An Initial Experience of Completion Hemispherotomy via Magnetic Resonance-Guided Laser Interstitial Therapy.

INTRODUCTION: In carefully selected patients with medically refractory epilepsy, disconnective hemispherotomy can result in significant seizure freedom; however, incomplete disconnection can result in ongoing seizures and poses a significant challenge. Completion hemispherotomy provides an opportunity to finish the disconnection. We describe the use of magnetic resonance-guided laser interstitial thermal ablation (MRgLITT) for completion hemispherotomy. METHODS: Patients treated with completion hemispherotomy using MRgLITT at our institution were identified. Procedural and seizure outcomes were evaluated retrospectively. RESULTS: Five patients (3 males) underwent six MRgLITT procedures (one child treated twice) for completion hemispherotomy at a median age of 6 years (range 1.8-12.9). Two children had hemimegalencephaly, two had Rasmussen encephalitis, and one had polymicrogyria. All five children had persistent seizures likely secondary to incomplete disconnection after their functional hemispherotomy. The mean time from open hemispherotomy to MRgLITT was 569.5 ± 272.4 days (median 424, range 342-1,095). One patient underwent stereoelectroencephalography before MRgLITT. The mean number of ablation targets was 2.3 ± 0.47 (median 2, range 2-3). The mean length of the procedure was 373 min ± 68.9 (median 374, range 246-475). Four of the five patients were afforded improvement in their neurocognitive functioning and speech performance after ablation, with mean daily seizure frequency at 1 year of 1.03 ± 1.98 (median 0, range 0-5). Two patients achieved Engel Class I outcomes at 1 year after ablation, one was Engel Class III, and two were Engel Class IV. The mean follow-up time was 646.8 ± 179.5 days (median 634, range 384-918). No MRgLITT-related complications occurred. Delayed retreatment (>1 year) occurred in three patients: one child underwent redo ablation and two underwent anatomic hemispherectomy. CONCLUSION: We have demonstrated the feasibility of a minimally invasive approach for completion hemispherotomy using MRgLITT. Delayed retreatment was needed in three patients; thus, further study of this technique with comparison to other surgical techniques is warranted.

Epilepsy Surgery in Young Children With Tuberous Sclerosis Complex: A Novel Hybrid Multimodal Surgical Approach.

BACKGROUND: Surgery has become integral in treating children with tuberous sclerosis complex (TSC)-related drug-resistant epilepsy (DRE). OBJECTIVE: To describe outcomes of a multimodal diagnostic and therapeutic approach comprising invasive intracranial monitoring and surgical treatment and compare the complementary techniques of open resection and magnetic resonance-guided laser interstitial thermal therapy. METHODS: Clinical and radiographic data were prospectively collected for pediatric patients undergoing surgical evaluation for TSC-related DRE at our tertiary academic hospital. Seizure freedom, developmental improvement, and Engel class were compared. RESULTS: Thirty-eight patients (20 females) underwent treatment in January 2016 to April 2019. Thirty-five underwent phase II invasive monitoring with intracranial electrodes: 24 stereoencephalography, 9 craniotomy for grid/electrode placement, and 2 grids + stereoencephalography. With the multimodal approach, 33/38 patients (87%) achieved >50% seizure freedom of the targeted seizure type after initial treatment; 6/9 requiring secondary treatment and 2/2 requiring a third treatment achieved >50% freedom. The median Engel class was II at last follow-up (1.65 years), and 55% of patients were Engel class I/II. The mean age was lower for children undergoing open resection (2.4 vs 4.9 years, P = .04). Rates of >50% reduction in seizures (86% open resection vs 88% laser interstitial thermal therapy) and developmental improvement (86% open resection vs 83% magnetic resonance-guided laser interstitial thermal therapy) were similar. CONCLUSION: This hybrid approach of using both open surgical and minimally invasive techniques is safe and effective in treating DRE secondary to TSC. Clinical trials focused on treatment method with longer follow-up are needed to determine the optimal candidates for each approach and compare the treatment modalities more effectively.

Electrical Status Epilepticus in Sleep (ESES) in an Elderly Adult: A Case Report.

Electrical status epilepticus in sleep (ESES) is a pattern of continuous spikes seen in electroencephalography (EEG) and may be associated with neuropsychological deficits in children. This EEG pattern has not previously been reported in older adults. In this case report, a 66-year-old woman with post-traumatic epilepsy presented to the emergency department following a breakthrough seizure. Her EEG exhibited a striking pattern of continuous spikes during sleep that stopped abruptly with wakefulness, which is characteristic of the ESES phenomenon. This patient had triggers for a breakthrough seizure including subtherapeutic seizure medication levels, exposure to flashing lights, and iatrogenic hyperthyroidism, but none of these triggers have been known to cause selectively continuous spikes during sleep on EEG. This finding suggests that the phenomenon of ESES may persist into older adulthood.

Successful Treatment of Osteosarcoma Without Methotrexate in a 13-Year-Old Boy With Down Syndrome.

Osteosarcoma is the most common primary bone tumor in children, and only 1 article in the literature describes a case of osteosarcoma in a patient with Down syndrome. Although osteosarcoma is generally treated with chemotherapy regimens that include high-dose methotrexate, patients with Down syndrome have heightened sensitivity to the toxicities of methotrexate. The patient from the aforementioned case study died from sepsis soon after treatment with high-dose methotrexate. This case report describes the successful treatment of osteosarcoma in a pediatric patient with Down syndrome without methotrexate.

Determination of Differences in Seed-Based Resting State Functional Magnetic Resonance Imaging Language Networks in Pediatric Patients with Left- and Right-Lateralized Language: A Pilot Study.

BACKGROUND AND PURPOSE: The current tools available for localization of expressive language, including functional magnetic resonance imaging (fMRI) and cortical stimulation mapping (CSM), require that the patient remain stationary and follow language commands with precise timing. Many pediatric epilepsy patients, however, have intact language skills but are unable to participate in these tasks due to cognitive impairments or young age. In adult subjects, there is evidence that language laterality can be determined by resting state (RS) fMRI activity, however there are few studies on the use of RS to accurately predict language laterality in children. METHODS: A retrospective review of pediatric patients at Texas Children's Hospital was performed to identify patients who have undergone epilepsy surgical planning over 3 years with language localization using traditional methods of Wada testing, CSM, or task-based fMRI with calculated laterality index, as well as a 7-minute RS scan available without excessive motion or noise. We found the correlation between each subject's left and right Broca's region activity and each of 68 cortical regions. RESULTS: A group of nine patients with left-lateralized language were found to have greater voxel-wise correlations than a group of six patients with right-lateralized language between a left hemispheric Broca's region seed and the following six cortical regions: left inferior temporal, left lateral orbitofrontal, left pars triangularis, right lateral orbitofrontal, right pars orbitalis and right superior frontal regions. CONCLUSIONS: In a cohort of children with epilepsy, we found that patients with left- and right-hemispheric language lateralization have different RS networks.

Longitudinal Effects of Everolimus on White Matter Diffusion in Tuberous Sclerosis Complex.

OBJECTIVE: We studied the longitudinal effects of everolimus, an inhibitor of the mammalian target of rapamycin (mTOR), on callosal white matter diffusion tensor imaging (DTI) in patients with tuberous sclerosis complex (TSC). METHODS: Serial imaging data spanning nine years were used from the open label, Phase I/II trial (NCT00411619) and open-ended extension phase of everolimus for the treatment of subependymal giant cell astrocytoma associated with TSC. From 28 patients treated with everolimus and 25 untreated control patients, 481 MRI scans were available. Rigorous quality control resulted in omission of all scans with diffusion weighted imaging data in less than 15 directions or more than eight artifacted volumes, and all postsurgical scans. We applied a linear mixed-effects model to the remaining 125 scans (17 treated, 24 controls) for longitudinal analysis of each DTI metric of manually drawn callosal regions of interest. RESULTS: On a population level, mTOR inhibition was associated with a decrease in mean diffusivity. In addition, in treated patients only, a decrease of radial diffusivity was observed; in untreated patients only, an increase of axial diffusivity was seen. In patients below age 10, effect-sizes were consistently greater, and longer treatment was associated with greater rate of diffusion change. There was no correlation between DTI metrics and reduction of subependymal giant cell astrocytoma volume, or everolimus serum levels. CONCLUSIONS: Effects from mTOR overactivity on white matter microstructural integrity in TSC were modified through pharmacologic inhibition of mTOR. These changes sustained over time, were greater with longer treatment and in younger patients during a time of rapid white matter maturation.

FMRI group analysis combining effect estimates and their variances.

Conventional functional magnetic resonance imaging (FMRI) group analysis makes two key assumptions that are not always justified. First, the data from each subject is condensed into a single number per voxel, under the assumption that within-subject variance for the effect of interest is the same across all subjects or is negligible relative to the cross-subject variance. Second, it is assumed that all data values are drawn from the same Gaussian distribution with no outliers. We propose an approach that does not make such strong assumptions, and present a computationally efficient frequentist approach to FMRI group analysis, which we term mixed-effects multilevel analysis (MEMA), that incorporates both the variability across subjects and the precision estimate of each effect of interest from individual subject analyses. On average, the more accurate tests result in higher statistical power, especially when conventional variance assumptions do not hold, or in the presence of outliers. In addition, various heterogeneity measures are available with MEMA that may assist the investigator in further improving the modeling. Our method allows group effect t-tests and comparisons among conditions and among groups. In addition, it has the capability to incorporate subject-specific covariates such as age, IQ, or behavioral data. Simulations were performed to illustrate power comparisons and the capability of controlling type I errors among various significance testing methods, and the results indicated that the testing statistic we adopted struck a good balance between power gain and type I error control. Our approach is instantiated in an open-source, freely distributed program that may be used on any dataset stored in the universal neuroimaging file transfer (NIfTI) format. To date, the main impediment for more accurate testing that incorporates both within- and cross-subject variability has been the high computational cost. Our efficient implementation makes this approach practical. We recommend its use in lieu of the less accurate approach in the conventional group analysis.

A neural basis for interindividual differences in the McGurk effect, a multisensory speech illusion.

The McGurk effect is a compelling illusion in which humans perceive mismatched audiovisual speech as a completely different syllable. However, some normal individuals do not experience the illusion, reporting that the stimulus sounds the same with or without visual input. Converging evidence suggests that the left superior temporal sulcus (STS) is critical for audiovisual integration during speech perception. We used blood-oxygen level dependent functional magnetic resonance imaging (BOLD fMRI) to measure brain activity as McGurk perceivers and non-perceivers were presented with congruent audiovisual syllables, McGurk audiovisual syllables, and non-McGurk incongruent syllables. The inferior frontal gyrus showed an effect of stimulus condition (greater responses for incongruent stimuli) but not susceptibility group, while the left auditory cortex showed an effect of susceptibility group (greater response in susceptible individuals) but not stimulus condition. Only one brain region, the left STS, showed a significant effect of both susceptibility and stimulus condition. The amplitude of the response in the left STS was significantly correlated with the likelihood of perceiving the McGurk effect: a weak STS response meant that a subject was less likely to perceive the McGurk effect, while a strong response meant that a subject was more likely to perceive it. These results suggest that the left STS is a key locus for interindividual differences in speech perception.

The developmental trajectory of brain-scalp distance from birth through childhood: implications for functional neuroimaging.

Measurements of human brain function in children are of increasing interest in cognitive neuroscience. Many techniques for brain mapping used in children, including functional near-infrared spectroscopy (fNIRS), electroencephalography (EEG), magnetoencephalography (MEG) and transcranial magnetic stimulation (TMS), use probes placed on or near the scalp. The distance between the scalp and the brain is a key variable for these techniques because optical, electrical and magnetic signals are attenuated by distance. However, little is known about how scalp-brain distance differs between different cortical regions in children or how it changes with development. We investigated scalp-brain distance in 71 children, from newborn to age 12 years, using structural T1-weighted MRI scans of the whole head. Three-dimensional reconstructions were created from the scalp surface to allow for accurate calculation of brain-scalp distance. Nine brain landmarks in different cortical regions were manually selected in each subject based on the published fNIRS literature. Significant effects were found for age, cortical region and hemisphere. Brain-scalp distances were lowest in young children, and increased with age to up to double the newborn distance. There were also dramatic differences between brain regions, with up to 50% differences between landmarks. In frontal and temporal regions, scalp-brain distances were significantly greater in the right hemisphere than in the left hemisphere. The largest contributors to developmental changes in brain-scalp distance were increases in the corticospinal fluid (CSF) and inner table of the cranium. These results have important implications for functional imaging studies of children: age and brain-region related differences in fNIRS signals could be due to the confounding factor of brain-scalp distance and not true differences in brain activity.

Neural correlates of interindividual differences in children's audiovisual speech perception.

Children use information from both the auditory and visual modalities to aid in understanding speech. A dramatic illustration of this multisensory integration is the McGurk effect, an illusion in which an auditory syllable is perceived differently when it is paired with an incongruent mouth movement. However, there are significant interindividual differences in McGurk perception: some children never perceive the illusion, while others always do. Because converging evidence suggests that the posterior superior temporal sulcus (STS) is a critical site for multisensory integration, we hypothesized that activity within the STS would predict susceptibility to the McGurk effect. To test this idea, we used BOLD fMRI in 17 children aged 6-12 years to measure brain responses to the following three audiovisual stimulus categories: McGurk incongruent, non-McGurk incongruent, and congruent syllables. Two separate analysis approaches, one using independent functional localizers and another using whole-brain voxel-based regression, showed differences in the left STS between perceivers and nonperceivers. The STS of McGurk perceivers responded significantly more than that of nonperceivers to McGurk syllables, but not to other stimuli, and perceivers' hemodynamic responses in the STS were significantly prolonged. In addition to the STS, weaker differences between perceivers and nonperceivers were observed in the fusiform face area and extrastriate visual cortex. These results suggest that the STS is an important source of interindividual variability in children's audiovisual speech perception.

Dynamic changes in superior temporal sulcus connectivity during perception of noisy audiovisual speech.

Humans are remarkably adept at understanding speech, even when it is contaminated by noise. Multisensory integration may explain some of this ability: combining independent information from the auditory modality (vocalizations) and the visual modality (mouth movements) reduces noise and increases accuracy. Converging evidence suggests that the superior temporal sulcus (STS) is a critical brain area for multisensory integration, but little is known about its role in the perception of noisy speech. Behavioral studies have shown that perceptual judgments are weighted by the reliability of the sensory modality: more reliable modalities are weighted more strongly, even if the reliability changes rapidly. We hypothesized that changes in the functional connectivity of STS with auditory and visual cortex could provide a neural mechanism for perceptual reliability weighting. To test this idea, we performed five blood oxygenation level-dependent functional magnetic resonance imaging and behavioral experiments in 34 healthy subjects. We found increased functional connectivity between the STS and auditory cortex when the auditory modality was more reliable (less noisy) and increased functional connectivity between the STS and visual cortex when the visual modality was more reliable, even when the reliability changed rapidly during presentation of successive words. This finding matched the results of a behavioral experiment in which the perception of incongruent audiovisual syllables was biased toward the more reliable modality, even with rapidly changing reliability. Changes in STS functional connectivity may be an important neural mechanism underlying the perception of noisy speech.

fMRI-Guided transcranial magnetic stimulation reveals that the superior temporal sulcus is a cortical locus of the McGurk effect.

A compelling example of auditory-visual multisensory integration is the McGurk effect, in which an auditory syllable is perceived very differently depending on whether it is accompanied by a visual movie of a speaker pronouncing the same syllable or a different, incongruent syllable. Anatomical and physiological studies in human and nonhuman primates have suggested that the superior temporal sulcus (STS) is involved in auditory-visual integration for both speech and nonspeech stimuli. We hypothesized that the STS plays a critical role in the creation of the McGurk percept. Because the location of multisensory integration in the STS varies from subject to subject, the location of auditory-visual speech processing in the STS was first identified in each subject with fMRI. Then, activity in this region of the STS was disrupted with single-pulse transcranial magnetic stimulation (TMS) as subjects rated their percept of McGurk and non-McGurk stimuli. Across three experiments, TMS of the STS significantly reduced the likelihood of the McGurk percept but did not interfere with perception of non-McGurk stimuli. TMS of the STS was effective at disrupting the McGurk effect only in a narrow temporal window from 100 ms before auditory syllable onset to 100 ms after onset, and TMS of a control location did not influence perception of McGurk or control stimuli. These results demonstrate that the STS plays a critical role in the McGurk effect and auditory-visual integration of speech.

The effects of repeated spectroscopic pressure measurements on fluorescence intensity in the cervix.

OBJECTIVE: Fluorescence spectroscopy is a promising technology for the detection of cervical squamous intraepithelial lesions (SILs). In this study we took repeated measures in the cervix to determine whether the order of measurement produces changes in fluorescence intensity and whether there are differences in variation due to pressure. METHODS: A pressure sensitive fiber-optic probe to measure fluorescence spectra was calibrated at light, medium, and firm levels (0.2, 0.4, 0.6 N). Measurements were made 3 times at each of 2 sites in the patient's cervix. Spectroscopic data were preprocessed and analyzed to compare order of pressure and intensity variability as a function of pressure on measurements. RESULTS: Four providers took 3 measurements from 2 sites each in 18 patients, yielding 108 measurements. After corrections for multiple comparisons, neither the order of probe pressure nor the variability of probe pressure significantly affected variations in fluorescence intensity. CONCLUSION: This study shows that the probe pressure variability is probably not an issue for these devices.

Effect of probe pressure on cervical fluorescence spectroscopy measurements.

Fluorescence spectroscopy is a promising technology for detection of epithelial precancers and cancers. While age and menopausal status influence measurements in the cervix, other variables do not significantly affect the diagnosis. In this study we examine probe pressure as a variable. A fiber optic probe to measure fluorescence spectra at different calibrated levels of pressure was designed and tested. A pilot study was conducted measuring fluorescence excitation emission matrices in 20 patients at light, medium, and firm pressure. Spectroscopic data were pre-processed and analyzed to compare mean peak intensities as a function of pressure. Further statistical analyses tested for differences in intensities at each excitation/emission wavelength pair. Four providers made measurements from 41 sites; 33 yielded good quality spectroscopic data (22 squamous normal, 7 squamous abnormal, 3 columnar normal, 1 transformation zone) from 17 of 20 patients. At all pressure levels, abnormal tissue showed less fluorescence intensity than normal tissue, and post-menopausal patients showed higher fluorescence intensity than premenopausal patients, consistent with previous analyses. A permutation analysis suggests that pressure does not significantly affect fluorescence intensity or lineshape. While other studies are needed to confirm these findings, this study suggests that fluorescence spectroscopy is a robust technology likely not influenced by fiber optic probe pressure.

Relationship between collagen autofluorescence of the human cervix and menopausal status.

The goal of this study was to evaluate the effect of different menopausal states (pre- and post-) on the endogenous fluorescence of normal cervical tissues. In particular, the average fluorescence as well as the interpatient and intrasample variability in the average fluorescence of the epithelium and stroma were evaluated as a function of pre- and postmenopausal states. High-resolution fluorescence images at excitation-emission wavelengths of 440, 520 nm and 365, 465 nm were obtained from epithelia and stroma of freeze-trapped cervical tissue blocks maintained at -196 degrees C. The fluorescence images were recorded using a low temperature optical scanner. Fluorescence images from a normal sample population (n = 27) were quantitatively analyzed, and the average epithelial and stromal fluorescence intensities were obtained. Data grouped according to menopausal status (pre- vs post-) showed statistically significant differences (P < 0.002) in stromal fluorescence. In particular, the cervical stroma of postmenopausal women showed (1) significantly greater average fluorescence and (2) greater interpatient and intrasample variability in the fluorescence, relative to that of premenopausal women. These results provide evidence for changes in collagen cross-linking with menopause.