Migraine with brainstem aura: Why not a cortical origin?

Background Migraine with brainstem aura is defined as a migraine with aura including at least two of the following symptoms: dysarthria, vertigo, tinnitus, hypacusis, diplopia, ataxia and/or decreased level of consciousness. Aim The aim of this study is to review data coming from clinical observations and functional mapping that support the role of the cerebral cortex in the initiation of brainstem aura symptoms. Results Vertigo can result from a vestibular cortex dysfunction, while tinnitus and hypacusis can originate within the auditory cortex. Diplopia can reflect a parieto-occipital involvement. Dysarthria can be caused by dysfunctions located in precentral gyri. Ataxia can reflect abnormal processing of vestibular, sensory, or visual inputs by the parietal lobe. Alteration of consciousness can be caused by abnormal neural activation within specific consciousness networks that include prefrontal and posterior parietal cortices. Conclusion Any symptom of so-called brainstem aura can originate within the cortex. Based on these data, we suggest that brainstem aura could have a cortical origin. This hypothesis would explain the co-occurrence of typical and brainstem aura during attacks and would fit with the theory of cortical spreading depression. We propose that migraine with brainstem aura should be classified as a typical migraine aura.

Prospective Cohort Study Evaluating the Prognostic Value of Simple EEG Parameters in Postanoxic Coma

We prospectively studied early bedside standard EEG characteristics in 61 acute postanoxic coma patients. Five simple EEG features, namely, isoelectric, discontinuous, nonreactive to intense auditory and nociceptive stimuli, dominant delta frequency, and occurrence of paroxysms were classified yes or no. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating characteristic curve (AUC) of each of these variables for predicting an unfavorable outcome, defined as death, persistent vegetative state, minimally conscious state, or severe neurological disability, as assessed 1 year after coma onset were computed as well as Synek's score. The outcome was unfavorable in 56 (91.8%) patients. Sensitivity, specificity, PPV, NPV, and AUC of nonreactive EEG for predicting an unfavorable outcome were 84%, 80%, 98%, 31%, and 0.82, respectively; and were all very close to the ones of Synek score>3, which were 82%, 80%, 98%, 29%, and 0.81, respectively. Specificities for predicting an unfavorable outcome were 100% for isoelectric, discontinuous, or dominant delta activity EEG. These 3 last features were constantly associated to unfavorable outcome. Absent EEG reactivity strongly predicted an unfavorable outcome in postanoxic coma, and performed as accurate as a Synek score>3. Analyzing characteristics of some simple EEG features may easily help nonneurophysiologist physicians to investigate prognostic issue of postanoxic coma patient. In this study (a) discontinuous, isoelectric, or delta-dominant EEG were constantly associated with unfavorable outcome and (b) nonreactive EEG performed prognostic as accurate as a Synek score>3.

Advanced [(18)F]FDG and [(11)C]flumazenil PET analysis for individual outcome prediction after temporal lobe epilepsy surgery for hippocampal sclerosis

Purpose

We have previously shown that an imaging marker, increased periventricular [¹¹C]flumazenil ([¹¹C]FMZ) binding, is associated with failure to become seizure free (SF) after surgery for temporal lobe epilepsy (TLE) with hippocampal sclerosis (HS). Here, we investigated whether increased preoperative periventricular white matter (WM) signal can be detected on clinical [¹⁸F]FDG-PET images. We then explored the potential of periventricular FDG WM increases, as well as whole-brain [¹¹C]FMZ and [¹⁸F]FDG images analysed with random forest classifiers, for predicting surgery outcome.

Methods

Sixteen patients with MRI-defined HS had preoperative [¹⁸F]FDG and [¹¹C]FMZ-PET. Fifty controls had [¹⁸F]FDG-PET (30), [¹¹C]FMZ-PET (41), or both (21). Periventricular WM signal was analysed using Statistical Parametric Mapping (SPM8), and whole-brain image classification was performed using random forests implemented in R (http://www.r-project.org). Surgery outcome was predicted at the group and individual levels.

Results

At the group level, non-seizure free (NSF) versus SF patients had periventricular increases with both tracers. Against controls, NSF patients showed more prominent periventricular [¹¹C]FMZ and [¹⁸F]FDG signal increases than SF patients. All differences were more marked for [¹¹C]FMZ. For individuals, periventricular WM signal increases were seen at optimized thresholds in 5/8 NSF patients for both tracers. For SF patients, 1/8 showed periventricular signal increases for [¹¹C]FMZ, and 4/8 for [¹⁸F]FDG. Hence, [¹⁸F]FDG had relatively poor sensitivity and specificity. Random forest classification accurately identified 7/8 SF and 7/8 NSF patients using [¹¹C]FMZ images, but only 4/8 SF and 6/8 NSF patients with [¹⁸F]FDG.

Conclusion

This study extends the association between periventricular WM increases and NSF outcome to clinical [¹⁸F]FDG-PET, but only at the group level. Whole-brain random forest classification increases [¹¹C]FMZ-PET's performance for predicting surgery outcome.

Periventricular [(11)C]flumazenil binding for predicting postoperative outcome in individual patients with temporal lobe epilepsy and hippocampal sclerosis

A third of patients with intractable temporal lobe epilepsy and hippocampal sclerosis (HS) are not seizure free (NSF) after surgery. Increased periventricular [¹¹C]flumazenil (FMZ) binding, reflecting heterotopic neuron concentration, has been described as one predictor of NSF outcome at the group level. We aimed to replicate this finding in an independent larger cohort and investigated whether NSF outcome can be predicted in individuals.

Preoperative [¹¹C]FMZ summed radioactivity images were available for 16 patients with HS and 41 controls. Images were analyzed using SPM8, explicitly including the white matter, and correction for global radioactivity via group-specific ANCOVA. Periventricular increases were assessed with a mask and different cutoffs for distinguishing NSF and seizure free (SF) patients.

NSF patients had increased [¹¹C]FMZ binding around the posterior horn of the ventricles ipsilaterally (z = 2.53) and contralaterally (z = 4.44) to the seizure focus compared with SF patients. Compared with controls, SF patients had fewer periventricular increases (two clusters, total volume 0.87 cm³, z_max = 3.8) than NSF patients (two ipsilateral and three contralateral clusters, 6.15 cm³, z_max = 4.8). In individuals and at optimized cutoffs, five (63%) of eight NSF patients and one (13%) of eight SF patients showed periventricular increases compared with controls (accuracy 75%). Only one (2%) of the 41 controls had increases at the same cutoff.

The association between periventricular [¹¹C]FMZ increases and NSF outcome after temporal lobe resection for HS has been confirmed in an independent cohort on simple summed activity images. [¹¹C]FMZ-PET may be useful for individual preoperative counseling with clinically relevant accuracy.

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[¹¹C]FMZ periventricular WM binding for predicting surgery outcome in mTLE-HS.

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Summed radioactivity images allowed replicating a prior study at the group level.

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Blood sampling constraint removed in comparison to the previous study.

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Periventricular abnormalities may allow predicting surgery outcome in individuals.

Long-term outcome of gamma-knife surgery in temporal lobe epilepsy

PURPOSE

Indication of gamma-knife surgery (GKS) in temporal lobe epilepsy (TLE) remains a matter of debate. Either positive or negative results have been reported in studies with a maximum follow-up of 24 months. No long-term data have been published yet.

METHODS

We collected data from 15 TLE patients who underwent GKS and whose follow-up was longer than 24 months. Localisation and extension of the epileptogenic zone (EZ) were assessed by SEEG in eight patients. Ten patients were presenting with mesial TLE (mTLE) while in the other five SEEG showed that the EZ was extending beyond mesio-temporal structures. GKS procedure was targeted to the EZ at a dose of 21.1+/-2.6Gy at the margin.

RESULTS

The mean duration of the follow-up was 60+/-22.3 months. At last follow-up, seven patients (46.7%) were free of disabling seizure. The last seizure following GKS occurred on average after a delay of 19.75+/-20.62 months. No patient suffered recurrent seizures after a long period free of disabling seizures. No significant prognostic predictor could be individualized in this population. However, 6 of the 10 patients with mTLE (60%) were seizure free whereas only 1 of the 5 (20%) whose EZ was more extended exhibited the same seizure outcome.

CONCLUSION

When a positive outcome is achieved, the risk of seizure recurrence remains low at long term. In patients with typical mTLE, long-term GKS results may be closed to those observed after conventional surgery. Conversely, this procedure should not be proposed to patients in whom SEEG results suggest that the EZ is not restricted to mesial temporal structures.

Recommendations for the clinical use of somatosensory-evoked potentials

The International Federation of Clinical Neurophysiology (IFCN) is in the process of updating its Recommendations for clinical practice published in 1999. These new recommendations dedicated to somatosensory-evoked potentials (SEPs) update the methodological aspects and general clinical applications of standard SEPs, and introduce new sections dedicated to the anatomical-functional organization of the somatosensory system and to special clinical applications, such as intraoperative monitoring, recordings in the intensive care unit, pain-related evoked potentials, and trigeminal and pudendal SEPs. Standard SEPs have gained an established role in the health system, and the special clinical applications we describe here are drawing increasing interest. However, to prove clinically useful each of them requires a dedicated knowledge, both technical and pathophysiological. In this article we give technical advice, report normative values, and discuss clinical applications.

Opsoclonus-myoclonus as a manifestation of Lyme disease

Opsoclonus-myoclonus syndrome (OMS) is a rare condition that includes chaotic multidirectional saccadic eye movements associated with myoclonus and ataxia. In adults, it is usually considered to be an autoimmune disease occurring either in a paraneoplastic context or after central nervous system infection. We report the case of a patient who presented with the classic features of OMS as a manifestation of acute Borrelia burgdorferi infection that was shown both on serum and cerebrospinal fluid examination. The outcome was favourable after prolonged antibiotic treatment. Lyme disease could be added to the list of aetiologies to be screened in OMS, as it would allow effective treatment and avoidance of unnecessary investigations.

Ipsilateral Head Deviation in Frontal Lobe Seizures

PURPOSE

The lateralizing value of ictal head deviation (HD) in frontal lobe epilepsy (FLE) is a matter of debate. Although FLE is typically associated with tonic or clonic HD contralateral to seizure onset, ipsilateral HD has been noted in numerous reports. Whether both types of HD can be distinguished according to their clinical patterns has not yet been specifically investigated.

METHODS

We studied the clinical pattern and time of occurrence of HD of 129 seizures in 13 consecutive patients, who underwent successful surgery for FLE, including 12 investigated with an intracerebral stereotactic EEG procedure.

RESULTS

Ictal HD was ipsilateral to the epileptogenic zone (EZ) in four (30%) patients and 27 (20.9%) seizures and contralateral in five (38%) patients and 15 (11.6%) seizures. Ipsilateral HD was rarely tonic and never associated with clonic manifestation. Contralateral HD was always tonic, unnatural, and associated with hemifacial clonic movements in 86% of seizures. Ipsilateral HD occurred earlier than contralateral HD (p < 0.03), with a mean delay of 1 +/- 2 s after the first detectable ictal sign, as compared with a delay of 17 +/- 11 s for contralateral HD. Moreover, ipsilateral HD always occurred before contralateral HD when both signs coexisted in the same seizure. Our patients with ipsilateral HD demonstrated either an anterior or dorsolateral frontal EZ.

CONCLUSIONS

Ipsilateral HD is a common ictal sign during FLE and can be distinguished from contralateral HD by its time of occurrence at or immediately after seizure onset and its lacking association with clonic movements.

Extraction of epileptogenic foci from PET and SPECT images by fuzzy modeling and data fusion

During the presurgical evaluation of medically intractable epilepsy, isotopic functional imagery provides an increasing amount of data concerning the potential location of the focus. The aim of this study is to facilitate the surgical decision by presenting an image fusion method able to extract epileptogenic foci from periictal single photon emission computed tomography (SPECT), interictal SPECT, fluoro-desoxy-glucose (FDG) position emission tomography (PET), and flumazenil PET. After spatial coregistration, the images are converted into fuzzy maps whose membership functions indicate the pathological degree of each voxel, according to each modality. These maps are then fused together thanks to a combination operator managing uncertainty (due to the sensitivity) and imprecision (due to poor resolution and partial volume effect) of the images. In the framework of possibilistic theory, this operator mimics the way the physicians evaluate and compare the various exams. The technique was successfully tested on simulated images with well-defined abnormalities, in terms of size and intensity. A preliminary clinical study was also performed and gave results in accordance with the "gold standard" investigation (deep electrodes or postsurgical outcome) in 11 patients out of 12.

Neurophysiological monitoring for epilepsy surgery: the Talairach SEEG method. StereoElectroEncephaloGraphy. Indications, results, complications and therapeutic applications in a series of 100 consecutive cases

OBJECT OF THE STUDY

In some candidates for epilepsy surgery in whom the decision to operate is difficult to make, invasive presurgical investigations, namely depth electrode recordings, may be needed. The SEEG (StereoElectroEncephaloGraphy) method consists of stereotactic orthogonal implantation of depth electrodes (5 to 15, 11 on average). The object of this study is to clarify the indications for SEEG, to expose its complications, and to display its usefulness in terms of surgical strategy and results.

PATIENTS AND METHODS

100 patients, suffering from drug-resistant epilepsy and selected as candidates for surgical resection, underwent SEEG between 1996 and 2000. A total of 1,118 electrodes were implanted. For each single case, the sites of implantation of the electrodes were chosen in order to determine either the side of the onset of seizures, or the uni- or multilobar feature of them, or a possible operculo-insular propagation from a temporal onset, and also, using direct electrode stimulation, the proximity of speech or motor area.

RESULTS

Complications occurred in 5 patients (2 superficial infections, 2 breakages of electrodes, and 1 intracerebral hematoma responsible for death). SEEG was helpful in most (84%) of the 100 patients to confirm or annul surgical indication, and to adjust the extent of the resection. In some cases (14%), SEEG allowed to propose a resection that might have been disputable based solely on noninvasive investigation data. For frontal epilepsy, SEEG was crucial in all cases to delineate the extent of resection.

CONCLUSION

SEEG proved to be a relatively safe and a very useful method in 'difficult' candidates for epilepsy surgery. In addition, in some cases the implanted electrodes can be used to perform therapeutic RF thermocoagulation of epileptic foci or networks.

Asymmetrical localization of benzodiazepine receptors in the human auditory cortex

In humans, administration of benzodiazepines (BZD) has been shown to have an asymmetrical effect on the medial olivocochlear system. Indeed, a decrease of evoked otoacoustic emission suppression by contralateral acoustic stimulation, which explores the medial olivocochlear efferent system, was observed in the right ear, with no left ear effect. This result suggests a possible left-right auditory pathway BZD receptor asymmetry. Given the anatomical link between auditory centers and the medial olivocochlear system, the existence of a larger volume of cortical connecting fibers in the left hemisphere, and the possible link between BZD receptor density and neuronal density, we tested the hypothesis of an asymmetrical localization of BZD receptors in the auditory system in 10 right-handed subjects using [11C]flumazenil positron emission tomography. Semi-quantitative measurements of flumazenil binding were evaluated in Heschl's gyrus showing a left-right asymmetry in favor of left auditory cortex. This result indicates a higher density of neurons in left auditory cortex. The possible link between neurochemical asymmetry and functional asymmetry, and the perceptual outcome of BZD administration, will be discussed.

Anatomy of optic nerve radiations as assessed by static perimetry and MRI after tailored temporal lobectomy

AIMS

To determine the course of optic nerve radiations in the temporal lobe, especially their retinotopic organisation and the anterior limit of the Meyer's loop.

METHODS

18 adult patients who had undergone a tailored temporal lobectomy for epilepsy were included in this study between 1994 and 1998. The rostrocaudal extent of the lateral temporal lobe resection assessed intraoperatively by the surgeon and by postoperative MRI was compared with the postoperative visual fields determined by automated static perimetry (ASP).

RESULTS

15 patients (83%) presented a postoperative visual field deficit (VFD) confined to the superior homonymous field contralateral to the side of the resection. All degrees from a minimal upper field loss to a complete quadrantanopia were observed. The VFDs were somewhat stereotyped, predominating along the vertical meridian. The smallest anteroposterior resection resulting in a VFD was limited to 20 mm from the tip of the temporal lobe. A relation was observed between the extent of the lateral resection in front of the second and third convolutions and the occurrence and extent of postoperative VFDs. No patient reported persisting subjective visual impairment.

CONCLUSION

The high frequency of postoperative VFDs appears to be due to the greater sensitivity of ASP. The characteristics of the stereotyped VFDs allow new conclusions about the course and retinotopy of optic nerve radiations. The anterior limit of Meyer's loop is likely to be located more rostrally than previously believed.

Timing and characteristics of perceptual attenuation by transcranial stimulation: a study using magnetic cortical stimulation and somatosensory-evoked potentials

Transcranial cortical magnetic stimulation (CMS) is a noninvasive, non-noxious procedure to induce perceptual attenuation when applied concomitant to sensory stimuli. To investigate the perceptual timing of simple stimulus features in the somatosensory modality, we applied right hemisphere CMS at different intervals following a stimulus delivered to the left hand. Different intervals between peripheral stimuli and CMS were defined according to the components of the somatosensory-evoked potentials (SEP), previously obtained in response to the same stimulus. Perceptual attenuation was maximal when CMS coincided with the primary cortical response (parietal N20 potential); conversely, perception of stimulus intensity was not modified when CMS was concomitant with the N200 and P300 potentials. Using small CMS intensities, a "perceptual dip" was observed when CMS arrived in coincidence with the N120 potential, a SEP response thought to be originated in part in the second somatic area. Our results support the view that both N200 and P300 are post-perceptual responses. The results also suggest that the cortical processes active during the N20 and N120 potentials may be essential for the conscious perception of somatosensory stimuli delivered to the hand.

Evidence for an abnormal cortical sensory processing in dystonia: selective enhancement of lower limb P37-N50 somatosensory evoked potential

We evaluated brain stem P30, contralateral frontal N37, and the vertex-ipsilateral central P37, N50 somatosensory evoked potentials (SEPs) obtained in response to stimulation of the tibial nerve in 10 patients with idiopathic dystonia. Results were compared with those obtained in 10 healthy subjects matched for age and sex. The amplitude of the brain stem P30 potential and of the contralateral frontal N37 response in dystonic patients was not significantly different from that recorded in normal subjects. The vertex- ipsilateral central P37-N50 complex, which is thought to originate in the pre-rolandic cortex, was significantly enhanced in patients compared with the control group. These results suggest the enhancement of the vertex-ipsilateral central P37-N50 complex might reflect an abnormal response to somatosensory inputs of a precentral cortex which is excessively activated because of a disorder of the basal ganglia. Such inefficient sensory processing in motor areas might contribute to motor impairment in dystonia.

Dipolar sources of the early scalp somatosensory evoked potentials to upper limb stimulation. Effect of increasing stimulus rates

Brain electrical source analysis (BESA) of the scalp electroencephalographic activity is well adapted to distinguish neighbouring cerebral generators precisely. Therefore, we performed dipolar source modelling in scalp medium nerve somatosensory evoked potentials (SEPs) recorded at 1.5-Hz stimulation rate, where all the early components should be identifiable. We built a four-dipole model, which was issued from the grand average, and applied it also to recordings from single individuals. Our model included a dipole at the base of the skull and three other perirolandic dipoles. The first of the latter dipoles was tangentially oriented and was active at the same latencies as the N20/P20 potential and, with opposite polarity, the P24/N24 response. The second perirolandic dipole showed an initial peak of activity slightly earlier than that of the N20/P20 dipolar source and, later, it was active at the same latency as the central P22 potential. Lastly, the third perirolandic dipole explaining the fronto-central N30 potential scalp distribution was constantly more posterior than the first one. In order to evaluate the effect of an increasing repetition frequency on the activity of SEP dipolar sources, we applied the model built from 1.5-Hz SEPs to traces recorded at 3-Hz and 10-Hz repetition rates. We found that the 10-Hz stimulus frequency reduced selectively the later of the two activity phases of the first perirolandic dipole. The decrement in strength of this dipolar source can be explained if we assume that: (a) the later activity of the first perirolandic dipole can represent the inhibitory phase of a "primary response"; (b) two different clusters of cells generate the opposite activities of the tangential perirolandic dipole. An additional finding in our model was that two different perirolandic dipoles contribute to the centro-parietal N20 potential generation.

Predictions of carbamazepine concentrations using a Bayesian program (PKS System, Abbott): a retrospective evaluation in an outpatient population

This work evaluates the performance of a Bayesian program (PKS System, Abbott) for predicting carbamazepine concentrations in an outpatient population. The retrospective study involved 20 epileptic patients (12 adults and 8 children) receiving carbamazepine monotherapy orally. The program was used to predict measured serum levels after feedback of 0, 1 or 2 steady-state concentrations. A significant negative prediction bias was observed when no feedback concentration was used for estimation. However, the prediction bias (mean prediction error; m.e.) decreased as soon as one feedback concentration was used for estimation. Precision (mean absolute prediction error; m.a.e.) was significantly improved with one feedback concentration and was even better with two concentrations. Likewise, r.m.s.e. (root mean squared error; composite of bias and precision) regularly decreased when the number of feedback concentrations used was increased. Eleven percent of the estimates were unacceptable clinically (prediction error > 2 mg L-1) when 1 feedback concentration was used; less than 3% were unacceptable when two concentrations were used. Thus the performance of the Bayesian dosing program is acceptable when two feedback concentrations are known, and seems able to help the clinician adjust carbamazepine dosage in an outpatient population.

Parameter and index images of benzodiazepine receptor concentration in the brain

In vivo studies of ligand-receptor interactions with PET data are based on different approaches that provide either quantitative results (receptor density and affinity) or indices that are assumed to be correlated with the receptor concentration. The aims of this study are to obtain parametric images of benzodiazepine receptor concentration and of flumazenil affinity and to study the validity of two receptor concentration indexes.

METHODS

A three-compartment ligand-receptor model, [11C]flumazenil, and experimental data obtained using a three-injection protocol in human volunteers were used to acquire parametric images. The delayed activity method and the apparent distribution volume (estimated using a two-compartment model) were also tested and their results compared with those of the multi-injection approach.

RESULTS

Parametric images of receptor density, affinity and all kinetic parameters were obtained with acceptable variation coefficients. A correlation between receptor density and apparent affinity was found (r = 0.83; p < 0.0005). The correlation between receptor concentration and apparent distribution volume (estimated with three- and two-compartment models, respectively) was accessed using both a linear (the usual hypothesis) and a nonlinear correlation derived from the relationship between the receptor density and the affinity.

CONCLUSION

In spite of the complexity of this protocol (three injections, a 2-hr experiment, blood sampling and a metabolite study), we showed that the multi-injection approach is suitable for parametric brain imaging. By using this approach as a reference, we deduced that the distribution volume and delayed activity images are valid methods in the usual range of the benzodiazepine receptor concentrations found in the human brain.

Magnetic resonance imaging in refractory focal epilepsy with normal CT scans

One hundred patients suffering from focal epilepsy with complex partial seizures refractory to medical treatment and showing no abnormality at CT were explored by MRI with an 0.5 Tesla magnet. MRI detected an abnormality in 25 patients with, in 17 of them, good correlation between MRI and clinical as well as electroencephalographic findings. Abnormal morphology and signal was found in 5 patients, with positive CT results on reexamination of previous CT images or on new CT scans in 4 of them. There was a diffuse temporal lobe high-intensity signal in 3 cases and a localized high-intensity signal in 9 cases (temporal lobe 4, occipital lobe 3, frontal lobe 1, fronto-parietal and parietal lobes 1). Thus, in 13% of the cases MRI demonstrated a lesion that had not been detected at CT, and the location of the lesion was concordant with clinical and electroencephalographic data.

Separate generators with distinct orientations for N20 and P22 somatosensory evoked potentials to finger stimulation?

Sequential spatial maps of scalp potentials, obtained with a 16-channel montage, were used in 12 healthy subjects in order to assess the temporal and spatial distribution of early cortical SEPs to single finger stimulation. It was found that when the contralateral parietal N20 negativity peaks there is a synchronous frontal P20 positivity, supporting the view of a tangentially orientated dipolar generator for this couple of scalp SEPs components. It was not possible to show a distribution of N20 peak on the scalp that would parallel the somatotopic finger representations in area S1; however, the orientation of the putative dipolar source of the N20/P20 complex was found to change according to the finger stimulated. A central P22 component was also constantly obtained without any synchronous negativity on the scalp surface corresponding to the electrode array; a clear somatotopic organisation was found for P22. These features favour the hypothesis that this latter component has a radially orientated generator situated in the prerolandic motor cortex, close to the scalp surface. Because of overlapping between the P20 and P22 components, the determination of P22 onset latency was hazardous in some cases, and spatial mapping was then essential to identify this component. The conclusion that the contralateral parietal N20 and central P22 could be generated by separate dipolar generators with distinct orientations is supported by recent data from combined electrical and magnetic field recording.

Listening with one or two hemispheres: verbal dichotic testing after intracarotid barbiturate injection

A verbal dichotic test was given to 16 patients during right or left hemisphere narcosis induced by intracarotid barbiturate injection (Wada's procedure). During right hemisphere narcosis patients did not repeat left ear words. This demonstrates an intrahemispheric competition within the left hemisphere at the detriment of left ipsilateral ear words. After left dominant hemisphere narcosis, when aphasia had apparently disappeared, patients temporarily did not repeat right ear words. This suggests that, during this critical time period, two competitive processes took place. First the right hemisphere selected the left ear words by an intrahemispheric competition. Second it imposed them on the recovering left hemisphere at the detriment of right ear words, because of an interhemispheric competition.

[Peroperative monitoring of early auditory evoked potentials]

Brainstem auditory evoked potentials (BAEP) were monitored during 37 neurosurgical operations (acoustic neurinomas with preoperative useful hearing, microvascular decompression of cranial nerves for hemispasm or trigeminal neuralgia, cerebellopontine angle tumors other than acoustic neurinomas, brainstem tumors and posterior circulation surgery). Intraoperative BAEPs were unchanged in 13 patients. Transient BAEP alterations (delay of I-V interval, transient obliteration of BAEP for as long as 8 minutes and 20 minutes) were seen in 13 other patients; irreversible BAEP alterations (loss of evoked response in 6 patients, delay of I-V interval) were seen in 11 patients. BAEP stability or alterations have been correlated with the ongoing surgical maneuver, the neurological outcome and the postoperative auditory function. BAEPs were found to be good predictors of post-operative auditory function but poorer predictors of neurological outcome. Some alterations are strictly associated with surgical retraction or with eighth nerve manipulation either immediately after the surgical maneuver or several minutes later. No detectable cause of BAEP changes was found in a few cases. The value of this monitoring is discussed. It may also help elucidate the mechanisms of hearing loss in acoustic neurinoma surgery.

Anatomical evidence for medial pulvinar connections with the posterior cingulate cortex, the retrosplenial area, and the posterior parahippocampal gyrus in monkeys

Reciprocal connections between the medial pulvinar and the limbic neocortex in monkeys were demonstrated by means of tritiated amino acid injections in the medial pulvinar and the cingulate cortex, and HRP injections in the medial pulvinar. It appears that the medial nucleus of the pulvinar sends projection fibres to the posterior cingulate gyrus (area 23), the retrosplenial area, and the posterior parahippocampal gyrus (areas TH and TF). The labeled terminals were concentrated in two bands, one in the deeper part of layer III and in layer IV, and the other in layer I. These projections were observed to be reciprocal, and the cortical afferent fibers to the medial pulvinar were found to originate from the deep layers of the cortex. The medial nucleus of the pulvinar was already known to be connected with the prefrontal cortex and with the inferior parietal lobule. Since this nucleus is now demonstrated to be connected with the posterior limbic neocortex, it is envisaged as being the thalamic counterpart of a cortical triad (prefrontal, parietal, and limbic) involved in modulating directed attention.

[Visual evoked potentials (VEP's) obtained by black and white or red and black checkerboard inversion. Results in healthy subjects and in multilocular sclerosis patients]

Visual evoked potentials (VEPs) were elicited in a control group and in 125 multiple sclerosis (MS) patients by reversal of TV black and white checkerboard patterns with two different check sizes and contrasts (44'/contrast 50%; 22'/contrast 20%), and also by a display of red light emitting diodes (LEDs) generating a 'true' pattern reversal. In control subjects LED pattern reversal produced responses of lower amplitude and of longer latency compared to responses to TV black and white checkerboards. The interindividual variability of P100 latency was lower with the LED display than with the low contrasted TV pattern. In 18 patients with definite or suspected MS, VEPs were normal with the two TV patterns when delayed or absent with the LED display. Thus LED pattern reversal was a more effective stimulus than black and white pattern reversal for the detection of demyelinating lesions of the optic nerves in MS. LED stimulation proved to be particularly useful in patients with progressive spastic paraparesis or with previous history of isolated optic neuritis.

[Cervical somatosensory evoked potentials in the healthy subject: analysis of the effect of the location of the reference electrode on aspects of the responses]

Cervical SEPs were recorded in 111 normal subjects following stimulation of the median nerve at the wrist, using 3 different sites for the reference electrode (Fz, earlobe, shoulder). It was shown that cephalic reference electrodes (Fz or earlobe) modify the wave form of the cervical response, because they pick up far-field SEPs (P9, P11, P13, P14) originating from cervical roots, spinal cord and brainstem. These far-field SEP components are injected as negativities in the activity recorded by the cervical electrode. The responses recorded with cephalic reference differ from those recorded at the same cervical site, with a non-cephalic reference in 3 main points: (1) the amplitude of negative components N11 and N13 is increased; (2) the onset latency of N11 is significantly shorter; (3) an N14 negativity is added, the origin of which is probably in the brainstem; this component may occupy the peak of the cervical negativity; thus the central conduction time, calculated as the time interval between N14 and N20, does not take into account the time for spinal propagation of the somatosensory afferent inputs. A topographic study of cervical responses in 10 normal subjects showed an increase of the onset latency of N11 (mean 0.89) from the lower cervical region to the cervico-occipital junction, provided that a non-cephalic reference is used. This result suggests that N11 corresponds to the travelling of action potentials in the ascending spinal somatosensory pathways. The use of a medio-frontal (Fz) reference electrode results in: (1) a masking of the latency shift of N11 latency because of the subtraction of the far-field Fz-recorded P11 component, the onset of which was found to be synchronous with the entry of afferent volleys in the lower cervical spinal cord; (2) a modification of the spatial organization of the responses, due to the subtraction of far-field scalp-recorded positivities P9, P11, P13 and P14, that creates negative N9, N11, N13 and N14 potentials far below the level where cervical roots enter the spinal cord.

A crossed corticotectal projection from the lateral suprasylvian area in the cat

Crossed cortical projections to the superior colliculus of the cat were demonstrated by unilateral superior colliculus injections of horseradish peroxidase (HRP) and by cortical injections of radioactive amino acids. This crossed corticotectal projection originates in the lateral bank of the middle suprasylvian sulcus and in both banks of the posterior suprasylvian sulcus. The site of termination of the contralateral corticotectal projection is restricted to the anterior margin of the superior colliculus (SC) while the ipsilateral projection spreads over the whole SC. The contralateral terminal areas are restricted to the superficial tectal layers. The projection fibers reach the contralateral superior colliculus by crossing the collicular commissure. The existence of such a connection may help to explain certain electrophysiological observations.

[Discriminant analysis of graphic elements of the EEG. Application to the detection of episodes of diffuse spike-waves]

A database of EEG information was collected from EEG recordings performed in epileptic patients with diffuse spike-wave complex discharges. Normal activity, spike-waves, slow waves and artefacts were mixed up in these recordings. The analysis of EEGs stored in the database was performed, channel by channel, through a 2.56 s moving window. For each so defined EEG sequence, a set of 22 variables chosen for their discriminatory power was computed. A subset of 8 highly discriminating variables was selected by the means of a stepwise discriminant analysis. Each class of the learning set contained 40 up to 100 EEG sequences. A classifying algorithm that takes into account zones of uncertainty is proposed. It has been evaluated on a test set which was composed of 1981 EEG sequences issued from 15 different patients. The results have been checked by two neurologists. The agreement rate between each of them and the proposed algorithm was more than 92%; this result is comparable to the agreement rate between the two neurologists (94%). A contextual analysis algorithm, using bi-dimensional smoothing techniques, allowed to improve the agreement rates which exceeded 94%.

[Short-latency somatosensory evoked potentials (SEPs) in dyssynergia cerebellaris myoclonica (author's transl)]

Short-latency SEPs following stimulation of the median nerve at the wrist have been studied in 6 patients suffering from dyssynergia cerebellaris myoclonica (DCM). Cervical N14 and scalp-recorded P15 potentials were found to be normal in patients with appropriate recording conditions. The N20 potential, usually recorded in normals in the parietal region contralateral to the stimulated side, was recorded only in 3 cases out of 6. When present, the N20 potential was found to be normal in latency, amplitude and topography. These data suggest that the electrophysiological events related with information processing at the subcortical levels of the lemniscal pathways (N14, P15) are unmodified in DCM, and lend substance to the hypothesis of a cortical long-loop reflex responsible for the triggering of intention myoclonus in these patients.

The duality of the cingulate gyrus in monkey. Neuroanatomical study and functional hypothesis

According to most behavioural, electrophysiological, and clinical studies, the cingulate gyrus is widely thought to be involved in regulation of emotional life, reactivity to painful stimuli, memory processing, and attention to sensory stimuli. Anatomically the cingulate cortex is composed of two distinct areas numbered 24 and 23 in Brodmann's classification. We have investigated the connections of the cingulate gyrus in monkeys, using horseradish peroxydase and radioautographic techniques, in order to verify the hypothesis of an anatomical complementarity of these cytoarchitectonic subdivisions. The posterior cingulate gyrus (area 23) is specifically connected with the associative temporal cortex, the medial temporal and orbitofrontal cortices, and with the medial pulvinar. The anterior cingulate gyrus (area 24) is related to the intralaminar, mediodorsal, and ventral anterior thalamic nuclei, the amygdala, and the nucleus accumbens septi. The two cingulate areas were found to be interconnected and to have, in common, connections with the 'limbic' thalamic nuclei (AM, AV, LD), the caudate nucleus, the claustrum, the lateral frontal and the posterior parietal (area 7) cortices.

[Significance of epileptic seizures occurring during the first week of traumatic coma (author's transl)]

Clinically evident epileptic seizures were observed in 145 patients during the first week of traumatic coma. They frequently occurred during the first day in young subjects in reactive coma, and were often isolated attacks. When ssen at a later stage they are more common in adults with non-reactive coma. The partial or generalised nature of the seizures, the depth of the coma, and the chronological order in which the seizures appear have no bearing on the etiology; the only positive finding was that recurrent seizures were more frequent in patients with intracranial hematoma (18,6% of the patients). The early appearance of seizures does not worsen the prognosis of reactive coma or non-reactive coma in young people. Critical discharges without clinical manifestations were present in 37 patients with traumatic coma during the first week. The average age of these injured patients was higher, and the prognosis for non-reactive coma worse in this group. The comatous state does not modify the clinical aspects or the etiological significance of these early post-traumatic discharges.

["Functional and anatomical organization of associative" cortical areas 7, 21 and 22 in monkeys. A study of the cortical projections from the pulvinar by means of HRP tracing technique (author's transl)]

The thalamic projections to the parietal and temporal associative areas (Brodmann's areas 7, 21 and 22) have been revealed by means of the retrograde axonal transport of horseradish peroxidase (HRP). The medial pulvinar (PM) was found to send afferents to the three studied areas. Labelled neurones of the PM appeared to be grouped in terms of their cortical target; indeed, neurones of origin of projection fibres to areas 7, 21 and 22 were respectively localized in the dorso-lateral, ventro-lateral and ventro-medial part of the PM. Although the multimodal sensory nature of the PM has been demonstrated by electrophysiological works, the function of PM neurones and the significance of their topographical repartition remain unknown. However PM could be involved in the transmission of specific sensory informations to the three associative areas 7, 21 and 22. Such an hypothesis is discussed according to the hitherto available data.

Projections of the ascending somesthetic pathways to the cat superior colliculus visualized by the horseradish peroxidase technique

Projections of the somesthetic ascending pathways to the superior colliculus (SC) of the cat have been demonstrated by means of the horseradish peroxidase (HRP) tracing technique. Following HRP injection in one SC, marked neurons were found in the contralateral dorsal horn and in the contralateral dorsal column nuclei, mainly the cuneate nucleus. Moreover, in the contralateral trigeminal complex, the sub-nucleus caudalis of the spinal nucleus of the Vth nerve, and the subnucleus oralis plus the main sensory trigeminal nucleus were labeled. Thus, the anterolateral system and the lemniscal system subserving face and forelimb sensation send afferent fibers to the contralateral SC.