Speech activation of language dominant hemisphere:

Beyond the Wada: An updated approach to pre-surgical language and memory testing: An updated review of available evaluation techniques and recommended workflow to limit Wada test use to essential clinical cases

The Intracarotid amobarbital test (IAT), also called Wada test, is considered the "gold standard" for lateralizing language dominance in the pre-surgical evaluation of patients with epilepsy. In addition, it has been further modified to assess the postoperative risk of amnesia in patients undergoing temporal lobectomy. Since then it has been utilized to lateralize language and assess pre-surgical memory function. Over the years, its popularity has declined due to several limitations and availability of alternative procedures like fMRI and MEG. A survey of its use in the pre-surgical evaluation for epilepsy surgery has not been performed since the 2008 international survey by Baxendale et al. and it was heavily skewed due to data from European and North American countries. Only approximately 12% of the epilepsy centers indicated that they used the Wada test in every patient to assess preoperative memory function and language lateralization before temporal lobectomy. Nowadays, we have many functional mapping tools at our disposal. It has become somewhat unsuitable to have epilepsy patients undergo an invasive test such as the Wada test for the risks associated with it outweigh the benefits. Our objective is to review the Wada Test and alternative methods of assessing language and memory dominance, as it is past its prime and should only be used in specific circumstances.

Influence of Human Jaw Movement on Cerebral Blood Flow

Temporal changes in cerebral blood flow induced by jaw movement have yet to be investigated. To assess the influence of pattern and intensity of muscle contraction during jaw movement on task-induced change in cerebral blood flow, we performed bilateral transcranial Doppler ultrasound examination during clenching, gum chewing, and tooth tapping in healthy volunteers. A random-effects model analysis revealed a significant increase in middle cerebral artery blood flow velocity during clenching (high muscle activity) and gum chewing (moderate muscle activity), compared with the preceding rest period; however, such an increase was not detected during tooth tapping (low muscle activity). Cerebral blood flow was greater on the working side during the intensive isometric contraction of the masseter muscle in clenching. These results suggest that task-induced change in cerebral blood flow during jaw movement is influenced by the change in peripheral circulation evoked by muscle contraction.

Feasibility of transcranial Doppler and single photon emission computed tomography in compound neuroactivation task

The aim of this study was to test feasibility of transcranial Doppler (TCD) and single photon emission computed tomography (SPECT) during compound neuroactivation task. The study was performed in 60 healthy right-handed volunteers. Cerebral blood flow velocity was measured by TCD in both middle cerebral arteries (MCA) at baseline and during computer game. The same stimulus and response pattern was used in 15 subjects that additionally underwent brain SPECT. Percentage differences between measurements were determined through quantitative result assessment. Both methods detected a statistically significant cerebral blood flow increase during neuroactivation. Correlation of TCD and SPECT showed statistically significant correlation only for the increase of cerebral blood flow velocity in the right MCA and for the right-sided cerebral blood flow increase, demonstrating that both methods partially measure similar cerebral blood flow changes that occur during neuroactivation. Comparison of TCD and SPECT showed TCD to be inadequately sensitive method for evaluation of cerebral blood flow during complex activation paradigm.

The contribution of functional near-infrared spectroscopy (fNIRS) to the presurgical assessment of language function in children

Before performing neurosurgery, an exhaustive presurgical assessment is required, usually including an investigation of language cerebral lateralization. Among the available procedures, the intracarotid amobarbital test (IAT) was formerly the most widely used. However, this procedure has many limitations: it is invasive and potentially traumatic, especially for children. To overcome these limitations, neuroimaging techniques such as functional magnetic resonance imaging (fMRI) have been used. Again, these methods are difficult to use with children, who must remain motionless during data acquisition. Functional near-infrared spectroscopy (fNIRS) is a noninvasive functional imaging technique that is easily applied to pediatric and cognitively limited patients. It has been used recently in epileptic children for presurgical assessment of expressive and receptive language brain lateralization. The aim of this review is to present the contribution of fNIRS to the presurgical assessment of language function in children with neurological diseases.

Language mapping in temporal lobe epilepsy in children: special considerations

Temporal lobe epilepsy (TLE) in children is a slightly different entity than TLE in adults not only because of its semiology and pathology but also because of the different approach to surgical treatment. Presurgical investigations for eloquent cortex, especially language, must take these differences into account. Most diagnostic tests were created for adults, and many of the assessment tools need to be adapted for children because they are not just small adults. This paper will highlight the specific challenges and solutions in mapping language in a pediatric population with TLE.

Presurgical language mapping in children with epilepsy: clinical usefulness of functional magnetic resonance imaging for the planning of cortical stimulation

PURPOSE

Presurgical language mapping in dominant hemisphere epilepsy to evaluate the risk of postoperative deficit is particularly difficult in children. Extraoperative invasive cortical stimulation can show some areas critical to language, but not all of them, due to scarce sampling, poor cooperation, cortical immaturity, or network reorganization, whereas functional magnetic resonance imaging (fMRI) displays entire networks involved in, but not necessarily critical to, language. In a homogeneous series of children with epilepsy, we compared the contributions of language fMRI and depth electrode stimulations to optimize language mapping.

METHODS

Eight children (7.5-15.5 years) with left frontal or temporal epilepsy underwent language fMRI and language stimulation with depth electrodes as part of their comprehensive presurgical workup. fMRI data collected during sentence generation were analyzed using statistical parametric mapping (SPM2) (false discovery rate [FDR] p < 0.05). Bipolar stimulations were performed during language production tasks. By coregistering fMRI and postimplantation computed tomography (CT) images, we were able to directly compare the cortical areas identified by both investigations.

KEY FINDINGS

fMRI during sentence generation robustly showed activation in the whole perisylvian regions with little reorganization (left hemisphere dominant in 7). Of the 184 electrode contacts tested for language, only 8 were positive (language disruption) in three of the seven patients with periictal language impairment and left language dominance. All of the positive contacts colocalized with an fMRI activated cluster, that is, fMRI did not miss any region critical to language (sensitivity = 100%). However, 54 of the 176 negative contacts were within activated clusters (low specificity).

SIGNIFICANCE

In children with epilepsy, the sensitivity of fMRI during sentence generation allows for the detection of all critical regions displayed by cortical stimulation within the large perisylvian language network, but with a low specificity. It is, therefore, useful to optimize the placement of intracranial electrodes when language mapping is necessary. Systematic planning of the electrode placement according to language fMRI maps should increase the yield of extraoperative cortical stimulation, which appears rather low in children when compared to adults.

Wada test using secobarbital sodium (Ional) to determine language dominance

The intracarotid sodium amobarbital (Amytal) test, the Wada test, remains an efficient test for evaluation of language and memory function. However, due to a world shortage of amobarbital, it has become necessary to investigate the use of alternatives. We report the efficacy of the Wada test using secobarbital sodium (Ional) in determining language dominance. An accurate determination of language dominance was required in 43 patients preoperatively at our institution. Patients underwent the Wada test using secobarbital sodium, effectiveness and safety were assessed. Patients were monitored for vital signs (blood pressure, respiratory rates, heart rates and saturation of oxygen). Ten patients were further monitored for continuous intra-arterial blood pressure and monitored with scalp electroencephalography (EEG). Language dominance was determined by the Wada test with secobarbital sodium in all patients. Total volume of secobarbital sodium injected was 10-25 mg (mean 16.5 ± 3.2 mg). Changes in vital signs were minimal and any induced neurological deficits completely disappeared within 8 min. On EEG records, induced theta waves immediately appeared on the ipsilateral side of the intra-arterial injection and disappeared within 6 min. One patient described a scintillating scotoma (sensation of shimmering light in his eyes) at the moment of injection; another experienced an epileptic episode during the test and recovered after 6 min. No adverse events were observed in the remaining 41 cases. We propose secobarbital sodium as a safe and reliable alternative to sodium amobarbital used in the Wada test to determine language dominance.

Power spectral density changes and language lateralization during covert object naming tasks measured with high-density EEG recordings

Our objective was to study changes in EEG time-domain power spectral density (PSDt) and localization of language areas during covert object naming tasks in human subjects with epilepsy. EEG data for subjects with epilepsy were acquired during the covert object naming tasks using a net of 256 electrodes. The trials required each subject to provide the names of common objects presented every 4 seconds on slides. Each trial comprised the 1.0 second before and 3.0 seconds after initial object presentation. PSDt values at baseline and during tasks were calculated in the theta, alpha, beta, low gamma, and high gamma bands. The spatial contour plots reveal that PSDt values during object naming were 10-20% higher than the baseline values for different bands. Language was lateralized to left frontal or temporal areas. In all cases, the Wada test disclosed language lateralization to the left hemisphere as well.

An update on determination of language dominance in screening for epilepsy surgery: the Wada test and newer noninvasive alternatives

The intracarotid amobarbital procedure or Wada test has been the gold standard for lateralization of language dominance before epilepsy surgery. It is based on deactivation of language cortex with intracarotid anesthesia. However, it is an invasive test with risks and discomforts, and it also has limitations. There has been great interest in replacing the Wada test with a noninvasive procedure. One alternative, repetitive magnetic stimulation works by deactivating language cortex, but most other promising alternatives are based on brain activation. Functional magnetic resonance imaging (fMRI), 15O-water positron emission tomography, single photon emission computerized tomography, transcranial Doppler, and near infrared spectroscopy detect hemodynamic responses to language cortex activation, while magnetoencephalography more directly measures event-related physiological activation. Some of the techniques also provide localization of language functions, whereas the Wada test is strictly a lateralization method. Based on widespread availability, fMRI will likely be the most widely used alternative.

Bilingual and multilingual language processing

This chapter addresses the interesting question on the neurolinguistics of bilingualism and the representation of language in the brain in bilingual and multilingual subjects. A fundamental issue is whether the cerebral representation of language in bi- and multilinguals differs from that of monolinguals, and if so, in which specific way. This is an interdisciplinary question which needs to identify and differentiate different levels involved in the neural representation of languages, such as neuroanatomical, neurofunctional, biochemical, psychological and linguistic levels. Furthermore, specific factors such as age, manner of acquisition and environmental factors seem to affect the neural representation. We examined the question whether verbal memory processing in two unrelated languages is mediated by a common neural system or by distinct cortical areas. Subjects were Finnish-English adult multilinguals who had acquired the second language after the age of ten. They were PET-scanned whilst either encoding or retrieving word pairs in their mother tongue (Finnish) or in a foreign language (English). Within each language, subjects had to encode and retrieve four sets of 12 visually presented paired word associates which were not semantically related. Two sets consisted of highly imaginable words and the other two sets of abstract words. Presentation of pseudo-words served as a reference condition. An emission scan was recorded after each intravenous administration of O-15 water. Encoding was associated with prefrontal and hippocampal activation. During memory retrieval, precuneus showed a consistent activation in both languages and for both highly imaginable and abstract words. Differential activations were found in Broca's area and in the cerebellum as well as in the angular/supramarginal gyri according to the language used. The findings advance our understanding of the neural representation that underlies multiple language functions. Further studies are needed to elucidate the neuronal mechanisms of bi/multilingual language processing. A promising perspective for future bi/multilingual research is an integrative approach using brain imaging studies with a high spatial resolution such as fMRI, combined with techniques with a high temporal resolution, such as magnetoencephalography (MEG).

Neuromagnetic responses to vowels vs. tones reveal hemispheric lateralization

OBJECTIVE

To evaluate whether a simple auditory paradigm could demonstrate a difference in cortical lateralization between right- and left-handed subjects. Such information would be important for later development of clinical noninvasive tests of hemispheric language dominance in candidates for brain surgery.

METHODS

Healthy subjects (10 strongly right-handed, 10 strongly left-handed, 5 weakly right-handed, and two ambidextrous) listened to binaural pairs of tones and pairs of Finnish vowels and decided whether the items in the pair were the same (target probability 20%). Cortical responses were recorded with whole-scalp magnetoencephalography.

RESULTS

The laterality index for strengths of the auditory-cortex 100 ms responses (N100m) to vowels vs. tones suggested left-hemispheric dominance in 8 of the 10 strongly right-handed subjects, and right-hemispheric dominance in 7 of the 10 left-handed subjects.

CONCLUSIONS

Our results demonstrate difference in hemispheric dominance for processing of vowels between right-handed and left-handed subjects. This difference resembles language lateralization suggested by previous invasive studies as well as by anatomical and functional comparisons in left- and right-handed subjects.

SIGNIFICANCE

After comparison with the Wada test, this simple paradigm could prove useful as a noninvasive test for language lateralization in clinical settings.

Speech activation spect and plasticity of language networks

Neuronal activity might be measured by regional cerebral blood flow (rCBF) Single Photon Emission Computed Tomography (SPECT) as there is a close relationship between neuronal activity and rCBF changes. In order to study the hemispheric dominance for language and the plasticity of language networks by measuring the rCBF rest and language activation SPECT studies were performed in the presurgical evaluation of ten right-handed and two left handed patients with brain lesions of the dominant hemisphere. A special group of hemisphere-specific neuropsychologic tasks were used for activation, after a proper psychologic conditioning. The rCBF results were calculated by comparing the rest and activation SPECT data using a special regions of interest program and asymmetry index (AI). We compared the results of speech-activation to the results of clinical, morphological (MRI), and postoperative data. In controls, significant activation was found in Brodmann's area 44 and 45, contralateral cerebellum, superior middle and posterior temporal gyrus. In patients, additional regions of activation were seen in contralateral frontal and temporal regions, and in ipsilateral temporal region. AIs of the cerebellum demonstrated a negative correlation with hemispheric dominance for language. In conclusion, significant changes in rCBF in or adjacent to the eloquent areas with various patterns of rCBF changes of the additional regions demonstrate the close relationship between neuronal activity and cerebral blood flow, that can be measured by SPECT.

Unified inflectional processing of regular and irregular verbs: a PET study

Psycholinguistic theories propose different models of inflectional processing of regular and irregular verbs: dual mechanism models assume separate modules with lexical frequency sensitivity for irregular verbs. In contradistinction, connectionist models propose a unified process in a single module. We conducted a PET study using a 2 x 2 design with verb regularity and frequency. We found significantly shorter voice onset times for regular verbs and high frequency verbs irrespective of regularity. The PET data showed activations in inferior frontal gyrus (BA 45), nucleus lentiformis, thalamus, and superior medial cerebellum for both regular and irregular verbs but no dissociation for verb regularity. Our results support common processing components for regular and irregular verb inflection.