Cortical stimulation mapping and Wada results demonstrate a normal variant of right hemisphere language organization.

PURPOSE: Exclusive right hemisphere language lateralization is rarely observed in the Wada angiography results of epilepsy surgery patients. Cortical stimulation mapping (CSM) is infrequently performed in such patients, as most undergo nondominant left hemisphere resections, which are presumed not to pose any risk to language. Early language reorganization is typically assumed in such individuals, taking left hemisphere epileptiform activity as confirmation of change resulting from a pathologic process. We present data from CSM and Wada studies demonstrating that right hemisphere language occurs in the absence of left hemisphere pathology, suggesting it can exist as a normal, but rare variant, in some individuals. Furthermore, these data confirm the Wada test findings of atypical dominance. METHODS: Cortical stimulation mapping data were examined for all right hemisphere surgical patients with right hemisphere speech at our center between 1974 and 2006. Of 1,209 interpretable Wada procedures, 89 patients (7.4%) had exclusive right hemisphere speech, and 21 (1.7%) of these patients underwent surgery involving the right hemisphere. Language site location was determined by examining intraoperative photographs, and site distribution was statistically compared to published findings from left hemisphere language dominant patients. KEY FINDINGS: Language cortex was identified in the right hemisphere during CSM for all patients with available data. All sites could be classified in superior or middle temporal gyri, inferior parietal lobe, or inferior frontal gyrus, all of which were common zones where language was identified in the left hemisphere dominant comparison sample. SIGNIFICANCE: Results suggest that the Wada procedure is a valid measure for identifying right hemisphere language processing without any false lateralization found in the patients mapped with CSM (i.e., a positive Wada is 100% sensitive for finding right hemisphere language sites), and that the distribution of language sites is consistent across right hemisphere and left hemisphere language dominant patients, supporting the theory that right hemisphere language can occur as a normal variant of language lateralization.

Individual variation in human motor-sensory (rolandic) cortex.

Eloquent cortex is generally identified using a variety of techniques including direct electrical stimulation to identify motor-sensory, language, and memory cortex and somatosensory evoked potentials to identify motor-sensory cortex. It is important that these areas of cortex be identified so as to prevent damage during the course of neurosurgical procedures. Seventy epilepsy patients undergoing evaluation for epilepsy surgery with chronically implanted subdural grids were retrospectively studied using both somatosensory evoked potentials and direct electrical stimulation. Direct electrical stimulation of motor-sensory cortex elicited responses over a larger area than did somatosensory evoked potentials. A great deal of individual variation was identified using both techniques. The results presented here support previous conclusions that the concept of homunculus somatotopy (point to point representation) of the motor-sensory cortex be abandoned and that of functional mosaicism of the motor-sensory cortex replace the earlier model. The individual variation found in the human motor-sensory cortex will require a continuation of "brain mapping" to identify eloquent cortex so that these vital areas will be spared during neocortical neurosurgical procedures.

Electrical stimulation of tooth pulp in humans. I. Relationships among physical stimulus intensities, psychological magnitude estimates and cerebral evoked potentials.

Brief electrical pulses were applied to the pulp of individual pre-molar teeth of 14 healthy, adult volunteers via wire electrodes implanted and sealed in dentine. The sensation threshold was estimated in each individual by the Two-Alternative Forced-Choice Staircase (2AFCS) method. Seven, 5 or 4 stimulus intensities were employed which were equally spaced in a logarithmic scale between 10 microA above threshold and 500 microA. Magnitude estimates of the subjective intensity of the sensation produced by individual dental excitations were obtained. Cerebral tooth pulp-evoked potentials were simultaneously recorded in 11 subjects. The growth of psychological sensory magnitude with increasing strength of electrical stimulus conformed to the general psychophysical power law. Individual power function exponents varied from 0.204 to 0.907 with a mean of 0.475 and a standard deviation of 0.190. The amplitude of TPEPs, measured between components N135 and P293, also was a power function of stimulus intensity. The exponents of individual TPEP amplitude-intensity functions ranged from 0.055 to 0.362 with a mean of 0.144 and a standard deviation of 0.100. These last exponents were substantially smaller than those describing the growth of psychological magnitude estimates. Neither magnitude estimation nor TPEP amplitude-intensity functions displayed abrupt changes in slope which might accompany transition from one operating sensory mechanism to another and/or changes in qualities of subjective sensations from 'innocuous' to 'uncomfortable' to 'painful.' The result of our psychophysical and electrophysiologic experiments indicate that: (1) albeit highly specialized both morphologically and functionally, human tooth pulp has certain fundamental properties in common with other sensory systems and (2) late midline TPEP components may provide measures of central events that, within a range of stimulus intensities, are associated with the perception of pain, but should not be looked upon as specific indicators of pain processes.

Electrical stimulation of tooth pulp in humans. II. Qualities of sensations.

Individual premolar teeth of 22 normal volunteers were stimulated via intradentinal electrodes using brief electrical pulses. Questionnaires were used to determine the qualities of sensations produced by this stimulation. Operationally defined 'innocuous' sensations predominated between 1 and 10 dB SL, and were absent above 30 dB SL. Similarly defined 'painful' sensations were observed throughout the range of suprathreshold intensities but were most common above 20 dB SL. These findings demonstrate that non-painful sensations can arise from electrical tooth pulp excitation in circumstances in which spread of the stimulating current to periodontal and gingival structures is most unlikely. Two interpretations of these results are considered: (1) that tooth pulp afferents may have some unspecified sensory function besides mediation of painful sensations and (2) that they may be specialized in the mediation of nociceptive impulses but may give rise to innocuous sensations under special circumstances.

Cortical stimulation mapping of language cortex by using a verb generation task: effects of learning and comparison to mapping based on object naming.

OBJECT: Cortical stimulation mapping has traditionally relied on disruption of object naming to define essential language areas. In this study, the authors reviewed the use of a different language task, verb generation, in mapping language. This task has greater use in brain imaging studies and may be used to test aspects of language different from those of object naming. METHODS: In 14 patients, cortical stimulation mapping performed using a verb generation task provided a map of language areas in the frontal and temporoparietal cortices. These verb generation maps often overlapped object naming ones and, in many patients, different areas of cortex were found to be involved in the two functions. In three patients, stimulation mapping was performed during the initial performance of the verb generation task and also during learned performance of the task. Parallel to findings of published neuroimaging studies, a larger area of stimulated cortex led to disruption of verb generation in response to stimulation during novel task performance than during learned performance. CONCLUSIONS: Results of cortical stimulation mapping closely resemble those of functional neuroimaging when both implement the verb generation task. The precise map of the temporoparietal language cortex depends on the task used for mapping.

Localization of language function in children: results of electrical stimulation mapping.

OBJECT: The authors examined the localization of language sites and the frequency of naming errors at these sites in a population of children undergoing electrical stimulation mapping during surgeries in which epileptic foci and dominant hemisphere neoplasms were resected. The frequency with which essential language sites were found (that is, "the frequency of language sites") in children was compared with that of a population of adults who had undergone this procedure, to assess the relationship of age to the distribution of essential areas for language. METHODS: The results of electrical stimulation mapping to determine sites of naming and speech arrest in 26 children ranging in ages from 4 to 16 years are presented in this report. Mapping was performed in the intraoperative setting in eight patients and in the extraoperative setting, by stimulation across a subdural grid, in 18 patients. The frequency and distribution of essential language areas were analyzed in populations of different ages and according to the method used to obtain the map. Considerable variability was found in the localization of language sites. When the language site distribution in pediatric patients was compared with the language site distribution found previously in a population of patients older than 16 years of age, a relative paucity of language sites was found in all perisylvian cortices in the younger age group. This relationship was also found within the group of patients 16 years of age and younger, when segregated into two groups: those patients 8 years of age or younger, and those patients between 9 and 16 years of age. These findings are relevant to theories of the intrahemispheric organization of the cortex devoted to language function. CONCLUSIONS: The differences found between groups of younger and older patients in the frequencies of sites where stimulation produces naming errors was identified suggests the possibility that, with advancing age, maturational processes contribute new foci of cortex essential for language.