Introducing navigated transcranial magnetic stimulation as a refined brain mapping methodology

A major intrinsic limitation of transcranial magnetic stimulation (TMS) to map the human brain lies in the unclear relationship between the position of the stimulating coil on the scalp and the underlying stimulated cortex. The relationship between structure and function as the major feature constituting a brain mapping modality can therefore not be established. Recent advances in image processing allowed us to refine TMS by combining magnetic resonance imaging (MRI) modalities with TMS using a neuronavigation system to measure the position of the stimulating coil and map this position onto a MRI data set. This technique has several advantages over recent TMS mapping strategies. The position of the coil on the scalp can be held constant as verified by real time visual guidance. When evaluating higher cortical functions, the relationship between underlying cortical anatomy and the scalp stimulation site can be accurately assessed. Cortical motor output maps can be easily obtained for preoperative planning and decision making for mass lesions near rolandic cortex in patients. In conclusion, navigated TMS is a reliable alternative for localizing cortical functions and therefore may be a useful adjunct or in selected patients even a helpful alternative to other functional neuroimaging methods.

Hemodynamic changes in simple partial epilepsy: a functional MRI study

We performed functional MRI (fMRI) on a patient with a mass lesion while she happened to experience a simple partial seizure. We used regional T2* signal changes to localize seizure-related hemodynamic changes. Seizure activity was associated with changes in MR signal in different regions that showed sequential activation and deactivation. Our study has shown that epileptic activity leads to changes in cerebral hemodynamics. In selected patients, therefore, it might be possible to use fMRI as a noninvasive tool to detect and investigate cortical patterns of activation associated with seizure activity.

Photosensitive epilepsy studied by functional magnetic resonance imaging and magnetic resonance spectroscopy

PURPOSE

To study metabolic and hemodynamic correlates of photic stimulation-triggered discharges.

METHODS

Simultaneous EEG, functional MRI (tMRI) and magnetic resonance spectroscopy (MRS) were performed in nine patients with photosensitive epilepsy and in 12 normal subjects.

RESULTS

Prominent visual cortex activation was seen in all normal subjects and patients, and no tMRI-registered hemodynamic abnormalities were correlated with the brief photoparoxysmal spike-wave activity evoked in the photosensitive patients. However, irrespective of the presence of a spike-wave response to the photic stimulation, the photosensitive patients showed four findings not seen in the normal subjects: (a) slightly, but significantly, elevated lactate levels in the occipital cortex in the resting state; (b) an increased area of visual cortical activation with photic stimulation; (c) simultaneous with the occipital cortex stimulus-induced increased fMRI signal, there were noncontiguous areas of signal attenuation most prominent in perirolandic regions; and (d) a marked decrement (undershoot) of fMRI signal intensity immediately after the photic stimulation in the occipital cortex and in the region of the posterior cingulate gyrus.

CONCLUSIONS

These findings suggest abnormal interictal metabolism and increased vascular reactivity in the photosensitive patients.

Transcranial magnetic stimulation identifies upper motor neuron involvement in motor neuron disease

OBJECTIVE

To evaluate the sensitivity of transcranial magnetic stimulation (TMS) to identify upper motor neuron involvement in patients with motor neuron disease.

BACKGROUND

Diagnosis of ALS depends on upper and lower motor neuron involvement. Lower motor neuron involvement may be documented with electromyography, whereas definite evidence of upper motor neuron involvement may be elusive. A sensitive, noninvasive test of upper motor neuron function would be useful.

METHODS

TMS and clinical assessment in 121 patients with motor neuron disease.

RESULTS

TMS revealed evidence of upper motor neuron dysfunction in 84 of 121 (69%) patients, including 30 of 40 (75%) patients with only probable upper motor neuron signs and unsuspected upper motor neuron involvement in 6 of 22 (27%) patients who had purely lower motor neuron syndromes clinically. In selected cases, upper motor neuron involvement identified with TMS was verified in postmortem examination. Increased motor evoked potential threshold was the abnormality observed most frequently and was only weakly related to peripheral compound muscle action potential amplitude. In a subset of 12 patients reexamined after 11+/-6 months, TMS showed progression of abnormalities, including progressive inexcitability of central motor pathways and loss of the normal inhibitory cortical stimulation silent period.

CONCLUSIONS

TMS provides a sensitive means for the assessment and monitoring of excitatory and inhibitory upper motor neuron function in motor neuron disease.

Hemodynamic and metabolic aspects of photosensitive epilepsy revealed by functional magnetic resonance imaging and magnetic resonance spectroscopy

PURPOSE

To study in humans the hemodynamic and metabolic consequences of both photic stimulation-triggered and spontaneous generalized epileptiform discharges.

METHODS

Simultaneous EEG, functional magnetic resonance imaging (fMRI) and MR spectroscopy were performed in a 1.5-T scanner in 16 patients with generalized epilepsy, including nine with photosensitive epilepsy, and 12 normal subjects.

RESULTS

With a flash stimulation duration of 2 s, prominent visual cortex activation was seen in all normals and patients. There were no fMRI-registered hemodynamic abnormalities found in relation to the brief photoparoxysmal spike-wave activity evoked in the photosensitive patients. However, irrespective of the presence of a spike-wave response to the photic stimulation, the photosensitive patients showed four unique findings compared with normals: (a) slightly, but significantly, increased lactate levels in the occipital cortex in the resting state, (b) an increased area of visual cortical activation with photic stimulation, (c) simultaneous with the occipital cortex stimulus-induced increased fMRI signal there were noncontiguous areas of signal attenuation most prominent in perirolandic regions, and (d) a marked decrement (undershoot) of fMRI signal intensity immediately after the photic stimulation in the occipital cortex and in the region of the posterior cingulate gyrus.

CONCLUSIONS

These findings suggest abnormal interictal metabolism and increased vascular reactivity in the photosensitive patients.

Accuracy of EEG dipole source localization using implanted sources in the human brain

OBJECTIVES

The location of electrical sources in the brain can be estimated by calculating inverse solutions in which the location, amplitude and orientation of the electrical sources are fitted to the scalp EEG. To assess localization accuracy of the moving dipole inverse solution algorithm (ISA), we studied two patients who had depth electrodes implanted for presurgical planning of epilepsy surgery.

METHODS

Artificial dipoles were created by connecting a single sine wave pulse generator to different pairs of electrodes in multiple orientations and depths. Surface EEG recordings of the resulting pulses were evaluated with the ISA using a 4-shell spherical head model and plotted on the subjects' MRI. Dipole localization errors were evaluated with respect to the number of averaged pulses, different electrode montages and different dipole locations and orientations.

RESULTS

Dipoles located at 40-57 mm from the scalp surface had localization errors that were greater than those located at 62-85 mm. Localization accuracy improved with increasing numbers of pulses and recording electrodes. Results with a standard 10-20 array of 21 electrodes showed an average localization error of 17 mm, whereas 41 electrodes improved this to 13 mm. Mean angular errors were 31 and 30 degrees, respectively.

CONCLUSIONS

The ISA was able to differentiate between tangential and radial dipoles. We conclude that our implementation of the ISA is a useful and sound method for localizing electrical activity in the brain.

Accuracy of electroencephalographic dipole localization of epileptiform activities associated with focal brain lesions

We evaluated the accuracy of an electroencephalographic (EEG) localization technique (dipole inverse solution) in a consecutive series of 12 focal intracerebral lesions of diverse etiologies whose EEGs showed interictal spike activity or rhythmic activity at seizure onset. The calculated equivalent dipole was plotted on three axes in the patients' magnetic resonance image, and the distance between the dipole and the lesion margin was measured assuming that the shell of the lesion constituted an epileptogenic region. In all cases the dipole localized closer than 0.8 cm to the nearest lesion margin. In addition, we compared the postsurgical outcome of 6 patients to the dipole localization and the resection margins. In all 6 patients in whom the dipole, and hence the estimated seizure generator, was removed the surgical outcome was favorable. We conclude that the inverse solution algorithm is a promising method for using the scalp EEG to localize the sources of electrical activity in the human brain in routine clinical electroencephalography and provides three-dimensional data not available from conventional analysis.

Evaluation and prognostication in coma

Electroencephalography (EEG) and evoked potential (EP) studies are neurophysiologic techniques which provide information on physiological state and response to therapy, and may aid diagnosis and prognosis. Serial studies or continuous monitoring may enable changes to be detected prior to irreversible deterioration in the patient's condition. Current computer technology allows simultaneous display and correlation of electrophysiologic parameters, cardiovascular state and ICP. Continuous EEG monitoring in the ICU has been shown to have a decisive or contributing impact on medical decision making in more than three-quarters of patients. In addition, continuous EEG monitoring has revealed previously unsuspected non-convulsive seizures in two-thirds of patients. Somatosensory and auditory EPs can provide useful prognostic information in coma patients, however, these tests are etiologically non-specific and must be carefully integrated into the clinical situation. Motor EPs offer a potentially useful tool for evaluating motor system abnormalities in the ICU. Thus, neurophysiologic tests are established monitoring tools in the neurological intensive care unit.

Stereotactic transcranial magnetic stimulation: correlation with direct electrical cortical stimulation

OBJECTIVE

To evaluate stereotactic transcranial magnetic stimulation (TMS) as a tool for presurgical functional mapping of human motor cortex.

METHODS

Transcranial magnetic stimulation using a frameless stereotactic system was performed in two patients with tumors near the central sulcus. TMS motor function maps were plotted on the patients' three-dimensional volumetric magnetic resonance imaging data and compared with direct electrical cortical stimulation at surgery with the patient under local anesthesia.

RESULTS

Stereotactic TMS was well tolerated by both patients and was consistent with known somatotopic representation of human motor cortex. The results demonstrated a good correlation between the TMS and electrical cortical stimulation maps, with all TMS responses eliciting more than 75% of the maximum motor evoked potential falling within 1 cm of the electrical cortical stimulation site.

CONCLUSIONS

Our findings indicate that stereotactic TMS is feasible and can provide accurate noninvasive localization of cortical motor function. It may prove to be a useful method for presurgical planning.

Functional magnetic resonance imaging and transcranial magnetic stimulation: complementary approaches in the evaluation of cortical motor function

Functional magnetic resonance imaging (fMRI) and transcranial magnetic stimulation (TMS) represent different approaches to mapping the motor cortex. fMRI identifies areas of hemodynamic changes during task performance while TMS provides electrophysiologic data concerning the localization and density of cortical motoneurons. Here we define the spatial correlation between fMRI and TMS maps and compared them with direct electrical cortical stimulation (ECS). We performed fMRI at 1.5 T on 3 normal subjects and 2 patients with mass lesions near the central sulcus using a multislice, asymmetric, spin-echo, echo-planar pulse sequence during the performance of a motor task. We also performed focal TMS with surface EMG recordings from the muscles primarily involved in the fMRI task. We coregistered the stimulation sites in real time with the fMRI maps using a frameless stereotactic system. In both patients we also performed ECS of the cortex during surgery under local anesthesia. fMRI maps were validated by the electrophysiologic data both pre- and intraoperatively. Our results suggest that regions of fMRI activation correspond spatially to areas of highest motoneuron density as demonstrated by electrophysiologic techniques.

Periodic lateralized epileptiform discharges--a critical review

It is the purpose of this review to critically consider and organize the literature dealing with the ephemeral electroencephalographic (EEG) pattern periodic lateralized epileptiform discharges (PLEDs). Although the retrospective nature of these studies limits their ability to discuss accurately the clinical and pathophysiological aspects of this EEG entity, the available data strongly emphasize stroke as the dominant etiology and its high association with seizures. Recent evidence, particularly from functional neuroimaging studies, strongly suggests that PLEDs might reflect a key pattern for focal hyperexcitability in the penumbra zone of ischemic stroke. The authors prefer to consider PLEDs as an EEG signature of a dynamic pathophysiological state in which unstable neurobiological processes create an ictal-interictal continuum, with the nature of the underlying neuronal injury, the patient's preexisting propensity to have seizures, and the co-existence of any acute metabolic derangements all contributing to whether seizures occur or not. This review underlines the need for further sophisticated prospective controlled studies implementing early continuous EEG monitoring in order to contribute to an understanding of the incidence, dynamics, and relevance of this pattern.

Assessment of cortical motor output: compound muscle action potential versus twitch force recording

To determine whether motor evoked potential (MEP) amplitude and area are accurate measurements of the magnitude of response to magnetic cortical stimulation, we simultaneously recorded the twitch and MEP in the first dorsal interosseous muscle of 8 normal subjects. Consecutive stimuli were delivered at increasing stimulus intensities (SI) or with increasing levels of background voluntary muscle contraction (BVC). There was stimulus to stimulus variability in MEP amplitude, area and twitch force. At low SI and at low levels of background contraction, there was a good correlation between twitch amplitude and MEP amplitude and area (r = 0.6-0.96, P < 0.005). Increasing either variable caused the correlation to decrease significantly (r = 0.02-0.31, P > 0.01). With increasing SI, MEP amplitude and area plateaued but twitch force continued to increase. A similar pattern was observed with higher levels of background muscle contraction although in some subjects a second increase in MEP amplitude and area was seen. Collision experiments demonstrated that the amplitude of the EMG activity resulting from repetitive motoneuron firing increased as SI was increased. This is due to multiple descending volleys which result in repetitive firing of some spinal motoneurons. Rapid, repetitive firing of some motor units is likely to result in phase cancellation and, therefore, the MEP amplitude, and to a lesser extent area, do not accurately reflect the net motor output.

Significance of spontaneous epileptiform abnormalities associated with a photoparoxysmal response

Spontaneous epileptiform abnormalities (SEAs) are reported to occur in up to 65% of patients with a photoparoxysmal response (PPR). Although the PPR is usually assumed to indicate primary generalized epilepsy, the clinical significance of associated SEAs is not known. We conducted the first study designed to correlate seizure classification with type of SEA in photosensitive patients. We examined seizure classifications and SEAs in 115 consecutive patients who had a PPR. A PPR was the only epileptiform abnormality in 47 patients (41%). Twenty-seven patients (24%) had focal SEAs and 41 (36%) had only generalized SEAs. Seventeen patients (15%) had partial seizures and 40 (35%) had only generalized seizures. Seizure classification was strongly associated with type of SEA (p < 0.0001). Patients with focal SEAs tended to have partial seizures, while patients with generalized SEAs tended to have only generalized tonic-clonic or absence seizures. Also, the presence of SEAs was significantly associated with a history of seizures (p < 0.0001), compared with patients who had a PPR but no SEAs. Although the PPR is often presumed to signify primary generalized epilepsy, most patients with a PPR and focal SEAs have partial seizures.

Crossed inhibition in the human motor system

We used transcranial magnetic stimulation in humans to investigate the effect of focal unilateral stimulation of the motor cortex on the function of the contralateral motor cortex. Surface-recorded, rectified, averaged electromyography (EMG) showed relative silent periods in small hand muscles at 35-64 and 123-158 ms following ipsilateral cortical stimulation over the hand area. The first inhibitory phase started 11 ms after the minimum corticospinal conduction time from the contralateral cortex, appropriate for transcallosal conduction. Foot muscles (with focal stimulation over the ipsilateral hand area) also showed silent periods at 61-104 ms, indicating a marked spread of the inhibitory effect throughout the opposite motor cortex. H-reflex studies in the upper limb showed that this inhibitory effect was not mediated at the level of the alpha motoneuron. Single motor unit peristimulus time histogram studies in upper limb muscles showed inhibition similar to that seen in the surface recordings and no evidence of excitation following ipsilateral motor cortex stimulation. Transcranial magnetic stimulation performed with large circular coils centered at the vertex activates both excitatory and inhibitory processes bilaterally so that focal unilateral stimulation is preferable in detailed studies of motor system physiology.

Electrophysiologic monitoring in the intensive care unit

Electroencephalography (EEG) and evoked potential studies are established monitoring tools in the neurological intensive care unit (ICU). These neurophysiologic techniques provide information on physiological state and response to therapy, and may aid diagnosis and prognosis. Serial studies or continuous monitoring may enable changes to be detected prior to irreversible deterioration in the patient's condition. Current computer technology allows simultaneous display and correlation of electrophysiologic parameters, cardiovascular state and intracranial pressure (ICP). Continuous EEG monitoring in the ICU has been shown to have a decisive or contributing impact on medical decision making in more than three-quarters of patients. In addition, continuous EEG monitoring has revealed previously unsuspected non-convulsive seizures in one-third of patients. SEPs and BAEPs can provide useful prognostic information in coma-however, these tests are etiologically nonspecific and must be carefully integrated into the clinical situation. Motor evoked potentials offer a potentially useful tool for evaluating motor system abnormalities in the ICU.

Effects of routine hyperventilation on PCO2 and PO2 in normal subjects: implications for EEG interpretations

There are few data in the EEG literature describing the time course of hyperventilation-(HV) induced changes in blood gases, despite this being a routine activating procedure. We studied changes in blood gases and EEG in nine normal adult subjects before, during, and after HV. The mean PCO2 fell 18 mm Hg from the baseline during HV and recovered in 7 min. The mean PO2 rose 7 mmHg during HV and fell to 25 mm Hg below baseline 5 min after HV. The PCO2 recovery period is longer than is usually assumed in clinical EEG. The PO2 fall to a nadir at 5 min after the end of HV suggests that close attention should be paid to this period, as is confirmed by the re-buildup seen in moyamoya disease. Despite uniform changes in blood gases, the EEG median power frequency change showed marked variability; on average, it dropped by 1 Hz during HV and returned to baseline within 2 min of resumption of normal respiration. The EEG root-mean-square power showed a 200% increase during HV and also had returned to normal within 2 min.

Physiological motor asymmetry in human handedness: evidence from transcranial magnetic stimulation

We hypothesized that human handedness might be associated with measurable differences in the excitability of the motor system. We compared the thresholds for electromyographic activation of the left and right abductor pollicis brevis (APB) and biceps muscles in 30 left-handers and 30 right-handers, by varying the direction of a brief monophasic pulse in a circular electromagnetic coil centered over the vertex of the scalp. In right-handers, we found that the threshold for activation of muscles in the right arm was lower than the threshold for activation of corresponding muscles in the left arm. In left-handers, the reverse was true. Threshold asymmetry was influenced significantly by the consistency with which each subject used the writing hand to perform other motor tasks, and was not significant between non-consistent left-handers and right-handers. Our results indicate that human handedness, and in particular, consistency of hand preference, are associated with lateralized differences in the excitability of motor system projections activated by transcranial magnetic stimulation. Our findings might reflect physiological differences in corticospinal tract function or cortical motor representation.

Transcranial motor evoked potentials

History, methodology and description of recording motor action potentials elicited by magnetic stimulation of the cortex through the skull. Summary of clinical results published in the literature and those carried out by the author.

Facilitation of magnetic motor evoked potentials during the cortical stimulation silent period

We investigated the relationship between stimulus intensity and magnetic motor evoked potentials (MEPs) elicited 100 msec after a conditioning stimulus that was 25% of stimulator output above resting motor threshold (RMT) during tonic contraction of abductor pollicis brevis. In five subjects, MEPs elicited with stimuli less than 25% above RMT were inhibited during the EMG cortical stimulation silent period (CSSP) produced by the conditioning stimulus, relative to MEPs elicited with the test stimulus given at rest. However, increasing the intensity of the test stimulus increased the amplitude of MEPs elicited during the CSSP relative to MEPs elicited at rest, such that MEPs elicited with stimuli 30 to 45% above RMT were facilitated during the CSSP. Increasing the intensity of the test stimulus also increased the amplitude of MEPs elicited with paired stimulation at rest, and caused facilitation in one subject. Since facilitation of MEPs was never accompanied by shortening of MEP latency, our observations point to supraspinal facilitory mechanisms. We suggest that facilitation of MEPs during the CSSP reflects temporal and spatial summation of conditioning and test stimuli.

Ifosfamide causes a diazepam-sensitive encephalopathy

An encephalopathy characterized by confusion, stupor, and mutism frequently occurs during administration of the chemotherapeutic drug ifosfamide (IFX). We investigated two patients who developed encephalopathy during IFX infusion. Both exhibited a rapid and near-complete restoration of baseline mental status functioning concurrent with EEG improvement after administration of intravenous diazepam. We recommend an EEG and trial of benzodiazepines in patients with IFX encephalopathy.

Variability of motor potentials evoked by transcranial magnetic stimulation

We studied the effect of stimulus intensity, coil size, mental alertness and prestimulus muscle contraction on the variability of motor evoked potentials (MEPs) produced by magnetic cortical stimulation (MCS). In 5 healthy subjects we delivered MCS either with a circular coil centered at the vertex or a figure-8 coil centered over the motor cortex hand area, recording from first dorsal interosseous. With the subject at rest or exerting 5% maximum voluntary contraction, 30 consecutive stimuli were given at 4 stimulus intensities (SIs) in 10% increments above resting motor threshold. Concurrent mental arithmetic constituted mental alertness. Spectral analysis was performed on data from 300 consecutive stimuli. The variability of MEP response size was inversely related to stimulus intensity, prestimulus voluntary muscle contraction, the recruitment of motoneurons and the size of the field generated by the magnetic coil. The MEP variability was larger than and not correlated with the variability of the H-reflex. Fast Fourier transformation and cross-correlation analysis did not identify a consistent dominant frequency, suggesting that the variability in MEP size is essentially random. We suggest that the variability in MEP response is caused by constant, rapid, spontaneous fluctuations in corticospinal and segmental motoneuron excitability levels. Any maneuver that raises this level or increases the probability of motoneuron firing will decrease MEP variability.

Cortical and spinal motor excitability during the transcranial magnetic stimulation silent period in humans

We investigated the electromyographic silent period in abductor pollicis brevis (APB) and flexor carpi radialis muscles following transcranial magnetic stimulation of human motor cortex. In APB, we measured cortical stimulation silent period (CSSP) duration as a function of stimulus intensity, motor-evoked potential (MEP) amplitude and muscle twitch force. We used peri-stimulus-time histograms to study the effect of cortical stimulation on single-motor unit firing patterns. We compared F-waves, H-reflexes and magnetic MEPs elicited during the CSSP to control responses elicited at rest and during voluntary contraction. CSSP duration depended on the intensity of cortical stimulation. However, we found no relationship between CSSP duration and MEP amplitude or muscle twitch force, thus the CSSP is not dependent solely on Renshaw cell inhibition or on changes in Ia and Ib afferent activity following the cortically induced muscle twitch. At low intensities of stimulation, the interval to resumption of motor unit firing following the peak in the peri-stimulus-time histogram corresponding to MEP latency sometimes exceeded that which could be accounted for by the motor unit's firing rate prior to the stimulus, suggesting that synchronization of motor unit firing by cortical stimulation cannot account for the CSSP. We found brief inhibition of F-waves during the CSSP in some subjects, reflecting activation of inhibitory corticospinal projections or segmental effects. In contrast, we observed longer inhibition of H-reflexes during the CSSP in all subjects, perhaps resulting from presynaptic inhibition of Ia afferents. Magnetic MEPs also were inhibited during the CSSP, suggesting inhibition of cortical elements by transcranial magnetic stimulation.

Motor inhibition and excitation are independent effects of magnetic cortical stimulation

We administered magnetic cortical stimulation (MCS) during voluntary contraction of intrinsic hand muscles to 8 patients with motor neuron disease (MND), 5 patients with pure lower motor neuron syndromes (LMN), a patient with severe subacute sensory neuropathy (SSN), and 10 healthy volunteers. Patients with MND had clinical evidence of upper MND and elevated thresholds for (3 patients) or absence of (5 patients) motor evoked potentials (MEPs). MCS during sustained contraction inhibited electromyographic activity in 6 of 8 patients with MND, without preceding MEPs. MCS had no effect on the electromyogram (EMG) of the other 2 patients with MND. In normal subjects and patients with LMN, inhibition of EMG was never seen without a preceding MEP, regardless of stimulus intensity. In the patient with SSN, MCS elicited normal MEPs and inhibited the EMG in a pattern similar to normal subjects, whereas supramaximal electrical stimulation of median and ulnar nerves failed to inhibit the EMG despite normal M and F responses. Our findings indicate that the inhibitory effects of MCS on EMG are not dependent solely on changes in afferent feedback caused by the muscle twitch produced by the MEP, or on Renshaw cell inhibition. We suggest that some of the inhibitory and excitatory effects of MCS on the motor system are mediated by distinct cortical elements, which may have different susceptibilities to pathophysiological processes in MND.

Retinocalcarine function in Alzheimer's disease. A clinical and electrophysiological study

Impaired visual function in Alzheimer's disease (AD) could result from either precortical or cortical lesions, or both. In a parallel psychophysical study of visual function in AD, we found that contrast sensitivity function, color vision, stereoacuity, and backward masking were impaired relative to the performance of age-matched control subjects, whereas performance on a critical flicker fusion test was normal. The intent of the present study was to determine whether abnormalities of the retinocalcarine pathway contribute to visual dysfunction. We performed neuro-ophthalmological examinations on 38 patients with AD; from this group, 25 received additional psychophysical testing and 13 underwent electrophysiological testing. Clinical neuro-ophthalmological examinations, full-field electroretinograms, focal electroretinograms, and pattern visual evoked potentials were normal in all patients tested. There was no evidence of retinocalcarine abnormality specific to AD. We conclude that the visual impairment experienced by some patients with AD primarily results from involvement of the visual association cortices rather than from precortical damage, at least before the end stage of the disease.

Hemispheric threshold differences for motor evoked potentials produced by magnetic coil stimulation

A brief monophasic pulse through an electromagnetic coil preferentially activates motor pathways of each hemisphere, depending on the direction of coil current flow. Using the preferred direction for each hemisphere, the minimum stimulus intensity (threshold) that evoked compound muscle action potentials in the contralateral abductor digiti minimi (ADM) muscle was significantly less for the left hemisphere than the right. Threshold for biceps on each side was significantly higher than ADM, but there was no side-to-side difference. Assessing handedness using a standard handedness index, those who had less tendency to use the right hand for everyday tasks had greater differences between hemispheres for ADM thresholds. The lower threshold of the left-hemisphere projection to hand muscles is probably related to the asymmetry of corticomotoneuronal monosynaptic connections; a greater number project to the motor neuron pool of the right- than left-hand muscles.

Cervical magnetic stimulation

We stimulated the cervical region with a 9-cm-diameter magnetic coil on centered on the spinous processes in 21 normal subjects. We obtained maximal amplitudes with clockwise coil current in right-sided upper extremity muscles and counterclockwise coil current in left-sided upper extremity muscles. Optimal stimulation sites for biceps, triceps, and abductor digiti minimi were C-3 or C-4, C-4 or C-5, and C-4, C-5, or C-6, respectively. The latencies of the muscle responses varied little in the same subject in spite of marked amplitude changes due to suboptimal position of the coil or submaximal stimulator output. In abductor digiti minimi, the amplitude of the muscle response on cervical magnetic stimulation was 9 to 100% of the supramaximal amplitude on wrist electrical stimulation. We established normal values for latency, amplitude, and interside differences for the above 3 upper extremity muscles. The findings were reproducible, and the latencies obtained with large coils from different manufacturers in the same subjects were comparable. We found no advantage in bipolar recording over tendon-belly montage. Comparison of magnetic and electrical needle root stimulation in the same subjects showed that the magnetic stimulus was more proximal in biceps and triceps, and that the site of excitation was approximately the same in abductor digiti minimi. Indirect assessment of the longitudinal site of excitation based on F-wave minimal latency indicated that excitation occurred within millimeters of the emergence of axon of the peripheral motor neuron.

Clinical correlations of photoparoxysmal responses

Reilly and Peters (1973) reported that photoparoxysmal responses (PPRs) that outlasted the stimulus correlated significantly with seizures as compared to self-limited PPRs. However, they defined a wide range of activity, including occipital spikes and slow wave bursts, as PPR. We examined EEGs of 3557 patients and 48 normal subjects for PPRs defined only as generalized spikes or spike-wave activity. None of the 48 normal subjects showed a PPR. PPRs were seen in 35 (1%) patients, 27 (77%) of these had a definite history of epilepsy, 3 (9%) had a questionable history, and 5 (14%) had had no seizures. PPRs were prolonged more than 100 msec beyond the stimulus in 11, and self-limited in 24. The incidence of seizures was not statistically different in these 2 groups. Furthermore, the classification of PPRs into these 2 groups could be influenced by the time at which the stimulus was stopped after the appearance of the PPR. PPRs are rare in normal subjects and non-epileptic patients and have a high correlation with seizures irrespective of their relationship to the strobe stimulus.

Computerized EEG frequency analysis: sensitivity and specificity in patients with focal lesions

We performed computerized EEG frequency analysis (C-EEGFA) in 69 controls and 20 patients with focal brain lesions and focally abnormal conventional EEGs. Individual channel EEG frequency analysis variables that were helpful in differentiating the 2 groups were absolute delta and theta band power, relative delta, theta, and alpha band powers, and median-power frequency. High-frequency beta band power (20 to 32 Hz) was not useful. Changes in EEG with age were seen only after age 50 and generally consisted of an increase in anterior alpha power, with no significant increase in slowing. Correlations of C-EEGFA variables with posterior alpha power were more significant than correlations with age. Calculating normative C-EEGFA data for 5 subsets of controls, each with a different amount of posterior alpha power, increased the sensitivity of the EEG frequency analysis test without altering the specificity. Even with this correction 2 of 20 patients with focal lesions and focally abnormal conventional EEGs had normal C-EEGFA studies. If these obvious focal lesions produced normal results, more subtle diseases might not be detected. A significant clinical utility of C-EEGFA remains to be proven.

Magnetic stimulation of the human motor cortex: facilitation and its relationship to a visual motor task

Transcranial magnetic stimulation of the motor cortex can evoke motor responses in small hand muscles. This response can be facilitated by a background muscle contraction of the target muscle, resulting in an enhanced compound muscle action potential (CMAP) with a shorter onset latency. A number of intracortical mechanisms may account for this facilitatory effect, including, in part, direct input from visual to motor cortex. We studied the facilitation produced by a visual-motor task and compared those results with the facilitation produced by the same task without the visual cues. No differences in facilitation of amplitude or latency were observed. This suggests that there is no direct influence exerted by the visual cortex upon those elements of the motor cortex activated by a tangential magnetic stimulus, i.e., corticocortical and corticospinal neurons and their processes. Also, the large majority of facilitation (90%) was produced by a very small background voluntary contraction (less than 5% of maximum), indicating that any mild-to-moderate contraction of the target muscles will produce a consistent response for clinical measurements.

Pattern ERG: effects of reference electrode site, stimulus mode and check size

We studied monocular pattern ERG (PERG) in 10 normal subjects and a patient with optic neuritis. No clinically significant PERG could be recorded from the occluded eye with any reference (ipsilateral ear or temple, or midfrontal), indicating that cross-contamination is not present with binocular testing. Ipsilateral temple reference minimized VEP (P100/N100) contribution to the PERG N95 which occurred with ipsilateral ear or midfrontal reference. The conclusions were confirmed by results from the patient, who had marked monocular delay of a normal amplitude P100. Twenty-four subjects were tested with monocular and binocular stimulation using an ipsilateral temple reference. There were differences in PERG latencies and amplitudes although the interside amplitude ratio showed smaller differences with binocular stimulation. Increasing check size (17, 35 and 70 min) decreased P50 and N95 latencies and increased P50 amplitude.

Use of evoked potentials for diagnosis of multiple sclerosis

The author discusses visual evoked potentials, brain stem auditory evoked potentials, somatosensory evoked potentials, motor evoked potentials, and MRI for the diagnosis of MS. Most patients with MS will eventually have an MRI scan. However, certain specific questions regarding function and anatomic regions are better studied with evoked potentials, especially those of optic nerve, brain stem, and spinal cord.

Short-term variability in EEG frequency analysis

Knowledge of short-term EEG variability in computerized analysis is important before interpreting spectral EEGs or assessing changes that may be due to inherent variability and not necessarily related to a task (e.g., listening to a story), therapy or changes in underlying disease. Eighty to 120 sec of 14-channel, edited, bipolar EEG were recorded in normal subjects and analyzed using an FFT. Absolute and relative power in 5 standard frequency bands, and median and peak power frequencies were obtained for each 4 sec epoch, and the mean and standard deviation calculated for each parameter. The average variation of the mean power, absolute and relative, in the frequency bands was less than 10% although some parameters varied by up to 50% in an individual subject. Median and peak power had the least variability, about 3%. Changes in total power correlated positively with relative alpha power, but negatively or not at all with the other relative power measures. This suggests that interpretation of relative measures of delta, theta and beta in individual spectra may be dependent on total power or absolute alpha power. In addition, mathematical transformations were necessary to normalize the epoch data, suggesting that the mean and standard deviation of data from a series of epochs may not have maximal value unless a transformation is used. These results also indicate that caution is needed in interpreting changes in EEG frequency analysis data that are of the same magnitude as spontaneous EEG variability.

Evoked potentials in motor system diseases

We studied pattern-shift visual (PSVEP), brainstem auditory (BAEP), and somatosensory (SEP) evoked potentials in 38 unselected patients with motor system diseases (MSD) (28 sporadic, 10 familial). PSVEPs were normal in all patients, and BAEPs were normal in all except one with clinical hearing loss who had absent waves I and III and prolonged wave V latencies. Median and tibial SEPs revealed definite CNS conduction abnormalities in only 1 of 30 and 1 of 18 patients, respectively. In addition, four patients had peripheral and four had peripheral or central delays on tibial nerve testing. There were no or only small group differences in central conduction SEP, BAEP, and PSVEP values in patients with normal studies compared with controls. This study suggests that central conduction SEP, BAEP, or PSVEP abnormalities can rarely be attributed to MSD and that their presence in patients suspected of having this disorder should prompt a search for an alternative diagnosis.

Electroencephalography in AIDS and AIDS-related complex

EEG records from 47 patients with the acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC) were reviewed retrospectively to correlate EEG findings with neurologic abnormalities. Abnormal EEGs were found in 22 of 33 (67%) patients with AIDS and 5 of 14 (36%) patients with ARC. Among 27 patients with abnormal EEGs, there were 9 patients with dementia, 10 with opportunistic infections of the CNS, and 6 with no apparent neurologic disease. AIDS dementia was associated with intermittent or continuous slowing, often most prominent anteriorly. Focal slowing or sharp activity was usually found in patients who had focal CNS processes, such as cerebral toxoplasmosis and CNS lymphoma. These findings suggest the EEG can be a useful diagnostic test for evaluating patients with AIDS and ARC, particularly when these patients present with seizures, psychiatric symptoms, or cognitive dysfunction. The significance of abnormal EEGs in patients who are neurologically asymptomatic is unknown.

Normal temporal variability of the P100

Determination of clinically significant temporal changes in P100 latency requires knowledge of the degree of normal intraindividual variability. Checkerboard visual evoked potentials using 3 check sizes (17', 35' and 70') were performed serially on 20 healthy volunteers. Each subject was tested at least twice an average of 6 months apart. The P100 latency was measured at Oz with a forehead reference (Pz, O1 and O2 channels were also recorded). The overall average P100 latency change between studies for all check sizes and both eyes was 2.9 msec. However, the maximum absolute latency change was 11 msec. There was no significant difference between the average latency change for the 3 check sizes. The P100 interocular difference changed a mean of 2.5 msec (maximum 9 msec). Amplitude was more variable, with a mean change of about 1.5 microV or 25% (maximum was a 60% decrease in amplitude). A P100 latency change of up to at least 11 msec needs to be acknowledged as normal when assessing the clinical significance of changes in P100 latencies in patients. Also, P100 latency changes greater than 11 or 12 msec are very suggestive of an abnormality in the visual pathway.

Evoked potentials in Guillain-Barré syndrome

We studied evoked potentials (EPs) in 27 patients with typical acute Guillain-Barré syndrome and 3 with Fisher's syndrome. Three of 21 had BAEP abnormalities: 1 with bilateral I-III, 1 with unilateral I-III, and another with unilateral III-V interwave latency prolongations. Three with Fisher's syndrome had normal BAEPs (one had a poorly formed wave V unilaterally with one click polarity only). Ten of 21 median nerve EPs and 9 of 12 peroneal or tibial nerve somatosensory EPs were abnormal. Seven patients with normal somatosensory EPs had abnormal F waves from the same nerve; none had normal late responses and abnormal somatosensory EPs. These observations differ from previous reports on the frequency and interpretation of EP abnormalities in Guillain-Barré syndrome.

Early evolution and incidence of electroencephalographic abnormalities in Creutzfeldt-Jakob disease

The clinical and EEG findings in patients in the literature with Creutzfeldt-Jakob disease (CJD) were reviewed and compared with findings in 36 patients with CJD at the Massachusetts General Hospital (MGH). Twenty-one of the 36 MGH cases had histopathology, all with findings consistent with CJD. EEGs in 18 patients studied pathologically and in 10 without pathological investigation (28 of the 36) had periodic sharp wave complexes (PSWC) at some time during the clinical course. Of the other eight patients, two had only a single EEG early in the course of the illness, four experienced unusually long clinical courses, and two never showed PSWC despite numerous EEGs. PSWC made their appearance within 12 weeks of onset of clinical symptoms in 25 of 27 in whom EEGs were done during that period. In the early stages, EEGs in 14 of 28 showed focal PSWC or amplitude asymmetries of PSWC that corresponded well with focal myoclonus or other focal neurological abnormalities. In the literature, PSWC occurred within 12 weeks of the onset of the illness in 66 of 75 patients (88%) with CJD who had comparable clinical and neuropathological findings and adequate EEG data during the first 3 months of the illness. In the approximately 10% of patients who experienced unusually long courses, PSWC occurred in only about 55%. The presence of PSWC in association with the appropriate clinical, biochemical, cerebrospinal fluid, and neuroradiological findings is diagnostic of CJD. Brain biopsy is, therefore, unnecessary even when clinical therapeutic trials are undertaken and certainty of diagnosis is required. The absence of PSWC in the EEG after 12 weeks' duration of illness is a point strongly against the diagnosis of CJD unless it is a rare subtype of long duration. Only those patients without PSWC need to be biopsied.