Electrical Stimulation Mapping of the Brain: Basic Principles and Emerging Alternatives

Awake glioma surgery: technical evolution and nuances

INTRODUCTION

Multiple studies have demonstrated that improved extent of resection is associated with longer overall survival for patients with both high and low grade glioma. Awake craniotomy was developed as a technique for maximizing resection whilst preserving neurological function.

METHODS

We performed a comprehensive review of the literature describing the history, indications, techniques and outcomes of awake craniotomy for patients with glioma.

RESULTS

The technique of awake craniotomy evolved to become an essential tool for resection of glioma. Many perceived contraindications can now be managed. We describe in detail our preferred technique, the testing paradigms utilized, and critically review the literature regarding functional and oncological outcome.

CONCLUSIONS

Awake craniotomy with mapping has become the gold standard for safely maximizing extent of resection for tumor in or near eloquent brain. Cortical and subcortical mapping methods have been refined and the technique is associated with an extremely low rate of complications.

Novel Use of Stimulating Fence-Post Technique for Functional Mapping of Subcortical White Matter During Tumor Resection: A Technical Case Series

Background

Maximal safe resection remains a key principle in infiltrating glioma management. Stimulation mapping is a key adjunct for minimizing functional morbidity while “fence-post” procedures use catheters or dye to mark the tumor border at the start of the procedure prior to brain shift.

Objective

To report a novel technique using stereotactically placed electrodes to guide tumor resection near critical descending subcortical fibers.

Methods

Navigated electrodes were placed prior to tumor resection along the deep margin bordering presumed eloquent tracts. Stimulation was administered through these depth electrodes for subcortical motor and language mapping.

Results

Twelve patients were included in this preliminary technical report. Seven patients (7/12, 58%) were in asleep cases, while the other 5 cases (5/12, 42%) were performed awake. Mapping of motor fibers was performed in 8 cases, and language mapping was done in 1 case. In 3 cases, both motor and language mapping were performed using the same depth electrode spanning corticospinal tract and the arcuate fasciculus.

Conclusion

Stereotactic depth electrode placement coupled with stimulation mapping of white matter tracts can be used concomitantly to demarcate the border between deep tumor margins and eloquent brain, thus helping to maximize extent of resection while minimizing functional morbidity.

Acute Effects and the Dreamy State Evoked by Deep Brain Electrical Stimulation of the Amygdala: Associations of the Amygdala in Human Dreaming, Consciousness, Emotions, and Creativity

Accurate localization of complex human experiences such as emotions, dreaming, creativity, and consciousness to specific cerebral structures or neural networks has remained elusive despite technological advances. We report the use of acute deep brain stimulation (DBS) to evoke behavioral and emotional effects by applying electrical stimulation (ES) at various voltage strengths to the basolateral and central subnuclei of the amygdala in addition to the head of hippocampus (HC) for two subjects with medically refractory post-traumatic stress disorder (PTSD). Our results suggest that the amygdala could be a node in a neural network responsible for the generation of complex vivid mental imagery and integrated sensory experiences similar to John Hughlings Jackson's "dreamy state" and "double consciousness," which have been classically associated with temporal lobe epilepsy during uncinate seizures. That we were able to elicit similar vivid, dynamic, complex, bizarre, and original mental imagery with ES in non-epileptic subjects suggests that Jackson's seizure related "dreamy state" and "double consciousness" may arise from heightened innate brain mechanisms with the amygdala acting as a node in the neural network responsible for physiologic dreaming and creative functions. Furthermore, our subjects experienced different emotions with different stimulation strengths at various electrode contacts. Our results suggest that higher voltage stimulation of the amygdala and HC at 4-5 V leads to predominantly negative responses and 2-4 V stimulation showed inversely coupled positive and negative responses of the amygdala in either hemisphere which may imply hemispheric dominance of emotional valences without relation to handedness. Due to the unique and complex responses dependent on location and strength of stimulation, we advise that all patients receiving DBS of the amygdala undergo acute stimulation mapping in a monitored setting before selecting therapeutic parameters for chronic stimulation.

Detection of after-discharges during intraoperative functional brain mapping in awake brain tumor surgery using a novel high-density circular grid

OBJECTIVE

To evaluate intraoperative use of a novel high-density circular grid in detecting after-discharges (AD) on electrocorticography (ECoG) during functional brain mapping (FBM).

METHODS

FBM during glioma surgery (10/2016 to 5/2019) recorded ADs using a 22-channel circular grid compared to conventional strip electrodes. ADs were analyzed for detection, duration, amplitude, morphology, histology, direction, and clinical signs.

RESULTS

Thirty-two patients (mean age 54.2 years; r = 30-75) with glioma (WHO grade II-IV; 20 grade IV) had surgery. ADs during FBM were more likely in patients with wild-type as opposed to IDH-1 mutants (p < 0.0001) using more contacts compared with linear strip electrodes (p = 0.0001). More sensors tended to be involved in ADs detected by the circular grid vs strips (6.61 vs 3.43; p = 0.16) at lower stimulus intensity (3.14 mA vs 4.13 mA; p = 0.09). No difference in the number of cortical stimulations before resection was present (38.9 mA vs 47.9 mA; p = 0.26). ADs longer than 10 seconds were 32.5 seconds (circular grid) vs 58.4 (strips) (p = 0.12).

CONCLUSIONS

High-density circular grids detect ADs in 360 degrees during FBM for glioma resection. Provocation of ADs was more likely in patients with wild-type than IDH-1 mutation.

SIGNIFICANCE

Circular grids offer high-resolution ECoG during intraoperative FBM for detection of ADs.

Functional Ultrasound (fUS) During Awake Brain Surgery: The Clinical Potential of Intra-Operative Functional and Vascular Brain Mapping

Background and Purpose

Oncological neurosurgery relies heavily on making continuous, intra-operative tumor-brain delineations based on image-guidance. Limitations of currently available imaging techniques call for the development of real-time image-guided resection tools, which allow for reliable functional and anatomical information in an intra-operative setting. Functional ultrasound (fUS), is a new mobile neuro-imaging tool with unprecedented spatiotemporal resolution, which allows for the detection of small changes in blood dynamics that reflect changes in metabolic activity of activated neurons through neurovascular coupling. We have applied fUS during conventional awake brain surgery to determine its clinical potential for both intra-operative functional and vascular brain mapping, with the ultimate aim of achieving maximum safe tumor resection.

Methods

During awake brain surgery, fUS was used to image tumor vasculature and task-evoked brain activation with electrocortical stimulation mapping (ESM) as a gold standard. For functional imaging, patients were presented with motor, language or visual tasks, while the probe was placed over (ESM-defined) functional brain areas. For tumor vascular imaging, tumor tissue (pre-resection) and tumor resection cavity (post-resection) were imaged by moving the hand-held probe along a continuous trajectory over the regions of interest.

Results

A total of 10 patients were included, with predominantly intra-parenchymal frontal and temporal lobe tumors of both low and higher histopathological grades. fUS was able to detect (ESM-defined) functional areas deep inside the brain for a range of functional tasks including language processing. Brain tissue could be imaged at a spatial and temporal resolution of 300 μm and 1.5-2.0 ms respectively, revealing real-time tumor-specific, and healthy vascular characteristics.

Conclusion

The current study presents the potential of applying fUS during awake brain surgery. We illustrate the relevance of fUS for awake brain surgery based on its ability to capture both task-evoked functional cortical responses as well as differences in vascular characteristics between tumor and healthy tissue. As current neurosurgical practice is still pre-dominantly leaning on inherently limited pre-operative imaging techniques for tumor resection-guidance, fUS enters the scene as a promising alternative that is both anatomically and physiologically informative.

Human brain function and brain-computer interfaces

Human brain function research has evolved dramatically in the last decades. In this chapter the role of modern methods of recording brain activity in understanding human brain function is explained. Current knowledge of brain function relevant to brain-computer interface (BCI) research is detailed, with an emphasis on the motor system which provides an exceptional level of detail to decoding of intended or attempted movements in paralyzed beneficiaries of BCI technology and translation to computer-mediated actions. BCI technologies that stand to benefit the most of the detailed organization of the human cortex are, and for the foreseeable future are likely to be, reliant on intracranial electrodes. These evolving technologies are expected to enable severely paralyzed people to regain the faculty of movement and speech in the coming decades.

Novel diffusion tractography methodology using Kalman filter prediction to improve preoperative benefit-risk analysis in pediatric epilepsy surgery

OBJECTIVE

In this study the authors investigated the clinical reliability of diffusion weighted imaging maximum a posteriori probability (DWI-MAP) analysis with Kalman filter prediction in pediatric epilepsy surgery. This approach can yield a suggested resection margin as a dynamic variable based on preoperative DWI-MAP pathways. The authors sought to determine how well the suggested margin would have maximized occurrence of postoperative seizure freedom (benefit) and minimized occurrence of postoperative neurological deficits (risk).

METHODS

The study included 77 pediatric patients with drug-resistant focal epilepsy (age 10.0 ± 4.9 years) who underwent resection of their presumed epileptogenic zone. In preoperative DWI tractography from the resected hemisphere, 9 axonal pathways, Ci=1-9, were identified using DWI-MAP as follows: C1-3 supporting face, hand, and leg motor areas; C4 connecting Broca's and Wernicke's areas; C5-8 connecting Broca's, Wernicke's, parietal, and premotor areas; and C9 connecting the occipital lobe and lateral geniculate nucleus. For each Ci, the resection margin, di, was measured by the minimal Euclidean distance between the voxels of Ci and the resection boundary determined by spatially coregistered postoperative MRI. If Ci was resected, di was assumed to be negative (calculated as -1 × average Euclidean distance between every voxel inside the resected Ci volume, ri). Kalman filter prediction was then used to estimate an optimal resection margin, d*i, to balance benefit and risk by approximating the relationship between di and ri. Finally, the authors defined the preservation zone of Ci that can balance the probability of benefit and risk by expanding the cortical area of Ci up to d*i on the 3D cortical surface.

RESULTS

In the whole group (n = 77), nonresection of the preoperative preservation zone (i.e., actual resection margin d*i greater than the Kalman filter-defined d*i) accurately predicted the absence of postoperative motor (d*1-3: 0.93 at seizure-free probability of 0.80), language (d*4-8: 0.91 at seizure-free probability of 0.81), and visual deficits (d*9: 0.90 at seizure-free probability of 0.75), suggesting that the preservation of preoperative Ci within d*i supports a balance between postoperative functional deficit and seizure freedom. The subsequent subgroup analyses found that preservation of preoperative Ci =1-4,9 within d*i =1-4,9 may provide accurate deficit predictions independent of age and seizure frequency, suggesting that the DWI-based surgical margin can be effective for surgical planning even in young children and across a range of epilepsy severity.

CONCLUSIONS

Integrating DWI-MAP analysis with Kalman filter prediction may help guide epilepsy surgery by visualizing the margins of the eloquent white matter pathways to be preserved.

Roberts Bartholow: the progenitor of human cortical stimulation and his contentious experiment

Roberts Bartholow, a physician, born and raised in Maryland, was a surgeon and Professor in Medicine who had previously served the Union during the Civil War. His interest in scientific research drove him to perform the first experiment that tested the excitability of the human brain cortex. His historical experiment on one of his patients, Mary Rafferty, with a cancerous ulcer on the skull, was one of his great accomplishments. His inference from this experiment and proposed scientific theory of cortical excitation and localization in humans was one of the most critically acclaimed topics in the medical community, which attracted the highest commendation for the unique discovery as well as criticism for possible ethical violations. Despite that criticism, his theory and methods of cortical localization are the cornerstone of modern brain mapping and have, in turn, led to countless medical innovations.

Memory and the developing brain: From description to explanation with innovation in methods

Recent advances in human cognitive neuroscience show great promise in extending our understanding of the neural basis of memory development. We briefly review the current state of knowledge, highlighting that most work has focused on describing the neural correlates of memory in cross-sectional studies. We then delineate three examples of the application of innovative methods in addressing questions that go beyond description, towards a mechanistic understanding of memory development. First, structural brain imaging and the harmonization of measurements across laboratories may uncover ways in which the maturation of the brain constrains the development of specific aspects of memory. Second, longitudinal designs and sophisticated modeling of the data may identify age-driven changes and the factors that determine individual developmental trajectories. Third, recording memory-related activity directly from the developing brain presents an unprecedented opportunity to examine how distinct brain structures support memory in real time. Finally, the growing prevalence of data sharing offers additional means to tackle questions that demand large-scale datasets, ambitious designs, and access to rare samples. We propose that the use of such innovative methods will move our understanding of memory development from a focus on describing trends to explaining the causal factors that shape behavior.

Monopolar 250-500 Hz language mapping: Results of 41 patients

•

Monopolar mapping is effective for cortical and subcortical language areas.

•

250–500 Hz stimulation parameters are adequate and safe for speech testing.

•

It may improve resection rate of infiltrating tumor areas involving the speech area.

Objectives

To determine whether high-frequency 250–500 Hz monopolar stimulation is effective for mapping cortical and subcortical language structures during brain tumor resection.

Methods

Using high-frequency monopolar stimulation, we mapped the speech areas of 41 awake patients undergoing brain tumor resection in the dominant hemisphere, subject to risk of lesions in the cortical and subcortical speech tracts. Patients were tested for object naming, semantic and other language tasks.

Results

Mapping was positive in 22 out of 41 patients. Nine patients presented clinical worsening immediately after surgery. Only one patient did not recover after the 30-day follow-up. Nineteen patients showed negative mapping for language tracts, none of whom exhibited worsening of symptoms at the final evaluation. The applied method showed 89% sensitivity and 56% specificity rates.

Conclusions

The applied method was effective in identifying cortical and subcortical speech areas during the surgical resection of brain tumors.

Significance

Determining whether monopolar high-frequency stimulation is effective for language mapping is important, since it may be very effective in infiltrating tumor areas and nearby edema region.

Passive functional mapping of receptive language areas using electrocorticographic signals

OBJECTIVE

To validate the use of passive functional mapping using electrocorticographic (ECoG) broadband gamma signals for identifying receptive language cortex.

METHODS

We mapped language function in 23 patients using ECoG and using electrical cortical stimulation (ECS) in a subset of 15 subjects.

RESULTS

The qualitative comparison between cortical sites identified by ECoG and ECS show a high concordance. A quantitative comparison indicates a high level of sensitivity (95%) and a lower level of specificity (59%). Detailed analysis reveals that 82% of all cortical sites identified by ECoG were within one contact of a site identified by ECS.

CONCLUSIONS

These results show that passive functional mapping reliably localizes receptive language areas, and that there is a substantial concordance between the ECoG- and ECS-based methods. They also point to a more refined understanding of the differences between ECoG- and ECS-based mappings. This refined understanding helps to clarify the instances in which the two methods disagree and can explain why neurosurgical practice has established the concept of a "safety margin."

SIGNIFICANCE

Passive functional mapping using ECoG signals provides a fast, robust, and reliable method for identifying receptive language areas without many of the risks and limitations associated with ECS.