Characterization of the mu rhythm during rapid eye movement sleep.

OBJECTIVE: The rolandic mu rhythm, a resting activity of somatosensory cortex, is a striking feature of the waking human electroencephalogram. This study will demonstrate that activity with identical features occurs during rapid eye movement (REM) sleep. METHODS: Eye and chin leads were added during prolonged closed circuit television (video) electroencephalographic (EEG) recording with scalp (12 patients) or subdural electrodes including 64 contract grids over the frontoparietal cortices (5 patients). Sleep staging was performed by reformatting into standard polysomnography montages (using two EEG channels, and eye and chin channels) and applying standard scoring criteria. The recordings were then reviewed using all EEG channels to assess rhythmic EEG activity by a reader blinded to the sleep staging. RESULTS: During scalp recordings, 7-10 Hz central rhythms were seen during wakefulness in 7 patients, with 6 of these also having similar rhythms during REM sleep. Similar activity was seen over somatosensory cortex during wakefulness and REM in all invasively recorded patients. This activity was blocked by contralateral body movement or contralateral somatosensory stimuli, even during REM sleep. It was absent in other sleep stages. CONCLUSIONS: This REM sleep activity recapitulates all the characteristics of the waking rolandic mu rhythm. This demonstrates functional similarity between the states of wakefulness and REM sleep.

Spatial spectral analysis of human electrocorticograms including the alpha and gamma bands.

Spatial spectral analysis is essential for deriving spatial patterns from simultaneous recordings of electrocorticograms (ECoG), in order to determine the optimal interval between electrodes in arrays, and to design spatial filters, particularly for extraction of information about the dynamics of human gamma activity. ECoG were recorded from up to 64 electrodes 0.5 mm apart in a linear array 3.2 cm long, which was placed on the exposed superior temporal gyrus or motor cortex of volunteers undergoing diagnostic surgery. Visual displays of multiple traces revealed broad spectrum oscillations in episodic bursts having a common aperiodic wave form with recurring patterns of spatial amplitude modulation (AM patterns) on selected portions of the array. The one-dimensional spatial spectrum of the human ECoG was calculated at successive time samples and averaged over periods of up to 20 s. Log power decreased monotonically with increasing log spatial frequency in cycles/mm (c/mm) to the noise level approximately 2 log units below maximal power at minimal frequency (0.039+/-0.002 c/mm). The inflection point at 0.40+/-0.05 c/mm specified an optimal value for a low pass spatial filter to remove noise, and an optimal interelectrode spacing of 1.25 mm to avoid undersampling and aliasing. An 8 x 8 array with that spacing would be 10 x 10 mm.

Excitotoxic swelling occurs in oxygen and glucose deprived human cortical slices.

The experimental evidence linking glutamate to ischemic neuronal injury is derived from in vitro or in vivo animal stroke models. We, therefore, developed an in vitro preparation to determine whether glutamate contributes to early neuronal swelling in oxygen and glucose deprived (OGD) human neocortical slices. In order to monitor neuronal swelling, we measured extracellular tissue resistance in brain slices by passing constant current pulses through two electrodes and recording the voltage drop between them. We verified that NMDA (30 microM) or OGD induced a rise in tissue resistance in rat neocortical slices. We then examined human neocortical slices from 11 patients undergoing resections for intractable epilepsy. Both the rodent and human neocortical slices swelled within 10 min of OGD. In both, the glutamate antagonist dizocilpine (MK-801) reduced the swelling. In the rats, MK-801 (5 microM) prolonged the latency to onset of neuronal swelling following OGD from 7.6 +/- 0.6 min (mean +/- S.E.M., n = 16) to 17.4 +/- 2.6 min (n = 6; p < 0.01). Other putative neuroprotective agents were much less effective in this paradigm. In the human slices, MK-801 again prolonged the latency to resistance increase from 8.6 +/- 0.4 min (n = 8) to 17.2 +/- 1.7 min (n = 9, p < 0.01). This is the direct demonstration that glutamate receptor activation leads to neuronal swelling in substrate deficient human brain. These results, which are similar to those obtained in the rodent brain slices, help validate the animal slices as appropriate models for the study of OGD in human brain.

Increased functional vascular response in the region of a glioma.

Functional imaging of a language task using positron emission tomography was performed as part of the preoperative assessment of a patient with a left supplementary motor area (SMA) tumor. Positron emission tomography scans were obtained during language tasks (verb generation and word reading of visually presented nouns) that normally lead to increased blood flow in the SMA relative to a control condition (visual fixation). In the patient, the normal SMA response was an order of magnitude larger in the region of the tumor. Other regions, such as left inferior frontal cortex and right cerebellum, showed equivalent activation in the patient and normal subjects. Histopathologic study revealed an anaplastic astrocytoma. Thus, this exaggerated vascular response to local neuronal activation occurred in the setting of a proliferation of glial cells. This is consistent with models of coupling of regional CBF and neuronal activity that implicate glia as the mediator between neurons and vasculature. The concept that tumoral disruption of normal vascular responses could, in some cases, potentially enhance rather than dampen the response is proposed.

Dysembryoplastic neuroepithelial tumor and oligodendroglioma: the diagnostic value of magnetic resonance spectroscopy. Case report and review of the literature.

Preoperative differentiation between dysembryoplastic neuroepithelial tumor (DNT) and low-grade glioma is often not possible. Dysembryoplastic neuroepithelial tumor is a recently described entity of uncertain origin; however, the diagnosis has important clinical implications. Clinical and radiological findings of DNT and low-grade glioma, especially oligodendroglioma, may be similar. Treatment options and prognosis differ significantly between these two lesions; consequently, accurate diagnosis is imperative. The authors describe two individuals who presented simultaneously at their institution: one patient with an oligodendroglioma and a second patient with DNT. The natural history, neurodiagnostic, and pathological features of each are reviewed with special emphasis on the potential utility of magnetic resonance spectroscopy in differentiating these lesions.

Localization of language cortices by functional MR imaging compared with intracarotid amobarbital hemispheric sedation.

OBJECTIVE: We undertook this study to investigate functional MR imaging as a new clinical method for determining hemispheric language dominance. Seven patients undergoing surgical evaluation for chronic intractable epilepsy were studied. Intracarotid amobarbital injection was also performed and the findings compared with the functional MR imaging results. CONCLUSION: Functional MR imaging studies enabled localization of the frontal and temporal lobe language cortices. The results of functional MR imaging and intracarotid amobarbital testing of hemispheric language dominance agreed in all seven patients, including two right-handed patients with right-hemisphere language dominance. These preliminary results show that functional MR imaging is an accurate noninvasive method of determining language dominance that may replace the amobarbital test for some purposes if confirmed by additional research.

Isolation and characterization of human malignant glioma cells from histologically normal brain.

Brain invasion prevents complete surgical extirpation of malignant gliomas; however, invasive cells from distant, histologically normal brain previously have not been isolated, cultured, and characterized. To evaluate invasive human malignant glioma cells, the authors established cultures from gross tumor and histologically normal brain. Three men and one woman, with a mean age of 67 years, underwent two frontal and two temporal lobectomies for tumors, which yielded specimens of both gross tumor and histologically normal brain. Each specimen was acquired a minimum of 4 cm from the gross tumor. The specimens were split: a portion was sent for neuropathological evaluation (three glioblastomas multiforme and one oligodendroglioma) and a portion was used to establish cell lines. Morphologically, the specimens of gross tumor and histologically normal brain were identical in three of the four cell culture pairs. Histochemical staining characteristics were consistent both within each pair and when compared with the specimens sent for neuropathological evaluation. Cultures demonstrated anchorage-independent growth in soft agarose and neoplastic karyotypes. Growth rates in culture were greater for histologically normal brain than for gross tumor in three of the four culture pairs. Although the observed increases in growth rates of histologically normal brain cultures do not correlate with in vivo behavior, these findings corroborate the previously reported stem cell potential of invasive glioma cells. Using the radial dish assay, no significant differences in motility between cultures of gross tumor and histologically normal brain were found. In summary, tumor cells were cultured from histologically normal brain acquired from a distance greater than 4 cm from the gross tumor, indicating the relative insensitivity of standard histopathological identification of invasive glioma cells (and hence the inadequacy of frozen-section evaluation of resection margins). Cell lines derived from gross tumor and histologically normal brain were usually histologically identical and demonstrated equivalent motility, but had different growth rates.

Tumors of Heschl's gyrus: report of two cases.

OBJECTIVE AND IMPORTANCE: The clinical presentation and treatment of patients with lesions involving Heschl's gyrus is reported. Intraoperative bipolar cortical stimulation mapping of Heschl's gyrus has not been previously reported. Only monopolar stimulation of this region (with potential electrical recruitment of large areas of surrounding cortex) has been undertaken. CLINICAL PRESENTATION: Two patients with intrinsic brain tumors located in Heschl's gyrus, in the hemisphere dominant for speech, presented with interictal or ictal auditory changes. INTERVENTION: Craniotomies were performed with the patients awake and with intraoperative bipolar cortical stimulation mapping of language cortex and of Heschl's gyrus. CONCLUSION: In contrast to previous studies using monopolar cortical stimulation, auditory changes were not elicited by stimulation. In one of the patients, a persistent interictal ringing sound stopped abruptly during lesion resection. Neither patient had essential temporal lobe language cortex near the lesion. Lesions in Heschl's gyrus can be identified by clinical presentation and magnetic resonance imaging. Based on topographic anatomy, cytoarchitecture, and functional mapping data, these lesions may be resectable without language or auditory mapping, although further experience will be necessary to confirm this observation.

Mitogens as motogens.

Numerous in vivo methodologies have documented the invasive behavior of glioma cells through normal brain parenchyma. Glioma cell locomotion has also been assessed with a number of in vitro assays including the Boyden chamber and other chemotaxis assays, colloidal gold cell tracking, analysis of migration of cells tumor cells from spheroids, confrontation cultures of glioma cells with aggregates of non-neoplastic tissue, time-lapse video microscopy, electron microscopic examination of the cytomorphologic correlates of cell motility, the radial dish assay, and quantitative enzyme immunoassay of proteins associated with invasion (e.g. laminin). Several of these techniques have been specifically modified to assess the effects of cytokines on glioma cell motility in vitro. Cytokines studied utilizing these methods include: epidermal growth factor (EGF), basic fibroblast growth factor (bFGF), the bb dimer of platelet-derived growth factor (PDGFbb), nerve growth factor (NGF), interleukin 2 (IL-2), transforming growth factors alpha and beta 1 (TGF alpha and TGFstraat1), and tumor necrosis factor alpha (TNF alpha). This review summarizes the investigational methods used to evaluate random and directional glioma cell motility and invasion in vivo and in vitro. The roles of specific mitogens as motogens, as evaluated with these methods are then presented.

Subtemporal transparahippocampal amygdalohippocampectomy for surgical treatment of mesial temporal lobe epilepsy. Technical note.

Amygdalohippocampectomy (AH) is an accepted surgical option for treatment of medically refractory mesial temporal lobe epilepsy. Operative approaches to the amygdala and hippocampus that previously have been reported include: the sylvian fissure, the superior temporal sulcus, the middle temporal gyrus, and the fusiform gyrus. Regardless of the approach, AH permits not only extirpation of an epileptogenic focus in the amygdala and anterior hippocampus, but interruption of pathways of seizure spread via the entorhinal cortex and the parahippocampal gyrus. The authors report a modification of a surgical technique for AH via the parahippocampal gyrus, in which excision is limited to the anterior hippocampus, amygdala and parahippocampal gyrus while preserving the fusiform gyrus and the rest of the temporal lobe. Because transparahippocampal AH avoids injury to the fusiform gyrus and the lateral temporal lobe, it can be performed without intracarotid sodium amobarbital testing of language dominance and language mapping. Thus the operation would be particularly suitable for pediatric patients in whom intraoperative language mapping before resection is difficult.

A new method of acrylic cranioplasty.

BACKGROUND: Previous acrylic cranioplasty techniques have relied on wire or suture fixation of the acrylic to the skull. A new methyl methacrylate cranioplasty technique, using acrylic with titanium plating, is described. METHODS: Titanium plates were bent into a "Z" shape and attached to the skull at the perimeter of the skull defect, extending into the defect. The acrylic was then poured into the defect and held in place during setting with a sheet of plastic. The plates are thereby embedded in the acrylic. RESULTS: Standard methyl methacrylate and titanium plates and screws were used to perform a new method of cranioplasty. CONCLUSIONS: A rigid, form-fitting, aesthetic construct can be easily and quickly created. This technique also offers the benefit of allowing secondary craniotomy, if necessary.

Preserved function in brain invaded by tumor.

OBJECTIVE: Intrinsic brain tumors can arise within regions of the cortex that are essential to language, motor, and somatosensory functions. Although it is commonly thought that such tumors can be safely resected, as long as the resection is limited to grossly abnormal cortex, functional mapping of the cerebral cortex during tumor resection does not support this contention. METHODS: We report our experience with 14 patients (9 men, 5 women; median age, 43 yr) with intrinsic brain tumors of varying degrees of malignancy (four glioblastomas multiforme, four anaplastic astrocytomas, two anaplastic oligodendrogliomas, one anaplastic mixed glioma, three gangliogliomas). Cortical mapping was performed either intraoperatively (n = 11) or extraoperatively via intracranial electrodes (n = 3). RESULTS: Tumors were found to grossly invade functioning cortices (frontal lobe language cortex, four tumors; temporal lobe language cortex, five tumors; motor cortex, four tumors; somatosensory cortex, one tumor). The gross invasion of functional cortex by tumor limited safe resection in all patients. Three patients experienced transient postoperative deficits caused by the proximity of the resection to functional cortex. One patient suffered a delayed postoperative hemorrhage, with resultant persistent motor aphasia. CONCLUSION: Intrinsic brain tumors grow by infiltration of normal brain. Consequently, brain that appears to be abnormal may remain functional, thus precluding safe tumor resection.

Large-dose propofol alone in adult epileptic patients: electrocorticographic results.

The primary objective of this study was to evaluate the electrophysiologic effects of large-dose propofol, used as the sole anesthetic in patients with epilepsy. Nine patients with medically intractable complex partial epilepsy undergoing a three-stage approach to the surgical management of epilepsy were recruited. State I involved placement of the intracranial electrode array, while Stage II consisted of extraoperative localization of the seizure focus. The patients were studied during induction of anesthesia for Stage III (removal of electrodes and resection of seizure focus). Unpremedicated patients were induced with a propofol infusion (0.5 mg.kg-1.min-1) until one of the following occurred: 1) electrical seizure activity, 2) burst suppression, or 3) total dose of 10 mg/mg. Electrocorticography (ECoG) was recorded continuously during this period. Two patients were excluded from the study after experiencing delayed awakening after the Stage I procedure. Both had received propofol along with other anesthetics. No ECoG evidence of seizure activity was detected in the seven patients completing the study. Burst suppression was attained in six patients using a mean dose of 5.7 mg/kg +/- 2.6. We conclude that large dose propofol alone does not trigger electrical epileptiform activity on the ECoG of seizure patients.

Early postoperative magnetic resonance imaging following nonneoplastic cortical resection.

Postcraniotomy residual tumor is often determined by magnetic resonance (MR) imaging. Magnetic resonance changes that occur in the postoperative setting must be defined to ensure both the optimum timing of postoperative image acquisition and the accurate assessment of images for residual tumor. Postoperative changes in nontumor parenchyma have previously been described for computerized tomography but not for MR imaging. In the present study, 11 patients without intracranial neoplastic disease (six females and five males with a median age of 36 years) submitted to MR imaging 17 to 28 hours after undergoing temporal lobectomies for epilepsy. Four of the operations were performed with the patients under general anesthesia and seven under local anesthesia. Postoperative MR images (T1-weighted, T1-weighted gadolinium enhanced, and T2-weighted) were reviewed. Extraaxial fluid, air, or blood was present in all cases. Enhancement of the resection bed parenchyma occurred in seven (64%) of 11 patients. In three of the remaining four patients, assessment of parenchymal enhancement was obscured by extraaxial fluid collections. Dural enhancement occurred adjacent to the resection site in all of the cases and remotely in 73%. Eight (73%) of 11 patients displayed enhancement of the pia-arachnoid of the ipsilateral cerebral convexity, two (18%) of the contralateral convexity, and four (36%) of the pia-arachnoid overlying the cerebellum. Contrary to previous reports, contrast enhancement of nonneoplastic human brain parenchyma can occur postoperatively within 17 hours. Benign parenchymal contrast enhancement is usually linear in appearance; nonneoplastic dural and leptomeningeal enhancement can occur both adjacent to and distant from the surgical site. Extraaxial fluid collections can hinder MR evaluation of the resection bed.

Intrasellar abscess following transsphenoidal surgery.

BACKGROUND: Intrasellar abscess following transsphenoidal surgery has been described only twice in the English language medical literature. Overall mortality associated with intrasellar abscesses is 51%, while mortality in reported cases not treated surgically is 100%. METHODS: Two cases of intrasellar abscess following uncomplicated transsphenoidal surgery for pituitary pathology are reported. The incidence, radiographic features, clinical presentations, and treatment of intrasellar abscesses are discussed. RESULTS: Both patients described underwent uncomplicated transsphenoidal procedures for treatment of a primary pituitary lesion. Neither developed postoperative CSF rhinorrhea, and initial recovery was uneventful. The first patient presented with new symptoms several weeks after transsphenoidal surgery; the second patient almost two years postoperatively. The first displayed signs of an expanding sellar mass, requiring transsphenoidal drainage and postoperative antibiotics. The second presented with recurrent meningitis without discernible CSF leak, and was treated with transnasal endoscopic drainage in conjunction with antibiotic therapy. CONCLUSIONS: The high mortality associated with intrasellar abscess mandates its inclusion in the differential diagnosis of patients presenting with symptoms of meningitis or an expanding sellar mass after transsphenoidal intervention. Although antibiotic therapy is an important adjunct, surgical drainage is required for definitive treatment.

Intraoperative transligamentous ultrasound in the evaluation of thoracic intraspinal disease. Technique.

STUDY DESIGN: Intraoperative transligamentous ultrasonography was used in a variety of different thoracic surgical procedures for spinal cord compression secondary to neoplastic disease. OBJECTIVES: The utility and practicality of intraoperative transligamentous ultrasonography for thoracic intraspinal disease was evaluated. SUMMARY OF BACKGROUND DATA: Because intraoperative localization and evaluation of targeted levels in the thoracic spine using radiographs is often difficult or imprecise, alternative or complementary techniques may be helpful. Intraoperative transligamentous ultrasound, performed before laminectomy, via an interlaminar window, has not been widely used for thoracic intraspinal pathology. METHODS: A standard 7.5-MHz hand-held probe, used in conjunction with a Codman OR 330 ultrasound machine, was used to evaluate the practicality of intraoperative transligamentous ultrasound in the thoracic spine. RESULTS: A clear sonographic window, permitting visualization of the spine and the intraspinal contents, can frequently be found. However, densely calcified ligamentum flavum or overlapping laminas do not allow effective insonation. Four illustrative cases are presented. CONCLUSIONS: Transligamentous ultrasound before laminectomy can be used for localization and evaluation of intraspinal disease in many patients. Overlapping laminas or calcified ligamentum flavum can impede adequate sonographic visualization, but in these cases adequate intraoperative transligamentous ultrasound evaluation is usually possible through a small laminotomy. Evaluation of intraspinal lesions and localization of the correct surgical level is facilitated by dynamic real time sonographic imaging.

Invading C6 glioma cells maintaining tumorigenicity.

To characterize rat glioma cell invasion, 2 x 10(6) fluorophore-labeled or transfection-labeled C6 rat glioma cells were implanted in the rat frontal lobe. Eighty percent of the rats implanted formed bulk tumors (3-4 mm in diameter). Two weeks after implantation, fluorescence microscopy revealed single tumor cells in sites over 16 mm from the bulk brain tumor. Tumor cells distant from the bulk tumor remained single without mass formation and invaded primarily along white matter tracts. Two weeks after tumor implantation, three cell lines were created from each brain by disaggregation and initiation in culture of 1) bulk tumor, 2) contralateral hemisphere, and 3) cerebellum; all disaggregated specimens generated viable cultures. Cells cultured from the contralateral hemisphere were morphologically indistinguishable from cells from the bulk tumor and from the original C6 cell line. Cells cultured from the cerebellum were morphologically quite distinct from the C6 cell line. Cells from disaggregated specimens obtained from the tumor, contralateral hemisphere, and cerebellum were implanted in the frontal lobe of naive rats to test tumorgenicity. Bulk tumor formed in 58% of the rats implanted with specimens from tumor, in 75% of the rats implanted with specimens from contralateral hemisphere, and in only 12.5% of the rats implanted with specimens from the cerebellar hemispheres. Experiments using C6 cells labeled by transfection with the p3' ss DNA vector prior to implantation confirmed that the cells cultured from the contralateral hemisphere were derived from the implanted C6 cells. Experiments with C6 cells anchored in agar served to verify that movement to the contralateral hemisphere was secondary to parenchymal invasion rather than dispersion in the cerebrospinal fluid.