The role of neurocritical care: a brief report on the survey results of neurosciences and critical care specialists

BACKGROUND

Neurocritical care is a new subspecialty field in medicine that intersects with many of the neuroscience and critical care specialties, and continues to evolve in its scope of practice and practitioners. The objective of this study was to assess the perceived need for and roles of neurocritical care intensivists and neurointensive care units among physicians involved with intensive care and the neurosciences.

METHODS

An online survey of physicians practicing critical care medicine, and neurology was performed during the 2008 Leapfrog initiative to formally recognize neurocritical care training.

RESULTS

The survey closed in July 2009 and achieved a 13% response rate (980/7524 physicians surveyed). Survey respondents (mostly from North America) included 362 (41.4%) neurologists, 164 (18.8%) internists, 104 (11.9%) pediatric intensivists, 82 (9.4%) anesthesiologists, and 162 (18.5%) from other specialties. Over 70% of respondents reported that the availability of neurocritical care units staffed with neurointensivists would improve the quality of care of critically ill neurological/neurosurgical patients. Neurologists were reported as the most appropriate specialty for training in neurointensive care by 53.3%, and 57% of respondents responded positively that neurology residency programs should offer a separate training track for those interested in neurocritical care.

CONCLUSION

Broad level of support exists among the survey respondents (mostly neurologists and intensivists) for the establishment of neurological critical care units. Since neurology remains the predominant career path from which to draw neurointensivists, there may be a role for more comprehensive neurointensive care training within neurology residencies or an alternative training track for interested residents.

Use of 64-channel electroencephalography to study neural otolith-evoked responses

BACKGROUND

The vestibular evoked myogenic potential (VEMP) is a myogenic response that can be used clinically to evaluate the function of the saccule. However, to date, little is known about the thalamo-cortical representation of saccular activation. It is important to understand all aspects of the VEMP, as this test is currently used clinically in the evaluation of saccular function.

PURPOSE

To identify the areas of the brain that are activated in response to stimuli used clinically to evoke the VEMP.

RESEARCH DESIGN

Electroencephalography (EEG) recordings combined with current density analyses were used to identify the areas of the brain that are activated in response to stimuli presented above VEMP threshold (500 Hz, 120 dB peak SPL [pSPL] tone bursts), as compared to stimuli presented below VEMP threshold (90 dB pSPL, 500 Hz tone bursts). Ten subjects without any history of balance or hearing impairment participated in the study.

RESULTS

The neural otolith-evoked responses (NOERs) recorded in response to stimuli presented below VEMP threshold were absent or smaller than NOERs that were recorded in response to stimuli presented above VEMP threshold. Subsequent analyses with source localization techniques, followed by statistical analysis with SPM5 (Statistical Parametric Mapping), revealed several areas that were activated in response to the 120 dB pSPL tone bursts. These areas included the primary visual cortex, the precuneus, the precentral gyrus, the medial temporal gyrus, and the superior temporal gyrus.

CONCLUSIONS

The present study found a number of specific brain areas that may be activated by otolith stimulation. Given the findings and source localization techniques (which required limited input from the investigator as to where the sources are believed to be located in the brain) used in the present study as well as the similarity in findings between studies employing galvanic stimuli, fMRI (functional magnetic resonance imaging), and scalp-recorded potentials in response to VEMP-eliciting stimuli, our study provides additional evidence that these brain regions are activated in response to stimuli that can be used clinically to evoke the VEMP.

Multi-site phasic neural activity mediates the execution of an auditory continuous performance task: a PET and electrophysiological study

BACKGROUND AND PURPOSE

We studied an auditory continuous performance task with positron emission tomography(PET) and EEG-derived current density reconstructions (CDRs) to define the spatial and temporal aspects of auditory attention.

METHODS

The CDRs were employed to segregate responses to targets and non-targets at sites identified by PET. We then studied the time course of brain activity using statistical parametric mapping (SPM) of the CDR data.

RESULTS

In contrast to target EEG activity, non-targets did not produce significant peaks after 300 ms. Pre-300 ms biphasic activation of auditory, left posterior frontal, left supplemental,and primary motor cortices and the anterior cingulate (AC) and biphasic suppression of posterior cingulate and occipital cortex were identical for targets and non-targets and may mediate the target non-target decision. SPM analysis of post-300 ms CDRs showed cingulate cortices were the first to be reactivated, remained active through 672 ms, and were accompanied by reactivation and deactivation of the same sites observed in the pre-P300 responses.

CONCLUSIONS

The cingulate may play an important role in post-decisional activity and control activity at other sites involved in post-decisional cognitive processing.

Multi-site phasic neural activity mediates the execution of an auditory continuous performance task: a PET and electrophysiological study

BACKGROUND AND PURPOSE

We studied an auditory continuous performance task with positron emission tomography (PET) and EEG-derived current density reconstructions (CDRs) to define the spatial and temporal aspects of auditory attention.

METHODS

The CDRs were employed to segregate responses to targets and non-targets at sites identified by PET. We then studied the time course of brain activity using statistical parametric mapping (SPM) of the CDR data.

RESULTS

In contrast to target EEG activity, non-targets did not produce significant peaks after 300 ms. Pre-300 ms biphasic activation of auditory, left posterior frontal, left supplemental, and primary motor cortices and the anterior cingulate (AC) and biphasic suppression of posterior cingulate and occipital cortex were identical for targets and non-targets and may mediate the target non-target decision. SPM analysis of post-300 ms CDRs showed cingulate cortices were the first to be reactivated, remained active through 672 ms, and were accompanied by reactivation and deactivation of the same sites observed in the pre-P300 responses.

CONCLUSIONS

The cingulate may play an important role in post-decisional activity and control activity at other sites involved in post-decisional cognitive processing.

Cognitive therapy for irritable bowel syndrome is associated with reduced limbic activity, GI symptoms, and anxiety

This study sought to identify brain regions that underlie symptom changes in severely affected IBS patients undergoing cognitive therapy (CT). Five healthy controls and 6 Rome II diagnosed IBS patients underwent psychological testing followed by rectal balloon distention while brain neural activity was measured with O-15 water positron emission tomography (PET) before and after a brief regimen of CT. Pre-treatment resting state scans, without distention, were compared to post-treatment scans using statistical parametric mapping (SPM). Neural activity in the parahippocampal gyrus and inferior portion of the right cortex cingulate were reduced in the post-treatment scan, compared to pre-treatment (x, y, z coordinates in MNI standard space were -30, -12, -30, P=0.017; 6, 34, -8, P=0.023, respectively). Blood flow values at these two sites in the controls were intermediate between those in the pre- and post-treatment IBS patients. Limbic activity changes were accompanied by significant improvements in GI symptoms (e.g., pain, bowel dysfunction) and psychological functioning (e.g., anxiety, worry). The left pons (-2, -26, -28, P=0.04) showed decreased neural activity which was correlated with post-treatment anxiety scores. Changes in neural activity of cortical-limbic regions that subserve hypervigilance and emotion regulation may represent biologically oriented change mechanisms that mediate symptom improvement of CT for IBS.

Neurodegenerative diseases: an overview of environmental risk factors

The population of the United States is aging, and an ever-increasing number of Americans are afflicted with neurodegenerative diseases. Because the pathogenesis of many of these diseases remains unknown, we must consider that environmental factors may play a causal role. This review provides an overview of the epidemiologic evidence for environmental etiologies for neurodegenerative diseases such as Alzheimer disease, Parkinson disease, parkinsonian syndromes (multiple system atrophy and progressive supranuclear palsy), and amyotrophic lateral sclerosis. Epidemiologic evidence for an association between environmental agents' exposure and neurodegenerative diseases is not conclusive. However, there are indications that there may be causal links, and the need for more research is obvious.

Mapping the 40-Hz auditory steady-state response using current density reconstructions

We mapped the 40-Hz aSSR from nine normal subjects using PET-independent low-resolution electroencephalographic tomography (LORETA) as well as PET-weighted LORETA and minimum norm (MinNorm) current density reconstructions. In grand mean data, PET-independent LORETA identified seven sites with peaks in current density in right temporal lobe, right brainstem/cerebellum, right parietal lobe, left cerebellum/temporal lobe, and right frontal lobe. PET-weighted LORETA found six of the same sites as the PET-independent LORETA: the right brainstem source was eliminated and two right-frontal sources were added. Both LORETA analyses revealed considerable phase dispersion across identified sources. In both LORETA analyses, the relative time course of activation measured from an arbitrary starting phase progressed from right temporal lobe to right mid-frontal lobe to right parietal-frontal to right inferior parietal and finally to left cerebellum and left temporal lobe. MinNorm analysis incorporating PET information identified sources in the same locations as specified in the PET data. These sources were synchronized, with their amplitudes peaking almost simultaneously. Both PET-independent and PET-weighted LORETA results suggest that the aSSR is: (1) the result of a reverberating network with two or more groups of sources that recurrently excite each other or (2) the result of sequential auditory processing through various levels of a hierarchical network. In contrast, the PET-weighted MinNorm results suggest that the 40-Hz response represents simultaneous activation over widely spaced areas of the brain, perhaps due to synchronization of gamma-band activity to a common neural clock.

Blood ammonia levels and hepatic encephalopathy

The importance of measurements of the blood ammonia concentration in the evaluation of patients with known or suspected hepatic encephalopathy (HE) is still disputed in spite of a general acknowledgment that ammonia is important in the pathogenesis of the disorder. Several recent studies have suggested that it is not necessary to utilize arterial blood when measuring ammonia in the blood. Venous blood or a computation of the partial pressure of ammonia gas in blood samples may suffice. The value of blood ammonia measurements is limited by the fact that this is not the variable that is the most important. Ideally, one would like to know how much ammonia enters the brain, not how much is in the blood. The blood-brain barrier (BBB) is the critical and poorly understood element in this relationship. Although both ammonia in the gas and ionic forms cross the BBB, the ease with which this movement occurs is significantly higher in patients with HE. In the absence of simple methods to measure the brain ammonia metabolic rate and to assess the BBB to ammonia in conjunction with measuring the blood ammonia concentration, the variables that would be the most desirable to measure, the use of arterial and/or venous blood measurements needs to be coupled with a complete understanding of the physiology of cerebral ammonia metabolism.

Human testing of pesticides: ethical and scientific considerations

I reviewed ethical and scientific aspects of 6 human pesticide-dosing studies submitted to the Environmental Protection Agency (EPA) for consideration during the pesticide reregistration process. All had serious ethical or scientific deficiencies-or both-including unacceptable informed consent procedures, unmanaged financial conflicts of interest, inadequate statistical power, inappropriate test methods and endpoints, and distorted results. Given today's knowledge of the effects of pesticides, there is no assurance that any such study can be completely free of short-term risks, long-term risks, or both. Therefore, there is no basis for allowing pesticide studies to continue or for using them during the pesticide reregistration process. An EPA committee that is free from political and financial conflicts of interest should review this practice.

PET imaging of the 40 Hz auditory steady state response

The auditory steady state response (aSSR) is an oscillatory electrical potential recorded from the scalp induced by amplitude-modulated (AM) or click/tone burst stimuli. Its clinical utility has been limited by uncertainty regarding the specific areas of the brain involved in its generation. To identify the generators of the aSSR, 15O-water PET imaging was used to locate the regions of the brain activated by a steady 1 kHz pure tone, the same tone amplitude modulated (AM) at 40 Hz and the specific regions of the brain responsive to the AM component of the stimulus relative to the continuous tone. The continuous tone produced four clusters of activation. The boundaries of these activated clusters extended to include regions in left primary auditory cortex, right non-primary auditory cortex, left thalamus, and left cingulate. The AM tone produced three clusters of activation. The boundaries of these activated clusters extended to include primary auditory cortex bilaterally, left medial geniculate and right middle frontal gyrus. Two regions were specifically responsive to the AM component of the stimulus. These activated clusters extended to include the right anterior cingulate near frontal cortex and right auditory cortex. We conclude that cortical sites, including areas outside primary auditory cortex, are involved in generating the aSSR. There was an unexpected difference between morning and afternoon session scans that may reflect a pre- versus post-prandial state. These results support the hypothesis that a distributed resonating circuit mediates the generation of the aSSR.

Functional imaging during covert auditory attention in multiple sclerosis

Recent literature suggests that the brain in multiple sclerosis (MS) undergoes reorganization that subserves the performance of visual and motor tasks. We identified sites of cerebral activity in 16 MS patients while performing a covert attention (CA) task, presented in the auditory modality. Positron emission tomography (PET) revealed activation of rostral/dorsal anterior cingulate cortex (ACC) in normal subjects studied previously. Activity in this region was not significant in MS patients, but there was a large region of activity in superior temporal cortex. Decreased activation of frontal attentional networks and greater activity in sensory/perceptual cortical areas (auditory association cortex) suggests a reduction of transmission along white matter tracts connecting these regions. This study demonstrates cingulate hypoactivity and cerebral reorganization during auditory attention in MS.

Mapping the neural systems that mediate the Paced Auditory Serial Addition Task (PASAT)

The paced auditory serial addition task (PASAT), in which subjects hear a number-string and add the two most-recently heard numbers, is a neuropsychological test sensitive to cerebral dysfunction. We mapped the brain regions activated by the PASAT using positron emission tomography (PET) and 15O-water to measure cerebral blood flow. We parsed the PASAT by mapping sites activated by immediate repetition of numbers and by repetition of the prior number after the presentation of the next number in the series. The PASAT activated dispersed non-contiguous foci in the superior temporal gyri, bifrontal and biparietal sites, the anterior cingulate and bilateral cerebellar sites. These sites are consistent with the elements of the task that include auditory perception and processing, speech production, working memory, and attention. Sites mediating addition were not identified. The extent of the sites activated during the performance of the PASAT accounts for the sensitivity of this test and justifies its use in a variety of seemingly disparate conditions.

Positron emission tomography in the study of hepatic encephalopathy

Positron emission tomography (PET) is a powerful and versatile tool for the investigation of hepatic encephalopathy (HE). This nuclear medicine imaging technique produces quantitative images of the distribution of a radiopharmaceutical at one or more times after its administration. Thus, PET images can be used as data in mathematical models of physiologically important processes, including cerebral blood flow, an index of neural activity, or glucose and ammonia metabolism. Using PET, we have demonstrated abnormalities in all of these processes in patients, even though many had only minimal HE. In HE patients we have found increases in the cerebral ammonia metabolic rate, because of hyperammonemia and an increase in the permeability of the blood-brain barrier to ammonia and abnormal patterns of blood flow and glucose metabolism. In a recent collaborative study, alterations in the resting glucose metabolic rate were found to have significant correlations with a variety of neuropsychological tests used to detect mild HE including Trailmaking A and B, symbol-digit, and other tests. Activation techniques have not yet been applied to map sites affected by HE, but recent data using the paced serial auditory addition test and an auditory continuous performance task have proven to be sensitive indicators in minimally impaired patients. The full potential of PET to evaluate neurotransmitter function is as yet unrealized.

Brain imaging of the effects of lidocaine on tinnitus

Using a single-blind placebo-controlled design, we mapped lidocaine related changes in neural activity, measured by regional cerebral blood flow (rCBF) with (15)O-H(2)O positron emission tomography. Intravenous lidocaine produced both increases and decreases in the loudness of tinnitus. The change in tinnitus loudness was associated with a statistically significant change in neural activity in the right temporal lobe in auditory association cortex. Decreases in tinnitus loudness resulted in larger changes in rCBF than increases. The unilateral activation pattern associated with tinnitus, in contrast with the bilateral activation produced by a real sound, suggests that tinnitus originates in the central auditory system rather than the cochlea. In addition, generalized lidocaine effects were found in the basal ganglia, thalamus, and a region spanning the Rolandic fissure.

PET imaging of the normal human auditory system: responses to speech in quiet and in background noise

The neural mechanisms involved in listening to sentences, and then detecting and verbalizing a specific word are poorly understood, but most likely involve complex neural networks. We used positron emission tomography to identify the areas of the human brain that are activated when young, normal hearing males and females were asked to listen to a sentence and repeat the last word from the Speech in Noise (SPIN) test. Listening conditions were (1) Quiet, (2) Speech, (3) Noise, and (4) SPIN with stimuli presented monaurally to either the left ear or the right ear. The least difficult listening task, Speech, resulted in bilateral activation of superior and middle temporal gyrus and pre-central gyrus. The Noise and SPIN conditions activated many of the same regions as Speech alone plus additional sites within the cerebellum, thalamus and superior/middle frontal gyri. Comparison of the SPIN condition versus Speech revealed additional activation in the right anterior lobe of the cerebellum and right medial frontal gyrus, near the cingulate. None of the left ear-right ear stimulus comparison revealed any significant differences except for the SPIN condition that showed greater activation in the left superior temporal gyrus for stimuli presented to the right ear. No gender differences were observed. These results demonstrate that repeating the last word in a sentence activates mainly auditory and motor areas of the brain when Speech is presented, whereas more difficult tasks, such as SPIN or multi-talker Noise, activate linguistic, attentional, cognitive, working memory, and motor planning areas.

Correlations between cerebral glucose metabolism and neuropsychological test performance in nonalcoholic cirrhotics

Many cirrhotics have abnormal neuropsychological test scores. To define the anatomical-physiological basis for encephalopathy in nonalcoholic cirrhotics, we performed resting-state fluorodeoxyglucose positron emission tomographic scans and administered a neuropsychological test battery to 18 patients and 10 controls. Statistical parametric mapping correlated changes in regional glucose metabolism with performance on the individual tests and a composite battery score. In patients without overt encephalopathy, poor performance correlated with reductions in metabolism in the anterior cingulate. In all patients, poor performance on the battery was positively correlated (p < 0.001) with glucose metabolism in bifrontal and biparietal regions of the cerebral cortex and negatively correlated with metabolism in hippocampal, lingual, and fusiform gyri and the posterior putamen. Similar patterns of abnormal metabolism were found when comparing the patients to 10 controls. Metabolic abnormalities in the anterior attention system and association cortices mediating executive and integrative function form the pathophysiological basis for mild hepatic encephalopathy.

Hepatic encephalopathy

Many patients with cirrhosis of the liver who appear to be overtly normal, using standard bedside examination techniques, test in the impaired range on one or more neuropsychological tests. These impairments affect the quality of life. Improvement in affected cognitive domains and the quality of life may follow the institution of treatment.

Effects of background noise on audiometric thresholds during positron emission tomography: passive and active noise-reduction

Position emission tomography (PET) is used to assess the functional activity of the human auditory brain; however, the activity detected by PET could be affected by ambient acoustic noise from the PET equipment. To evaluate these effects, we compared behavioural thresholds in the PET camera with those measured in an audiometric sound booth. Thresholds were measured with: (i) ER2 earphones, (ii) ER2 earphones + Cabot earmuffs, (iii) ER2 earphones + Bose Series II Aviation Headset with active noise-reduction off, and (iv) ER2 earphones + Bose Series II Aviation Headset with active noise-reduction on. Overall ambient noise level in the camera was 73 dB SPL and the maximum octave-band SPL was 68 dB SPL at 250 Hz. Threshold elevations in the PET camera were greatest with ER2 (17 dB, 125 Hz) earphones and lowest with ER2 earphones + Bose Series II Aviation Headset (8 dB at 250 Hz) with active noise-reduction. Thus, PET scanner noise had little or no effect on threshold when stimuli were presented through ER2 earphones covered with an activated Bose Series II Aviation Headset.

The functional anatomy of gaze-evoked tinnitus and sustained lateral gaze

OBJECTIVE

To identify neural sites associated with gaze-evoked tinnitus (GET), an unusual condition that may follow cerebellar-pontine angle surgery.

METHODS

The authors examined eight patients with GET and used PET to map the neural sites activated by lateral gaze in them and seven age- and sex-matched control subjects.

RESULTS

In patients with GET, tinnitus loudness and pitch increased with lateral gaze and, to a lesser extent, up and down gaze. Evidence for neural activity related to GET was seen in the auditory lateral pontine tegmentum or auditory cortex. GET-associated nystagmus appears to activate the cuneus and cerebellar vermis. These sites were found in addition to an extensive network that included frontal eye fields and other sites in frontal, parietal, and temporal cortex that were activated by lateral gaze in seven control subjects and the patients. The unilateral deafness in patients with GET was associated with expansion of auditory cortical areas responsive to tones delivered to the good ear. In addition to GET, unilateral deafness, end-gaze nystagmus, and facial nerve dysfunction were common.

CONCLUSIONS

Patients with GET have plastic changes in multiple neural systems that allow neural activity associated with eye movement, including those associated with the neural integrator, to stimulate the auditory system. Anomalous auditory activation is enhanced by the failure of cross-modal inhibition to suppress auditory cortical activity. The time course for the development of GET suggests that it may be due to multiple mechanisms.

Pesticides and parkinsonism: is there an etiological link?

Two hundred years ago, Parkinson's disease was rare. Now, it is the second most common neurodegenerative disorder. A recent twin study showed clearly that genetic factors play a minor role in determining whether an individual develops this disease, rekindling an interest in the etiological significance of environmental factors. Earlier studies had shown that a MPTP, a contaminant found in some illegal drugs, caused Parkinson's disease. This provided the original impetus for the pesticide hypothesis. Similarities between MPTP and pesticides coupled with epidemiological and animal studies have strengthened the possible link between pesticide exposure and the subsequent development of Parkinson's disease.

Neuroanatomy of tinnitus

We tested the hypothesis that tinnitus was due to excessive spontaneous activity in the central auditory system by seeking cerebral blood flow (CBF) changes that paralleled changes in the loudness of tinnitus in patients able to alter the loudness of their tinnitus. We found CBF changes in the left temporal lobe in patients with right ear tinnitus, in contrast to bilateral temporal lobe activity associated with stimulation of the right ear. The tones activated more extensive portions of the brain in patients than controls. We conclude that tinnitus is not cochlear in origin and associated with plastic transformations of the central auditory system. We suggest that tinnitus arises as a consequence of these aberrant new pathways and may be the auditory system analog to phantom limb sensations in amputees.

The functional anatomy of the normal human auditory system: responses to 0.5 and 4.0 kHz tones at varied intensities

Most functional imaging studies of the auditory system have employed complex stimuli. We used positron emission tomography to map neural responses to 0.5 and 4.0 kHz sine-wave tones presented to the right ear at 30, 50, 70 and 90 dB HL and found activation in a complex neural network of elements traditionally associated with the auditory system as well as non-traditional sites such as the posterior cingulate cortex. Cingulate activity was maximal at low stimulus intensities, suggesting that it may function as a gain control center. In the right temporal lobe, the location of the maximal response varied with the intensity, but not with the frequency of the stimuli. In the left temporal lobe, there was evidence for tonotopic organization: a site lateral to the left primary auditory cortex was activated equally by both tones while a second site in primary auditory cortex was more responsive to the higher frequency. Infratentorial activations were contralateral to the stimulated ear and included the lateral cerebellum, the lateral pontine tegmentum, the midbrain and the medial geniculate. Contrary to predictions based on cochlear membrane mechanics, at each intensity, 4.0 kHz stimuli were more potent activators of the brain than the 0.5 kHz stimuli.

Positron emission tomography in the study of hepatic encephalopathy

Positron-emission tomography (PET) is a quantitative technique that produces images of biological or physiological processes. The nature of the image depends on the tracer used: common tracers used to study HE include 18F-fluordeoxyglucose, a marker of glucose metabolism; 15O-water, a marker of cerebral blood flow; and 13N-ammonia, a marker of ammonia metabolism. Combined blood flow and ammonia metabolism studies can be used to calculate the permeability surface area product for ammonia at the blood brain barrier. To take full advantage of PET, the data should be analyzed using one of the several sophisticated image processing and analysis techniques that are available. Thus, PET is an ideal technique to evaluate ammonia metabolism and, because of a close linkage of blood flow and glucose metabolism with neural activity, to investigate the neural response to drugs and other treatments and to examine neural systems that mediate specific tasks that are impaired in patients with HE.

Modulation of tinnitus by voluntary jaw movements

OBJECTIVE

The authors describe symptoms and population characteristics in patients with tinnitus who report the ability to control the loudness of their tinnitus by performing voluntary movements.

DESIGN

The authors used a questionnaire.

SETTING

The study was conducted at a tertiary care center.

PATIENTS

Respondents have the self-reported ability to control the loudness of their tinnitus by performing voluntary movements.

RESULTS

The authors describe symptoms and population characteristics in 93 patients with tinnitus (83% men, 17% women) who report the ability to control the loudness of their tinnitus by performing voluntary movements: 85% of these report jaw movements and 9% report eye movements affect their tinnitus. In the jaw-movement group, tinnitus loudness increased in 90%. Jaw movement affected the pitch in 51% with an increase in pitch reported by 90%. Other maneuvers, such as pressure applied to the head, affected tinnitus in many subjects. Tinnitus had a major impact on the lives of the authors' respondents: 27% registered mild to moderate depression and 8% moderate to severe depression as shown by the Beck Depression Inventory.

CONCLUSIONS

The ability to modulate tinnitus by performing voluntary somatosensory or motor acts is likely the result of plastic changes in the brains of these patients with the development of aberrant connections between the auditory and sensory-motor systems. The strong predominance of men in the sample suggests the presence of a gender-specific factor that mediates these changes.

Sex differences in brain regions activated by grammatical and reading tasks

Do the brains of men and women show similar patterns of functional organization for language, or are men more strongly lateralized? We used PET to measure cerebral blood flow (CBF) as men and women read real and nonce verbs, and produced past tense forms. While the overall patterns of reaction time, error, and brain activation were similar, there were also significant sex-related differences in CBF patterns. During the past tense generation tasks, men showed left-lateralized activation while women recruited bilateral perisylvian cortex, confirming differences in functional laterality. During all tasks, women showed higher activation in occipital and/or cerebellar regions, suggesting differences in basic reading strategies. We conclude that sex differences in functional cortical organization exist in the absence of significant behavioral differences.

Functional neuroimaging of attention in the auditory modality

Previous functional neuroimaging studies of attention have emphasized the visual modality. We developed an auditory version of the continuous performance test (CPT) that included simple, focused and divided attention conditions. Positron emission tomographic (PET) scans were acquired during CPT performance in normal young adults and then submitted to statistical parametric mapping. Simple attention brought about a large region of activation involving the anterior cingulate gyrus and the right anterior/mesial frontal lobe. Focused and divided attention CPT conditions were compared but there were few significant differences. The findings are consistent with activation of an anterior attention network during auditory attention, without involvement of posterior attention structures which are more likely to vary in accordance with sensory modality.

The functional neuroanatomy of tinnitus: evidence for limbic system links and neural plasticity

We used PET to map brain regions responding to changes in tinnitus loudness in four patients who could alter tinnitus loudness by performing voluntary oral facial movements (OFMs). Cerebral blood flow was measured in four patients and six controls at rest, during the OFM, and during stimulation with pure tones. OFM-induced loudness changes affected the auditory cortex contralateral to the ear in which tinnitus was perceived, whereas unilateral cochlear stimulation caused bilateral effects, suggesting a retrocochlear origin for their tinnitus. Patients, compared with controls, showed evidence for more widespread activation by the tones and aberrant links between the limbic and auditory systems. These abnormal patterns provide evidence for cortical plasticity that may account for tinnitus and associated symptoms. Although audiologic symptoms and examinations of these patients were typical, the unusual ability to modulate tinnitus loudness with an OFM suggests some caution may be warranted in generalizing these findings.

An image of the brain in patients with liver disease

As imaging techniques have advanced from those that are based on tissue density and hence are strictly anatomical in nature, to include those based on physiologic and biochemical factors, the expectation has grown that imaging will be used to evaluate patients with diseases that are caused by disordered metabolism. In this review, recent advances in neuroimaging are discussed that have led to new insights into the pathophysiology of hepatic encephalopathy, a common condition that is caused by the failure of the liver to remove metabolic wastes from the blood.

Attentional systems and the allocation of cerebral resources in reading and grammatical tasks

To evaluate the possible role of attentional centers as modulators of neural networks that mediate visual tasks involving reading and grammatical manipulations of verbs, we measured cerebral blood flow (CBF) using positron emission tomography (PET), and reaction times as subjects read verbs, "nonce verbs" such as jelt or brep, and formed past tenses of regular, irregular and nonce verbs after viewing their stems. Statistical parametric maps (SPMs) showed significant activation of the pulvinar in the read verb irregular, and generate nonce past tense tasks, compared to rest. This was confirmed by a post hoc ANOVA of CBF values from a discrete locus in the pulvinar (p = .0000417). Functional links between the pulvinar and other brain regions were shown by high correlations of CBF in the pulvinar with CBF in brain regions known to have anatomical connections to the pulvinar, particularly those mediating vision. There was also a significant relationship between task-specific reaction times and rest minus task CBF differences in a multiple regression analysis that included CBF values from the pulvinar, superior colliculus plus reticular formation, and the anterior cingulate, known attentional centers (p = .021, r2 = 0.99). Regression analyses relating reaction time to the amount of brain activated (pixels in the SPMs) and the degree of activation of the pixels (mean Z score) yielded p values of .078 and .074, respectively. Our data provide direct experimental evidence to support the hypothesis that attentional centers are activated in proportion to the complexity of visually mediated language tasks and that the centers that mediate attention modulate the activity of task-specific neural networks.

Positron-emission tomographic localization of abnormalities of brain metabolism in patients with minimal hepatic encephalopathy

Many patients with compensated cirrhosis without overt hepatic encephalopathy have deficits in visual-spatial perception, a condition we call minimal hepatic encephalopathy. Five patients with alcohol-induced cirrhosis and nine control subjects underwent positron-emission tomographic imaging of the brain with 18F-fluorodeoxyglucose. Patients also underwent neuropsychological and clinical chemistry tests. The patients had mild arterial hyperammonemia (62 +/- 13 mumol/L, range = 11 to 35 mumol/L) and other abnormalities typical of patients with cirrhosis. The patients' mean percentile scores on the digit symbol and block design subtests, from the Wechsler Adult Intelligence Scale (revised), and Purdue pegboard test were 11 +/- 7, 24 +/- 7 and 7 +/- 8 (right hand). Tests of vocabulary, memory, and new learning were normal. The technique of statistical parametric mapping was used to identify regions where cerebral 18F-fluorodeoxyglucose uptake and metabolism were abnormal. We noted significant reductions in the cingulate gyrus, a center mediating attention, target analysis and response formulation and significant increases in visual associative regions subserving motion and color perception and object orientation. We suggest that minimal hepatic encephalopathy is due to a deficit in the detection and formulation of responses to visual stimuli, a function of the cingulate, which is a part of the anterior attentional system of the brain. Increases in 18F-fluorodeoxyglucose metabolism may be compensatory. These studies show that brain regions differ in their sensitivity to the agents that cause hepatic encephalopathy and that positron-emission tomography is useful in studying the pathophysiology of this disorder.