Cortical language localization in left, dominant hemisphere. An electrical stimulation mapping investigation in 117 patients

Performance in picture naming and word comprehension: evidence for common neuronal substrates from intraoperative language mapping

Correlations of naming ability and performance in the Token Test are known from aphasia; however, the mechanisms underlying these correlations are unclear. Naming tasks are commonly used in intraoperative mapping for identification of cortical areas involved in language processing. In the present study, we measured performance in an elementary Token Test task, i.e., single word comprehension, during electrical stimulation of cortical sites at which this stimulation previously had disturbed the naming process. It was found that at about half of the sites at which naming could be disturbed electrical stimulation also led to disturbances in Token Test performance, indicating that there are common neural structures critical for performance in both tasks. These findings are discussed in terms of a multilayered semantic network in which the level of the simultaneous binding of features into concepts and the level of units that are organized with respect to semantic relations may be disturbed separately.

Location-probability profiles for the mouth region of human primary motor-sensory cortex: model and validation

The mouth representation of the human, primary motor cortex (M1) is not reliably identified by surface anatomy but may be reliably localized by means of spatial coordinates. For this report, three quantitative metanalyses were performed which jointly described the mean location, location variability and location-probability profiles of the human M1-mouth representation. First, a literature metanalysis of intersubject functional-area variability was performed using eleven, per-subject studies, each of which reported a coordinate-referenced measure of intersubject variability for one or more brain areas. From these data, a weighted-mean value for intersubject variability was computed, which proved to be small (5.6 mm, standard deviation), consistent across coordinate axes (x, y, z), and consistent across brain areas. Second, a literature metanalysis of the location of M1-mouth was performed using seven, coordinate-referenced, group-mean studies (71 subjects in all), each of which reported a grand-average location for M1-mouth. From this, a weighted-mean location and weighted values for total variability (interlaboratory plus interindividual) were determined. Using these two literature metanalyses as input data, location-probability profiles were computed for the cardinal axes (x, y, and z) of the reference space, using the functional volumes modeling (FVM) statistical model. Third, an original-data metanalysis was performed on in-house PET data from 30 normal subjects performing overt-speech tasks. M1-mouth's mean location, location variability, and location-probability profiles were consistent with those conjointly modeled by FVM from the two literature metanalyses. Collectively, these observations provide a detailed, consensus probabilistic description of the location of the human M1-mouth representation in standardized coordinates.

Electroencephalographic activity over temporal brain areas during phonological encoding in picture naming

OBJECTIVES

The present study examined electroencephalographic (EEG) correlates of phonological encoding during picture naming with special emphasis on hemispheric asymmetries of these EEG correlates. We also examined whether a small set of stimuli was sufficient to study the phonological encoding, and to what extent the complexity of the produced message affects the EEG responses.

METHODS

Event-related electrical brain activity during the covert and overt production of names and nominal phrases derived from 16 variants from 4 different pictures was compared with that during passive viewing of the same pictures.

RESULTS

Topographical and source analyses of the differential EEG activity (naming versus passive viewing) indicated that the N1 and P2 components of the visual evoked potential resulted from the same brain areas, but were activated stronger during naming as compared to passive viewing. In contrast, the differential EEG activity from 275 to 400 ms suggested the involvement of additional brain areas during naming with more pronounced left- than right-hemispheric activation in middle and posterior temporal regions for both overt and covert naming.

CONCLUSIONS

Results suggest the involvement of Wernicke's area in the phonological encoding of a message during speech production, which can even be obtained with a small set of pictures and a large number of repetitions.

Audiovisual integration of letters in the human brain

Letters of the alphabet have auditory (phonemic) and visual (graphemic) qualities. To investigate the neural representations of such audiovisual objects, we recorded neuromagnetic cortical responses to auditorily, visually, and audiovisually presented single letters. The auditory and visual brain activations first converged around 225 ms after stimulus onset and then interacted predominantly in the right temporo-occipito-parietal junction (280345 ms) and the left (380-540 ms) and right (450-535 ms) superior temporal sulci. These multisensory brain areas, playing a role in audiovisual integration of phonemes and graphemes, participate in the neural network supporting the supramodal concept of a "letter." The dynamics of these functions bring new insight into the interplay between sensory and association cortices during object recognition.

Structural and functional imaging in children with partial epilepsy

Imaging plays an increasingly important role in the evaluation of children with complex partial seizures. Most partial epilepsy, especially of temporal lobe origin, begins during childhood. Structural imaging with high-resolution MRI can help identify the etiology of partial seizure disorders in many children. MRI studies also show the more widespread effect of seizures on brain structure. Progressive volume loss of the hippocampal formation in some patients with temporal lobe epilepsy provides evidence that continued seizures may be associated with progressive neuronal injury. FDG-PET studies show regional decreases in glucose consumption in the cortical zone from which seizures arise. Functional abnormalities often are more extensive than the seizure focus. Studies in children with recent-onset epilepsy show that metabolic abnormalities are considerably less common than in adults with partial epilepsy, supporting the notion that in some patients there may be progressive metabolic changes that occur with continued seizures. Functional MRI may be used to identify language areas in children with partial epilepsy. fMRI language tasks reliably identify the dominant hemisphere for language dominance when compared to the intracarotid amytal procedure. Tests of verbal fluency and semantic decision identify frontal lobe language areas, while reading text paradigms and auditory passage paradigms are better for identifying temporal language areas. A panel of paradigms is best used to identify language areas in children being considered for epilepsy surgery. fMRI is a valuable tool for elucidating the impact of chronic neurologic disease states on the functional organization of language networks during development.

Predictors of Patient Inability to Cooperate during Intraoperative Language Mapping

We examined the demographic, seizure history, personality, and intellectual variables in seizure surgery patients who underwent intraoperative language mapping to identify variables that may help predict inability to cooperate with intraoperative mapping. Of 26 patients who had intraoperative language testing during left hemisphere lobectomy, 9 were unable to cooperate with language mapping procedures. Mapping "failure" consisted of an inability to conform to task demands due to anxiety, inattention, immaturity, or confusion that necessitated changing from local to general endotracheal anesthesia. Patients who were unable to cooperate with intraoperative mapping had significantly lower IQs, lower educational attainment, and higher Depression scale scores on the Minnesota Multiphasic Personality Inventory (MMPI) relative to cooperative patients. There were no statistically significant differences between groups with respect to age, handedness, sex, age of onset of habitual seizures, seizure type, site of seizure focus, presence of a lesion, or previous psychiatric history.

The insular lobe: physiopathological and surgical considerations

OBJECTIVE

Surgery of the insula represents a technical challenge, because of the proximity of the internal capsule to the lenticulostriate arteries and the lack of certainty concerning its functionality. Using intraoperative direct cerebral stimulation, combined with neuronavigation, the authors operated on 12 insular gliomas. On the basis of this experience, the physiopathological and surgical implications are discussed.

METHODS

A low-grade insular glioma, revealed by seizures, was diagnosed in 12 right-handed patients with a normal neurological status. Preoperative magnetic resonance imaging showed that, according to Yasargil's classification system, three patients harbored Type 3 lesions and nine patients had Type 5 lesions (10 tumors on the right side and 2 on the left dominant side). All patients underwent surgery using direct cerebral stimulation, under general anesthesia in nine patients (motor mapping) and under local anesthesia in three patients (sensorimotor and language mapping). Ultrasonography and/or neuronavigation was used in all cases. Preoperative angio-computed tomographic scanning showed the lenticulostriate arteries in two patients.

RESULTS

The internal capsule was systematically detected, and the language areas were identified within the left insula in the awake patients. The lenticulostriate arteries were seen in two patients. Seven patients presented an immediate postoperative deficit; six of them recovered completely within 3 months. Four resections were total, six were subtotal, and two were partial (left insula).

CONCLUSION

The use of intraoperative direct cerebral stimulation and neuronavigation allows surgery of the insula with minimization of the risk of sequelae, but its use is still limited with regard to the dominant hemisphere, owing to the essential role of this structure in language.

Craniotomy under local anesthesia and monitored conscious sedation for the resection of tumors involving eloquent cortex

OBJECTIVE

Resection or even biopsy of an intra-axial mass lesion in close relationship to eloquent cortex carries a major risk of neurological deficit. We have assessed the safety and effectiveness of craniotomy under local anesthesia and monitored conscious sedation for the resection of tumors involving eloquent cortex.

METHODS

We have performed a retrospective review of a consecutive series of 157 adult patients who underwent craniotomy under local anesthesia by one surgeon (P.M.B.) at Brigham and Women's Hospital in Boston. All patients had tumors in close proximity to eloquent cortex, including speech, motor, primary sensory, or visual cortex. In most cases the lesion was considered inoperable by the referring surgeon. All resection was verified by post-operative imaging approximately one month after surgery and all cases were reviewed by an independent neurosurgeon (A.D.).

RESULTS

In 122 cases, brain mapping was performed to identify eloquent cortex and in the remainder neurological monitoring was maintained during the procedure. Radiological gross total resection was achieved in 57% of patients and greater than 80% resection was achieved in 23%. Thus 4 out of 5 of patients had major resection despite the close relationship of tumor to eloquent cortex. In 13%, less than 80% of tumor was removed because of danger of neurological deficit. In 7% of patients, only a biopsy could be done because of infiltration into eloquent cortex that could only be assessed at surgery. In 76 patients with pre-operative neurological deficits, there was complete resolution of these deficits in 33%, improvement in 32%, no change in 28%, and long-term worsening in 8%. Among 81 patients with no pre-operative neurological deficit, 1 patient suffered a major permanent neurological deficit, and 2 developed minor deficits. There was a transient post-operative deficit in one-third of cases, but this had resolved at one month in all but three patients. Monitored conscious sedation was performed without anesthetic complications using midazolam, sufentanyl and fentanyl with or without propofol. Only one case needed to be converted to general anesthesia. Patient satisfaction with the procedure has been good. Operating time and hospital stay were lower than the mean for brain tumor craniotomy at this hospital.

CONCLUSIONS

Tumor surgery with conscious sedation is a safe technique that allows maximal resection of lesions in close anatomical relationship to eloquent cortex, with a low risk of new neurological deficit. Only 7% of intrinsic cortical tumors were ineligible for partial or complete resection with this technique.

An integrated functional magnetic resonance imaging procedure for preoperative mapping of cortical areas associated with tactile, motor, language, and visual functions

OBJECTIVE

To evaluate an integrated battery of preoperative functional magnetic resonance imaging (fMRI) tasks developed to identify cortical areas associated with tactile, motor, language, and visual functions.

METHODS

Sensitivity of each task was determined by the probability that a targeted region was activated for both healthy volunteers (n = 63) and surgical patients with lesions in these critical areas (n = 125). Accuracy of each task was determined by the correspondence between the fMRI maps and intraoperative electrophysiological measurements, including somatosensory evoked potentials (n = 16), direct cortical stimulation (n = 9), and language mapping (n = 5), and by preoperative Wada tests (n = 13) and visual field examinations (n = 6).

RESULTS

For healthy volunteers, the overall sensitivity was 100% for identification of the central sulcus, visual cortex, and putative Wernicke's area, and 93% for the putative Broca's area (dominant hemisphere). For patients with tumors affecting these regions of interest, task sensitivity was 97% for identification of the central sulcus, 100% for the visual cortex, 91% for the putative Wernicke's area, and 77% for the putative Broca's area. These sensitivities were enhanced by the use of multiple tasks to target related functions. Concordance of the fMRI maps and intraoperative electrophysiological measurements was observed whenever both techniques yielded maps and Wada and visual field examinations were consistent with fMRI results.

CONCLUSION

This integrated fMRI task battery offers standardized and noninvasive preoperative maps of multiple critical functions to facilitate assessment of surgical risk, planning of surgical routes, and direction of conventional, intraoperative electrophysiological procedures. Thus, a greater range of structural and functional relationships is brought to bear in the service of optimal outcomes for neurosurgery.

Language representation in the human brain: evidence from cortical mapping

The manner in which the human brain processes grammatical-syntactic and lexical-semantic functions has been extensively debated in neurolinguistics. The discreteness and selectivity of the representation of syntactic-morphological properties in the dominant frontal cortex and the representation of the lexical-semantics in the temporo-parietal cortex have been questioned. Three right-handed adult male neurosurgical patients undergoing left craniotomy for intractable seizures were evaluated using various grammatical and semantic tasks during cortical mapping. The sampling of language tasks consisted of trials with stimulation (experimental) and without stimulation (control) from sites in the dominant fronto-temporo-parietal cortex The sampling of language implicated a larger cortical area devoted to language (syntactic-morphological and lexical-semantic) tasks. Further, a large part of the fronto-parieto-temporal cortex was involved with syntactic-morphological functions. However, only the parieto-temporal sites were implicated with the ordering of lexicon in sentence construction. These observations suggest that the representation of language in the human brain may be columnar or multilayered.

Intersubject variability in cortical activations during a complex language task

Intersubject variability in the functional organization of the human brain has theoretical and practical importance for basic and clinical neuroscience. In the present study, positron emission tomography (PET) and anatomical magnetic resonance imaging (MRI) were used to study the functional anatomy of language processes. Intersubject variability in task-induced activations in six brain regions was assessed in 20 normal subjects (10 men and 10 women) for frequency of occurrence, location, intensity, and extent. A complex, but well-studied task (overt verb generation) was compared to a simple baseline (visual fixation) to induce activations in brain areas serving perceptual, motoric, and cognitive functions. The frequency of occurrence was high for all selected brain areas (80-95%). The variability in response location in Talairach space, expressed as the standard deviation along each axis (x, y, z), ranged from 5.2 to 9.9 mm. This variability appears to be uniformly distributed across the brain, uninfluenced by regional differences in the complexity of gyral anatomy or mediated behavior. The variability in response location, expressed as the average Euclidean distances (averaged across subjects) about mean locations of activations, varied from 9.40 to 13.36 mm and had no significant differences by region (P>0.05, beta = 0.20). Intensity variability was also relatively small and homogenous across brain regions. In contrast, response extent was much more variable both across subjects and across brain regions (0.79 to 1.77, coefficient of variation). These findings are in good agreement with previous PET studies of intersubject variability and bode well for the possibility of using functional neuroimaging to study neural plasticity subsequent to congenital and acquired brain lesions.

Cognitive deficits before treatment among patients with brain tumors

OBJECTIVE

There are few data available on the cognitive deficits of patients with primary or secondary intracranial mass lesions before treatment. The aim of the present study was to document the incidence of cognitive impairments among patients with brain tumors of the frontal or temporal lobes, immediately after diagnosis but before the commencement of treatment.

METHODS

One hundred thirty-nine patients were neuropsychologically examined using standardized psychometric testing procedures that measured various aspects of memory, attention, language, and executive functions. Furthermore, reports by the patients of their own cognitive functioning in the weeks before treatment were recorded.

RESULTS

With the classification of test performances below the 10th percentile as impaired, more than 90% of patients displayed impairments in at least one area of cognition. Impairments of executive functions were observed for 78% of patients, and impairments of memory and attention were observed for more than 60% of patients. Analysis of the correlation between the patients' own reports and the neuropsychological assessment results revealed only a weak relationship. No effects of anticonvulsant drugs on cognition were observed.

CONCLUSION

The present findings suggest that most patients with brain tumors of the frontal or temporal lobes demonstrate impairments of cognitive functioning at the time of diagnosis. Therefore, for quality assessments of neurosurgical procedures, baseline evaluations of cognitive measures should be performed.

A common language network for comprehension and production: a contribution to the definition of language epicenters with PET

In this paper, we report on a PET activation study designed to assess whether functional neuroimaging would help to uncover essential language areas in normal volunteers and to provide a more accurate definition of their localization. Regional cerebral blood flow was repeatedly monitored in eight right-handed male volunteers, while performing a language comprehension task (listening to factual stories) and a language production task (covert generation of verbs semantically related to heard nouns), using silent resting as a control condition. The conjunction analysis, conducted with SPM, was used to uncover the network of activations common to both task that included three left hemisphere areas, namely (1) the pars opercularis and triangularis of the inferior frontal gyrus, (2) the posterior part of the superior temporal cortex centered around the superior temporal sulcus, extending to the planum temporale posterior part but sparing the supramarginalis and angular gyri, and (3) the most anterior part of the left inferior temporal gyrus at the junction with the anterior fusiform gyrus. The inferior and lateral parts of the right cerebellar cortex were also included in the conjunction network. Each of the three cortical areas, when they are site of lesion or electrical stimulation, elicit impairment in both language comprehension and production and can thus be considered as essential to language. Accordingly, the present results provide conservative anatomofunctional definitions of the Broca, Wernicke, and basal language areas. Interestingly, contralateral homologues of Broca's and Wernicke's areas also lighted up in the conjunction analysis that could be related to the interindividual variability of hemispheric language dominance.

Insights into brain function and neural plasticity using magnetic source imaging

This review outlines the rationale for the use of magnetoencephalography (MEG) or magnetic source imaging (MSI), a noninvasive functional imaging technique, and the features that any imaging method should display to make a substantial contribution to cognitive neuroscience. After a brief discussion of the basic experimental approach used in the authors' studies, the use of early sensory components of brain magnetic responses is reviewed to address issues of the functional organization of the primary sensory cortices, followed by a comment on the clinical use of these components. Second, normative studies focusing on the late components of magnetic responses for establishing the validity and reliability of MSI maps of the language-specific cortex in normal subjects are reviewed. Third, the authors' investigations of fine spatiotemporal features of brain activation maps, specific to receptive language and to reading, are reviewed. Fourth, experience with presurgical mapping of the language-specific cortex in neurosurgery candidates and in patients undergoing the "Wada" procedure is summarized followed by a comment on the perfect agreement of the MSI maps with those derived by more direct invasive brain mapping procedures. Fifth. MSI-derived evidence of often dramatic, functional reorganization of brain areas subserving both simple sensory and linguistic functions is summarized along with comments on the use of MSI as a means for investigating brain plasticity. Finally, in the sixth section of this review, the authors relate their experience with the use of MSI in deriving brain activation profiles during silent reading of real words and pseudowords that are specific to dyslexic children. The review concludes with a discussion on the further use of MSI in assessing, among other issues, the effectiveness of intervention strategies designed to improve reading fluency in dyslexic children.

Intraoperative direct subcortical stimulation for identification of the internal capsule, combined with an image-guided stereotactic system during surgery for basal ganglia lesions

BACKGROUND

The two main problems of surgery for basal ganglia lesions are: first, the difficulty of accurately localizing the lesion in this deep location; and second, the proximity to the internal capsule, with the risk of permanent postoperative sequelae. The author describes the use of intraoperative direct electrical subcortical stimulation in the identification and preservation of the internal capsule, combined with an image-guided stereotactic system for the selection of the best surgical approach in a case of deep cavernoma.

CASE DESCRIPTION

A 33-year-old man was admitted to our institution with a history of three episodes of transitory left hemiparesia in the last 12 years. Neurological examination revealed a mild left weakness. Magnetic resonance imaging (MRI) showed typical features of a right posterior capsular-lentiform cavernoma. To prevent another hemorrhagic event, surgery was performed via a right transdistal sylvian approach, using a computer-assisted stereotactic method that allowed us to reach the lesion directly and direct stimulations to detect the subcortical pyramidal pathways. The patient had a transitory worsening with complete recovery in 10 days. Control MRI showed total resection.

CONCLUSION

As described at the cortical level, the intraoperative direct subcortical stimulations seem also to represent an easy, safe, accurate, and reliable method of real-time functional identification of the internal capsule during surgery for basal ganglia lesions. The combination with an image-guided stereotactic system to accurately localize the lesion minimizes the risk of postoperative sequelae, and seems to warrant an increase of the surgical indications in this location.

Odors elicit three different oscillations in the turtle olfactory bulb

We measured the spatiotemporal aspects of the odor-induced population response in the turtle olfactory bulb using a voltage-sensitive dye, RH414, and a 464-element photodiode array. In contrast with previous studies of population activity using local field potential recordings, we distinguished four signals in the response. The one called DC covered almost the entire area of the olfactory bulb; in addition, three oscillations, named rostral, middle, and caudal according to their locations, occurred over broad regions of the bulb. In a typical odor-induced response, the DC signal appeared almost immediately after the start of the stimulus, followed by the middle oscillation, the rostral oscillation, and last, the caudal oscillation. The initial frequencies of the three oscillations were 14.1, 13.0, and 6.6 Hz, respectively. When the rostral and caudal oscillations occurred together, their frequencies differed by a factor of 1.99 +/- 0.01. The following evidence suggests that the four signals are functionally independent: (1) in different animals some signals could be easily detected whereas others were undetectable; (2) the four signals had different latencies and frequencies; (3) the signals occurred in different locations and propagated in different directions; (4) the signals responded differently to changes in odor concentration; (5) the signals had different shapes; and (6) the rostral and caudal signals added in a simple, linear manner in regions where the location of the two signals overlapped. However, the finding that the frequency of the rostral oscillation is precisely two times that of the caudal oscillation suggests a significant relationship between the two. The location of the caudal oscillation in the bulb changed from cycle to cycle, implying that different groups of neurons are active in different cycles. This result is consistent with the earlier findings in the olfactory system of the locust (). Our results suggest an additional complexity of parallel processing of olfactory input by multiple functional population domains.

Postictal aphasia and paresis: a clinical and intracerebral EEG study

BACKGROUND

We examined the lateralizing value of postictal language and motor deficits and studied their underlying mechanisms.

PATIENTS AND METHODS

The total sample consisted of 35 patients (26 temporals, 8 frontals, 1 parietal) with a good postsurgical outcome (Engel's class I and II). Postictal examination was blindly reviewed on videotapes. In 15 cases (29 seizures), postictal language manifestations were analyzed in relation with the diffusion of the epileptic discharge recorded by intracerebral EEG. Language dominance was determined by the intracarotid amobarbital test.

RESULTS

Postictal aphasia was observed only when (1) seizure originated in the dominant hemisphere and (2) ictal activity spread to language areas (Wernicke and/or Broca areas). When the epileptic focus was in the nondominant hemisphere, no postictal aphasia was observed even if there was secondary generalization of ictal activity affecting the language areas of the dominant hemisphere. Postictal motor deficits also had a strong lateralizing value even when seizures were secondarily generalized.

CONCLUSION

Postictal aphasia in temporal epilepsies and postical motor deficits in temporal and extra temporal epilepsies provided excellent lateralizing information. Postictal deficits appear to be the result of inhibitory mechanisms induced by previous ictal activity of the structures related to these functions.

Comparison of fMRI and intraoperative direct cortical stimulation in localization of receptive language areas

PURPOSE

The purpose of this work was to compare the cortical localization of receptive speech using functional MRI (fMRI) and direct intraoperative electrical stimulation.

METHOD

Three strongly right-handed patients with primary neoplasms of the left parasylvian region underwent fMRI while subjected to a passive listening task designed to activate receptive language areas. All three subjects then underwent awake intraoperative language mapping using direct electrical stimulation of the cortex.

RESULTS

In all three subjects, similar, but nonidentical, cortical regions were identified as involved in receptive language function by fMRI and direct cortical stimulation mapping.

CONCLUSION

fMRI provides excellent receptive language mapping, but its results must be interpreted with caution due to conceptual and technical differences from direct cortical stimulation mapping.

Localization of language-specific cortex by using magnetic source imaging and electrical stimulation mapping

OBJECT

In this paper the authors demonstrate the concordance between magnetic source (MS) imaging and direct cortical stimulation for mapping receptive language cortex.

METHODS

In 13 consecutive surgical patients, cortex specialized for receptive language functions was identified noninvasively by obtaining activation maps aided by MS imaging in the context of visual and auditory word-recognition tasks. Surgery was then performed for treatment of medically intractable seizure disorder (eight patients), and for resection of tumor (four), or angioma (one). Mapping of language areas with cortical stimulation was performed intraoperatively in 10 patients and extraoperatively in three. Cortical stimulation mapping verified the accuracy of the MS imaging-based localization in all cases.

CONCLUSIONS

Information provided by MS imaging can be especially helpful in cases of atypical language representation, including bihemispheric representation, and location of language in areas other than those expected within the dominant hemisphere, such as the anterior portion of the superior temporal gyrus, the posteroinferior portion of the middle temporal gyrus, the basal temporal cortex, and the lateral temporooccipital cortex.

Sex differences in EEG coherence during a verbal memory task in normal adults

Coherence analysis was applied to the EEG of 15 female and 15 male subjects who had to memorise dichotically presented lists of concrete nouns. The EEG was recorded from 16 scalp electrodes placed in accordance with the 10/20 system. The results show significant gender-related differences in total coherence reactivity due to a greater increase of rest to task coherence in female than in male subjects. Women differed by showing higher coherence reactivity in the right hemisphere for all analysed (theta 1, theta 2, alpha 1, and alpha 2) frequency bands. They also had more extensive task-induced increases of interhemispheric coherence in theta bands in comparison with single changes in male subjects. In women these changes were mainly between the frontal electrodes of the left hemisphere paired with posterior electrodes of the other hemisphere. These findings indicate sex-related differences in functional cortical organisation during verbal memory tasks.

Functional roles of Broca's area and SMG: evidence from cortical stimulation mapping in a deaf signer

The importance of the left hemisphere in language function has been firmly established and current work strives to understand regional specializations within the perisylvian language areas. This paper reports a case study of a deaf user of American Sign Language undergoing an awake cortical stimulation mapping procedure. Patterns of sign errors accompanying electrical stimulation of Broca's area and the supramarginal gyrus (SMG) are reported. Our findings show Broca's area to be involved in the motor execution of sign language. These data demonstrate that the linguistic specificity of Broca's area is not limited to speech behavior. In addition, unusual semantic-phonological errors were observed with stimulation to the SMG; these data may implicate the SMG in the binding of linguistic features in the service of language production. Taken together, these findings provide important insight into the linguistic specificity of Broca's area and the functional role of the supramarginal gyrus in language processing.

Comparative localization of auditory comprehension by using functional magnetic resonance imaging and cortical stimulation

OBJECT

The authors previously described a functional magnetic resonance (fMR) imaging task for the localization of auditory comprehension in which focal activation of posterior temporal and inferior frontal regions of the left hemisphere was reliably demonstrated. Because this study was conducted in neurologically normal volunteers, it was not possible to determine whether the activated regions were critical to the performance of language tasks; that is, whether the fMR imaging activations provided a valid measure of language processing. A direct comparison of fMR imaging language activation with cortical stimulation must be completed before it can be used with confidence in presurgical planning, and this comparison is performed in the present study.

METHODS

The authors report on a series of 33 consecutive patients who underwent dominant hemisphere resection and in whom fMR imaging mapping of auditory comprehension was performed at the Yale neurosurgical program. In 23 of the 33 patients fMR imaging activation was consistent with the typical results obtained in normal participants in the earlier study. In 16 of these 23 patients language mapping was performed using either intra- or extraoperative cortical stimulation. Cortical stimulation failed to localize language areas in two of the 16 patients. Electrical stimulation that was performed in proximity to the fMR image activations interfered with auditory comprehension, object naming, or speech production in 12 of the remaining 14 patients. Five of the 10 cases in which evocation of reliable fMR imaging activation failed were attributable to technical problems and/or patient head movement.

CONCLUSIONS

Cortical stimulation results and fMR imaging findings were consistent in all but two patients. However, the spatial extent of the activation produced by fMR imaging and the spatial extent of stimulation-induced language disruption that was caused by direct cortical stimulation did not always correspond. Problems in defining the extent of activation by both methods are discussed.

Visual confrontation naming outcome after standard left anterior temporal lobectomy with sparing versus resection of the superior temporal gyrus: a randomized prospective clinical trial

PURPOSE

Intraoperative mapping of eloquent cortex during left (speech dominant) anterior temporal lobectomy has shown a significant proportion of patients to have sites on the anterior superior temporal gyrus at which visual confrontation naming can be disrupted by electrical stimulation. The purpose of this investigation was to conduct a randomized clinical trial to determine whether sparing versus resection of the superior temporal gyrus affected visual confrontation naming outcome after standard left anterior temporal lobectomy. Also examined was the degree to which inherent patient characteristics were associated with language outcome regardless of surgical technique.

METHODS

Thirty patients with intractable left temporal lobe epilepsy undergoing standard anterior temporal lobectomy were randomized in regard to whether the superior temporal gyrus was resected or spared. Patients were tested preoperatively and 6-8 months postoperatively by using two conventional tests of visual confrontation naming ability.

RESULTS

No significant differences were found between the groups in either confrontation naming or surgical outcome. Postoperative decline in nominal speech was most closely associated with later age at onset of epilepsy/absence of hippocampal sclerosis.

CONCLUSIONS

It appears that specific types of localization-related temporal lobe epilepsy are more closely associated with the risk of adverse language outcome after anterior temporal lobectomy than with the surgical variations investigated in this study.

Activity of neurons in human temporal cortex during identification and memory for names and words

Extracellular recordings of human temporal cortical neuronal activity during identification and memory for object names or words were obtained from 31 neurons at 18 sites in 12 left language dominant patients undergoing left (10) or right (2) awake craniotomy for epilepsy under local anesthesia. Frequency of activity during identification was compared with perceptual controls, that during the encoding phase of recent memory to identification of the same material. Statistically significant changes in one or more temporal epoch (p < 0.005) of one or more comparisons were present for 27 of the 31 neurons in either hemisphere. Few neurons changed activity in the same direction for both words and names. The instruction to retain an item in recent memory changed activity in most neurons from that during identification of the same material, although the items presented were identical and overtly identified in each task. Any individual neuron usually changed activity in one direction for only one task. There are separate, widely distributed neural networks for identification or recent memory for each type of material. The majority of nearby neurons recorded through the same extracellular microelectrode were related to the networks for different tasks. The temporal characteristics of these changes were also investigated; 31% of the changes were "phasic": temporally related to presentation or response to the item. Most of the remaining neuron changes were sustained throughout a task, often for several minutes. These task-specific sustained changes may reflect effects of thalamo-cortical attentional systems. Individual neurons had both sustained and phasic changes to different tasks.

Preoperative PET activation for assessment of motor cortex area in precentral chondroma

BACKGROUND

A main problem in the preoperative planning for precentral tumors is the exact assessment of the spatial relationship between the tumor and the functionally relevant brain areas, which may be difficult using only morphologically oriented imaging (CT, MRI). Therefore, we applied motor activation PET and PET/MRI overlay in a patient with a precentral tumor.

DESCRIPTION

We report the case of a 21-year-old woman suffering from progressive right-sided headache and intermittent dysesthesia of the left leg. MRI showed a hypointense tumor with inhomogenous contrast enhancement in the right precentral area. For preoperative assessment of the spatial relationship between the tumor and the motor cortex area, the patient underwent two F-18-fluorodeoxyglucose positron emission tomography (PET) scans (1. resting condition and 2. motor activation of the left leg) and subsequent calculation of subtraction images of activation minus rest. Fusion of PET and MRI data (PET/MRI overlay) was performed for bimodal function and morphology presentation. PET revealed an activation pattern behind and below the tumor, indicating that the motor cortex area was shifted to the back. PET findings were confirmed by intraoperative electrophysiology. Cortical stimulation combined with intraoperative neuronavigation localized the motor area of the left foot and leg exactly at the dorsal border, below and lateral to the lesion. After complete resection of the solid tumor, histopathological examination revealed a chondroma. The postoperative course was uneventful, and the patient was discharged without neurological deficits.

CONCLUSIONS

This case shows that biomodal imaging (PET/MRI) provides a noninvasive exact assessment of functionally important cortex areas for preoperative planning in patients with cerebral lesions.

Effects of repetition and competition on activity in left prefrontal cortex during word generation

Neuroimaging studies have revealed an association between word generation and activity in the left inferior frontal gyrus (IFG) that is attentuated with item repetition. The experiment reported here examined the effects of repeated word generation, under conditions in which completion was either decreased or increased, on activity measured during whole-brain echoplanar functional magnetic resonance imaging. Activity in left IFG decreased during repetition conditions that reduced competition but increased during repetition conditions that increased competition; this pattern was contrasted to repetition effects observed in other cortical areas, specifically regions of left temporal cortex. The increase in left IFG activity, which is not predicted by a simple semantic retrieval account of prefrontal function, is consistent with the hypothesis that left IFG subserves the selection of semantic knowledge among competing alternatives.

Patterns of brain activity during visual imagery of letters

Cortical signals associated with visual imagery of letters were recorded from 10 healthy adults with a whole-scalp 122-channel neuromagnetometer. The auditory stimulus sequence consisted of 20 different phonemes corresponding to single letters of the Roman alphabet and of tone pips (17%), delivered once every 1.5 sec in a random order. The subjects were instructed to visually imagine the letter corresponding to the auditory stimulus and to examine its visuospatial properties: The associated brain activity was compared with activity evoked by the same stimuli when the subjects just detected the intervening tones. All subjects produced broad imagery-related responses over multiple cortical regions. After initial activation of the auditory cortices, the earliest imagery-related responses originated in the left prerolandic area 320 msec after the voice onset. They were followed within 70 msec by signals originating in the posterior parietal lobe close to midline (precuneus) and, 100 msec later, in the posterior superior temporal areas, predominantly in the left hemisphere. The activations were sustained and partially overlapping in time. Imagery-related activity in the left lateral occipital cortex was observed in two subjects, and weak late activity in the calcarine cortex in one subject. Real audiovisually presented letters activated multiple brain regions, and task-induced visuospatial processing of these stimuli further increased activity in some of these regions and activated additional areas: Some of these areas were activated during imagery as well. The results suggest that certain brain areas involved in high-level visual perception are activated during visual imagery and that the extent of imagery-related activity is dictated by the requirements of the stimuli and the task.

Function-specific high-probability "nodes" identified in posterior language cortex

PURPOSE

Posterior, "Wenicke's," language areas have a high degree of between-subject variability, as shown by electrical-stimulation mapping. We investigated the possibility of an organized structure in the distribution of posterior language areas.

METHODS

Extraoperative subdural grid stimulation was performed on 67 left hemisphere-dominant patients before resective epilepsy surgery during counting, naming, and reading. Intersubject-averaged language maps were generated in which stimulation disrupted only one language function and not the others, or combinations of language functions.

RESULTS

Language sites, although highly variable between subjects, were not organized randomly and appeared to be arranged into several focal, non-contiguous, higher probability "nodes" devoted to different aspects of language processing. Speech-arrest sites were concentrated in classic Wernicke's area. Areas where stimulation induced only reading errors were found in the posterior middle temporal gyrus and the inferior parietal lobule. These regions may correspond with an orthographic input lexicon. Areas eliciting only naming errors were found in the posterior inferior temporal gyrus extending into the mid-middle temporal gyrus and may represent a visual-representation input lexicon. Sites where stimulation elicited errors in both naming and reading were more variable in location than sites devoted to only one function, extended farther anteriorly along the temporal neocortex, and may correspond with a semantic lexicon.

CONCLUSIONS

The existence of high-probability nodes in posterior language cortex supports a modality-specific modular architecture and the possibility of a conserved, universal structure.

Improvement of Functional Magnetic Resonance Imaging by a Novel Fibre-Optic Device and 3D Software

This report describes three years of clinical experience with a new set of devices aimed at improving functional MRI of speech areas. They provide a valuable tool for pre-operative definition of hemispheric localization and spatial extension of these areas, especially in left-handed persons.

The fibre-optic device described here transmits stimuli for cognitive tasks to patients undergoing MR investigations. Cognitive tasks elicit a defined brain activity lasting for several minutes. The resultant metabolic changes are detectable by functional MRI. The software (FIT ware) applied to process raw data allows semi-automated segmentation of the brain so as to obtain 3D images. Furthermore it allows the superposition of functional data. The effectiveness of the equipment was assessed on the basis of data from 140 fMRI studies. Intra-operative verification in eight patients with tumours located in the speech areas showed that the new set-up identified the speech-dominant side in each case and located speech areas in accordance with electrophysiological procedures.

Magnetoencephalography in presurgical evaluation of children with the Landau-Kleffner syndrome

PURPOSE

Our aim was (a) to localize the primary epileptogenic cortex for possible multiple subpial transsection in four children with the Landau-Kleffner syndrome (LKS), and (b) to evaluate the impact of magnetoencephalography (MEG) in the localizing process.

METHODS

We used EEG to detect the overall epileptiform activity and MEG for selective recording of fissural spikes. The cortical generators of MEG spikes were modeled with dipoles, and their activation order was determined. The voltage distribution, consistent with the earliest MEG sources, was then identified during the course of the patient's EEG spikes to determine the relative timing between stereotypic EEG and MEG spikes and to distinguish the earliest (primary) source area among the secondary ones.

RESULTS

In all patients, the earliest spike activity originated in the intrasylvian cortex, spreading in one subject to the contralateral sylvian cortex within 20 ms. Secondary spikes occurred within 10-60 ms in ipsilateral perisylvian, temporooccipital, and parietooccipital areas. A single intrasylvian pacemaker initiated all epileptic activity in two patients, whereas the other two had independent left- and right-hemisphere circuits or focal spikes. MEG source dynamics predicted the results of the methohexital suppression test in two patients and was confirmed by surgery outcome in one patient, in whom all epileptic activity ceased after a small transsection of the sylvian pacemaker.

CONCLUSIONS

(a) The intrasylvian cortex is a likely pacemaker of epileptic discharges in LKS, and (b) MEG provides useful presurgical information of the cortical spike dynamics in LKS patients.

Gender differences in the human cerebral cortex: more neurons in males; more processes in females

This study's objective was to investigate morphometric gender differences of the cerebral cortex in six males and five females, 12 to 24 years old. Though human brains lack sexual dimorphism on routine neuropathologic examinations, gender-specific brain weight, functional, and morphologic differences exist, suggesting that cortical differences may be found. Yet the cerebral cortex may be exempt from gender differences, as demonstrated by the fact that normal males and females perform comparably on intelligence tests. Stereologic morphometry on standardized histologic sections from 30 bilateral cortical loci determined cortical thickness, neuronal density, and derived neuronal number estimates. The mean +/- SD cortical thickness of the 60 loci examined was similar in males and females with right and left hemispheric gender ratios being balanced. In contrast, the average neuronal density of the same 60 loci was significantly higher in the male group than in the female group, and the corresponding mean male-to-female ratios were 1.18 in the right and 1.13 in the left hemisphere, which differ significantly from each other and from the balanced cortical thickness ratios. Estimates of neuronal numbers -- the product of neuronal thickness times density -- were 13% higher in males than in females, with mean male-to-female ratios of 1.13 in both hemispheres. The data provide morphologic evidence of considerable cerebral cortical dimorphism with the demonstration of significantly higher neuronal densities and neuronal number estimates in males, though with similar mean cortical thickness, implying a reciprocal increase in neuropil/neuronal processes in the female cortex.

Comparative localization of auditory comprehension using functional magnetic resonance imaging and cortical stimulation

The authors have previously described a functional magnetic resonance (fMR) imaging procedure for the localization of auditory comprehension in which focal activation of posterior temporal and inferior frontal regions of the left hemisphere was reliably demonstrated. Because this past study was conducted in neurologically normal volunteers, it was not possible to determine whether the activated regions were critical to the performance of language tasks; that is, whether the fMR imaging activations provided a rate measure of language processing. A direct comparison of fMR imaging language activation with cortical stimulation must be completed before the tool can be used with confidence in presurgical planning.

Here the authors report a series of 33 consecutive patients who underwent dominant hemisphere resection in which fMR image mapping of auditory comprehension was performed at the Yale neurosurgical program.

In 23 of the 33 patients reliable fMR imaging activation was shown. In 16 of these 23 patients language mapping was performed using either intra- or extraoperative cortical stimulation. Cortical stimulation failed to localize language areas in two of the 16 patients. Electrical stimulation that was performed in close proximity to the fMR image activations interfered with auditory comprehension, object naming, or speech production in 12 of the remaining 14 patients. Five of the 10 cases in which evocation reliable fMR imaging activation failed were attributable to technical problems and/or patient head movement.

Cortical stimulation results and fMR imaging findings were consistent in all but two patients. However, the spatial extent of the activation produced by fMR imaging and the spatial extent of stimulation-induced language disruption that was caused by direct cortical stimulation did not always correspond. Problems in defining the extent of activation by both methods are discussed.

Magnetoencephalographic mapping of the language-specific cortex

OBJECT

In this paper the authors introduce a novel use of magnetoencephalography (MEG) for noninvasive mapping of language-specific cortex in individual patients and in healthy volunteers.

METHODS

The authors describe a series of six experiments in which normative MEG data were collected and the reliability, validity, and topographical accuracy of the data were assessed in patients who had also undergone the Wada procedure or language mapping through intraoperative cortical stimulation.

CONCLUSIONS

Findings include: 1) receptive language-specific areas can be reliably activated by simple language tasks and this activation can be readily recorded in short MEG sessions; 2) MEG-derived maps of each individual are reliable because they remain stable over time and are independent of whether auditory or visual stimuli are used to activate the brain; and 3) these maps are also valid because they concur with results of the Wada procedure in assessing hemispheric dominance for language and with the results of cortical stimulation in identifying the precise topography of receptive language regions within the dominant hemisphere. Although the MEG mapping technique should be further refined, it has been shown to be efficacious by correctly identifying the language-dominant hemisphere and specific language-related regions within this hemisphere. Further development of the technique may render it a valuable adjunct for routine presurgical planning in many patients who harbor tumors or have epilepsy.

Awake craniotomy with brain mapping as the routine surgical approach to treating patients with supratentorial intraaxial tumors: a prospective trial of 200 cases

OBJECT

Awake craniotomy was performed as the standard surgical approach to supratentorial intraaxial tumors, regardless of the involvement of eloquent cortex, in a prospective trial of 200 patients surgically treated by the same surgeon at a single institution.

METHODS

Patient presentations, comorbid conditions, tumor locations, and the histological characteristics of lesions were recorded. Brain mapping was possible in 195 (97.5%) of 200 patients. The total number of patients sustaining complications was 33 for an overall complication rate of 16.5%. There were two deaths in this series, for a mortality rate of 1%. New postoperative neurological deficits were seen in 13% of the patients, but these were permanent in only 4.5% of them. Complication rates were higher in patients who had gliomas or preoperative neurological deficits and in those who had undergone prior radiation therapy or surgery. No patient who entered the operating room neurologically intact sustained a permanent neurological deficit postoperatively. Of the most recent 50 patients treated, three (6%) required a stay in the intensive care unit, and the median total hospital stay was 1 day.

CONCLUSIONS

Use of awake craniotomy can result in a considerable reduction in resource utilization without compromising patient care by minimizing intensive care time and total hospital stay. Awake craniotomy is a practical and effective standard surgical approach to supratentorial tumors with a low complication rate, and provides an excellent alternative to craniotomy performed with the patient in the state of general anesthesia because it allows the opportunity for brain mapping and avoids general anesthesia.

Preoperative predictors of anterior temporal language areas

OBJECT

Although it is known that 5 to 10% of patients have language areas anterior to the rolandic cortex, many surgeons still perform standard anterior temporal lobectomies for epilepsy of mesial onset and report minimal long-term dysphasia. The authors examined the importance of language mapping before anterior temporal lobectomy.

METHODS

The authors mapped naming, reading, and speech arrest in a series of 67 patients via stimulation of long-term implanted subdural grids before resective epilepsy surgery and correlated the presence of language areas in the anterior temporal lobe with preoperative demographic and neuropsychometric data. Naming (p < 0.03) and reading (p < 0.05) errors were more common than speech arrest in patients undergoing surgery in the anterior temporal lobe. In the approximate region of a standard anterior temporal lobectomy, including 2.5 cm of the superior temporal gyrus and 4.5 cm of both the middle and inferior temporal gyrus, the authors identified language areas in 14.5% of patients tested. Between 1.5 and 3.5 cm from the temporal tip, patients who had seizure onset before 6 years of age had more naming (p < 0.02) and reading (p < 0.01) areas than those in whom seizure onset occurred after age 6 years. Patients with a verbal intelligence quotient (IQ) lower than 90 had more naming (p < 0.05) and reading (p < 0.02) areas than those with an IQ higher than 90. Finally, patients who were either left handed or right hemisphere memory dominant had more naming (p < 0.05) and reading (p < 0.02) areas than right-handed patients with bilateral or left hemisphere memory lateralization. Postoperative neuropsychometric testing showed a trend toward a greater decline in naming ability in patients who were least likely to have anterior language areas, that is, those with higher verbal IQ and later seizure onset.

CONCLUSIONS

Preoperative identification of markers of left hemisphere damage, such as early seizure onset, poor verbal IQ, left handedness, and right hemisphere memory dominance should alert neurosurgeons to the possibility of encountering essential language areas in the anterior temporal lobe (1.5-3.5 cm from the temporal tip). Naming and reading tasks are required to identify these areas. Whether removal of these areas necessarily induces long-term impairment in verbal abilities is unknown; however, in patients with a low verbal IQ and early seizure onset, these areas appear to be less critical for language processing.

Magnetoencephalographic mapping of the language-specific cortex

Object

In this paper the authors introduce a novel use of magnetoencephalography (MEG) for noninvasive mapping of language-specific cortex in individual patients and in healthy volunteers.

Methods

The authors describe a series of six experiments in which normative MEG data were collected and the reliability, validity, and topographical accuracy of the data were assessed in patients who had also undergone the Wada procedure or language mapping through intraoperative cortical stimulation.

Conclusions

Findings include: 1) receptive language-specific areas can be reliably activated by simple language tasks and this activation can be readily recorded in short MEG sessions; 2) MEG-derived maps of each individual are reliable because they remain stable over time and are independent of whether auditory or visual stimuli are used to activate the brain; and 3) these maps are also valid because they concur with results of the Wada procedure in assessing hemispheric dominance for language and with the results of cortical stimulation in identifying the precise topography of receptive language regions within the dominant hemisphere.

Although the MEG mapping technique should be further refined, it has been shown to be efficacious by correctly identifying the language-dominant hemisphere and specific language-related regions within this hemisphere. Further development of the technique may render it a valuable adjunct for routine presurgical planning in many patients who harbor tumors or have epilepsy.

MRI asymmetries of Broca's area: the pars triangularis and pars opercularis

Broca's area, which includes the pars triangularis (PTR) and pars opercularis (POP), is a neuroanatomic region important in speech-language production. Previous data demonstrated that PTR asymmetries are highly correlated with language dominance determined by selective hemispheric anesthesia or Wada testing, suggesting that asymmetries of the PTR may, in part, predict language dominance. The POP, however, has not been measured on volumetric magnetic resonance imaging (MRI), and therefore, it is unclear whether morphological asymmetries of the POP exist, and whether these asymmetries differ in right- and left-handers. The purpose of this study was to determine if measurable asymmetries of the POP exist on MRI, and whether the direction of the asymmetries differ in right- and left-handers. The PTR and POP were measured on volumetric MRI scans of 16 right-handers and 16 left-handers matched for age and gender. There was a significant leftward asymmetry of the PTR in right- and left-handers, although the asymmetry was reduced in the left-handers. In contrast, there was a leftward asymmetry of the POP in right-handers, and a rightward asymmetry in the left-handers. Handedness, derived from a handedness inventory, was positively correlated with POP asymmetry.

An MEG study of picture naming

The purpose of this study was to relate a psycholinguistic processing model of picture naming to the dynamics of cortical activation during picture naming. The activation was recorded from eight Dutch subjects with a whole-head neuromagnetometer. The processing model, based on extensive naming latency studies, is a stage model. In preparing a picture"s name, the speaker performs a chain of specific operations. They are, in this order, computing the visual percept, activating an appropriate lexical concept, selecting the target word from the mental lexicon, phonological encoding, phonetic encoding, and initiation of articulation. The time windows for each of these operations are reasonably well known and could be related to the peak activity of dipole sources in the individual magnetic response patterns. The analyses showed a clear progression over these time windows from early occipital activation, via parietal and temporal to frontal activation. The major specific findings were that (1) a region in the left posterior temporal lobe, agreeing with the location of Wernicke"s area, showed prominent activation starting about 200 msec after picture onset and peaking at about 350 msec (i.e., within the stage of phonological encoding), and (2) a consistent activation was found in the right parietal cortex, peaking at about 230 msec after picture onset, thus preceding and partly overlapping with the left temporal response. An interpretation in terms of the management of visual attention is proposed.

Lessons from the Human Brain: Neuronal Activity Related to Cognition

Several special clinical settings provide opportunities for extracellular recording of neuronal activity in the human brain during measures of cognition. The limited experience with recordings obtained from human temporal and frontal cortex, medial temporal lobe, and subcortical structures in association with language, visuospatial processes, memory, learning, and music is reviewed here. The frequency of activity in a high proportion of neurons changes with a specific behavior. These neurons are widely distributed in both hemispheres. Relative inhibition of activity is prominent in cortical recordings made during language measures, particularly in the dominant hemisphere. Widespread excitation is prominent in recordings made during measures of recent explicit memory and learning. However, any individual neuron often has a narrow behavioral repertory, with activation to only one specific behavior in a range of behaviors. Some of the behaviors associated with consistent changes are not intuitively obvious. Nearby neurons often have different behavioral repertories. A few patterns of activity that may represent specific coding for a behavior, in some cases even sparse coding, have been identified. Neuronal recording in humans during cognitive measures provides an additional perspective on the neurobiological substrate of cognition that complements findings from other techniques.

The asleep-awake-asleep anesthetic technique for intraoperative language mapping

OBJECTIVE

We evaluated a combined technique designed for procedures requiring intraoperative language mapping. We planned to induce general anesthesia with endotracheal intubation and hyperventilation and then to awaken and extubate the patient for speech testing. After the latter, endotracheal reintubation and general anesthesia were planned.

METHODS

With the patient under intravenously induced sedation, we topically anesthetized the airway with lidocaine that was delivered through a spraying catheter. Fiberoptic endotracheal intubation was then performed on the awake patient, using a modified endotracheal tube. General anesthesia with intravenous propofol or sodium thiopental was induced, the patient's head was attached to a Mayfield holder, and the pin and operative sites were infiltrated with 0.5% bupivacaine with epinephrine. In anticipation of speech mapping, general anesthesia was discontinued and lidocaine was injected into the catheter that was spirally attached to the endotracheal tube. After speech mapping, the awake patients were endotracheally intubated, guided with the fiberoptic laryngoscope or tube changer, and general anesthesia was induced and maintained until termination of the surgery.

RESULTS

We did not observe any complications, such as coughing or head movements, during the preparation for general anesthesia, awakening and endotracheal extubation for speech mapping, and post-testing reintubation or induction of general anesthesia.

CONCLUSION

The combined technique that we describe abolished the potential discomfort of surgical stimulation on a sedated patient, reduced the duration of wakefulness, and provided a secure airway and the means to hyperventilate our patients before dural opening.