The intralaminar thalamus: a review of its role as a target in functional neurosurgery

Thalamic burst and tonic firing selectively indicate patients' consciousness level and recovery

Patients with disorders of consciousness suffer from severe impairments in arousal and awareness alongside anomalous brain connections and aberrant neuronal activities. The thalamus, a crucial hub in the brain connectome, has been empirically inferred to maintain consciousness and wakefulness. Here, we investigated thalamic spiking, brain connectivity, consciousness states, and recovery outcomes following deep brain stimulation in 29 patients. Our study reveals that thalamic neuronal activity serves as a marker of consciousness state. Patients diagnosed with vegetative state/unresponsive wakefulness syndrome exhibited less-active neurons, with longer and more variable burst discharges, than those in a minimally conscious state. Furthermore, neuronal profiles in the intralaminar thalamus, the direct stimulation site, predicted whether electrostimulation here improved recovery. Stronger tonic firing was correlated with enhanced thalamocortical connectivity and better recovery outcomes in patients. These findings suggest that thalamic spiking signatures, including single-neuron burst discharge and tonic firing, selectively indicate the representation and alteration of consciousness.

Human high-order thalamic nuclei gate conscious perception through the thalamofrontal loop

Human high-order thalamic nuclei activity is known to closely correlate with conscious states. However, it is not clear how those thalamic nuclei and thalamocortical interactions directly contribute to the transient process of human conscious perception. We simultaneously recorded stereoelectroencephalography data from the thalamic nuclei and prefrontal cortex (PFC), while patients with implanted electrodes performed a visual consciousness task. Compared with the ventral nuclei and PFC, the intralaminar and medial nuclei presented earlier and stronger consciousness-related activity. Transient thalamofrontal neural synchrony and cross-frequency coupling were both driven by the θ phase of the intralaminar and medial nuclei during conscious perception. The intralaminar and medial thalamic nuclei thus play a gate role to drive the activity of the PFC during the emergence of conscious perception.

Radiosurgery to the Medial Thalamus for Chronic Pain: A Single Group Experience and Review of Literature

Introduction Chronic pain presents a significant challenge in achieving effective treatment and can greatly reduce patients' quality of life. Many individuals can undergo multiple therapies with limited success. Stereotactic medial thalamotomy is a treatment option for certain types of chronic pain when other measures have failed. This study aims to assess the efficacy and safety of radiosurgical medial thalamotomy based on nearly a decade of experience in managing chronic intractable pain of both malignant and non-malignant origins. Methods This retrospective study included 56 patients who underwent radiosurgery to the medial thalamus for refractory neuropathic pain or mixed cancer pain. Treatment approaches involved single thalamic irradiation, bilateral thalamotomy, dual-target irradiation of the medial thalamus and trigeminal nerve, or triple-target irradiation of the pituitary gland and bilateral thalami. Results Pain intensity was significantly reduced at the final follow-up for patients treated with triple-target radiosurgery (Student's t-test, p < 0.001), dual-target radiosurgery (Wilcoxon test, p < 0.001), and single/bilateral thalamotomy (Wilcoxon test, p = 0.01). The median time to pain relief was 2.5 days for triple-target treatment, three days for dual-target treatment, 1.5 days for bilateral thalamotomy, and 33 days for single thalamotomy. Overall, treatment success, defined as achieving at least 50% pain relief, was 69.1% for the entire cohort. The success rate was 66.6% for oncologic pain and 71.7% for non-oncologic pain. Conclusion Radiosurgical irradiation of the medial thalamus is an effective alternative for treating refractory cancer-related pain and predominantly neuropathic non-oncologic pain. Various radiosurgical regimens can be employed in a multi-target strategy tailored to the origin and characteristics of the pain, offering relief to most patients with minimal morbidity.

Cholecystokinin neurons in the spinal trigeminal nucleus interpolaris regulate mechanically evoked predatory hunting in male mice

Predatory hunting plays a critical role in animal survival. Motion-related vibrissal somatosensory signaling is essential for prey detection and hunting in mice. However, little is known about the neural circuits that convert vibrissal somatosensory cues to trigger predatory hunting. Here, we report that mechanical force onto the vibrissal area of the male mice is a key stimulus for predatory hunting. Mechanically evoked predatory hunting was abrogated by the chemogenetic inactivation of cholecystokinin-positive (Cck+) neurons in the spinal trigeminal nucleus interpolaris (Sp5I). The Cck+ Sp5I neurons responded to the intensity of mechanical stimulus and sent neural signals to the superior colliculus that were relevant to stereotypical predatory hunting motor actions. Synaptic inactivation of the projections from Cck+ Sp5I neurons to the superior colliculus impaired mechanically evoked predatory attacks. Together, these data reveal a spinal trigeminal nucleus neural circuit that is specifically engaged in translating vibrissal somatosensory cues to provoke predatory hunting.

The brain's action-mode network

The brain is always intrinsically active, using energy at high rates while cycling through global functional modes. Awake brain modes are tied to corresponding behavioural states. During goal-directed behaviour, the brain enters an action-mode of function. In the action-mode, arousal is heightened, attention is focused externally and action plans are created, converted to goal-directed movements and continuously updated on the basis of relevant feedback, such as pain. Here, we synthesize classical and recent human and animal evidence that the action-mode of the brain is created and maintained by an action-mode network (AMN), which we had previously identified and named the cingulo-opercular network on the basis of its anatomy. We discuss how rather than continuing to name this network anatomically, annotating it functionally as controlling the action-mode of the brain increases its distinctiveness from spatially adjacent networks and accounts for the large variety of the associated functions of an AMN, such as increasing arousal, processing of instructional cues, task general initiation transients, sustained goal maintenance, action planning, sympathetic drive for controlling physiology and internal organs (connectivity to adrenal medulla), and action-relevant bottom-up signals such as physical pain, errors and viscerosensation. In the functional mode continuum of the awake brain, the AMN-generated action-mode sits opposite the default-mode for self-referential, emotional and memory processing, with the default-mode network and AMN counterbalancing each other as yin and yang.

A cortico-subcortical loop for motor control via the pontine reticular formation

Movement and locomotion are controlled by large neuronal circuits like the cortex-basal ganglia (BG)-thalamus loop. Besides the inhibitory thalamic output, the BG directly control movement via specialized connections with the brainstem. Whether other parallel loops with similar logic exist is presently unclear. Here, we demonstrate that the secondary motor and cingulate cortices (M2/Cg) target and strongly control the activity of glycine transporter 2-positive (GlyT2+) cells in the pontine reticular formation (PRF). In turn, PRF/GlyT2+ cells project to and powerfully inhibit the intralaminar/parafascicular nuclei of the thalamus (IL/Pf). M2/Cg cells co-innervate PRF/GlyT2+ cells and the IL/Pf. Thalamus-projecting PRF/GlyT2+ cells target ipsilateral subcortical regions distinct from BG targets. Activation of the thalamus-projecting PRF/GlyT2+ cells leads to contralateral turning. These results demonstrate that the PRF is part of a cortico-subcortical loop that regulates motor activity parallel to BG circuits. The cortico-PRF-thalamus loop can control turning synergistically with the BG loops via distinct descending pathways.

Antifragile control systems in neuronal processing: a sensorimotor perspective

The stability-robustness-resilience-adaptiveness continuum in neuronal processing follows a hierarchical structure that explains interactions and information processing among the different time scales. Interestingly, using "canonical" neuronal computational circuits, such as Homeostatic Activity Regulation, Winner-Take-All, and Hebbian Temporal Correlation Learning, one can extend the behavior spectrum towards antifragility. Cast already in both probability theory and dynamical systems, antifragility can explain and define the interesting interplay among neural circuits, found, for instance, in sensorimotor control in the face of uncertainty and volatility. This perspective proposes a new framework to analyze and describe closed-loop neuronal processing using principles of antifragility, targeting sensorimotor control. Our objective is two-fold. First, we introduce antifragile control as a conceptual framework to quantify closed-loop neuronal network behaviors that gain from uncertainty and volatility. Second, we introduce neuronal network design principles, opening the path to neuromorphic implementations and transfer to technical systems.

The lateral thalamus: a bridge between multisensory processing and naturalistic behaviors

The lateral thalamus (LT) receives input from primary sensory nuclei and responds to multimodal stimuli. The LT is also involved in regulating innate and social behaviors through its projections to cortical and limbic networks. However, the importance of multisensory processing within the LT in modulating behavioral output has not been explicitly addressed. Here, we discuss recent findings primarily from rodent studies that extend the classical view of the LT as a passive relay, by underscoring its involvement in associating multimodal features and encoding the salience, valence, and social relevance of sensory signals. We propose that the primary function of the LT is to integrate sensory and non-sensory aspects of multisensory input to gate naturalistic behaviors.

Neuroscience of coma

Coma and disorders of consciousness are frequently considered in terms of two linked anatomic-functional systems: the arousal system and the awareness system. The mesopontine tegmentum (namely the cuneiform/subcuneiform nuclei of the caudal midbrain and the pontis oralis nucleus of the rostral pons) and the monoamine nuclei generate signals of arousal. These signals are augmented in lateral hypothalamus and basal forebrain, which then project to the thalamus and diffusely across the cortex. The medial dorsal tegmental tract is the main conduit for the ascending arousal system to directly activate the thalamic intralaminar nuclei and modulate thalamocortical networks, while the lateral dorsal tegmental tract connects to the thalamic reticular nucleus for regulation of intrathalamic inhibitory networks. The central thalamus (particularly the intralaminar nuclei) and the mesocircuit regulate the arousal system. Lesions to any part of this system, particularly paramedian and bilateral lesions, result in a depressed level of arousal. Distinct from the arousal pathways, the awareness system runs continuously as a stream of consciousness. It consists of large-scale distributed cortical networks that are necessary for representations of the external (executive control network with the dorsal/ventral attention networks) and the internal world (executive control network in conjunction with the default network). A feature of the awareness system is that it does not capture external and internal worlds at once and instead, holds singular representations, serially moment-by-moment. The medial dorsal nucleus of the thalamus serves as the associative nuclei of the default network, and the thalamic reticular nucleus regulates the awareness system. Lesions that disrupt large-scale networks, particularly nodes of cortical hubs, result in lack of awareness. Integrative paradigms such as the integrated information theory and the global neuronal workspace models are attempts to bind awareness and arousal into a unified experience of consciousness.

Stereotactic radiosurgery for medically refractory non-lesional epilepsy: A case-based Radiosurgery Society (RSS) practice review

INTRODUCTION

Medically refractory epilepsy (MRE) occurs in about 30 % of patients with epilepsy, and the treatment options available to them have evolved over time. The classic treatment for medial temporal lobe epilepsy (mTLE) is anterior temporal lobectomy (ATL), but an initiative to find less invasive options has resulted in treatments such as neuromodulation, ablative procedures, and stereotactic radiosurgery (SRS). SRS has been an appealing non-invasive option and has developed an increasing presence in the literature over the last few decades. This article provides an overview of SRS for MRE with two example cases, and we discuss the optimal technique as well as the advantages, alternatives, and risks of this therapeutic option.

CASES

We present two example cases of patients with MRE, who were poor candidates for invasive surgical treatment options and underwent SRS. The first case is a 65-year-old female with multiple medical comorbidities, whose seizure focus was localized to the left temporal lobe, and the second case is a 19-year-old male with Protein C deficiency and medial temporal lobe sclerosis. Both patients underwent SRS to targets within the medial temporal lobe, and both achieve significant improvements in seizure frequency and severity.

DISCUSSION

SRS has generally been shown to be inferior to ATL for seizure reduction in medically refractory mTLE. However, there are patients with epilepsy for which SRS can be considered, such as patients with medical comorbidities that make surgery high risk, patients with epileptogenic foci in eloquent cortex, patients who have failed to respond to surgical management, patients who choose not to undergo surgery, and patients with geographic constraints to epilepsy centers. Patients and their physicians should be aware that SRS is not risk-free. Patients should be counseled on the latency period and monitored for risks such as delayed cerebral edema, visual field deficits, and radiation necrosis.

The posterior intralaminar thalamic nucleus promotes nose-to-nose contacts leading to prosocial reception in the sequence of mouse social interaction

Efficient social interaction is essential for an adaptive life and consists of sequential processes of multisensory events with social counterparts. Social touch/contact is a unique component that promotes a sequence of social behaviours initiated by detection and approach to assess a social stimulus and subsequent touch/contact interaction to form prosocial relationships. We hypothesized that the thalamic sensory relay circuit from the posterior intralaminar nucleus of the thalamus (pIL) to the paraventricular nucleus of the hypothalamus (PVN) and the medial amygdala (MeA) plays a key role in the social contact-mediated sequence of events. We found that neurons in the pIL along with the PVN and MeA were activated by social encounters and that pIL activity was more abundant in a direct physical encounter, whereas MeA activity was dominant in an indirect through grid encounter. Chemogenetic inhibition of pIL neurons selectively decreased the investigatory approach and sniffing of a same-sex, but not an opposite-sex, stimulus mouse in an indirect encounter situation and decreased the facial/snout contact ratio in a direct encounter setting. Furthermore, chemogenetic pIL inhibition had no impact on anxiety-like behaviours or body coordinative motor behaviours, but it impaired whisker-related and plantar touch tactile sense. We propose that the pIL circuit can relay social tactile sensations and mediate the sequence of nonsexual prosocial interactions through an investigatory approach to tactile contact and thus plays a significant role in establishing prosocial relationships in mouse models.

State-specific Regulation of Electrical Stimulation in the Intralaminar Thalamus of Macaque Monkeys: Network and Transcriptional Insights into Arousal

Long-range thalamocortical communication is central to anesthesia-induced loss of consciousness and its reversal. However, isolating the specific neural networks connecting thalamic nuclei with various cortical regions for state-specific anesthesia regulation is challenging, with the biological underpinnings still largely unknown. Here, simultaneous electroencephalogram-fuctional magnetic resonance imaging (EEG-fMRI) and deep brain stimulation are applied to the intralaminar thalamus in macaques under finely-tuned propofol anesthesia. This approach led to the identification of an intralaminar-driven network responsible for rapid arousal during slow-wave oscillations. A network-based RNA-sequencing analysis is conducted of region-, layer-, and cell-specific gene expression data from independent transcriptomic atlases and identifies 2489 genes preferentially expressed within this arousal network, notably enriched in potassium channels and excitatory, parvalbumin-expressing neurons, and oligodendrocytes. Comparison with human RNA-sequencing data highlights conserved molecular and cellular architectures that enable the matching of homologous genes, protein interactions, and cell types across primates, providing novel insight into network-focused transcriptional signatures of arousal.

Modulation of neuronal activity in human centromedian nucleus during an auditory attention and working memory task

Centromedian nucleus (CM) is one of several intralaminar nuclei of the thalamus and is thought to be involved in consciousness, arousal, and attention. CM has been suggested to play a key role in the control of attention, by regulating the flow of information to different brain regions such as the ascending reticular system, basal ganglia, and cortex. While the neurophysiology of attention in visual and auditory systems has been studied in animal models, combined single unit and LFP recordings in human have not, to our knowledge, been reported. Here, we recorded neuronal activity in the CM nucleus in 11 patients prior to insertion of deep brain stimulation electrodes for the treatment of epilepsy while subjects performed an auditory attention task. Patients were requested to attend and count the infrequent (p = 0.2) odd or "deviant" tones, ignore the frequent standard tones and report the total number of deviant tones at trial completion. Spikes were discriminated, and LFPs were band pass filtered (5-45 Hz). Average peri‑stimulus time histograms and spectra were constructed by aligning on tone onsets and statistically compared. The firing rate of CM neurons showed selective, multi-phasic responses to deviant tones in 81% of the tested neurons. Local field potential analysis showed selective beta and low gamma (13-45 Hz) modulations in response to deviant tones, also in a multi-phasic pattern. The current study demonstrates that CM neurons are under top-down control and participate in the selective processing during auditory attention and working memory. These results, taken together, implicate the CM in selective auditory attention and working memory and support a role of beta and low gamma oscillatory activity in cognitive processes. It also has potential implications for DBS therapy for epilepsy and non-motor symptoms of PD, such as apathy and other disorders of attention.

Drug-resistant juvenile myoclonic epilepsy: A literature review

The ILAE's Task Force on Nosology and Definitions revised in 2022 its definition of juvenile myoclonic epilepsy (JME), the most common idiopathic generalized epilepsy disorder, but this definition may well change again in the future. Although good drug response could almost be a diagnostic criterion for JME, drug resistance (DR) is observed in up to a third of patients. It is important to distinguish this from pseudoresistance, which is often linked to psychosocial problems or psychiatric comorbidities. After summarizing these aspects and the various definitions applied to JME, the present review lists the risk factors for DR-JME that have been identified in numerous studies and meta-analyses. The factors most often cited are absence seizures, young age at onset, and catamenial seizures. By contrast, photosensitivity seems to favor good treatment response, at least in female patients. Current hypotheses on DR mechanisms in JME are based on studies of either simple (e.g., cortical excitability) or more complex (e.g., anatomical and functional connectivity) neurophysiological markers, bearing in mind that JME is regarded as a neural network disease. This research has revealed correlations between the intensity of some markers and DR, and above all shed light on the role of these markers in associated neurocognitive and neuropsychiatric disorders in both patients and their siblings. Studies of neurotransmission have mainly pointed to impaired GABAergic inhibition. Genetic studies have generally been inconclusive. Increasing restrictions have been placed on the use of valproate, the standard antiseizure medication for this syndrome, owing to its teratogenic and developmental risks. Levetiracetam and lamotrigine are prescribed as alternatives, as is vagal nerve stimulation, and there are several other promising antiseizure drugs and neuromodulation methods. The development of better alternative treatments is continuing to take place alongside advances in our knowledge of JME, as we still have much to learn and understand.

Deep brain stimulation of the central thalamus restores arousal and motivation in a zolpidem-responsive patient with akinetic mutism after severe brain injury

After severe brain injury, zolpidem is known to cause spectacular, often short-lived, restorations of brain functions in a small subgroup of patients. Previously, we showed that these zolpidem-induced neurological recoveries can be paralleled by significant changes in functional connectivity throughout the brain. Deep brain stimulation (DBS) is a neurosurgical intervention known to modulate functional connectivity in a wide variety of neurological disorders. In this study, we used DBS to restore arousal and motivation in a zolpidem-responsive patient with severe brain injury and a concomitant disorder of diminished motivation, more than 10 years after surviving hypoxic ischemia. We found that DBS of the central thalamus, targeted at the centromedian-parafascicular complex, immediately restored arousal and was able to transition the patient from a state of deep sleep to full wakefulness. Moreover, DBS was associated with temporary restoration of communication and ability to walk and eat in an otherwise wheelchair-bound and mute patient. With the use of magnetoencephalography (MEG), we revealed that DBS was generally associated with a marked decrease in aberrantly high levels of functional connectivity throughout the brain, mimicking the effects of zolpidem. These results imply that 'pathological hyperconnectivity' after severe brain injury can be associated with reduced arousal and behavioral performance and that DBS is able to modulate connectivity towards a 'healthier baseline' with lower synchronization, and, can restore functional brain networks long after severe brain injury. The presence of hyperconnectivity after brain injury may be a possible future marker for a patient's responsiveness for restorative interventions, such as DBS, and suggests that lower degrees of overall brain synchronization may be conducive to cognition and behavioral responsiveness.

Disuse-driven plasticity in the human thalamus and putamen

Motor adaptation in cortico-striato-thalamo-cortical loops has been studied mainly in animals using invasive electrophysiology. Here, we leverage functional neuroimaging in humans to study motor circuit plasticity in the human subcortex. We employed an experimental paradigm that combined two weeks of upper-extremity immobilization with daily resting-state and motor task fMRI before, during, and after the casting period. We previously showed that limb disuse leads to decreased functional connectivity (FC) of the contralateral somatomotor cortex (SM1) with the ipsilateral somatomotor cortex, increased FC with the cingulo-opercular network (CON) as well as the emergence of high amplitude, fMRI signal pulses localized in the contralateral SM1, supplementary motor area and the cerebellum. From our prior observations, it remains unclear whether the disuse plasticity affects the thalamus and striatum. We extended our analysis to include these subcortical regions and found that both exhibit strengthened cortical FC and spontaneous fMRI signal pulses induced by limb disuse. The dorsal posterior putamen and the central thalamus, mainly CM, VLP and VIM nuclei, showed disuse pulses and FC changes that lined up with fmri task activations from the Human connectome project motor system localizer, acquired before casting for each participant. Our findings provide a novel understanding of the role of the cortico-striato-thalamo-cortical loops in human motor plasticity and a potential link with the physiology of sleep regulation. Additionally, similarities with FC observation from Parkinson Disease (PD) questions a pathophysiological link with limb disuse.

Deep brain stimulation in disorders of consciousness: 10 years of a single center experience

Disorders of consciousness (DoC), namely unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS), represent severe conditions with significant consequences for patients and their families. Several studies have reported the regaining of consciousness in such patients using deep brain stimulation (DBS) of subcortical structures or brainstem nuclei. Our study aims to present the 10 years' experience of a single center using DBS as a therapy on a cohort of patients with DoC. Eighty Three consecutive patients were evaluated between 2011 and 2022; entry criteria consisted of neurophysiological and neurological evaluations and neuroimaging examinations. Out of 83, 36 patients were considered candidates for DBS implantation, and 32 patients were implanted: 27 patients had UWS, and five had MCS. The stimulation target was the centromedian-parafascicular complex in the left hemisphere in hypoxic brain lesion or the one better preserved in patients with traumatic brain injury. The level of consciousness was improved in seven patients. Three out of five MCS patients emerged to full awareness, with the ability to interact and communicate. Two of them can live largely independently. Four out of 27 UWS patients showed consciousness improvement with two patients emerging to full awareness, and the other two reaching MCS. In patients with DoC lasting longer than 12 months following traumatic brain injury or 6 months following anoxic-ischemic brain lesion, spontaneous recovery is rare. Thus, DBS of certain thalamic nuclei could be recommended as a treatment option for patients who meet neurological, neurophysiological and neuroimaging criteria, especially in earlier phases, before occurrence of irreversible musculoskeletal changes. Furthermore, we emphasize the importance of cooperation between centers worldwide in studies on the potentials of DBS in treating patients with DoC.

A Comprehensive Review of Emerging Trends and Innovative Therapies in Epilepsy Management

Epilepsy is a complex neurological disorder affecting millions worldwide, with a substantial number of patients facing drug-resistant epilepsy. This comprehensive review explores innovative therapies for epilepsy management, focusing on their principles, clinical evidence, and potential applications. Traditional antiseizure medications (ASMs) form the cornerstone of epilepsy treatment, but their limitations necessitate alternative approaches. The review delves into cutting-edge therapies such as responsive neurostimulation (RNS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS), highlighting their mechanisms of action and promising clinical outcomes. Additionally, the potential of gene therapies and optogenetics in epilepsy research is discussed, revealing groundbreaking findings that shed light on seizure mechanisms. Insights into cannabidiol (CBD) and the ketogenic diet as adjunctive therapies further broaden the spectrum of epilepsy management. Challenges in achieving seizure control with traditional therapies, including treatment resistance and individual variability, are addressed. The importance of staying updated with emerging trends in epilepsy management is emphasized, along with the hope for improved therapeutic options. Future research directions, such as combining therapies, AI applications, and non-invasive optogenetics, hold promise for personalized and effective epilepsy treatment. As the field advances, collaboration among researchers of natural and synthetic biochemistry, clinicians from different streams and various forms of medicine, and patients will drive progress toward better seizure control and a higher quality of life for individuals living with epilepsy.