Motor potentials of inferior orbicularis oculi muscle to transcranial magnetic stimulation. Comparison with responses to electrical peripheral stimulation of facial nerve

TMS-induced blinking assessed with high-speed video: optical disruption of visual perception

It is known that TMS can induce blinking, but it is unknown to what extent and at what time TMS-induced blinking can cover the pupil. We applied single-pulse TMS with a leftward and rightward monophasic current through a round coil over the occipital pole in 8 healthy subjects, using high-speed video to monitor left or right eye with a spatial resolution of 0.1 mm and a temporal resolution of 2 ms. We plotted eyelid position relative to upper and lower pupil borders as a function of time after TMS for each subject and current direction. We found 2 blinks in every subject, an isolated late blink with one current direction and a superimposed early and late blink with the other current direction, in accordance with our previously reported association between a leftward and rightward lower coil rim current and an early blink in right and left eye, respectively. Blink extent varied, but 4 subjects showed total pupil covering with both current directions. Blink timing varied, but pupil covering was initiated as early as 32 ms after TMS and pupil uncovering was completed as late as 200 ms after TMS. We found no saccades. We conclude that TMS can cause an important optical disruption of visual perception.

Intraoperative facial motor evoked potential monitoring with transcranial electrical stimulation during skull base surgery

OBJECTIVE

To address the limitations of standard electromyography (EMG) facial nerve monitoring techniques by exploring the novel application of multi-pulse transcranial electrical stimulation (mpTES) to myogenic facial motor evoked potential (MEP) monitoring.

METHODS

In 76 patients undergoing skull base surgery, mpTES was delivered through electrodes 1cm anterior to C1 and C2 (M1-M2), C3 and C4 (M3-M4) or C3 or C4 and Cz (M3/M4-Mz), with the anode contralateral to the operative side. Facial MEPs were monitored from the orbicularis oris muscle on the operative side. Distal facial nerve excitation was excluded by the absence of single pulse responses and by onset latency consistent with a central origin.

RESULTS

M3/M4-Mz mpTES (n=50) reliably produced facial MEPs while M1-M2 (n=18) or M3-M4 (n=8) stimulation produced 6 technical failures. Facial MEPs could be successfully monitored in 21 of 22 patients whose proximal facial nerves were inaccessible to direct stimulation. Using 50, 35 and 0% of baseline amplitude criteria, significant facial deficits were predicted with a sensitivity/specificity of 1.00/0.88, 0.91/0.97 and 0.64/1.00, respectively.

CONCLUSIONS

Facial MEPs can provide an ongoing surgeon-independent assessment of facial nerve function and predict facial nerve outcome with sufficiently useful accuracy.

SIGNIFICANCE

This method substantially improves facial nerve monitoring during skull base surgery.

Significance of coil orientation for motor evoked potentials from nasalis muscle elicited by transcranial magnetic stimulation

OBJECTIVE

In transcranial magnetic stimulation (TMS) of the motor cortex, the optimal orientation of the coil on the scalp is dependent on the muscle under investigation, but not yet known for facial muscles.

METHODS

Using a figure-of-eight coil, we compared TMS induced motor evoked potentials (MEPs) from eight different coil orientations when recording from ipsi- and contralateral nasalis muscle.

RESULTS

The MEPs from nasalis muscle revealed three components: The major ipsi- and contra-lateral middle latency responses of approximately 10 ms onset latency proved entirely dependent on voluntary pre-innervation. They were most easily obtained from a coil orientation with posterior inducing current direction, and in this respect resembled the intrinsic hand rather than the masseter muscles. Early short duration responses of around 6 ms onset latency were best elicited with an antero-lateral current direction and not pre-innervation dependent, and therefore most probably due to stimulation of the nerve roots. Late responses (>18 ms) could inconsistently be elicited with posterior coil orientations in pre-innervated condition.

CONCLUSIONS

By using the appropriate coil orientation and both conditions relaxed and pre-innervated, cortically evoked MEP responses from nasalis muscle can reliably be separated from peripheral and reflex components and also from cross talk of masseter muscle activation.

Interference with vision by TMS over the occipital pole: a fourth period

We investigated the effect of single-pulse transcranial magnetic stimulation (TMS) over the occipital pole on a forced-choice visual letter-identification task. Magnetic stimuli were applied on the midline but with the initial current directed pseudorandomly toward either left or right hemisphere; visual stimuli were presented randomly in either left or right hemifield; magnetic-visual stimulus onset asynchrony varied randomly between 12 values: -500 ms and from -50 ms to +50 ms in 10 ms steps. The data revealed the existence of a hitherto unknown fourth task-interfering TMS effect that was maximal at -10 ms and specific for magnetic stimulus polarity and visual stimulus location. This -10 ms effect cannot be explained by reflex blinking (as the -50 ms effect can) and direct disruption of letter-induced activity (as the +20 ms and +100 ms effects can), but it could be explained by direct disruption of pre-letter activity or indirect disruption of letter-induced activity.

Cortical representation of the orbicularis oculi muscle as assessed by transcranial magnetic stimulation (TMS)

OBJECTIVES

To analyze characteristic features and details on motor-evoked potentials (MEPs) of the orbicularis oculi muscle resulting from cortical transcranial magnetic stimulation (TMS) in normal subjects as a basis for further investigations on motorcortical representation in patients presenting with facial nerve diseases.

STUDY DESIGN

MEPs of the orbicularis oculi muscle resulting from focal cortical TMS with a figure-8-shaped coil were investigated in 17 healthy subjects with special regard to amplitude and onset latency as a function of the coil position on the head surface along the interaural line and in the anterior-posterior direction. The results were then compared with our data on lower-lip mimetic muscles and on the frontalis muscle obtained in previous studies.

RESULTS

Bilateral reproducible responses could be observed at coil positions varying from 1 to 13 cm lateral to the vertex. During moderate muscle activation, maximum responses (mean amplitude 0.75 +/- 0.44 mV contralateral, 0.74 +/- 0.36 mV ipsilateral) were obtained at a mean stimulus position of 8.6 +/- 1.6 cm lateral and 2.0 +/- 2.2 cm anterior to the vertex for contralateral responses, and of 8.6 +/- 2.0 cm lateral and 2.8 +/- 2.4 cm anterior to the vertex for ipsilateral responses, respectively. Voluntary muscle activation by forced eye-closure was associated with a further increase in mean amplitudes. At rest, bilateral responses could be elicited in 15 subjects (88.2%). During moderate muscle activation, the shortest mean onset latencies were obtained at the optimum stimulus position on the interaural line, both for contralateral (10.2 +/- 1.3 ms) and ipsilateral (10.6 +/- 1.5 ms) MEPs. Comparing our data on the orbicularis oculi muscle with those obtained on lower-lip muscles and on the frontalis muscle, there was a considerable overlap of coil positions from which reproducible MEPs could be elicited in all three groups of mimetic muscles, but with the orbicularis oculi area being placed between forehead and lower-lip motorcortical areas.

CONCLUSIONS

A statistically significant separation of the cortical representation areas of forehead, orbicularis oris, and lower-lip mimetic muscles is possible by focal cortical TMS reflecting a kind of somatotopic organization of the face-associated motorcortex. Compared with the results on lower-lip and forehead muscles, orbicularis oculi muscle responses show characteristics of both.

Intracortical inhibition and facilitation in human facial motor area: difference between upper and lower facial area

OBJECTIVE

To investigate the intracortical inhibitory and excitatory systems in the motor cortical representation of upper and lower facial muscles.

METHODS

Paired-pulse transcranial magnetic stimulation (TMS) was applied to 7 healthy volunteers, with the interstimulus interval (ISI) between the conditioning stimulus (CS) and test stimulus, varied from 1 to 20 ms. CS was set at 90% of motor threshold. Muscle evoked potentials (MEPs) were recorded from first dorsal interosseus (FDI), orbicularis oculi (o. oculi) and mentalis muscles.

RESULT

TMS evoked MEPs in o. oculi on both ipsi- and contralateral sides in all subjects. In the paired-pulse study, MEP amplitude in the mentalis decreased at short ISIs of 1-3 ms, followed by increases at 12-20 ms. These effects were similar to those in the FDI. O. oculi did not show a distinct inhibitory period at short ISIs and facilitation at long ISIs was detected but was significantly less than in FDI and mentalis. In o. oculi, there was no significant difference between the effects of ipsilateral and contralateral CS on the MEPs.

CONCLUSION

The bi-hemispheric control of volitional movement and the modulation from brainstem projections appear to markedly influence intracortical inhibitory and excitatory systems in the motor cortical representation of o. oculi.

Cricopharyngeal sphincter muscle responses to transcranial magnetic stimulation in normal subjects and in patients with dysphagia

OBJECTIVE

Cricopharyngeal (CP) muscle of the upper oesophageal sphincter (UES) has a significant role in the pharyngo-esophageal phase of deglutition. The linkage between the CP muscle of UES and the motor cortex has not been previously studied electrophysiologically in healthy humans and in patients with neurogenic dysphagia.

METHODS

Needle recordings of EMG responses were carried out from the CP sphincter muscle following transcranial magnetic stimulation (TMS) over the vertex around the Cz electrode position (cortical MEP), and on the parieto-occipital skull and the occiput ipsilaterally (peripheral MEP) in 14 healthy control subjects and in 26 patients with and without neurogenic dysphagia. Needle recordings obtained from the cricothyroid muscle of the larynx were also evaluated in six healthy subjects.

RESULTS

The cortical motor latency of CP sphincter muscle was 10.7+/-0.5 ms with an amplitude of 0.8+/-0.2 mV in healthy subjects. Both the latency and amplitude of CP-MEP were facilitated during swallowing. The peripheral MEP of the CP muscle was very stable in all normal subjects (5.1+/-0.3 ms; 1.3+/-0.3 mV) and swallowing did not influence these parameters. The cortically elicited CP-MEP was significantly longer than the cortical MEPs obtained from the cricothyroid muscle of the larynx. In 10 dysphagic patients with corticobulbar tract involvement (6 ALS and 4 pseudobulbar palsy) and with pathologic and hyperreflexic EMG of the CP-sphincter muscle, the cortical MEP of CP muscle of the upper esophageal sphincter could not be elicited, although the peripheral CP-MEPs were obtained. TMS never produced a swallowing movement in neither healthy subjects nor patients.

CONCLUSION

The CP muscle of the upper esophageal sphincter can produce MEPs by cortical TMS and by stimulation at the root/nerve levels of vagus nerve. The MEP latency values and central motor delay suggest that there is an oligosynaptic corticobulbar pathway to the motoneurons of CP muscles. When the pathway is affected by a pathology (i.e. ALS or pseudobulbar palsy) the CP sphincter becomes hyperreflexic due to disinhibition and the cortical MEP of the CP muscle disappears due to degeneration of the corticobulbar pathway. These mechanisms appear to be responsible for the pathogenesis of dysphagia.

A simple method for recording motor evoked potentials of lingual muscles to transcranial magnetic and peripheral electrical stimulation

Motor evoked potentials were recorded from lingual muscles by means of clip electrodes applied on the lateral side of the tongue, following transcranial magnetic stimulation and peripheral electrical stimulation of the 12th cranial nerve at the mandible jaw. Using a circular coil, the stimulation of the cerebral cortex elicited a response of about 8 ms: its amplitude was higher in the right tongue placing the coil over the contralateral hemisphere, 4 cm from the vertex, with coil currents flowing counterclockwise. Coil position and current flow direction did not significantly modify the characteristics of responses recorded from the left side. The separate stimulation of either hemisphere was better obtained using an 8-shaped coil. The latency of the motor response measured 7.7-8.0 ms, the amplitude was greater on stimulation of the contralateral than the ipsilateral hemisphere and was larger recording from the right (3.3 +/- 1.1 mV) than from the left (1.2 +/- 0.7 mV) side. Positioning the circular coil over the parieto-occipital skull, a response of 4.1 +/- 0.3 ms was obtained, reflecting the intracranial activation of the hypoglossal nerve. The peripheral stimulation at the mandible elicited a response of 3.2 +/- 0.5 ms. The method described appears simple and reliable, potentially helpful in clinical practice.

A stimulator with wireless power and signal transmission for implantation in animal experiments and other applications

Functional electrical stimulation in alert experimental animals is often hampered, as free mobility of the animals is limited by the leads. On the other hand, portable devices carrying the power supply are not always accepted by the animal. For wireless transmission of power and stimulus code a system designed for implantation is described below. The power for the implant is supplied inductively by a rotating magnetic field. The stimulation signal is radio-transmitted by FM in the 140 MHz range and processed by the implant. Finally, a current source is driven for electrical stimulation. The present design is intended to be used for electrical cochlear stimulation. However, the circuit can also be used for other types of functional electrical stimulation.

Cortico-bulbar fibers to orofacial muscles: recordings with enoral surface electrodes

A new recording technique was developed to eliminate current problems on recording transcranial evoked facial muscle responses. A fork-shaped device equipped with 2 pairs of Ag/AgCl-electrodes was inserted enorally at the buccinator muscle level. Advantages offered by this method comprise clearly defined negative deflection of the compound muscle action potential, lack of relevant volume conduction from adjacent muscles, reliability of amplitude criteria, absence of interfering stimulus artifacts, easy achievement of preactivation, and noninvasive recording by surface electrodes. In 43 healthy subjects transcranial magnetic stimulation evoked contralateral responses at a mean latency and mean amplitude of 10.3 +/- 1.1 ms and 1.6 +/- 1.1 mV, respectively on the right side of the face and of 9.9 +/- 1.0 ms and 1.6 +/- 1.1 mV, on the left side of the face. Ipsilateral cortical evoked responses were observed in 29 and 25 subjects (left and right side of the face) at a mean latency and amplitude of 10.7 +/- 2.5 ms and 0.8 +/- 0.5 mV, respectively on the left side of face and of 11.9 +/- 3.2 ms and 1.1 +/- 1.2 mV, on the right side of face. No responses were obtained in 2 and 4 subjects (left and right side of the face), and could not be assessed due to simultaneous facial nerve stimulation in 12 and 14 subjects (left and right side of the face).

Responses in neck and facial muscles to sudden free fall and a startling auditory stimulus

EMG responses elicited by sudden onset of free fall and a startling auditory stimulus were investigated in healthy subjects while lying on a couch with their eyes closed. Muscle responses were recorded from masseter (V cranial nerve), orbicularis oculi and mentalis (VII nerve) and sternomastoid and trapezoid (XI nerve). A similar sequence of muscle activation and absolute latencies occurred in response to both stimulus modalities, consisting of a blink (30 msec) followed simultaneously by mentalis, sternomastoid and trapezoid (55 msec). Masseter could either be simultaneously activated with the latter muscles or follow after a delay of 10-20 msec. A patient with bilateral cochleo-vestibular nerve section had responses at comparable latencies in the free fall experiment. The similarities between the reaction to free fall and a startling auditory stimulus indicate that the early response to free fall constitutes a startle and that various stimuli converge onto a common response generator. The latency pattern of neck and facial muscles does not follow a sequence of innervation with increasing segmental distance from a single centre. Therefore, our data do not support the concept that the startle response is produced by a caudally and rostrally spreading volley from a putative pontomedullary centre. It is suggested that the startle response is a polysynaptically generated patterned muscle activation.

Origin of the facial long latency responses elicited by magnetic stimulation

With magnetic stimulation (MS) it is possible to elicit bilateral long latency facial motor responses (LLRs). Due to a relatively wide magnetic field, the site of neural activation may take place in many different structures. The purpose of this study was to determine the site of origin of facial LLRs. The motor long latency responses were recorded bilaterally on the naso-labial folds (NLFs) with reference electrodes on the nose, and on some subjects also with reference electrodes on the chin. The stimulating coil was placed in the right parietal area. LLRs obtained with MS were compared to LLRs elicited electrically at the right stylomastoid foramen, supraorbital foramen, as well as cutaneous sensory area V1 of the trigeminal nerve. In addition, right sided high intensity electrical stimuli, paired magnetic stimulation and electrical stimulation with interstimulus intervals ranging from 0 to 80 msec were also applied for comparison. LLRs recorded with reference to the nose were always elicitable with MS as well as with the other stimulation procedures. The responses elicited with MS did not differ from those elicited electrically at various extracranial stimulation sites. With paired stimuli the second LLRs were inhibited by the preceding stimulation, whether given magnetically or electrically. In subjects with elicitable LLRs with chin references, the responses were always bilateral. Based on the similar characteristics with extracranial electrical stimuli, bilateral distribution of the responses, and inhibition of the second response with paired stimuli, it is concluded that the neural origin of LLRs to MS is in the extracranial trigeminal or facial nerve branches.