Selective Posterior Cerebral Artery Wada Better Predicts Good Memory and Naming Outcomes Following Selective Stereotactic Thermal Ablation for Medial Temporal Lobe Epilepsy Than Internal Carotid Artery Wada.

The conventional intracarotid amobarbital (Wada) test has been used to assess memory function in patients being considered for temporal lobe epilepsy (TLE) surgery. Minimally invasive approaches that target the medial temporal lobe (MTL) and spare neocortex are increasingly used, but a knowledge gap remains in how to assess memory and language risk from these procedures. We retrospectively compared results of two versions of the Wada test, the intracarotid artery (ICA-Wada) and posterior cerebral artery (PCA-Wada) approaches, with respect to predicting subsequent memory and language outcomes, particularly after stereotactic laser amygdalohippocampotomy (SLAH). We included all patients being considered for SLAH who underwent both ICA-Wada and PCA-Wada at a single institution. Memory and confrontation naming assessments were conducted using standardized neuropsychological tests to assess pre- to post-surgical changes in cognitive performance. Of 13 patients who initially failed the ICA-Wada, only one patient subsequently failed the PCA-Wada (p=0.003, two-sided binomial test with p 0 =0.5) demonstrating that these tests assess different brain regions or networks. PCA-Wada had a high negative predictive value for the safety of SLAH, compared to ICA-Wada, as none of the patients who underwent SLAH after passing the PCA-Wada experienced catastrophic memory decline (0 of 9 subjects, p <.004, two-sided binomial test with p 0 =0.5), and all experienced a good cognitive outcome. In contrast, the single patient who received a left anterior temporal lobectomy after failed ICA- and passed PCA-Wada experienced a persistent, near catastrophic memory decline. On confrontation naming, few patients exhibited disturbance during the PCA-Wada. Following surgery, SLAH patients showed no naming decline, while open resection patients, whose surgeries all included ipsilateral temporal lobe neocortex, experienced significant naming difficulties (Fisher's exact test, p <.05). These findings demonstrate that (1) failing the ICA-Wada falsely predicts memory decline following SLAH, (2) PCA-Wada better predicts good memory outcomes of SLAH for MTLE, and (3) the MTL brain structures affected by both PCA-Wada and SLAH are not directly involved in language processing.

Stereoelectroencephalography-guided radiofrequency ablation of the epileptogenic zone as a treatment and predictor of future success of further surgical intervention.

OBJECTIVE: Stereoelectroencephalography (SEEG)-guided radiofrequency ablation (RFA) is increasingly being used as a treatment for drug-resistant localization-related epilepsy. The aim of this study is to analyze the successes and failures using RFA and how response correlates with surgical epilepsy treatment outcomes. METHODS: We retrospectively reviewed 62 patients who underwent RFA via SEEG electrodes. After excluding five, the remaining 57 were classified into subgroups based on procedures and outcomes. Forty patients (70%) underwent a secondary surgical procedure, of whom 32 were delayed: 26 laser interstitial thermal therapy (LITT), five resection, one neuromodulation. We determined the predictive value of RFA outcome upon subsequent surgical outcome by categorizing the delayed secondary surgery outcome as success (Engel I/II) versus failure (Engel III/IV). Demographic information, epilepsy characteristics, and the transient time of seizure freedom after RFA were calculated for each patient. RESULTS: Twelve of 49 patients (24.5%) who had RFA alone and delayed follow-up achieved Engel class I. Of the 32 patients who underwent a delayed secondary surgical procedure, 15 achieved Engel class I and nine Engel class II (24 successes), and eight were considered failures (Engel class III/IV). The transient time of seizure freedom after RFA was significantly longer in the success group (4 months, SD = 2.6) as compared to the failure group (.75 months, SD = 1.16; p < .001). Additionally, there was a higher portion of preoperative lesional findings in patients in the RFA alone and delayed surgical success group (p = .03) and a longer time to seizure recurrence in the presence of lesions (p < .05). Side effects occurred in 1% of patients. SIGNIFICANCE: In this series, RFA provided a treatment during SEEG-guided intracranial monitoring that led to seizure freedom in ~25% of patients. Of the 70% who underwent delayed surgery, longer transient time of seizure freedom after RFA was predictive of the results of the secondary surgeries, 74% of which were LITT.

Anterior nucleus of the thalamus deep brain stimulation vs temporal lobe responsive neurostimulation for temporal lobe epilepsy.

OBJECTIVE: Based on the promising results of randomized controlled trials, deep brain stimulation (DBS) and responsive neurostimulation (RNS) are used increasingly in the treatment of patients with drug-resistant epilepsy. Drug-resistant temporal lobe epilepsy (TLE) is an indication for either DBS of the anterior nucleus of the thalamus (ANT) or temporal lobe (TL) RNS, but there are no studies that directly compare the seizure benefits and adverse effects associated with these therapies in this patient population. We, therefore, examined all patients who underwent ANT-DBS or TL-RNS for drug-resistant TLE at our center. METHODS: We performed a retrospective review of patients who were treated with either ANT-DBS or TL-RNS for drug-resistant TLE with at least 12 months of follow-up. Along with the clinical characteristics of each patient's epilepsy, seizure frequency was recorded throughout each patient's postoperative clinical course. RESULTS: Twenty-six patients underwent ANT-DBS implantation and 32 patients underwent TL-RNS for drug-resistant TLE. The epilepsy characteristics of both groups were similar. Patients who underwent ANT-DBS demonstrated a median seizure reduction of 58% at 12-15 months, compared to a median seizure reduction of 70% at 12-15 months in patients treated with TL-RNS (p > .05). The responder rate (percentage of patients with a 50% decrease or more in seizure frequency) was 54% for ANT-DBS and 56% for TL-RNS (p > .05). The incidence of complications and stimulation-related side effects did not significantly differ between therapies. SIGNIFICANCE: We demonstrate in our single-center experience that patients with drug-resistant TLE benefit similarly from either ANT-DBS or TL-RNS. Selection of either ANT-DBS or TL-RNS may, therefore, depend more heavily on patient and provider preference, as each has unique capabilities and configurations. Future studies will consider subgroup analyses to determine if specific patients have greater seizure frequency reduction from one form of neuromodulation strategy over another.

Ordinal regression increases statistical power to predict epilepsy surgical outcomes.

Studies of epilepsy surgery outcomes are often small and thus underpowered to reach statistically valid conclusions. We hypothesized that ordinal logistic regression would have greater statistical power than binary logistic regression when analyzing epilepsy surgery outcomes. We reviewed 10 manuscripts included in a recent meta-analysis which found that mesial temporal sclerosis (MTS) predicted better surgical outcomes after a stereotactic laser amygdalohippocampectomy (SLAH). We extracted data from 239 patients from eight studies that reported four discrete Engel surgical outcomes after SLAH, stratified by the presence or absence of MTS. The rate of freedom from disabling seizures (Engel I) was 64.3% (110/171) for patients with MTS compared to 44.1% (30/68) without MTS. The statistical power to detect MTS as a predictor for better surgical outcome after a SLAH was 29% using ordinal regression, which was significantly more than the 13% power using binary logistic regression (paired t-test, P < .001). Only 120 patients are needed for this example to achieve 80% power to detect MTS as a predictor using ordinal regression, compared to 210 patients that are needed to achieve 80% power using binary logistic regression. Ordinal regression should be considered when analyzing ordinal outcomes (such as Engel surgical outcomes), especially for datasets with small sample sizes.

The Prognostic Value of Quantitative EEG in Patients Undergoing Mechanical Thrombectomy for Acute Ischemic Stroke.

PURPOSE: Previous work has shown that quantitative EEG measures correlate with the severity of ischemic stroke. This has not been systematically validated in patients with acute ischemic stroke who have undergone mechanical thrombectomy. METHODS: Data were collected from 73 patients who underwent mechanical thrombectomy and had a standard head set EEG performed during their hospital admission. For each patient, the global delta-alpha ratio (DAR) and its difference between the two hemispheres were calculated. Associations between the global and interhemispheric DAR difference with the patients' National Institutes of Health Stroke and Modified Rankin Scale scores at discharge and 3 months after thrombectomy were assessed. RESULTS: The interhemispheric DAR difference correlated with the National Institutes of Health Stroke scores at discharge (Spearman R = 0.41, P = 0.0008), National Institutes of Health Stroke scores at 3 months (Spearman R = 0.60, P = 0.02) and Modified Rankin Scale scores at 3 months (Spearman R = 0.27, P = 0.01). In contrast, the global DAR did not correlate significantly with any of these clinical outcomes when evaluated as continuous variables. In a multivariate logistic regression model, both the interhemispheric DAR difference (ß = 0.25, P = 0.03) and the infarct volume (ß = 0.02, P = 0.03) were independently predictive of good versus poor functional outcome (Modified Rankin Scale score ≤2 vs. >2) at 3 months. CONCLUSIONS: The quantitative EEG measure of interhemispheric slow relative to fast frequencies power asymmetry correlated with the discharge and 3-month National Institutes of Health Stroke and Modified Rankin Scale scores and provided added value to infarct volume in predicting functional outcome at 3 months. These data support the prognostic value of quantitative EEG in ischemic stroke patients who have undergone mechanical thrombectomy.

The Referential Montage Inadequately Localizes Corticocortical Evoked Potentials in Stereoelectroencephalography.

PURPOSE: Corticocortical evoked potentials (CCEPs) resulting from single pulse electrical stimulation are increasingly used to understand seizure networks, as well as normal brain connectivity. However, we observed that when using depth electrodes, traditional measures of CCEPs amplitude using a referential montage can be falsely localizing, often to white matter. METHODS: We pooled 27 linear electrode arrays targeting the amygdala, hippocampus, or cingulate cortex from eight participants. Using postoperative imaging, we classified contacts as being in gray matter, white matter, or bordering each and measured the amplitude using the root-mean-squared deviation from baseline in a referential, common average, bipolar, or Laplacian montage. RESULTS: Of 27 electrode contacts, 25 (93%) had a significantly higher mean amplitude when in gray matter than in white matter using a Laplacian montage, which was significantly more than the 12 of 27 electrodes (44%) when using a referential montage ( P = 0.0003, Fisher exact test). The area under the curve for a receiver operating characteristic classifying contacts as gray or white matter was significantly higher for either the Laplacian (0.79) or the bipolar (0.72) montage when compared with either the common average (0.56) or the referential (0.51) montage ( P ≤ 0.005, bootstrap). CONCLUSIONS: Both the Laplacian and bipolar montages were superior to the common average or referential montage in localizing CCEPs to gray matter. These montages may be more appropriate for interpreting CCEPs when using depth electrodes than the referential montage, which has typically been used in prior studies of CCEPs with subdural grids.

Cognitive and Emotional Mapping With SEEG.

Mapping of cortical functions is critical for the best clinical care of patients undergoing epilepsy and tumor surgery, but also to better understand human brain function and connectivity. The purpose of this review is to explore existing and potential means of mapping higher cortical functions, including stimulation mapping, passive mapping, and connectivity analyses. We examine the history of mapping, differences between subdural and stereoelectroencephalographic approaches, and some risks and safety aspects, before examining different types of functional mapping. Much of this review explores the prospects for new mapping approaches to better understand other components of language, memory, spatial skills, executive, and socio-emotional functions. We also touch on brain-machine interfaces, philosophical aspects of aligning tasks to brain circuits, and the study of consciousness. We end by discussing multi-modal testing and virtual reality approaches to mapping higher cortical functions.

Robot Assisted MRI-Guided LITT of the Anterior, Lateral, and Medial Temporal Lobe for Temporal Lobe Epilepsy.

Robotic systems have fundamentally altered the landscape of functional neurosurgery. These allow automated stereotaxy with high accuracy and reliability, and are rapidly becoming a mainstay in stereotactic surgeries such as deep brain stimulation (DBS), stereoelectroencephalography (SEEG), and stereotactic laser ablation/MRI guided laser interstitial thermal therapy (MRgLITT). Robotic systems have been effectively applied to create a minimally invasive approach for diagnostics and therapeutics in the treatment of epilepsy, utilizing robots for expeditious and accurate stereotaxy for SEEG and MRgLITT. MRgLITT has been shown to approach open surgical techniques in efficacy of seizure control while minimizing collateral injury. We describe the use of robot assisted MRgLITT for a minimally invasive laser anterior temporal lobotomy, describing the approach and potential pitfalls. Goals of MRgLITT are complete ablation of the epileptogenic zone and avoiding injury to uninvolved structures. In the middle fossa these include structures such as cranial nerves in the skull base and cavernous sinus and the thalamus. These can be mitigated with careful trajectory planning and control of laser ablation intensity.

Heterogeneous neural coding of corrective movements in motor cortex.

During a reach, neural activity recorded from motor cortex is typically thought to linearly encode the observed movement. However, it has also been reported that during a double-step reaching paradigm, neural coding of the original movement is replaced by that of the corrective movement. Here, we use neural data recorded from multi-electrode arrays implanted in the motor and premotor cortices of rhesus macaques to directly compare these two hypotheses. We show that while a majority of neurons display linear encoding of movement during a double-step, a minority display a dramatic drop in firing rate that is predicted by the replacement hypothesis. Neural activity in the subpopulation showing replacement is more likely to lag the observed movement, and may therefore be involved in the monitoring of the sensory consequences of a motor command.

Single-unit stability using chronically implanted multielectrode arrays.

The use of chronic intracortical multielectrode arrays has become increasingly prevalent in neurophysiological experiments. However, it is not obvious whether neuronal signals obtained over multiple recording sessions come from the same or different neurons. Here, we develop a criterion to assess single-unit stability by measuring the similarity of 1) average spike waveforms and 2) interspike interval histograms (ISIHs). Neuronal activity was recorded from four Utah arrays implanted in primary motor and premotor cortices in three rhesus macaque monkeys during 10 recording sessions over a 15- to 17-day period. A unit was defined as stable through a given day if the stability criterion was satisfied on all recordings leading up to that day. We found that 57% of the original units were stable through 7 days, 43% were stable through 10 days, and 39% were stable through 15 days. Moreover, stable units were more likely to remain stable in subsequent recording sessions (i.e., 89% of the neurons that were stable through four sessions remained stable on the fifth). Using both waveform and ISIH data instead of just waveforms improved performance by reducing the number of false positives. We also demonstrate that this method can be used to track neurons across days, even during adaptation to a visuomotor rotation. Identifying a stable subset of neurons should allow the study of long-term learning effects across days and has practical implications for pooling of behavioral data across days and for increasing the effectiveness of brain-machine interfaces.

Electrical activity and exocytotic correlates of biphasic insulin secretion from beta-cells of canine islets of Langerhans: contribution of tuning two modes of Ca2+ entry-dependent exocytosis to two modes of glucose-induced electrical activity.

Biphasic insulin secretion in response to glucose, consisting of a transient first phase followed by a progressive second phase, is well described in pancreatic islets. Using single canine beta-cells we have compared the time courses of electrical activity and insulin granule exocytosis to biphasic insulin secretion. Short trains of action potentials, similar those found during first phase insulin secretion, trigger phasic exocytosis from a small pool of insulin granules, likely an immediately releasable pool docked near voltage activated Ca(2+) channels. In contrast, plateau depolarizations to between -35 and -20 mV resembling those during second phase insulin secretion, trigger tonic exocytosis from a larger pool of insulin granules, likely a highly Ca(2+)-sensitive pool farther from Ca(2+) channels. Both phasic and tonic modes of exocytosis are enhanced by glucose, via its metabolism. Hence, in canine beta-cells two distinct components of exocytosis, tuned to two components of electrical activity, may contribute significantly to biphasic insulin secretion.

Phasic and tonic modes of depolarization-exocytosis coupling in beta-cells of porcine islets of Langerhans.

In response to depolarizations that open voltage dependent Ca2+ channels single porcine beta-cells display heterogeneous time courses of exocytosis. Some cells display phasic exocytosis that is triggered by individual or short burst of action potentials typically characteristic of glucose-induced electrical activity or brief voltage clamp depolarization. Other cells, singularly or additionally, display tonic exocytosis that (i) is triggered during prolonged (up to seconds-long) depolarizations to voltages (-30 to -20 mV), and (ii) coincides with rises in global cytosolic [Ca2+] >500 nM. We suggest that tonic exocytosis (i) likely results from a recently described pool of granules that is more Ca2+ sensitive and less co-localized with voltage-sensitive Ca2+ entry channels than that contributing to phasic exocytosis and (ii) helps tune exocytosis to glucose-induced electrical activity when the latter consists of spike activity followed by intervals of plateau depolarization to nearly -20 mV.

Ion channels underlying stimulus-exocytosis coupling and its cell-to-cell heterogeneity in beta-cells of transplantable porcine islets of Langerhans.

Given the growing interest in porcine islets as model tissue for studying the pathogenesis of human diabetes mellitus and its treatment by transplantation, we investigated stimulus-exocytosis coupling in single porcine beta-cells using patch clamp electrophysiology, Ca2+ imaging, capacitance tracking and amperometry. We establish that porcine beta-cells display several features prominently seen in beta-cells from human islets of Langerhans. These include: (i) wide heterogeneity of electrical responsiveness to glucose; (ii) dependence of action potential activity on voltage-dependent Na(+) as well as high voltage activated Ca2+ current; (iii) heterogeneity of time course of depolarization-evoked insulin granule exocytosis; and (iv) the dependence of vigorous single cell electrical activity and insulin granule exocytosis on the presence of agents that enhance cytosolic cAMP concentration. These findings promote the usefulness of porcine beta-cells as a model for studying beta-cell function in large mammals, including humans, as well as an appropriate source of tissue for xenotransplantation.

alpha-Latrotoxin increases spontaneous and depolarization-evoked exocytosis from pancreatic islet beta-cells.

alpha-Latrotoxin (alpha-LT), a potent excitatory neurotoxin, increases spontaneous, as well as action potential-evoked, quantal release at nerve terminals and increases hormone release from excitable endocrine cells. We have investigated the effects of alpha-LT on single human, mouse and canine beta-cells. In isolated and combined measurements, alpha-LT, at nanomolar concentrations, induces: (i) rises in cytosolic Ca(2+), into the micromolar range, that are dependent on extracellular Ca(2+); (ii) large conductance non-selective cation channels; and (iii) Ca(2+)-dependent insulin granule exocytosis, measured as increases in membrane capacitance and quantal release of preloaded serotonin. Furthermore, at picomolar concentrations, alpha-LT potentiates depolarization-induced exocytosis often without evidence of inducing channel activity or increasing cytosolic Ca(2+). These results strongly support the hypothesis that alpha-LT, after binding to specific receptors, has at least two complementary modes of action on excitable cells. (i) alpha-LT inserts into the plasma membrane to form Ca(2+) permeable channels and promote Ca(2+) entry thereby triggering Ca(2+)-dependent exocytosis in unstimulated cells. (ii) At lower concentrations, where its channel forming activity is hardly evident, alpha-LT augments depolarization-evoked exocytosis probably by second messenger-induced enhancement of the efficiency of the vesicle recruitment or vesicle fusion machinery. We suggest that both modes of action enhance exocytosis from a newly described highly Ca(2+)-sensitive pool of insulin granules activated by global cytosolic Ca(2+) concentrations in the range of approximately 1 microm.