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Saway BF, Palmer C, Hughes C, Triano M, Suresh RE, Gilmore J, George M, Kautz SA, Rowland NC. The evolution of neuromodulation for chronic stroke: From neuroplasticity mechanisms to brain-computer interfaces. Neurotherapeutics 2024; 21:e00337. [PMID: 38377638 DOI: 10.1016/j.neurot.2024.e00337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/05/2024] [Accepted: 02/13/2024] [Indexed: 02/22/2024] Open
Abstract
Stroke is one of the most common and debilitating neurological conditions worldwide. Those who survive experience motor, sensory, speech, vision, and/or cognitive deficits that severely limit remaining quality of life. While rehabilitation programs can help improve patients' symptoms, recovery is often limited, and patients frequently continue to experience impairments in functional status. In this review, invasive neuromodulation techniques to augment the effects of conventional rehabilitation methods are described, including vagus nerve stimulation (VNS), deep brain stimulation (DBS) and brain-computer interfaces (BCIs). In addition, the evidence base for each of these techniques, pivotal trials, and future directions are explored. Finally, emerging technologies such as functional near-infrared spectroscopy (fNIRS) and the shift to artificial intelligence-enabled implants and wearables are examined. While the field of implantable devices for chronic stroke recovery is still in a nascent stage, the data reviewed are suggestive of immense potential for reducing the impact and impairment from this globally prevalent disorder.
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Affiliation(s)
- Brian F Saway
- Department of Neurosurgery, Medical University of South Carolina, SC 29425, USA.
| | - Charles Palmer
- Department of Psychiatry, Medical University of South Carolina, SC 29425, USA
| | - Christopher Hughes
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Matthew Triano
- Department of Neurosurgery, Medical University of South Carolina, SC 29425, USA
| | - Rishishankar E Suresh
- College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Jordon Gilmore
- Department of Bioengineering, Clemson University, Clemson, SC 29634, USA
| | - Mark George
- Department of Psychiatry, Medical University of South Carolina, SC 29425, USA; Ralph H Johnson VA Health Care System, Charleston, SC 29425, USA
| | - Steven A Kautz
- Department of Health Science and Research, Medical University of South Carolina, SC 29425, USA; Ralph H Johnson VA Health Care System, Charleston, SC 29425, USA
| | - Nathan C Rowland
- Department of Neurosurgery, Medical University of South Carolina, SC 29425, USA; MUSC Institute for Neuroscience Discovery (MIND), Medical University of South Carolina, SC 29425, USA
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Bauerle L, Rogowski B, Shingala A, Rafka HE, Webb T, Saway BF, Kilb EF, Chalela JA, Rowland NC. Protracted respiratory failure in a case of global spinal syringomyelia and Chiari malformation following administration of diazepam: illustrative case. J Neurosurg Case Lessons 2023; 6:CASE23449. [PMID: 37992311 PMCID: PMC10664626 DOI: 10.3171/case23449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 10/18/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Syringomyelia is defined as dilation of the spinal cord's central canal and is often precipitated by skull base herniation disorders. Although respiratory failure (RF) can be associated with skull base abnormalities due to brainstem compression, most cases occur in pediatric patients and quickly resolve. The authors report the case of an adult patient with global spinal syringomyelia and Chiari malformation who developed refractory RF after routine administration of diazepam. OBSERVATIONS A 31-year-old female presented with malnutrition, a 1-month history of right-sided weakness, and normal respiratory dynamics. After administration of diazepam prior to magnetic resonance imaging (MRI), she suddenly developed hypercapnic RF followed MRI and required intubation. MRI disclosed a Chiari malformation type I and syrinx extending from C1 to the conus medullaris. After decompressive surgery, her respiratory function progressively returned to baseline status, although 22 months after initial benzodiazepine administration, the patient continues to require nocturnal ventilation. LESSONS Administration of central nervous system depressants should be closely monitored in patients with extensive syrinx formation given the potential to exacerbate diminished central respiratory drive. Early identification of syrinx in the context of Chiari malformation and hemiplegia should prompt clinical suspicion of underlying respiratory compromise and early involvement of intensive care consultants.
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Affiliation(s)
- Luke Bauerle
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Brandon Rogowski
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Aakash Shingala
- Department of General Surgery, Sidney Kimmel Medical College, Philadelphia, Pennsylvania
| | - Habib Emil Rafka
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Timothy Webb
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Brian F Saway
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Edward F Kilb
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy, and Sleep, Medical University of South Carolina, Charleston, South Carolina
| | - Julio A Chalela
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Nathan C Rowland
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
- Ralph Johnson VA Medical Center, Charleston, South Carolina
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina; and
- MUSC Institute for Neuroscience Discovery (MIND), Medical University of South Carolina, Charleston, South Carolina
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3
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Scherer M, Harmsen IE, Samuel N, Elias GJB, Germann J, Boutet A, MacLeod CE, Giacobbe P, Rowland NC, Lozano AM, Milosevic L. Oscillatory network markers of subcallosal cingulate deep brain stimulation for depression. Brain Stimul 2023; 16:1764-1775. [PMID: 38061548 PMCID: PMC10947774 DOI: 10.1016/j.brs.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/12/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023] Open
Abstract
Identifying functional biomarkers related to treatment success can aid in expediting therapy optimization, as well as contribute to a better understanding of the neural mechanisms of the treatment-resistant depression (TRD) and subcallosal cingulate deep brain stimulation (SCC-DBS). Magnetoencephalography data were obtained from 16 individuals with SCC-DBS for TRD and 25 healthy subjects. The first objective of the study was to identify region-specific oscillatory modulations that both (i) discriminate individuals with TRD (with SCC-DBS OFF) from healthy controls, and (ii) discriminate TRD treatment responders from non-responders (with SCC-DBS ON). The second objective of this work was to further explore the effects of stimulation intensity and frequency on oscillatory activity in the identified brain regions of interest. Oscillatory power analyses led to the identification of brain regions that differentiated responders from non-responders based on modulations of increased alpha (8-12 Hz) and decreased gamma (32-116 Hz) power within nodes of the default mode, central executive, and somatomotor networks, Broca's area, and lingual gyrus. Within these nodes, it was also found that low stimulation frequency had stronger effects on oscillatory modulation than increased stimulation intensity. The identified functional network biomarkers implicate modulation of TRD-related activity in brain regions involved in emotional control/processing, motor control, and the interaction between speech, vision, and memory, which have all been implicated in depression. These electrophysiological biomarkers have the potential to be used as functional proxies for therapy optimization. Additional stimulation parameter analyses revealed that oscillatory modulations can be strengthened by increasing stimulation intensity or reducing frequency, which may represent potential avenues of direction in non-responders.
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Affiliation(s)
- M Scherer
- Krembil Brain Institute, University Health Network, Toronto, Canada; Institute of Biomedical Engineering, University of Toronto, Canada
| | - I E Harmsen
- Krembil Brain Institute, University Health Network, Toronto, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; Mitchell Goldhar MEG Unit, University Health Network, Toronto, Canada
| | - N Samuel
- Krembil Brain Institute, University Health Network, Toronto, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - G J B Elias
- Krembil Brain Institute, University Health Network, Toronto, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - J Germann
- Krembil Brain Institute, University Health Network, Toronto, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - A Boutet
- Krembil Brain Institute, University Health Network, Toronto, Canada; Joint Department of Medical Imaging, University of Toronto, Canada
| | - C E MacLeod
- Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, Ontario, Canada
| | - P Giacobbe
- Department of Psychiatry, Sunnybrook Health Sciences, University of Toronto, Toronto, Ontario, Canada
| | - N C Rowland
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA; Murray Center for Research on Parkinson's Disease and Related Disorders, Medical University of South Carolina, Charleston, SC, USA
| | - A M Lozano
- Krembil Brain Institute, University Health Network, Toronto, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Canada
| | - L Milosevic
- Krembil Brain Institute, University Health Network, Toronto, Canada; Institute of Biomedical Engineering, University of Toronto, Canada; Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Canada; KITE Research Institute, University Health Network, Toronto, Canada.
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Yu CH, Lench DH, Cooper C, Rowland NC, Takacs I, Revuelta G. Deep brain stimulation for essential tremor versus essential tremor plus: should we target the same spot in the thalamus? Front Hum Neurosci 2023; 17:1271046. [PMID: 38021224 PMCID: PMC10644388 DOI: 10.3389/fnhum.2023.1271046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
Background Although ET is a phenomenologically heterogeneous condition, thalamic DBS appears to be equally effective across subtypes. We hypothesized stimulation sites optimized for individuals with essential tremor (ET) would differ from individuals with essential tremor plus syndrome (ET-plus). We examined group differences in optimal stimulation sites within the ventral thalamus and their overlap of with relevant white matter tracts. By capturing these differences, we sought to determine whether ET subtypes are associated with anatomically distinct neural pathways. Methods A retrospective chart review was conducted on ET patients undergoing VIM DBS at MUSC between 01/2012 and 02/2022. Clinical, demographic, neuroimaging, and DBS stimulation parameter data were collected. Clinical characteristics and pre-DBS videos were reviewed to classify ET and ET-plus cohorts. Patients in ET-plus cohorts were further divided into ET with dystonia, ET with ataxia, and ET with others. DBS leads were reconstructed using Lead-DBS and the volume of tissue activated (VTA) overlap was performed using normative connectomes. Tremor improvement was measured by reduction in a subscore of tremor rating scale (TRS) post-DBS lateralized to the more affected limb. Results Sixty-eight ET patients were enrolled after initial screening, of these 10 ET and 24 ET-plus patients were included in the final analyses. ET group had an earlier age at onset (p = 0.185) and underwent surgery at a younger age (p = 0.096). Both groups achieved effective tremor control. No significant differences were found in lead placement or VTA overlap within ventral thalamus. The VTA center of gravity (COG) in the ET-plus cohort was located dorsal to that of the ET cohort. No significant differences were found in VTA overlap with the dentato-rubral-thalamic (DRTT) tracts or the ansa lenticularis. Dystonia was more prevalent than ataxia in the ET-plus subgroups (n = 18 and n = 5, respectively). ET-plus with dystonia subgroup had a more medial COG compared to ET-plus with ataxia. Conclusion VIM DBS therapy is efficacious in patients with ET and ET-plus. There were no significant differences in optimal stimulation site or VTA overlap with white-matter tracts between ET, ET-plus and ET-plus subgroups.
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Affiliation(s)
- Cherry H. Yu
- Department of Neurology, Medical University of South Carolina, Charleston, SC, United States
| | - Daniel H. Lench
- Department of Neurology, Medical University of South Carolina, Charleston, SC, United States
| | - Christine Cooper
- Department of Neurology, Medical University of South Carolina, Charleston, SC, United States
- Ralph H. Johnson VA Medical Center, Charleston, SC, United States
| | - Nathan C. Rowland
- Ralph H. Johnson VA Medical Center, Charleston, SC, United States
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
| | - Istvan Takacs
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
| | - Gonzalo Revuelta
- Department of Neurology, Medical University of South Carolina, Charleston, SC, United States
- Ralph H. Johnson VA Medical Center, Charleston, SC, United States
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5
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Rogowski B, Miller A, Saway BF, Wessell J, Rowland NC, Lena JR, Vandergrift WA. Vasospasm secondary to responsive neurostimulator placement: a previously unreported complication. Illustrative case. J Neurosurg Case Lessons 2023; 5:CASE22435. [PMID: 37249138 PMCID: PMC10550669 DOI: 10.3171/case22435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 03/28/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND The Responsive Neurostimulation (RNS) system is an implantable device for patients with drug-resistant epilepsy who are not candidates for resection of a seizure focus. As a relatively new therapeutic, the full spectrum of adverse effects has yet to be determined. A literature review revealed no previous reports of cerebral vasospasm following RNS implantation. OBSERVATIONS A 35-year-old man developed severe angiographic and clinical vasospasm following bilateral mesial temporal lobe RNS implantation. He initially presented with concerns for status epilepticus 8 days after implantation. On hospital day 3, a decline in his clinical examination prompted imaging studies that revealed a left middle cerebral artery (MCA) stroke with angiographic evidence of severe vasospasm of the left internal carotid artery (ICA), MCA, anterior cerebral artery (ACA), and right ICA and ACA. Despite improvements in angiographic vasospasm after appropriate treatment, a thrombus developed in the posterior M2 branch, requiring mechanical thrombectomy. Ultimately, the patient was stabilized and discharged to a rehabilitation facility with residual cognitive and motor deficits. LESSONS Cerebral vasospasm as a cause of ischemic stroke after uneventful RNS implantation is exceedingly rare, yet demands particular attention given the potential for severe consequences and the growing number of patients receiving RNS devices.
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Affiliation(s)
- Brandon Rogowski
- College of Medicine, Drexel University, Philadelphia, Pennsylvania
| | - Aaron Miller
- College of Osteopathic Medicine, New York Institute of Technology, Glen Head, New York
| | - Brian F. Saway
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina; and
| | - Jeffrey Wessell
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina; and
| | - Nathan C. Rowland
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina; and
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jonathan Ross Lena
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina; and
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - William A. Vandergrift
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina; and
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina
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6
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Salazar CA, Feng W, Bonilha L, Kautz S, Jensen JH, George MS, Rowland NC. Transcranial Direct Current Stimulation for Chronic Stroke: Is Neuroimaging the Answer to the Next Leap Forward? J Clin Med 2023; 12:2601. [PMID: 37048684 PMCID: PMC10094806 DOI: 10.3390/jcm12072601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023] Open
Abstract
During rehabilitation, a large proportion of stroke patients either plateau or begin to lose motor skills. By priming the motor system, transcranial direct current stimulation (tDCS) is a promising clinical adjunct that could augment the gains acquired during therapy sessions. However, the extent to which patients show improvements following tDCS is highly variable. This variability may be due to heterogeneity in regions of cortical infarct, descending motor tract injury, and/or connectivity changes, all factors that require neuroimaging for precise quantification and that affect the actual amount and location of current delivery. If the relationship between these factors and tDCS efficacy were clarified, recovery from stroke using tDCS might be become more predictable. This review provides a comprehensive summary and timeline of the development of tDCS for stroke from the viewpoint of neuroimaging. Both animal and human studies that have explored detailed aspects of anatomy, connectivity, and brain activation dynamics relevant to tDCS are discussed. Selected computational works are also included to demonstrate how sophisticated strategies for reducing variable effects of tDCS, including electric field modeling, are moving the field ever closer towards the goal of personalizing tDCS for each individual. Finally, larger and more comprehensive randomized controlled trials involving tDCS for chronic stroke recovery are underway that likely will shed light on how specific tDCS parameters, such as dose, affect stroke outcomes. The success of these collective efforts will determine whether tDCS for chronic stroke gains regulatory approval and becomes clinical practice in the future.
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Affiliation(s)
- Claudia A. Salazar
- Department of Neurosurgery, College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
- Center for Biomedical Imaging, University of South Carolina, Columbia, SC 29208, USA
- Department of Neuroscience, College of Graduate Studies, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Leonardo Bonilha
- Department of Neurology, College of Medicine, Emory University, Atlanta, GA 30322, USA
- Department of Neurology, College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Steven Kautz
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
- Ralph H. Johnson VA Medical Center, Charleston, SC 29401, USA
| | - Jens H. Jensen
- Center for Biomedical Imaging, University of South Carolina, Columbia, SC 29208, USA
- Department of Neuroscience, College of Graduate Studies, Medical University of South Carolina, Charleston, SC 29425, USA
- Department of Radiology and Radiological Science, College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Mark S. George
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
- Ralph H. Johnson VA Medical Center, Charleston, SC 29401, USA
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Nathan C. Rowland
- Department of Neurosurgery, College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
- Center for Biomedical Imaging, University of South Carolina, Columbia, SC 29208, USA
- Department of Neuroscience, College of Graduate Studies, Medical University of South Carolina, Charleston, SC 29425, USA
- Department of Neurology, College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
- Ralph H. Johnson VA Medical Center, Charleston, SC 29401, USA
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7
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Bauerle L, Palmer C, Salazar CA, Larrew T, Kerns SE, Short EB, George MS, Rowland NC. Neurosurgery for psychiatric disorders: reviewing the past and charting the future. Neurosurg Focus 2023; 54:E8. [PMID: 36724525 DOI: 10.3171/2022.11.focus22622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/29/2022] [Indexed: 02/03/2023]
Abstract
Surgical techniques targeting behavioral disorders date back thousands of years. In this review, the authors discuss the history of neurosurgery for psychiatric disorders, starting with trephination in the Stone Age, progressing through the fraught practice of prefrontal lobotomy, and ending with modern neurosurgical techniques for treating psychiatric conditions, including ablative procedures, conventional deep brain stimulation, and closed-loop neurostimulation. Despite a tumultuous past, psychiatric neurosurgery is on the cusp of becoming a transformative therapy for patients with psychiatric dysfunction, with an ever-increasing evidence base suggesting reproducible and ethical therapeutic benefit.
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Affiliation(s)
- Luke Bauerle
- 1College of Medicine, Medical University of South Carolina
| | - Charles Palmer
- 2Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina
| | - Claudia A Salazar
- 3Department of Neurosurgery, Medical University of South Carolina.,4Department of Neurosciences, Medical University of South Carolina; and
| | - Thomas Larrew
- 3Department of Neurosurgery, Medical University of South Carolina
| | - Suzanne E Kerns
- 2Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina
| | - E Baron Short
- 2Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina
| | - Mark S George
- 2Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina.,5Ralph Johnson VA Medical Center, Charleston, South Carolina
| | - Nathan C Rowland
- 3Department of Neurosurgery, Medical University of South Carolina.,5Ralph Johnson VA Medical Center, Charleston, South Carolina
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8
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Samuel N, Harmsen IE, Ding MYR, Sarica C, Vetkas A, Wong C, Lawton V, Yang A, Rowland NC, Kalia SK, Valiante T, Wennberg R, Zadeh G, Kongkham P, Kalyvas A, Lozano AM. Investigation of neurophysiologic and functional connectivity changes following glioma resection using magnetoencephalography. Neurooncol Adv 2023; 5:vdad091. [PMID: 37547265 PMCID: PMC10403751 DOI: 10.1093/noajnl/vdad091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
Background In patients with glioma, clinical manifestations of neural network disruption include behavioral changes, cognitive decline, and seizures. However, the extent of network recovery following surgery remains unclear. The aim of this study was to characterize the neurophysiologic and functional connectivity changes following glioma surgery using magnetoencephalography (MEG). Methods Ten patients with newly diagnosed intra-axial brain tumors undergoing surgical resection were enrolled in the study and completed at least two MEG recordings (pre-operative and immediate post-operative). An additional post-operative recording 6-8 weeks following surgery was obtained for six patients. Resting-state MEG recordings from 28 healthy controls were used for network-based comparisons. MEG data processing involved artifact suppression, high-pass filtering, and source localization. Functional connectivity between parcellated brain regions was estimated using coherence values from 116 virtual channels. Statistical analysis involved standard parametric tests. Results Distinct alterations in spectral power following tumor resection were observed, with at least three frequency bands affected across all study subjects. Tumor location-related changes were observed in specific frequency bands unique to each patient. Recovery of regional functional connectivity occurred following glioma resection, as determined by local coherence normalization. Changes in inter-regional functional connectivity were mapped across the brain, with comparable changes in low to mid gamma-associated functional connectivity noted in four patients. Conclusion Our findings provide a framework for future studies to examine other network changes in glioma patients. We demonstrate an intrinsic capacity for neural network regeneration in the post-operative setting. Further work should be aimed at correlating neurophysiologic changes with individual patients' clinical outcomes.
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Affiliation(s)
- Nardin Samuel
- Corresponding Author: Andres M. Lozano, OC, MD, PhD, FRCSC, FRSC, FCAHS, University Professor and Alan and Susan Chair in Neurosurgery, University of Toronto, Toronto Western Hospital, 399 Bathurst Street, West Wing 4-431, Toronto, ON, Canada M5T 2S8 ()
| | | | - Mandy Yi Rong Ding
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Can Sarica
- Toronto Western Hospital, Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Artur Vetkas
- Toronto Western Hospital, Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Christine Wong
- Toronto Western Hospital, Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Vanessa Lawton
- Toronto Western Hospital, Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Andrew Yang
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nathan C Rowland
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Murray Center for Research on Parkinson’s Disease and Related Disorders, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Suneil K Kalia
- Toronto Western Hospital, Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Taufik Valiante
- Toronto Western Hospital, Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Richard Wennberg
- Mitchell Goldhar MEG Unit, University Health Network, Toronto, Canada
- Toronto Western Hospital, Division of Neurology, University Health Network, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Toronto Western Hospital, Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Paul Kongkham
- Toronto Western Hospital, Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
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9
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Idlett-Ali SL, Salazar CA, Bell MS, Short EB, Rowland NC. Neuromodulation for treatment-resistant depression: Functional network targets contributing to antidepressive outcomes. Front Hum Neurosci 2023; 17:1125074. [PMID: 36936612 PMCID: PMC10018031 DOI: 10.3389/fnhum.2023.1125074] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/14/2023] [Indexed: 03/06/2023] Open
Abstract
Non-invasive brain stimulation is designed to target accessible brain regions that underlie many psychiatric disorders. One such method, transcranial magnetic stimulation (TMS), is commonly used in patients with treatment-resistant depression (TRD). However, for non-responders, the choice of an alternative therapy is unclear and often decided empirically without detailed knowledge of precise circuit dysfunction. This is also true of invasive therapies, such as deep brain stimulation (DBS), in which responses in TRD patients are linked to circuit activity that varies in each individual. If the functional networks affected by these approaches were better understood, a theoretical basis for selection of interventions could be developed to guide psychiatric treatment pathways. The mechanistic understanding of TMS is that it promotes long-term potentiation of cortical targets, such as dorsolateral prefrontal cortex (DLPFC), which are attenuated in depression. DLPFC is highly interconnected with other networks related to mood and cognition, thus TMS likely alters activity remote from DLPFC, such as in the central executive, salience and default mode networks. When deeper structures such as subcallosal cingulate cortex (SCC) are targeted using DBS for TRD, response efficacy has depended on proximity to white matter pathways that similarly engage emotion regulation and reward. Many have begun to question whether these networks, targeted by different modalities, overlap or are, in fact, the same. A major goal of current functional and structural imaging in patients with TRD is to elucidate neuromodulatory effects on the aforementioned networks so that treatment of intractable psychiatric conditions may become more predictable and targeted using the optimal technique with fewer iterations. Here, we describe several therapeutic approaches to TRD and review clinical studies of functional imaging and tractography that identify the diverse loci of modulation. We discuss differentiating factors associated with responders and non-responders to these stimulation modalities, with a focus on mechanisms of action for non-invasive and intracranial stimulation modalities. We advance the hypothesis that non-invasive and invasive neuromodulation approaches for TRD are likely impacting shared networks and critical nodes important for alleviating symptoms associated with this disorder. We close by describing a therapeutic framework that leverages personalized connectome-guided target identification for a stepwise neuromodulation paradigm.
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Affiliation(s)
- Shaquia L. Idlett-Ali
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- *Correspondence: Shaquia L. Idlett-Ali,
| | - Claudia A. Salazar
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
| | - Marcus S. Bell
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
| | - E. Baron Short
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Nathan C. Rowland
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
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10
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Samuel N, Zeng K, Harmsen IE, Ding MYR, Darmani G, Sarica C, Santyr B, Vetkas A, Pancholi A, Fomenko A, Milano V, Yamamoto K, Saha U, Wennberg R, Rowland NC, Chen R, Lozano AM. Multi-modal investigation of transcranial ultrasound-induced neuroplasticity of the human motor cortex. Brain Stimul 2022; 15:1337-1347. [PMID: 36228977 DOI: 10.1016/j.brs.2022.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/25/2022] [Accepted: 10/03/2022] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION There is currently a gap in accessibility to neuromodulation tools that can approximate the efficacy and spatial resolution of invasive methods. Low intensity transcranial focused ultrasound stimulation (TUS) is an emerging technology for non-invasive brain stimulation (NIBS) that can penetrate cortical and deep brain structures with more focal stimulation compared to existing NIBS modalities. Theta burst TUS (tbTUS, TUS delivered in a theta burst pattern) is a novel repetitive TUS protocol that can induce durable changes in motor cortex excitability, thereby holding promise as a novel neuromodulation tool with durable effects. OBJECTIVE The aim of the present study was to elucidate the neurophysiologic effects of tbTUS motor cortical excitability, as well on local and global neural oscillations and network connectivity. METHODS An 80-s train of active or sham tbTUS was delivered to the left motor cortex in 15 healthy subjects. Motor cortical excitability was investigated through transcranial magnetic stimulation (TMS)-elicited motor-evoked potentials (MEPs), short-interval intracortical inhibition (SICI), and intracortical facilitation (ICF) using paired-pulse TMS. Magnetoencephalography (MEG) recordings during resting state and an index finger abduction-adduction task were used to assess oscillatory brain responses and network connectivity. The correlations between the changes in neural oscillations and motor cortical excitability were also evaluated. RESULTS tbTUS to the motor cortex results in a sustained increase in MEP amplitude and decreased SICI, but no change in ICF. MEG spectral power analysis revealed TUS-mediated desynchronization in alpha and beta spectral power. Significant changes in alpha power were detected within the supplementary motor cortex (Right > Left) and changes in beta power within bilateral supplementary motor cortices, right basal ganglia and parietal regions. Coherence analysis revealed increased local connectivity in motor areas. MEP and SICI changes correlated with both local and inter-regional coherence. CONCLUSION The findings from this study provide novel insights into the neurophysiologic basis of TUS-mediated neuroplasticity and point to the involvement of regions within the motor network in mediating this sustained response. Future studies may further characterize the durability of TUS-mediated neuroplasticity and its clinical applications as a neuromodulation strategy for neurological and psychiatric disorders.
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Affiliation(s)
- Nardin Samuel
- Toronto Western Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Ke Zeng
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Irene E Harmsen
- Toronto Western Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada; Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Mandy Yi Rong Ding
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Ghazaleh Darmani
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Can Sarica
- Toronto Western Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Brendan Santyr
- Toronto Western Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Artur Vetkas
- Toronto Western Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada; Department of Neurosurgery, Tartu University Hospital, University of Tartu, Estonia
| | - Aditya Pancholi
- Toronto Western Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Anton Fomenko
- Division of Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Vanessa Milano
- Toronto Western Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Kazuaki Yamamoto
- Toronto Western Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Utpal Saha
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Richard Wennberg
- Mitchell Goldhar MEG Unit, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; Division of Neurology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nathan C Rowland
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Robert Chen
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Division of Neurology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Andres M Lozano
- Toronto Western Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada; Krembil Research Institute, University Health Network, Toronto, Ontario, Canada.
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11
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Martínez JL, Domingo RA, Rowland NC, Vandergrift Iii WA. Trigeminal Neuralgia Secondary to Meckel's Cave Meningoencephaloceles: A Systematic Review and Illustrative Case. Neurol India 2022; 70:857-863. [PMID: 35864609 DOI: 10.4103/0028-3886.349629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND The culprit of trigeminal neuralgia (TGN) may occur at any point between the nerve's root entry zone (REZ) and Meckel's cave. Meckel's cave meningoencephaloceles are rare middle cranial fossa defects that usually remain asymptomatic but may contain prolapsed trigeminal nerve rootlets and result in TGN. Their management and surgical outcomes remain poorly understood. OBJECTIVES To perform a systematic review of clinical presentation and surgical outcomes of middle fossa defects presenting with trigeminal nerve-related symptoms. MATERIALS AND METHODS A systematic review was conducted in accordance with the PRISMA guidelines for all reports of middle cranial fossa defects causing trigeminal nerve-related symptoms. The pathophysiology, presentation, surgical management, and outcomes are discussed and illustrated with a case. RESULTS Initial search from inception to March 2021 identified 33 articles for screening. After applying inclusion and exclusion criteria, 6 articles were included representing a total of 8 cases in addition to our case (n = 9). All 9 patients were females and 33.3% (n = 3) presented with classic trigeminal neuralgia. "Empty sella" syndrome and radiologic signs of intracranial hypertension were present in 40%-62%. No patient presented with cerebrospinal fluid leak. The preferred treatment modality was surgical with subtemporal extradural repairs using combinations of autologous fat and muscle grafts and synthetic dura. Postoperative outcomes were only available in 55.5% (n = 5) of the cases, and nearly all reported complete symptom resolution, except for one case in which the meningoencephalocele wall was incised, along with trigeminal rootlets adhered to it. Our patient had immediate and durable symptom relief after a 4-year follow-up. CONCLUSIONS MEC containing prolapsed trigeminal nerve rootlets can cause typical trigeminal neuralgia from chronic pulsatile stress. This supports the hypothesis that the compressive or demyelinating culprit can locate more ventrally on the course of the trigeminal nerve. Subtemporal extradural surgical repairs can be safe, effective, and durable. Incising the MEC wall should be avoided as it may have trigeminal rootlets adhered to it.
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Affiliation(s)
- Jaime L Martínez
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Fl, United States of America
| | - Ricardo A Domingo
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Fl, United States of America
| | - Nathan C Rowland
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States of America
| | - William A Vandergrift Iii
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States of America
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12
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Gunasekaran A, Kulbarsh KD, Das A, Voelkel-Johnson C, Patel SJ, Lindhorst S, Yazdani M, Barley J, Rowland NC. Case report: Awake craniotomy during pregnancy for resection of glioblastoma. Clin Neurol Neurosurg 2022; 216:107218. [PMID: 35367747 DOI: 10.1016/j.clineuro.2022.107218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 03/14/2022] [Accepted: 03/20/2022] [Indexed: 11/29/2022]
Abstract
Few cases have been reported of the diagnosis and treatment of glioblastoma (GB) during pregnancy. Subsequently, surgical, medical, and obstetrical management of complicated primary central nervous system malignancy in antepartum and postpartum patients remains under-investigated. The authors report the case of a 24-year-old female patient who developed generalized tonic-clonic seizures and focal neurologic deficits. MRI imaging (3T Skyra, Siemens, Erlangen, Germany) revealed an intracranial mass suspicious for malignant tumor and surgical resection under awake sedation was scheduled. The patient was incidentally found to be in her first trimester of pregnancy. Using neuronavigation, neurophysiologic monitoring, and conscious sedation the tumor was debulked successfully and histopathologic analysis confirmed giant cell glioblastoma, WHO Grade IV, 1p/19q intact, IDH wild-type, with NF1 p.Y2285fs and RB1 p.S318fs somatic mutations. Post-surgical oncologic management continued with fractioned radiotherapy and use of the Optune® device. The patient underwent uncomplicated cesarean section at 34-weeks gestation, the child remains healthy and the patient remains disease-disease free at 1-year. Thus, this case presents an approach to management of complicated GBM during first trimester pregnancy.
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Affiliation(s)
- Arun Gunasekaran
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA.
| | - Kyle D Kulbarsh
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Arabinda Das
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | | | - Sunil J Patel
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Scott Lindhorst
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Milad Yazdani
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | - Jessica Barley
- Department of Clinical Neurophysiology, Medical University of South Carolina, Charleston, SC, USA
| | - Nathan C Rowland
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
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13
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Santos JLM, Domingo R, Rowland NC, Vandergrift WA. 192 Meckel's Cave Meningoencephaloceles Causing Typical Trigeminal Neuralgia. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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14
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Sasikumar S, Cohn M, Harmsen IE, Loh A, Cho SS, Sáenz-Farret M, Maciel R, Soh D, Boutet A, Germann J, Elias G, Youm A, Duncan K, Rowland NC, Strafella AP, Kalia SK, Lozano AM, Fasano A. Single-Trajectory Multiple-Target Deep Brain Stimulation for Parkinsonian Mobility and Cognition. Mov Disord 2021; 37:635-640. [PMID: 34806782 DOI: 10.1002/mds.28870] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/29/2021] [Accepted: 10/22/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) of the nucleus basalis of Meynert (NBM) is an emerging target to potentially treat cognitive dysfunction. OBJECTIVES The aim of this study is to achieve feasibility and safety of globus pallidus pars interna (GPi) and NBM DBS in advanced PD with cognitive impairment. METHODS We performed a phase-II double-blind crossover pilot trial in six participants to assess safety and cognitive measures, the acute effect of NBM stimulation on attention, motor and neuropsychological data at one year, and neuroimaging biomarkers of NBM stimulation. RESULTS NBM DBS was well tolerated but did not improve cognition. GPi DBS improved dyskinesia and motor fluctuations (P = 0.04) at one year. NBM stimulation was associated with reduced right frontal and parietal glucose metabolism (P < 0.01) and increased low- and high-frequency power and functional connectivity. Volume of tissue activated in the left NBM was associated with stable cognition (P < 0.05). CONCLUSIONS Simultaneous GPi and NBM stimulation is safe and improves motor complications. NBM stimulation altered neuroimaging biomarkers but without lasting cognitive improvement. © 2021 International Parkinson and Movement Disorder Society.
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Affiliation(s)
| | - Melanie Cohn
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada.,Krembil Brain Institute, Toronto, Ontario, Canada
| | - Irene E Harmsen
- Mitchell Goldhar MEG Unit, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Toronto Western Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Aaron Loh
- Toronto Western Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Sang Soo Cho
- Division of Brain, Imaging and Behaviour-Systems Neuroscience, Krembil Brain Institute, UHN, University of Toronto, Toronto, Ontario, Canada.,Department of Brain and Cognitive Sciences, Seoul National University, Seoul, Republic of Korea
| | - Michel Sáenz-Farret
- Edmond J. Safra Program in Parkinson's Disease and Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, UHN, Toronto, Ontario, Canada
| | - Ricardo Maciel
- Movement Disorders Unit, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Derrick Soh
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Alexandre Boutet
- Toronto Western Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.,Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Jürgen Germann
- Toronto Western Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Gavin Elias
- Toronto Western Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Ariana Youm
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada
| | - Katherine Duncan
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada
| | - Nathan C Rowland
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Antonio P Strafella
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Division of Brain, Imaging and Behaviour-Systems Neuroscience, Krembil Brain Institute, UHN, University of Toronto, Toronto, Ontario, Canada.,Edmond J. Safra Program in Parkinson's Disease and Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, UHN, Toronto, Ontario, Canada.,Brain Health Imaging Centre, Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada
| | - Suneil K Kalia
- Krembil Brain Institute, Toronto, Ontario, Canada.,Toronto Western Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.,Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada
| | - Andres M Lozano
- Krembil Brain Institute, Toronto, Ontario, Canada.,Toronto Western Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.,Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada
| | - Alfonso Fasano
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Brain Institute, Toronto, Ontario, Canada.,Edmond J. Safra Program in Parkinson's Disease and Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, UHN, Toronto, Ontario, Canada.,Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada
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15
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Chhatbar PY, Kautz SA, Takacs I, Rowland NC, Revuelta GJ, George MS, Bikson M, Feng W. Abstract #22: First report of recording transcranial direct current stimulation-generated electric fields in subthalamic nuclei using directional leads. Brain Stimul 2019. [DOI: 10.1016/j.brs.2018.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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16
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Rowland NC, Sammartino F, Tomaszczyk JC, Lozano AM. Deep Brain Stimulation of the Fornix: Engaging Therapeutic Circuits and Networks in Alzheimer Disease. Neurosurgery 2018; 63 Suppl 1:1-5. [PMID: 27399356 DOI: 10.1227/neu.0000000000001254] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nathan C Rowland
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Francesco Sammartino
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Jennifer C Tomaszczyk
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
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17
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Chhatbar PY, Kautz SA, Takacs I, Rowland NC, Revuelta GJ, George MS, Bikson M, Feng W. Evidence of transcranial direct current stimulation-generated electric fields at subthalamic level in human brain in vivo. Brain Stimul 2018; 11:727-733. [PMID: 29576498 PMCID: PMC6019625 DOI: 10.1016/j.brs.2018.03.006] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/28/2018] [Accepted: 03/08/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Transcranial direct current stimulation (tDCS) is a promising brain modulation technique for several disease conditions. With this technique, some portion of the current penetrates through the scalp to the cortex and modulates cortical excitability, but a recent human cadaver study questions the amount. This insufficient intracerebral penetration of currents may partially explain the inconsistent and mixed results in tDCS studies to date. Experimental validation of a transcranial alternating current stimulation-generated electric field (EF) in vivo has been performed on the cortical (using electrocorticography, ECoG, electrodes), subcortical (using stereo electroencephalography, SEEG, electrodes) and deeper thalamic/subthalamic levels (using DBS electrodes). However, tDCS-generated EF measurements have never been attempted. OBJECTIVE We aimed to demonstrate that tDCS generates biologically relevant EF as deep as the subthalamic level in vivo. METHODS Patients with movement disorders who have implanted deep brain stimulation (DBS) electrodes serve as a natural experimental model for thalamic/subthalamic recordings of tDCS-generated EF. We measured voltage changes from DBS electrodes and body resistance from tDCS electrodes in three subjects while applying direct current to the scalp at 2 mA and 4 mA over two tDCS montages. RESULTS Voltage changes at the level of deep nuclei changed proportionally with the level of applied current and varied with different tDCS montages. CONCLUSIONS Our findings suggest that scalp-applied tDCS generates biologically relevant EF. Incorporation of these experimental results may improve finite element analysis (FEA)-based models.
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Affiliation(s)
- Pratik Y Chhatbar
- Department of Neurology, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Steven A Kautz
- Department of Health Science & Research, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Istvan Takacs
- Department of Neurosurgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Nathan C Rowland
- Department of Neurosurgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Gonzalo J Revuelta
- Department of Neurology, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Mark S George
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA; Brain Stimulation Laboratory, Department of Psychiatry and Behavioral Science, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Marom Bikson
- Department of Biomedical Engineering, The City College of The City University of New York, New York, NY, USA
| | - Wuwei Feng
- Department of Neurology, College of Medicine, Medical University of South Carolina, Charleston, SC, USA; Department of Health Science & Research, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA.
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18
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Chhatbar PY, Kautz SA, Takacs I, Rowland NC, Revuelta GJ, George MS, Bikson M, Feng W. Abstract WP139: Transcranial Direct Current Stimulation (tDCS) Generates Electric Fields (EF) at the Level of Deep Nuclei of the Human Brain
in vivo. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.wp139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
tDCS is an investigational neuromodulatory therapy for stroke recovery and data has been inconsistent and mixed. The general perception for tDCS is that the majority of current gets shunted at the level of scalp and only minor portion penetrates to the superficial cortex. We aimed to detect electrical field (EF) via deep brain stimulation (DBS) leads in human brain.
Hypothesis:
Scalp-applied tDCS generates EF across the brain and forms detectable voltage gradient across DBS leads.
Methods:
We recruited patients undergoing DBS stage 2 procedure (implantable pulse generator or IPG implantation). We connected our recording setup to the IPG end of the DBS lead(s), which is otherwise unavailable except this specific surgical procedure. We applied 2 mA and 4 mA of tDCS using bitemporal and occipitofrontal montage and recorded voltage gradients across electrodes of DBS lead(s), while monitoring the applied voltage, injected current and body resistance through tDCS setup.
Results:
We recruited 3 patients with unilateral or bilateral DBS leads and found that tDCS application results in changed voltage gradient across contact points of the leads. Because of side-by-side orientation of the leads, bitemporal montage induces in voltage gradient in dose-dependent manner, but occipitofrontal montage did not detect any voltage gradient across the DBS leads because of their relatively equidistant positioning from the anode/cathode. Finally, 4 mA of tDCS resulted in lower body resistance (~20-30% less) when compared to 2 mA of tDCS.
Conclusions:
tDCS-generated EF were detected at the level of deep nuclei. Our findings offer insights into the body’s changing resistance to tDCS in a dose-dependent manner that can optimize tDCS simulation models towards improving tDCS efficacy in stroke recovery.
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Affiliation(s)
| | - Steven A Kautz
- Health Science & Rsch, Med Univ of South Carolina, Charleston, SC
| | - Istvan Takacs
- Neurosurgery, Med Univ of South Carolina, Charleston, SC
| | | | | | - Mark S George
- Psychiatry and Behavioral Science, Med Univ of South Carolina, Charleston, SC
| | - Marom Bikson
- Biomedical Engineering, The City College of New York of The City Univ of New York, New York, NY
| | - Wuwei Feng
- Medical Univ of South Carolina, Charleston, SC
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19
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Harmsen IE, Rowland NC, Wennberg RA, Lozano AM. Characterizing the effects of deep brain stimulation with magnetoencephalography: A review. Brain Stimul 2018; 11:481-491. [PMID: 29331287 DOI: 10.1016/j.brs.2017.12.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 12/26/2017] [Accepted: 12/28/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) is an important form of neuromodulation that is being applied to patients with motor, mood, or cognitive circuit disorders. Despite the efficacy and widespread use of DBS, the precise mechanisms by which it works remain unknown. Over the last decade, magnetoencephalography (MEG) has become an important functional neuroimaging technique used to study DBS. OBJECTIVE This review summarizes the literature related to the use of MEG to characterize the effects of DBS. METHODS Peer reviewed literature on DBS-MEG was obtained by searching the publicly accessible literature databases available on PubMed. The abstracts of all reports were scanned and publications which combined DBS-MEG in human subjects were selected for review. RESULTS A total of 32 publications met the selection criteria, and included studies which applied DBS for Parkinson's disease, dystonia, chronic pain, phantom limb pain, cluster headache, and epilepsy. DBS-MEG studies provided valuable insights into network connectivity, pathological coupling, and the modulatory effects of DBS. CONCLUSIONS As DBS-MEG research continues to develop, we can expect to gain a better understanding of diverse pathophysiological networks and their response to DBS. This knowledge will improve treatment efficacy, reduce side-effects, reveal optimal surgical targets, and advance the development of closed-loop neuromodulation.
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Affiliation(s)
- Irene E Harmsen
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Toronto Western Research Institute, Krembil Discovery Tower, University Health Network, Toronto, Ontario, Canada.
| | - Nathan C Rowland
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Richard A Wennberg
- Mitchell Goldhar Magnetoencephalography Unit, Krembil Neuroscience Centre, Toronto Western Hospital, Toronto, Ontario, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Toronto Western Research Institute, Krembil Discovery Tower, University Health Network, Toronto, Ontario, Canada
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20
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Wennberg R, Del Campo JM, Shampur N, Rowland NC, Valiante T, Lozano AM, Garcia Dominguez L. Feasibility of magnetoencephalographic source imaging in patients with thalamic deep brain stimulation for epilepsy. Epilepsia Open 2016; 2:101-106. [PMID: 29750219 PMCID: PMC5939388 DOI: 10.1002/epi4.12027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2016] [Indexed: 11/17/2022] Open
Abstract
Source localization of interictal spikes in patients with medically refractory epilepsy is the most common clinical application of magnetoencephalography (MEG). In recent decades, many patients with intractable epilepsy have been treated with various forms of neurostimulation, including thalamic deep brain stimulation (DBS). Patients with suboptimal seizure control after DBS might in some cases benefit from further investigations for resective epilepsy surgery, including MEG source imaging (MSI). We sought to determine the feasibility and accuracy of MSI in the setting of active thalamic DBS. Simultaneous EEG/MEG was obtained in a patient using an Elekta 306‐channel MEG system, with high‐frequency (100 Hz) DBS of the thalamic anterior nuclei cycling between on and off states. Magnetic artifacts associated with the DBS apparatus were successfully suppressed using the spatiotemporal signal space separation (tSSS) method. Electrical stimulation artifact was removed by standard digital low‐pass filtering. Dipole source modeling results for spike foci in frontal and posterior temporal regions were comparable between stimulation on and stimulation off states, and the source solutions corresponded well to the localization of spikes documented by intracranial EEG. MSI is thus feasible and source solutions can be accurate when performed in patients with active thalamic DBS for epilepsy.
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Affiliation(s)
- Richard Wennberg
- Mitchell Goldhar MEG Unit Division of Neurology Department of Medicine Krembil Neuroscience Centre University Health Network Toronto Western Hospital University of Toronto Toronto Ontario Canada
| | - J Martin Del Campo
- Mitchell Goldhar MEG Unit Division of Neurology Department of Medicine Krembil Neuroscience Centre University Health Network Toronto Western Hospital University of Toronto Toronto Ontario Canada
| | - Nat Shampur
- Mitchell Goldhar MEG Unit Division of Neurology Department of Medicine Krembil Neuroscience Centre University Health Network Toronto Western Hospital University of Toronto Toronto Ontario Canada
| | - Nathan C Rowland
- Division of Neurosurgery Department of Surgery Krembil Neuroscience Centre University Health Network Toronto Western Hospital University of Toronto Toronto Ontario Canada
| | - Taufik Valiante
- Division of Neurosurgery Department of Surgery Krembil Neuroscience Centre University Health Network Toronto Western Hospital University of Toronto Toronto Ontario Canada
| | - Andres M Lozano
- Division of Neurosurgery Department of Surgery Krembil Neuroscience Centre University Health Network Toronto Western Hospital University of Toronto Toronto Ontario Canada
| | - Luis Garcia Dominguez
- Mitchell Goldhar MEG Unit Division of Neurology Department of Medicine Krembil Neuroscience Centre University Health Network Toronto Western Hospital University of Toronto Toronto Ontario Canada
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Rowland NC, Sammartino F, Lozano AM. Advances in surgery for movement disorders. Mov Disord 2016; 32:5-10. [PMID: 27125681 DOI: 10.1002/mds.26636] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 03/03/2016] [Accepted: 03/06/2016] [Indexed: 12/27/2022] Open
Abstract
Movement disorder surgery has evolved throughout history as our knowledge of motor circuits and ways in which to manipulate them have expanded. Today, the positive impact on patient quality of life for a growing number of movement disorders such as Parkinson's disease is now well accepted and confirmed through several decades of randomized, controlled trials. Nevertheless, residual motor symptoms after movement disorder surgery such as deep brain stimulation and lack of a definitive cure for these conditions demand that advances continue to push the boundaries of the field and maximize its therapeutic potential. Similarly, advances in related fields - wireless technology, artificial intelligence, stem cell and gene therapy, neuroimaging, nanoscience, and minimally invasive surgery - mean that movement disorder surgery stands at a crossroads to benefit from unique combinations of all these developments. In this minireview, we outline some of these developments as well as evidence supporting topics of recent discussion and controversy in our field. Moving forward, expectations remain high that these improvements will come to encompass an even broader range of patients who might benefit from this therapy and decrease the burden of disease associated with these conditions. © 2016 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Nathan C Rowland
- Toronto Western Hospital, Division of Neurosurgery, Toronto, Ontario, Canada
| | | | - Andres M Lozano
- Toronto Western Hospital, Division of Neurosurgery, Toronto, Ontario, Canada
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Birk HS, Han SJ, Rolston JD, Rowland NC, Lau C, Theodosopoulos PV, McDermott MW. Resident-led Implementation of a Standardized Handoff System to Facilitate Transfer of Postoperative Neurosurgical Patients to the ICU. Cureus 2016; 8:e461. [PMID: 26929888 PMCID: PMC4762767 DOI: 10.7759/cureus.461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Transitions in care are pivotal moments for patient safety. Although many strategies have been suggested for handoff improvement in the healthcare realm, little focus has been placed on patient safety during the transition from the operative to the postoperative setting. Many surgical trainees have received limited instruction, if any, on how to conduct comprehensive handoffs that ensure the safe transition of care and optimize continuity of care. Therefore, structured transfers of patient care can be invaluable. Here, we describe the implementation of a standardized handoff system developed by residents in an academic neurosurgery department to communicate key perioperative data via both electronic documentation and in-person discussion as a means of reinforcement. Our results are part of a comprehensive effort to strengthen the culture of safety surrounding the care and treatment of neurosurgical patients at our institution.
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Affiliation(s)
- Harjus S Birk
- Department of Neurological Surgery, University of California, San Francisco ; Research Fellow, Howard Hughes Medical Institute
| | - Seunggu J Han
- Department of Neurological Surgery, University of California, San Francisco
| | - John D Rolston
- Department of Neurological Surgery, University of California, San Francisco
| | | | - Catherine Lau
- Department of Neurological Surgery, University of California, San Francisco
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Winkler EA, Rowland NC, Yue JK, Birk H, Ozpinar A, Tay B, Ames CP, Mummaneni PV, El-Sayed IH. A Tunneled Subcricoid Approach for Anterior Cervical Spine Reoperation: Technical and Safety Results. World Neurosurg 2015; 86:328-35. [PMID: 26409079 DOI: 10.1016/j.wneu.2015.09.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 09/09/2015] [Accepted: 09/11/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Anterior cervical spine decompression and fusion are common neurosurgical operations. Reoperation of the anterior cervical spine is associated with increased morbidity. The authors describe a novel subcricoid approach to protect the recurrent laryngeal nerve in a cuff of tissue while facilitating surgical access to the anterior cervical spine. METHODS Single institution, consecutive case review of 48 patients undergoing reoperation in the anterior cervical region including the level of C5 and below. Univariable and multivariable regression analysis was used to determine predictors of postoperative morbidity. RESULTS No intraoperative complications were reported. Estimated blood loss for the approach was 13.6 ± 3.1 mL. Nine of 48 patients developed immediate postoperative complications, including vocal cord paresis (10.4%), moderate-to-severe dysphagia (10.4%), and neck edema requiring intubation (2.1%). No postoperative hematomas or death occurred. All complications occurred with 4 or more levels of exposure (1-3 disc levels, 0%, vs. ≥ 4 disc levels, 31%). Extension of the exposure to the upper thoracic spine was associated with odds for postoperative complications (adjusted odds ratio, 6.50; 95% confidence interval, 1.14-37.03) and prolonged hospital stay (adjusted increase 4.23 days, P < 0.01). CONCLUSION The tunneled subcricoid approach is a relatively safe corridor to reapproach the anterior cervical spine at the level of C5 and below. However, caution must be exercised when using this approach to expose 4 or more disc levels and with extension of the exposure to the upper thoracic spine. Future comparative studies are needed to establish patient selection criteria in determining the use of this technique compared with classic approaches.
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Affiliation(s)
- Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Nathan C Rowland
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - John K Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Harjus Birk
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Alp Ozpinar
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Bobby Tay
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ivan H El-Sayed
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA.
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Rowland NC, De Hemptinne C, Swann NC, Qasim S, Miocinovic S, Ostrem JL, Knight RT, Starr PA. Task-related activity in sensorimotor cortex in Parkinson's disease and essential tremor: changes in beta and gamma bands. Front Hum Neurosci 2015; 9:512. [PMID: 26441609 PMCID: PMC4585033 DOI: 10.3389/fnhum.2015.00512] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 09/03/2015] [Indexed: 11/25/2022] Open
Abstract
In Parkinson's disease patients in the OFF medication state, basal ganglia local field potentials exhibit changes in beta and gamma oscillations that correlate with reduced voluntary movement, manifested as rigidity and akinesia. However, magnetoencephalography and low-resolution electrocorticography (ECoG) studies in Parkinson's patients suggest that changes in sensorimotor cortical oscillations differ from those of the basal ganglia. To more clearly define the role of sensorimotor cortex oscillatory activity in Parkinson's, we performed intraoperative, high-resolution (4 mm spacing) ECoG recordings in 10 Parkinson's patients (2 females, ages 47–72) undergoing deep brain stimulation (DBS) lead placement in the awake, OFF medication state. We analyzed ECoG potentials during a computer-controlled reaching task designed to separate movement preparation from movement execution and compared findings to similar invasive recordings in eight patients with essential tremor (3 females, ages 59–78), a condition not associated with rigidity or akinesia. We show that (1) cortical beta spectral power at rest does not differ between Parkinson's and essential tremor patients (p = 0.85), (2) early motor preparation in Parkinson's patients in the OFF medication state is associated with a larger beta desynchronization compared to patients with essential tremor (p = 0.0061), and (3) cortical broadband gamma power is elevated in Parkinson's patients compared to essential tremor patients during both rest and task recordings (p = 0.004). Our findings suggest an oscillatory profile in sensorimotor cortex of Parkinson's patients that, in contrast to the basal ganglia, may act to promote movement to oppose the anti-kinetic bias of the dopamine-depleted state.
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Affiliation(s)
- Nathan C Rowland
- Department of Neurological Surgery, University of California, San Francisco San Francisco, CA, USA
| | - Coralie De Hemptinne
- Department of Neurological Surgery, University of California, San Francisco San Francisco, CA, USA
| | - Nicole C Swann
- Department of Neurological Surgery, University of California, San Francisco San Francisco, CA, USA
| | - Salman Qasim
- Department of Neurological Surgery, University of California, San Francisco San Francisco, CA, USA
| | - Svjetlana Miocinovic
- Department of Neurology, University of California, San Francisco San Francisco, CA, USA
| | - Jill L Ostrem
- Department of Neurology, University of California, San Francisco San Francisco, CA, USA
| | - Robert T Knight
- Department of Neurological Surgery, University of California, San Francisco San Francisco, CA, USA ; Department of Neurology, University of California, San Francisco San Francisco, CA, USA ; Helen Wills Neuroscience Institute, University of California, Berkeley Berkeley, CA, USA ; Department of Psychology, University of California, Berkeley Berkeley, CA, USA
| | - Philip A Starr
- Department of Neurological Surgery, University of California, San Francisco San Francisco, CA, USA
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Rowland NC, Starr PA, Larson PS, Ostrem JL, Marks WJ, Lim DA. Combining cell transplants or gene therapy with deep brain stimulation for Parkinson's disease. Mov Disord 2014; 30:190-5. [DOI: 10.1002/mds.26083] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 10/16/2014] [Indexed: 01/15/2023] Open
Affiliation(s)
- Nathan C. Rowland
- Department of Neurological Surgery; University of California; San Francisco CA USA
| | - Philip A. Starr
- Department of Neurological Surgery; University of California; San Francisco CA USA
- Parkinson's Disease Research; Education, and Clinical Center at the San Francisco Veterans Affairs Medical Center, University of California; San Francisco CA USA
| | - Paul S. Larson
- Department of Neurological Surgery; University of California; San Francisco CA USA
- Parkinson's Disease Research; Education, and Clinical Center at the San Francisco Veterans Affairs Medical Center, University of California; San Francisco CA USA
| | - Jill L. Ostrem
- Department of Neurology; San Francisco Veterans Affairs Medical Center, University of California; San Francisco CA USA
- Parkinson's Disease Research; Education, and Clinical Center at the San Francisco Veterans Affairs Medical Center, University of California; San Francisco CA USA
| | - William J. Marks
- Department of Neurology; San Francisco Veterans Affairs Medical Center, University of California; San Francisco CA USA
- Parkinson's Disease Research; Education, and Clinical Center at the San Francisco Veterans Affairs Medical Center, University of California; San Francisco CA USA
| | - Daniel A. Lim
- Department of Neurological Surgery; University of California; San Francisco CA USA
- Parkinson's Disease Research; Education, and Clinical Center at the San Francisco Veterans Affairs Medical Center, University of California; San Francisco CA USA
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Raygor KP, Rowland NC, Cooke DL, Solomon DA, Huang MC. Aneurysm of the posterior meningeal artery embedded within a dorsal exophytic medullary hemangioblastoma: surgical management and review of literature. J Cerebrovasc Endovasc Neurosurg 2014; 16:293-8. [PMID: 25340034 PMCID: PMC4205258 DOI: 10.7461/jcen.2014.16.3.293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 07/01/2014] [Accepted: 08/11/2014] [Indexed: 12/02/2022] Open
Abstract
Hemangioblastomas are World Health Organization (WHO) Grade I neoplasms of the hindbrain and spinal cord, whose management can be complicated by preoperative hemorrhage. We report on a case of a young female in extremis with posterior fossa hemorrhage following rupture of a fusiform posterior meningeal artery aneurysm embedded within a medullary hemangioblastoma. We discuss management options, including operative staging and embolization, and review similar cases of hemangioblastoma associated with aneurysm.
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Affiliation(s)
- Kunal P Raygor
- UCSF Center for Stroke and Cerebrovascular Disease, Department of Neurological Surgery, University of California, San Francisco, CA, United States
| | - Nathan C Rowland
- UCSF Center for Stroke and Cerebrovascular Disease, Department of Neurological Surgery, University of California, San Francisco, CA, United States
| | - Daniel L Cooke
- Neuro-Interventional Section, Department of Radiology, University of California, San Francisco, CA, United States
| | - David A Solomon
- Department of Pathology, University of California, San Francisco, CA, United States
| | - Michael C Huang
- UCSF Center for Stroke and Cerebrovascular Disease, Department of Neurological Surgery, University of California, San Francisco, CA, United States
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Rowland NC, Miller KJ, Starr PA. Three-Dimensional Accuracy of ECOG Strip Electrode Localization Using Coregistration of Preoperative MRI and Intraoperative Fluoroscopy. Stereotact Funct Neurosurg 2014; 92:8-16. [DOI: 10.1159/000350027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 02/19/2013] [Indexed: 11/19/2022]
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Abstract
Juvenile psammomatoid ossifying fibroma (JPOF) is a benign fibro-osseous lesion typically associated with the jaw, paranasal region, or orbit. However, JPOF may also originate from the skull base and locally invade the cranium. In published reports, intracranial JPOFs constitute only a small percentage of cases, and therefore it is not known whether more aggressive behavior typifies this distinct population of JPOFs compared with those in other locations. Nevertheless, JPOF histopathology is characterized by a number of active processes, including cystic transformation, that may precipitate violation of skull base boundaries. In the following article, the authors present a case of skull base JPOF that underwent cystic expansion in a young girl, produced a focal neurological deficit, and was resolved using a staged surgical approach.
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Affiliation(s)
- Nathan C Rowland
- Brain Tumor Center, Department of Neurological Surgery, University of California-SanFrancisco, 505 Parnassus Avenue, San Francisco, CA 94143-0112, USA.
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Abstract
Brain–machine interfaces (BMIs) are on the horizon for clinical neurosurgery. Electrocorticography-based platforms are less invasive than implanted microelectrodes, however, the latter are unmatched in their ability to achieve fine motor control of a robotic prosthesis capable of natural human behaviors. These technologies will be crucial to restoring neural function to a large population of patients with severe neurologic impairment – including those with spinal cord injury, stroke, limb amputation, and disabling neuromuscular disorders such as amyotrophic lateral sclerosis. On the opposite end of the spectrum are neural enhancement technologies for specialized applications such as combat. An ongoing ethical dialogue is imminent as we prepare for BMI platforms to enter the neurosurgical realm of clinical management.
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Affiliation(s)
- Nathan C Rowland
- Department of Neurosurgery, 505 Parnassus Avenue, Rm M779, University of California, San Francisco, CA, USA
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Gandhoke G, Wu JC, Rowland NC, Meyer SA, Gupta C, Mummaneni PV. Anterior corpectomy versus posterior laminoplasty: is the risk of postoperative C-5 palsy different? Neurosurg Focus 2012; 31:E12. [PMID: 21961856 DOI: 10.3171/2011.8.focus11156] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Both anterior cervical corpectomy and fusion (ACCF) and laminoplasty are effective treatments for selected cases of cervical stenosis. Postoperative C-5 palsies may occur with either anterior or posterior decompressive procedures; however, a direct comparison of C-5 palsy rates between the 2 approaches is not present in the literature. The authors sought to compare the C-5 palsy rate of ACCF versus laminoplasty. METHODS The authors conducted a retrospective review of 31 ACCF (at C-4 or C-5) and 31 instrumented laminoplasty cases performed to treat cervical stenosis. The demographics of the groups were similar except for age (ACCF group mean age 53 years vs laminoplasty group mean age 62 years, p = 0.002). The mean number of levels treated was greater in the laminoplasty cohort (3.87 levels) than in the ACCF cohort (2.74 levels, p < 0.001). The mean preoperative Nurick grade of the laminoplasty cohort (2.61) was higher than the mean preoperative Nurick grade of the ACCF cohort (1.10, p < 0.001). RESULTS The overall clinical follow-up rate was 100%. The mean overall clinical follow-up was 15 months. There were no significant differences in the estimated blood loss or length of stay between the 2 groups (p > 0.05). There was no statistical difference between the complication or reoperation rates between the 2 groups (p = 0.184 and p = 0.238). There were 2 C-5 nerve root pareses in each group. Three of the 4 patients recovered full deltoid function, and the fourth patient recovered nearly full deltoid function at final follow-up. There was no statistical difference in the rate of deltoid paresis (6.5%) between the 2 groups (p = 1). CONCLUSIONS Both ACCF and laminoplasty are effective treatments for patients with cervical stenosis. The authors found no difference in the rate of deltoid paresis between ACCF and laminoplasty to treat cervical stenosis.
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Affiliation(s)
- Gurpreet Gandhoke
- Department of Neurological Surgery, University of California, San Francisco, California, USA
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Rowland NC, Englot DJ, Cage TA, Sughrue ME, Barbaro NM, Chang EF. A meta-analysis of predictors of seizure freedom in the surgical management of focal cortical dysplasia. J Neurosurg 2012; 116:1035-41. [DOI: 10.3171/2012.1.jns111105] [Citation(s) in RCA: 139] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Focal cortical dysplasia (FCD) is one of the most common causes of medically refractory epilepsy leading to surgery. However, seizure control outcomes reported in isolated surgical series are highly variable. As a result, it is not clear which variables are most crucial in predicting seizure freedom following surgery for FCD. The authors' aim was to determine the prognostic factors for seizure control in FCD by performing a meta-analysis of the published literature.
Methods
A MEDLINE search of the published literature yielded 37 studies that met inclusion and exclusion criteria. Seven potential prognostic variables were determined from these studies and were dichotomized for analysis. For each variable, individual studies were weighted by inverse variance and combined to generate an odds ratio favoring seizure freedom. The methods complied with a standardized meta-analysis reporting protocol.
Results
Two thousand fourteen patients were included in the analysis. The overall rate of seizure freedom (Engel Class I) among patients undergoing surgery for FCD in the cohort of studies was 55.8% ± 16.2%. Partial seizures, a temporal location, detection with MRI, and a Type II Palmini histological classification were associated with higher rates of postoperative seizure control. As a treatment-related factor, complete resection of the anatomical or electrographic abnormality was the most important predictor overall of seizure freedom. Neither age nor electroencephalographic localization of the ictal onset significantly affected seizure freedom after surgery.
Conclusions
Using a large population cohort pooled from the published literature, an analysis identified important factors that are prognostic in patients with epilepsy due to FCD. The most important of these factors—diagnostic imaging and resection—provide modalities through which improvements in the impact of FCD can be effected.
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Gross RE, Rowland NC, Sung EK, LaBorde DV, Suleiman SL. Anchoring depth electrodes for bedside removal: a "break-away" suturing technique for intracranial monitoring. Neurosurgery 2012; 71:52-6; discussion 56-7. [PMID: 22433201 DOI: 10.1227/neu.0b013e31825569c0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intracranial depth electrodes for epilepsy are easily dislodged during long-term monitoring unless adequately anchored, but a technique is not available that is both secure and allows easy explantation without reopening the incision. OBJECTIVE To describe a convenient and inexpensive method for anchoring depth electrodes that prevents migration and incidental pullout while allowing electrode removal at the bedside. METHODS An easily breakable suture (eg, MONOCRYL) is tied around both the depth electrode and a heavy nylon suture and anchored to a hole at the edge of the burr hole; the tails of both are tunneled together percutaneously. The "break-away" MONOCRYL suture effectively anchors the electrode for as long as needed. At the completion of the intracranial electroencephalography session, the 2 tails of the nylon suture are pulled to break their encompassing MONOCRYL anchor suture, thus freeing the depth electrode for easy removal. RESULTS The break-away depth electrode anchoring technique was used for 438 electrodes in 68 patients, followed by explantation of these and associated strip electrodes without reopening the incision. Only 1 electrode (0.2%) migrated spontaneously, and 3 depth electrodes (0.7%) fractured in 2 patients (2.9%) on explantation, necessitating open surgery to remove them in 1 of the patients (1.5%). CONCLUSION An easy and inexpensive anchoring configuration for depth electrodes is described that provides an effective and safe means of securing the electrodes while allowing easy explantation at the bedside.
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Affiliation(s)
- Robert E Gross
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
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Abstract
The high morbidity and mortality associated with acromegaly can be addressed with multiple treatment modalities, including surgery, medicines, and radiation therapy. Radiation was initially delivered through conventional fractionated radiotherapy, which targets a wide area over many treatment sessions and has been shown to induce remission in 50%–60% of patients with acromegaly. However, conventional fractionated radiotherapy takes several years to achieve remission in patients with acromegaly and carries a risk of hypopituitarism that may limit its use. Stereotactic radiosurgery, of which there are several forms, including Gamma Knife surgery, CyberKnife therapy, and proton beam therapy, offers slightly attenuated efficacy but achieves remission in less time and provides more precise targeting of the adenoma with better control of the dose of radiation received by adjacent structures such as the pituitary stalk, pituitary gland, optic chiasm, and cranial nerves in the cavernous sinus. Of the forms of stereotactic radiosurgery, Gamma Knife surgery is the most widely used and, because of its long-term follow-up in clinical studies, is the most likely to compete with medical therapy for first-line adjuvant use after resection. In this review, the authors outline the major modes of radiation therapies in clinical use today, and they critically assess the feasibility of these modalities for acromegaly treatment. Acromegaly is a multisystem disorder that demands highly specialized treatment protocols including neurosurgical and endocrinological intervention. As more efficient forms of pituitary radiation develop, acromegaly treatment options may continue to change with radiation therapies playing a more prominent role.
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Affiliation(s)
- Nathan C Rowland
- Department of Neurological Surgery, California Center for Pituitary Disorders, University of California, San Francisco, California 94143-0112, USA
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Rowland NC, Jaeger D. Responses to tactile stimulation in deep cerebellar nucleus neurons result from recurrent activation in multiple pathways. J Neurophysiol 2007; 99:704-17. [PMID: 18077662 DOI: 10.1152/jn.01100.2007] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In a previous study, we found that neurons in the deep cerebellar nuclei (DCN) respond to 5-ms brief facial tactile stimulation in rats anesthetized with ketamine-xylazine with multiphasic response patterns lasting over 200 ms. It remained unclear, however, to what extent these responses were shaped not only by ascending sensory input from the trigeminal nuclei but also by interactions with other major cerebellar afferent systems, in particular the inferior olive (IO) and cerebral cortex. In the present study, we recorded from the IO, cerebral cortex, cerebellar granule cell layer (GCL), and DCN during the presentation of 5-ms facial tactile stimuli to elucidate potential mechanisms of how extended DCN response patterns are generated. We found that tactile stimulation resulted in robust multiphasic local field potentials responses in the IO as well as in the activation of a wide region of the somatosensory cortex (SI) and the primary motor cortex (MI). DCN neurons responded to electrical stimulation of any of these structures (IO, SI, and MI) with complex temporal patterns strikingly similar to air-puff lip stimulation responses. Simultaneous recordings from multiple structures revealed that long-lasting activation patterns elicited in DCN neurons were based on recurrent network activation in particular between the IO and the DCN with a potential contribution of DCN rebound properties. These results are consistent with the hypothesis that sensory stimulation triggers a feedback network activation of cerebellum, IO, and cerebral cortex to generate temporal patterns of activity that may control the timing of behavior.
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Abstract
In the lateral hemispheres of the cerebellar cortex, somatosensory responses are represented in a finely grained fractured somatotopy. It is unclear, however, how these responses contribute to the ultimate output of the cerebellum from the deep cerebellar nuclei (DCN). Robust responses of DCN neurons to somatosensory stimuli have been described, but a detailed examination of their somatotopic arrangement and stimulus coding properties is lacking. To address these questions, we recorded extracellular, single-unit activity in the DCN of ketamine-anesthetized rats in response to air-puff stimuli aimed at six different orofacial and forelimb locations. In additional experiments, the duration and intensity of air-puff stimuli to the ipsilateral upper lip were systematically varied. Overall, we found that DCN neuron responses to air puff stimuli showed combinations of three distinct response components: a short-latency spike response, a pronounced inhibition, and a long-latency increase in firing. Individual neurons responsive to air-puff stimulation exhibited any combination of just one, two, or all three of these response components. The inhibitory response was most common and frequently consisted of a complete cessation of spiking despite a high spontaneous rate of baseline firing. In contrast to published findings from cerebellar cortical recordings, the receptive fields of all responsive neurons in the DCN were large. In fact, the receptive field of most neurons covered the ipsi- and contralateral face as well as forepaws. Response properties of individual neurons did not reliably indicate stimulus intensity or duration, although as a population DCN neurons showed significantly increasing response amplitudes as air-puff intensity or duration increased. Overall, the responses were characterized by a distinct temporal profile in each neuron, which remained unchanged with changes in stimulus condition. We conclude that the responses in the DCN of rats to air-puff stimuli differ substantially from cerebellar cortical responses in their receptive field properties and do not provide a robust code of tactile stimulus properties. Rather, the characteristic temporal response profile of each neuron may be tuned to control the timing of a specific task to which its output is linked.
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