functionally dissociated based on their activation time courses. CONCLUSIONS: The retro-splenial cortex is a dominant source of the parietal P3 maximum in EEG. SIGNIFICANCE: These results provide a new perspective for the interpretation of the extensive research based on the P3 response.

A role for retro-splenial cortex in the task-related P3 network.

Objective: The P3 is an event-related response observed in relation to task-relevant sensory events. Despite its ubiquitous presence, the neural generators of the P3 are controversial and not well identified. Methods: We compared source analysis of combined magneto- and electroencephalography (M/EEG) data with functional magnetic resonance imaging (fMRI) and simulation studies to better understand the sources of the P3 in an auditory oddball paradigm. Results: Our results suggest that the dominant source of the classical, postero-central P3 lies in the retro-splenial cortex of the ventral cingulate gyrus. A second P3 source in the anterior insular cortex contributes little to the postero-central maximum. Multiple other sources in the auditory, somatosensory, and anterior midcingulate cortex are active in an overlapping time window but can be functionally dissociated based on their activation time courses. Conclusion: The retro-splenial cortex is a dominant source of the parietal P3 maximum in EEG. Significance: These results provide a new perspective for the interpretation of the extensive research based on the P3 response.

Management of Cerebral Venous Thrombosis Due to Adenoviral COVID-19 Vaccination.

OBJECTIVE: Cerebral venous thrombosis (CVT) caused by vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare adverse effect of adenovirus-based severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) vaccines. In March 2021, after autoimmune pathogenesis of VITT was discovered, treatment recommendations were developed. These comprised immunomodulation, non-heparin anticoagulants, and avoidance of platelet transfusion. The aim of this study was to evaluate adherence to these recommendations and its association with mortality. METHODS: We used data from an international prospective registry of patients with CVT after the adenovirus-based SARS-CoV-2 vaccination. We analyzed possible, probable, or definite VITT-CVT cases included until January 18, 2022. Immunomodulation entailed administration of intravenous immunoglobulins and/or plasmapheresis. RESULTS: Ninety-nine patients with VITT-CVT from 71 hospitals in 17 countries were analyzed. Five of 38 (13%), 11 of 24 (46%), and 28 of 37 (76%) of the patients diagnosed in March, April, and from May onward, respectively, were treated in-line with VITT recommendations (p < 0.001). Overall, treatment according to recommendations had no statistically significant influence on mortality (14/44 [32%] vs 29/55 [52%], adjusted odds ratio [OR] = 0.43, 95% confidence interval [CI] = 0.16-1.19). However, patients who received immunomodulation had lower mortality (19/65 [29%] vs 24/34 [70%], adjusted OR = 0.19, 95% CI = 0.06-0.58). Treatment with non-heparin anticoagulants instead of heparins was not associated with lower mortality (17/51 [33%] vs 13/35 [37%], adjusted OR = 0.70, 95% CI = 0.24-2.04). Mortality was also not significantly influenced by platelet transfusion (17/27 [63%] vs 26/72 [36%], adjusted OR = 2.19, 95% CI = 0.74-6.54). CONCLUSIONS: In patients with VITT-CVT, adherence to VITT treatment recommendations improved over time. Immunomodulation seems crucial for reducing mortality of VITT-CVT. ANN NEUROL 2022;92:562-573.

Characteristics and Outcomes of Patients With Cerebral Venous Sinus Thrombosis in SARS-CoV-2 Vaccine-Induced Immune Thrombotic Thrombocytopenia.

Importance: Thrombosis with thrombocytopenia syndrome (TTS) has been reported after vaccination with the SARS-CoV-2 vaccines ChAdOx1 nCov-19 (Oxford-AstraZeneca) and Ad26.COV2.S (Janssen/Johnson & Johnson). Objective: To describe the clinical characteristics and outcome of patients with cerebral venous sinus thrombosis (CVST) after SARS-CoV-2 vaccination with and without TTS. Design, Setting, and Participants: This cohort study used data from an international registry of consecutive patients with CVST within 28 days of SARS-CoV-2 vaccination included between March 29 and June 18, 2021, from 81 hospitals in 19 countries. For reference, data from patients with CVST between 2015 and 2018 were derived from an existing international registry. Clinical characteristics and mortality rate were described for adults with (1) CVST in the setting of SARS-CoV-2 vaccine-induced immune thrombotic thrombocytopenia, (2) CVST after SARS-CoV-2 vaccination not fulling criteria for TTS, and (3) CVST unrelated to SARS-CoV-2 vaccination. Exposures: Patients were classified as having TTS if they had new-onset thrombocytopenia without recent exposure to heparin, in accordance with the Brighton Collaboration interim criteria. Main Outcomes and Measures: Clinical characteristics and mortality rate. Results: Of 116 patients with postvaccination CVST, 78 (67.2%) had TTS, of whom 76 had been vaccinated with ChAdOx1 nCov-19; 38 (32.8%) had no indication of TTS. The control group included 207 patients with CVST before the COVID-19 pandemic. A total of 63 of 78 (81%), 30 of 38 (79%), and 145 of 207 (70.0%) patients, respectively, were female, and the mean (SD) age was 45 (14), 55 (20), and 42 (16) years, respectively. Concomitant thromboembolism occurred in 25 of 70 patients (36%) in the TTS group, 2 of 35 (6%) in the no TTS group, and 10 of 206 (4.9%) in the control group, and in-hospital mortality rates were 47% (36 of 76; 95% CI, 37-58), 5% (2 of 37; 95% CI, 1-18), and 3.9% (8 of 207; 95% CI, 2.0-7.4), respectively. The mortality rate was 61% (14 of 23) among patients in the TTS group diagnosed before the condition garnered attention in the scientific community and 42% (22 of 53) among patients diagnosed later. Conclusions and Relevance: In this cohort study of patients with CVST, a distinct clinical profile and high mortality rate was observed in patients meeting criteria for TTS after SARS-CoV-2 vaccination.

Challenges of Acute Ischemic Stroke Treatment in Orally Anticoagulated Patients via Telemedicine.

BACKGROUND: Managing acute ischemic stroke (AIS) in patients receiving treatment with vitamin K antagonists (VKA) or non-VKA oral anticoagulants (NOACs) is difficult and the challenge this poses for stroke telemedicine remains unexplored. METHODS: We analyzed data from a random sample (n = 1500) of all teleneurological consultations conducted between July 2015 and December 2017. Management of patients suffering AIS with and without prior oral anticoagulation treatment was characterized, including potential vs. actual treatment with intravenous thrombolysis (IVT) and reasons for withholding it. RESULTS: n = 359 patients had suffered an AIS, of whom 63 (17.5%) were under treatment with oral anticoagulants (VKA, n = 24; NOAC, n = 39). Administration of IVT was more common in patients who had not received prior oral anticoagulation treatment (20.3% vs. 3.2%, p < 0.001). NOAC intake was the primary reason for withholding IVT in 37% of orally anticoagulated patients who were found potentially eligible for IVT. Furthermore, patients under oral anticoagulation tended to be transported to the comprehensive stroke center more often (23.8% vs. 13.9%, p = 0.056). CONCLUSIONS: AIS in patients on oral anticoagulation treatment is a frequent reason for telestroke consultation, and NOAC intake constitutes an important barrier to administering IVT.

Diagnostic Accuracy in Teleneurological Stroke Consultations.

BACKGROUND: The accuracy of diagnosing acute cerebrovascular disease via a teleneurology service and the characteristics of misdiagnosed patients are insufficiently known. METHODS: A random sample (n = 1500) of all teleneurological consultations conducted between July 2015 and December 2017 was screened. Teleneurological diagnosis and hospital discharge diagnosis were compared. Diagnoses were then grouped into two main categories: cerebrovascular disease (CVD) and noncerebrovascular disease. Test characteristics were calculated. RESULTS: Out of 1078 consultations, 52% (n = 561) had a final diagnosis of CVD. Patients with CVD could be accurately identified via teleneurological consultation (sensitivity 95.2%, 95% CI 93.2-96.8), but we observed a tendency towards false-positive diagnosis (specificity 77.4%, 95% CI 73.6-80.8). Characteristics of patients with a false-negative CVD diagnosis were similar to those of patients with a true-positive diagnosis, but patients with a false-negative CVD diagnosis had ischemic heart disease less frequently. In retrospect, one patient would have been considered a candidate for intravenous thrombolysis (0.2%). CONCLUSIONS: Teleneurological consultations are accurate for identifying patients with CVD, and there is a very low rate of missed candidates for thrombolysis. Apart from a lower prevalence of ischemic heart disease, characteristics of "stroke chameleons" were similar to those of correctly identified CVD patients.

Auditory cortex activity related to perceptual awareness versus masking of tone sequences.

Sequences of repeating tones can be masked by other tones of different frequency. When these tone sequences are perceived, nevertheless, a prominent neural response in the auditory cortex is evoked by each tone of the sequence. When the targets are detected based on their isochrony, participants know that they are listening to the target once they detected it. To explore if the neural activity is more closely related to this detection task or to perceptual awareness, this magnetoencephalography (MEG) study used targets that could only be identified with cues provided after or before the masked target. In experiment 1, multiple mono-tone streams with jittered inter-stimulus interval were used, and the tone frequency of the target was indicated by a cue. Results showed no differential auditory cortex activity between hit and miss trials with post-stimulus cues. A late negative response for hit trials was only observed for pre-stimulus cues, suggesting a task-related component. Since experiment 1 provided no evidence for a link of a difference response with tone awareness, experiment 2 was planned to probe if detection of tone streams was linked to a difference response in auditory cortex. Random-tone sequences were presented in the presence of a multi-tone masker, and the sequence was repeated without masker thereafter. Results showed a prominent difference wave for hit compared to miss trials in experiment 2 evoked by targets in the presence of the masker. These results suggest that perceptual awareness of tone streams is linked to neural activity in auditory cortex.

Context-dependent role of selective attention for change detection in multi-speaker scenes.

Disappearance of a voice or other sound source may often go unnoticed when the auditory scene is crowded. We explored the role of selective attention for this change deafness with magnetoencephalography in multi-speaker scenes. Each scene was presented two times in direct succession, and one target speaker was frequently omitted in Scene 2. When listeners were previously cued to the target speaker, activity in auditory cortex time locked to the target speaker's sound envelope was selectively enhanced in Scene 1, as was determined by a cross-correlation analysis. Moreover, the response was stronger for hit trials than for miss trials, confirming that selective attention played a role for subsequent change detection. If selective attention to the streams where the change occurred was generally required for successful change detection, neural enhancement of this stream would also be expected without cue in hit compared to miss trials. However, when listeners were not previously cued to the target, no enhanced activity for the target speaker was observed for hit trials, and there was no significant difference between hit and miss trials. These results, first, confirm a role for attention in change detection for situations where the target source is known. Second, they suggest that the omission of a speaker, or more generally an auditory stream, can alternatively be detected without selective attentional enhancement of the target stream. Several models and strategies could be envisaged for change detection in this case, including global comparison of the subsequent scenes.

Cortical networks for auditory detection with and without informational masking: Task effects and implications for conscious perception.

Ambiguous and masked stimuli have been used to study conscious perception by comparing neural activity during different percepts of identical physical stimuli. One limitation of this approach is that it typically requires a reporting task that may engage neural processes beyond those required for conscious perception. Here, we explored potential fMRI correlates of auditory conscious perception with and without overt report. In experiment 1, regular tone patterns were presented as targets under informational masking, and participants reported their percepts on each trial. In experiment 2, regular tone patterns were presented without masking, while the uninformed participants (i) passively fixated, (ii) performed an orthogonal visual task, and (iii) reported trial-wise the presence of the auditory pattern as in experiment 1 (in fixed order). Under informational masking, target-pattern detection was associated with activity in auditory cortex, superior temporal sulcus, and a distributed fronto-parieto-insular network. Unmasked and task-irrelevant tone patterns elicited activity that overlapped with the network observed under informational masking in auditory cortex, the right superior temporal sulcus, and the ventral precentral sulcus in an ROI analysis. We therefore consider these structures candidate regions for a neural substrate of auditory conscious perception. In contrast, activity in the intraparietal sulcus, insula, and dorsal precentral sulcus were only observed for unmasked tone patterns when they were task relevant. These areas therefore appear more closely related to task performance or top-down attention rather than auditory conscious perception, per se.

Auditory-cortex lesions impair contralateral tone-pattern detection under informational masking.

Impaired hearing contralateral to unilateral auditory-cortex lesions is typically only observed under conditions of perceptual competition, such as dichotic presentation or speech in noise. It remains unclear, however, if the source of this effect is direct competition in frequency-specific neurons, or if enhanced processing load in more distant frequencies can also impair auditory detection. To evaluate this question, we studied a group of patients with unilateral auditory-cortex lesions (N = 14, six left-hemispheric (LH), eight right-hemispheric (RH); four females; age range 26-72 years) and a control group (N = 25; 15 females; age range 18-76 years) with a target-detection task in presence of a multi-tone masker, which can produce informational masking. The results revealed reduced sensitivity for monaural target streams presented contralateral to auditory-cortex lesions, with an approximately 10% higher error rate in the contra-lesional ear. A general, bilateral reduction of target detection was only observed in a subgroup of patients, who were classified as additionally suffering from auditory neglect. These results demonstrate that auditory-cortex lesions impair monaural, contra-lesional target detection under informational masking. The finding supports the hypothesis that neural mechanisms beyond direct competition in frequency-specific neurons can be a source of impaired hearing under perceptual competition in patients with unilateral auditory-cortex lesions.

Transient human auditory cortex activation during volitional attention shifting.

While strong activation of auditory cortex is generally found for exogenous orienting of attention, endogenous, intra-modal shifting of auditory attention has not yet been demonstrated to evoke transient activation of the auditory cortex. Here, we used fMRI to test if endogenous shifting of attention is also associated with transient activation of the auditory cortex. In contrast to previous studies, attention shifts were completely self-initiated and not cued by transient auditory or visual stimuli. Stimuli were two dichotic, continuous streams of tones, whose perceptual grouping was not ambiguous. Participants were instructed to continuously focus on one of the streams and switch between the two after a while, indicating the time and direction of each attentional shift by pressing one of two response buttons. The BOLD response around the time of the button presses revealed robust activation of the auditory cortex, along with activation of a distributed task network. To test if the transient auditory cortex activation was specifically related to auditory orienting, a self-paced motor task was added, where participants were instructed to ignore the auditory stimulation while they pressed the response buttons in alternation and at a similar pace. Results showed that attentional orienting produced stronger activity in auditory cortex, but auditory cortex activation was also observed for button presses without focused attention to the auditory stimulus. The response related to attention shifting was stronger contralateral to the side where attention was shifted to. Contralateral-dominant activation was also observed in dorsal parietal cortex areas, confirming previous observations for auditory attention shifting in studies that used auditory cues.

Effects of Cross-modal Asynchrony on Informational Masking in Human Cortex.

In many everyday listening situations, an otherwise audible sound may go unnoticed amid multiple other sounds. This auditory phenomenon, called informational masking (IM), is sensitive to visual input and involves early (50-250 msec) activity in the auditory cortex (the so-called awareness-related negativity). It is still unclear whether and how the timing of visual input influences the neural correlates of IM in auditory cortex. To address this question, we obtained simultaneous behavioral and neural measures of IM from human listeners in the presence of a visual input stream and varied the asynchrony between the visual stream and the rhythmic auditory target stream (in-phase, antiphase, or random). Results show effects of cross-modal asynchrony on both target detectability (RT and sensitivity) and the awareness-related negativity measured with EEG, which were driven primarily by antiphasic audiovisual stimuli. The neural effect was limited to the interval shortly before listeners' behavioral report of the target. Our results indicate that the relative timing of visual input can influence the IM of a target sound in the human auditory cortex. They further show that this audiovisual influence occurs early during the perceptual buildup of the target sound. In summary, these findings provide novel insights into the interaction of IM and multisensory interaction in the human brain.

A roadmap for the study of conscious audition and its neural basis.

How and which aspects of neural activity give rise to subjective perceptual experience-i.e. conscious perception-is a fundamental question of neuroscience. To date, the vast majority of work concerning this question has come from vision, raising the issue of generalizability of prominent resulting theories. However, recent work has begun to shed light on the neural processes subserving conscious perception in other modalities, particularly audition. Here, we outline a roadmap for the future study of conscious auditory perception and its neural basis, paying particular attention to how conscious perception emerges (and of which elements or groups of elements) in complex auditory scenes. We begin by discussing the functional role of the auditory system, particularly as it pertains to conscious perception. Next, we ask: what are the phenomena that need to be explained by a theory of conscious auditory perception? After surveying the available literature for candidate neural correlates, we end by considering the implications that such results have for a general theory of conscious perception as well as prominent outstanding questions and what approaches/techniques can best be used to address them.This article is part of the themed issue 'Auditory and visual scene analysis'.

Neural Correlates of Auditory Perceptual Awareness and Release from Informational Masking Recorded Directly from Human Cortex: A Case Study.

In complex acoustic environments, even salient supra-threshold sounds sometimes go unperceived, a phenomenon known as informational masking. The neural basis of informational masking (and its release) has not been well-characterized, particularly outside auditory cortex. We combined electrocorticography in a neurosurgical patient undergoing invasive epilepsy monitoring with trial-by-trial perceptual reports of isochronous target-tone streams embedded in random multi-tone maskers. Awareness of such masker-embedded target streams was associated with a focal negativity between 100 and 200 ms and high-gamma activity (HGA) between 50 and 250 ms (both in auditory cortex on the posterolateral superior temporal gyrus) as well as a broad P3b-like potential (between ~300 and 600 ms) with generators in ventrolateral frontal and lateral temporal cortex. Unperceived target tones elicited drastically reduced versions of such responses, if at all. While it remains unclear whether these responses reflect conscious perception, itself, as opposed to pre- or post-perceptual processing, the results suggest that conscious perception of target sounds in complex listening environments may engage diverse neural mechanisms in distributed brain areas.

Lateralization and Binaural Interaction of Middle-Latency and Late-Brainstem Components of the Auditory Evoked Response.

We used magnetoencephalography to examine lateralization and binaural interaction of the middle-latency and late-brainstem components of the auditory evoked response (the MLR and SN10, respectively). Click stimuli were presented either monaurally, or binaurally with left- or right-leading interaural time differences (ITDs). While early MLR components, including the N19 and P30, were larger for monaural stimuli presented contralaterally (by approximately 30 and 36 % in the left and right hemispheres, respectively), later components, including the N40 and P50, were larger ipsilaterally. In contrast, MLRs elicited by binaural clicks with left- or right-leading ITDs did not differ. Depending on filter settings, weak binaural interaction could be observed as early as the P13 but was clearly much larger for later components, beginning at the P30, indicating some degree of binaural linearity up to early stages of cortical processing. The SN10, an obscure late-brainstem component, was observed consistently in individuals and showed linear binaural additivity. The results indicate that while the MLR is lateralized in response to monaural stimuli-and not ITDs-this lateralization reverses from primarily contralateral to primarily ipsilateral as early as 40 ms post stimulus and is never as large as that seen with fMRI.

Functional magnetic resonance imaging confirms forward suppression for rapidly alternating sounds in human auditory cortex but not in the inferior colliculus.

Forward suppression at the level of the auditory cortex has been suggested to subserve auditory stream segregation. Recent results in non-streaming stimulation contexts have indicated that forward suppression can also be observed in the inferior colliculus; whether this holds for streaming-related contexts remains unclear. Here, we used cardiac-gated fMRI to examine forward suppression in the inferior colliculus (and the rest of the human auditory pathway) in response to canonical streaming stimuli (rapid tone sequences comprised of either one repetitive tone or two alternating tones). The first stimulus is typically perceived as a single stream, the second as two interleaved streams. In different experiments using either pure tones differing in frequency or bandpass-filtered noise differing in inter-aural time differences, we observed stronger auditory cortex activation in response to alternating vs. repetitive stimulation, consistent with the presence of forward suppression. In contrast, activity in the inferior colliculus and other subcortical nuclei did not significantly differ between alternating and monotonic stimuli. This finding could be explained by active amplification of forward suppression in auditory cortex, by a low rate (or absence) of cells showing forward suppression in inferior colliculus, or both.

Does the mismatch negativity operate on a consciously accessible memory trace?

The extent to which the contents of short-term memory are consciously accessible is a fundamental question of cognitive science. In audition, short-term memory is often studied via the mismatch negativity (MMN), a change-related component of the auditory evoked response that is elicited by violations of otherwise regular stimulus sequences. The prevailing functional view of the MMN is that it operates on preattentive and even preconscious stimulus representations. We directly examined the preconscious notion of the MMN using informational masking and magnetoencephalography. Spectrally isolated and otherwise suprathreshold auditory oddball sequences were occasionally random rendered inaudible by embedding them in random multitone masker "clouds." Despite identical stimulation/task contexts and a clear representation of all stimuli in auditory cortex, MMN was only observed when the preceding regularity (that is, the standard stream) was consciously perceived. The results call into question the preconscious interpretation of MMN and raise the possibility that it might index partial awareness in the absence of overt behavior.