Functional anatomy of the human supplementary sensorimotor area: results of extraoperative electrical stimulation

Human eye fields in the frontal lobe as studied by epicortical recording of movement‐related cortical potentials

We studied the generator location of premovement subcomponents of movement-related cortical potentials (MRCPs) [Bereitschaftspotential (BP), negative slope (NS') and motor potential (MP)] associated with voluntary, self-paced horizontal saccade in the human frontal lobe. Self-paced horizontal saccade, wrist (or middle finger) extension and foot dorsiflexion were employed in 10 patients (lateral surface of the frontal lobe in seven and mesial in three) as part of the presurgical evaluation, and data of five patients (lateral in four and mesial in three) were used in the final analysis. On the lateral frontal lobe, the maximum BP, NS' or MP with horizontal saccade was seen at or 1-2 cm rostral to the hand, arm or face area of the primary motor cortex (MI) in all four subjects investigated. This area exactly corresponded to the frontal eye field (FEF) identified by electrical stimulation. The amplitude of MRCPs with saccade was smaller than that with hand movements. On the mesial surface, within the supplementary motor area (SMA) proper, BP and/or NS' for horizontal saccade was located 1-2 cm rostral to that for hand and foot movements. BP and/or NS' delineated the supplementary eye field (SEF) at the rostral part of the SMA proper, and SEF partly overlapped with the hand and foot areas of the SMA proper. At the area just rostral to the vertical anterior commissure line and/or the pre-SMA defined by electrical stimulation, BP and/or NS' was seen invariably, regardless of the sites of movements, and in contrast with the SMA proper, there was no somatotopic representation. No clear MPs were elicited by eye movements on the mesial surface. In one of the two subjects whose MRCPs with horizontal saccade were recorded simultaneously from the lateral and mesial surfaces of the frontal lobe, BP from the SEF and pre-SMA preceded that from the FEF. It is concluded that MRCPs with horizontal saccade are useful for defining the FEF, SEF and pre-SMA, and that the SEF and pre-SMA become active in preparation for horizontal saccade earlier than the FEF.

Single-neuron activity in the human supplementary motor area underlying preparation for action

OBJECT

The supplementary motor area (SMA) is considered critical in the planning, initiation, and execution of motor acts. Despite decades of research, including electrical stimulation mapping in patients undergoing neurosurgery, the contribution of this region to the generation of motor behavior has remained enigmatic. This is a study of single-neuron responses at various stages of a motor task during depth electrode recording in the SMA, pre-SMA, and medial temporal lobe of humans, with the goal of elucidating the disparate roles of neurons in these regions during movements.

METHODS

The patients were undergoing evaluation for epilepsy surgery requiring implantation of intracranial depth electrodes. Single-unit recordings were made during both the execution and mental imagery of finger apposition sequences. Only medial frontal neurons responded selectively to specific features of the motor plan, such as which hand performed the motor activity or the complexity of the sequence. Neuron activity progressively increased before the patient was given a "go" cue for the execution of movements; this activity peaked earlier in the pre-SMA than in the SMA proper. We observed similar patterns of activation during motor imagery and actual movement, but only neurons in the SMA differentiated between imagined and real movements.

CONCLUSIONS

These results provide support at the single-neuron level for the role of the medial frontal cortex in the temporal organization and planning of movements in humans.

Is the rhythm of physiological tremor involved in cortico-cortical interactions?

The function of low-frequency oscillations as correlates of physiological tremor in supplementary motor area (SMA) and M1 remains unclear. In epicortical recordings from M1 and SMA and surface electromyographic (EMG) recordings in an epileptic patient we found reproducibly significant coherence between all three recording sites in the 6- to 15-Hz band. The partial coherence between SMA and muscle, however, was not significant. There was a constant phase shift between SMA and M1 indicating synchronized activity. We conclude that the cortical correlates of physiological tremor may be involved in linking different cortical motor centers and might therefore play a role in cortical motor planning.

Impairment of motor function after frontal lobe resection with preservation of the primary motor cortex

We investigated the clinical course and characteristics of the motor deficits in patients who underwent surgical resection of the frontal lobe for tumorous lesions. Only patients who met the following criteria were included in the present study: 1) postoperative MRI revealed that resection of the frontal lobe involved the area closely adjacent to the primary motor cortex, but 2) the D wave of the corticospinal MEP did not decrease in amplitude below 50% of the original level during surgery. The extent of resection was classified into 4 groups. In Group A (6 cases), resection was limited within the area above the superior frontal sulcus and posterior to a line vertical to the line connecting the anterior and posterior commissures at the anterior commissure (AC vertical line). Resection was extended anterior to the AC vertical line in Group B (4 cases) or below the superior frontal sulcus in Group C (5 cases). In Group D (3 cases), resection was extended to both of these two boundaries. Severe motor paresis and/or apraxia of the upper and lower extremities were noted in all patients of Group D immediately after surgery. A complete recovery in the lower extremity was observed in these patients, while disturbance in the fine movements of the upper extremity remained for more than 1 year after the surgery. Disturbance in the fine movements and/or apraxia of the upper extremity were observed immediately after surgery in 2 of the Group A patients (33%), 2 of the Group B patients (50%) and 3 of the Group C patients (60%). However, a rapid recovery occurred in these patients, and only a subtle or mild disturbance remained for more than 1 year after the surgery in one of the Group B and one of the Group C patients. Permanent and severe motor deficit is rarely induced when resection of the frontal lobe is limited to only the SMA proper (corresponding roughly to Group A), the SMA proper and pre-SMA (corresponding roughly to Group B), or the SMA proper and premotor cortex (corresponding roughly to Group C), insofar as the primary motor cortex is preserved. Disturbance in fine movements of the upper extremity is frequently induced for the long term when wide areas of the SMA proper, pre-SMA as well as premotor cortex are resected altogether (corresponding roughly to Group D).

The human supplementary motor area-proper does not receive direct somatosensory inputs from the periphery: data from stereotactic depth somatosensory evoked potential recordings

Somatosensory evoked potentials to median nerve (MN) stimulation were recorded by stereotactically implanted electrodes in the frontal lobe of two epileptic patients in order to evaluate whether short-latency cortical responses could be generated in the supplementary motor area (SMA)-proper. In both patients two potentials, called P20 and N30 responses, showed a decreasing amplitude from the most superficial to the deepest contacts and were recorded in the white as well in the grey matter of the frontal lobe. Furthermore, no phase reversal of both P20 and N30 potentials was identifiable along electrode trajectories. Our results suggest that short-latency somatosensory evoked responses recorded in the SMA-proper contralateral to MN stimulation are volume conducted from remote cortical generators.

Incidence and clinical evolution of postoperative deficits after volumetric stereotactic resection of glial neoplasms involving the supplementary motor area

OBJECTIVE

We report the incidence and clinical evolution of postoperative deficits and supplementary motor area (SMA) syndrome after volumetric stereotactic resection of glial neoplasms involving the posterior one-third of the superior frontal convolution. We investigated variables that may be associated with the occurrence of SMA syndrome.

METHODS

The postoperative clinical status of 27 consecutive patients who underwent resection of SMA gliomas was retrospectively reviewed. Neurological examination results were recorded 1 day, 1 week, 1 month, and 6 months postoperatively. The extent of tumor resection, the percentage of SMA resection, violation of the cingulate gyrus, and operative complications were tabulated.

RESULTS

The overall incidence of SMA-related deficits was 26% (7 of 27 patients), with 3 patients having complete SMA syndrome and 4 patients having partial SMA syndrome. Two additional patients (7.5%) had other postoperative deficits, including one with mild facial weakness and one with transient aphasia. The resection of low-grade gliomas was associated with a higher incidence of SMA syndrome, an outcome that likely reflects more complete removal of functional SMA cortex in this subset of patients. Intraoperative monitoring localized the precentral sulcus within the preoperatively defined tumor volume in 6 (22%) of 27 patients, thereby precluding gross total resection. All 27 patients had excellent outcomes at the 6-month follow-up examination.

CONCLUSION

When the resection of SMA gliomas is limited to the radiographic tumor boundaries, the incidence and severity of SMA syndrome may be minimized. With the use of these resection parameters, patients with high-grade SMA gliomas are unlikely to experience SMA syndrome. These findings are helpful in the preoperative counseling of patients who are to undergo cytoreductive resection of SMA gliomas.

Shall I Move My Right or My Left Hand?

Abstract Event-related desynchronization/synchronization (ERD/ERS) at alpha (10Hz), beta (20Hz), and gamma (40Hz) bands and movement-related potentials (MRPs) were investigated in right-handed subjects who were “free” to decide the side of unilateral finger movements (“fixed” side as a control). As a novelty, this “multi-modal” EEG analysis was combined with the evaluation of involuntary mirror movements, taken as an index of “bimanual competition.” A main issue was whether the decision regarding the hand to be moved (“free” movements) could modulate ERD/ERS or MRPs overlying sensorimotor cortical areas typically involved in bimanual tasks. Compared to “fixed” movements, “free” movements induced the following effects: (1) more involuntary mirror movements discarded from EEG analysis; (2) stronger vertex MRPs (right motor acts); (3) a positive correlation between these potentials and the number of involuntary mirror movements; (4) gamma ERS over central areas; and (5) preponderance of postmovement beta ERS over left central area (dominant hemisphere). These results suggest that ERD/ERS and MRPs provide complementary information on the cortical processes belonging to a lateralized motor act. In this context, the results on vertex MRPs would indicate a key role of supplementary/cingulate motor areas not only for bimanual coordination but also for the control of “bimanual competition” and involuntary mirror movements.

Early ictal speech and motor inhibition in fronto-mesial epileptic seizures: a polygraphic study in one patient

OBJECTIVE

To investigate ictal motor inhibition occurring during seizures in a patient with a tumor located in the left fronto-mesial pre-central cortex.

METHODS

Awake and sleep video-polygraphic monitoring, recording scalp EEG and EMG activities from several cranial, trunk and limbs muscles, was performed in a patient with drug-resistant recurrent focal motor seizures before surgical treatment. Speech/motor tasks were repeatedly administered to the patient during the recording sessions in order to evaluate the occurrence of early ictal motor inhibition.

RESULTS

Thirty-four seizures were recorded during wakefulness showing a stereotyped pattern of inhibition of speech and voluntary movements followed by sequential activation of upper limb-trunk-lower limb muscles contralateral to the tumor. Polygraphic recordings showed that: (1) initial speech and motor arrest were associated with the EMG evidence of progressive muscle tone suppression in cranial and right distal upper limb muscles; (2) tonic contraction of right deltoid, biceps brachii, intercostalis and paraspinalis muscles appeared after motor inhibition; (3) tonic-clonic activity in the right tibialis anterior muscle occurred at the end of seizures. Eleven subclinical seizures were recorded during sleep showing mild focal tonic EMG activity in right side trunk muscles.

CONCLUSIONS

Our findings evidenced early and somatotopically organized inhibition of voluntary movement at the beginning of epileptic seizures with fronto-mesial onset. The demonstration that speech and motor arrest were associated with progressive EMG suppression in cranial and limb muscles supports the hypothesis of motor inhibitory seizures originating in the mesial aspect of pre-motor frontal cortex.

Cortical motor mapping in epilepsy patients: information from subdural electrodes in presurgical evaluation

It is essential to delineate an epileptogenic zone and to define the eloquent cortices at or close to the epileptogenic zone in patients with neocortical epilepsy for epilepsy surgery. Prolonged implantation of the subdural electrode in presurgical evaluation is currently one of the best clinical methods to provide the essential information before epilepsy surgery. Electric cortical stimulation and recording of sensory evoked potentials by means of subdural electrodes are widely used for functional cortical mapping. Bereitschaftspotential (BP) is clinically useful to delineate the primary and nonprimary motor cortices such as supplementary motor area proper (SMA proper) and pre-SMA, because BP occurs for any type of voluntary movements of the body, and because it is not associated with the risk of seizure induction in contrast with high-frequency cortical electric stimulation. Single-pulse electric cortical stimulation to record motor evoked potentials (MEPs) also could complement currently used high-frequency cortical electric stimulation, especially for mapping of the primary motor and premotor cortices with lower risk of seizure induction.

Preoperative mapping of the supplementary motor area in patients harboring tumors in the medial frontal lobe

OBJECT

Injury to the supplementary motor area (SMA) is thought to be responsible for transient motor and speech deficits following resection of tumors involving the medial frontal lobe. Because direct intraoperative localization of SMA is difficult, the authors hypothesized that functional magnetic resonance (fMR) imaging might be useful in predicting the risk of postoperative deficits in patients who undergo resection of tumors in this region.

METHODS

Twelve patients who had undergone fMR imaging mapping while performing speech and motor tasks prior to excision of their tumor, that is, based on anatomical landmarks involving the SMA, were included in this study. The distance between the edge of the tumor and the center of SMA activation was measured and was correlated with the risk of incurring postoperative neurological deficits. In every patient, SMA activation was noted in the superior frontal gyrus on preoperative fMR imaging. Two speech and two motor deficits typical of SMA injury were observed in three of the 12 patients. The two speech deficits occurred in patients with tumors involving the dominant hemisphere, whereas one of the motor deficits occurred in a patient with a tumor in the nondominant hemisphere. The risk of developing a postoperative speech or motor deficit was 100% when the distance between the SMA and the tumor was 5 mm or less. When the distance between SMA activation and the lesion was greater than 5 mm, the risk of developing a motor or a speech deficit was 0% (p = 0.0007).

CONCLUSIONS

Early data from this study indicated that fMR imaging might be useful in localizing the SMA and in determining the risk of postoperative deficits in patients who undergo resection of tumors located in the medial frontal lobe.

Partial epilepsy manifesting atonic seizure: report of two cases

PURPOSE

Atonic seizures are commonly seen in patients with generalized epilepsy but only infrequently in patients with partial epilepsy. Clinically generalized atonic seizures as a partial epilepsy have not been studied in detail with video/EEG monitoring. Here we describe the clinical and physiologic characteristics of atonic seizures due to partial epilepsy and discuss the underlying mechanism.

METHODS

Two patients with partial epilepsy manifesting atonic seizures, one with frontal lobe epilepsy (FLE) and the other with parietal lobe epilepsy (PLE), were reported. The long-term video/EEG monitoring, magnetic resonance imaging (MRI), and interictal fluorodeoxyglucose-positron emission tomography (FDG-PET) were investigated in each patient.

RESULTS

Paroxysmal diminution of muscle tone mainly involved the axial muscles in both patients. In contrast with the abrupt falls seen in patients with Lennox-Gastaut syndrome, the falls in these patients were slow, taking 2-5 s to fall down. Ictal EEG records showed low-voltage fast activity in the frontocentral area followed by repetitive spikes at the midline frontocentral area in the patient with FLE, and rhythmic spikes in the left central area in the patient with PLE. Interictal FDG-PET disclosed hypometabolic regions consistent with the clinical and EEG findings.

CONCLUSIONS

Slow falls might be a feature of atonic seizures in partial epilepsy. Long-lasting atonia in partial epilepsy could be due to either one of the following two possible mechanisms: (a) epileptic activities arising from the negative motor area, of which 50-Hz electric stimulation causes motor inhibition, or (b) sustained atonia with successive electromyogram (EMG) silent periods caused by epileptic discharges arising from the inhibitory area of the primary sensorimotor area.

Perceptual changes in illusory wrist flexion angles resulting from motor imagery of the same wrist movements

Recent neuroimaging studies have suggested that similar cortical motor areas are recruited both by kinesthetic sensations elicited by tendon vibration and by voluntarily imaging one's own movements of the same joints. Little is known, however, as to whether kinesthetic motor imagery interacts with kinesthetic illusion. We examined such interaction by behavioral analysis in which 19 subjects imagined wrist flexion or extension, with or without illusory flexion induced by tendon vibration. Electromyograms were also recorded to monitor the peripheral modulations caused by the interaction. The kinesthetic motor imagery had a psychophysical effect on kinesthetic illusion in the absence of overt movement. It was confirmed that the subjects could imagine wrist movements without facilitating muscle activities in the absence of vibration stimuli. The electromyogram activity of the vibrated extensor muscles was significantly higher than that of non-vibrated flexor muscles. Motor imagery of wrist extension, when illusory flexion was experienced, reduced the angle of illusory flexion while enhancing extensor muscle activities in comparison with the control. On the other hand, flexion motor imagery increased the angle of illusory flexion with or without enhancement of flexor muscle activities. Our results indicate that motor imagery interacts with kinesthetic illusion with or without enhancement of activities of the related muscles. This suggests (1) that common neural substrates shared by imagery and by illusion exist and (2) that different physiological mechanisms contribute to the enhancement of muscle activities of vibrated muscles and their antagonists.

Internally simulated movement sensations during motor imagery activate cortical motor areas and the cerebellum

It has been proposed that motor imagery contains an element of sensory experiences (kinesthetic sensations), which is a substitute for the sensory feedback that would normally arise from the overt action. No evidence has been provided about whether kinesthetic sensation is centrally simulated during motor imagery. We psychophysically tested whether motor imagery of palmar flexion or dorsiflexion of the right wrist would influence the sensation of illusory palmar flexion elicited by tendon vibration. We also tested whether motor imagery of wrist movement shared the same neural substrates involving the illusory sensation elicited by the peripheral stimuli. Regional cerebral blood flow was measured with H215O and positron emission tomography in 10 right-handed subjects. The right tendon of the wrist extensor was vibrated at 83 Hz ("illusion") or at 12.5 Hz with no illusion ("vibration"). Subjects imagined doing wrist movements of alternating palmar and dorsiflexion at the same speed with the experienced illusory movements ("imagery"). A "rest" condition with eyes closed was included. We identified common active fields between the contrasts of imagery versus rest and illusion versus vibration. Motor imagery of palmar flexion psychophysically enhanced the experienced illusory angles of plamar flexion, whereas dorsiflexion imagery reduced it in the absence of overt movement. Motor imagery and the illusory sensation commonly activated the contralateral cingulate motor areas, supplementary motor area, dorsal premotor cortex, and ipsilateral cerebellum. We conclude that kinesthetic sensation associated with imagined movement is internally simulated during motor imagery by recruiting multiple motor areas.

Surgical resection of grade II astrocytomas in the superior frontal gyrus

OBJECTIVE

Surgery in the superior frontal gyrus partially involving the supplementary motor area (SMA) may be followed by contralateral transient weakness and aphasia initially indistinguishable from damage to the primary motor cortex. However, recovery is different, and SMA deficits may resolve completely within days to weeks. No study has assessed the distinct postoperative deficits after tumor resection in the SMA on a homogeneous patient group.

METHODS

Twenty-four patients with World Health Organization Grade II astrocytomas in the superior frontal gyrus consecutively treated by surgery were studied. Degree and duration of postoperative deficits were evaluated according to tumor location and boundaries via magnetic resonance imaging scans, intraoperative neuromonitoring results, and extent of tumor resection.

RESULTS

Postoperatively, motor deficits were evident in 21 of 24 and speech deficits in 9 of 12 patients. Motor function quickly recovered in 11 and speech function in 3 patients. None of the 12 patients in whom the posterior tumor resection line was at a distance of more than 0.5 cm from the precentral sulcus experienced persistent motor deficits. Eight of these patients developed typical SMA syndrome with transient initiation difficulties. Seven of 12 patients in whom the tumor extended to the precentral sulcus still had motor deficits at the 12-month follow-up assessment.

CONCLUSION

Surgery for Grade II gliomas in the superior frontal gyrus is more likely to result in permanent morbidity when the resection is performed at a distance of less than 0.5 cm from the precentral gyrus or positive stimulation points. Therefore, cortical mapping of motor and speech function, in critical cases under local anesthesia with the patient as his or her own monitor, is recommended; resection should be tailored to obtain good functional outcome and maintain quality of life.

Effect of vibration-induced postural illusion on anticipatory postural adjustment of voluntary arm movement in standing humans

We investigated the contribution of sensory signals arising from muscle proprioceptive receptors to anticipatory postural adjustments (APAs). During vibration applied to ankle (tibialis anterior; TA, soleus; Sol) or neck muscles, subjects generally describe having illusory sensations of whole-body movement, namely, whole-body movement in a backward and forward direction induced by vibration of the Sol or TA, respectively, and the front or back surface of the neck muscles, respectively. Preceding electromyographic (EMG) activity of the ipsilateral biceps femoris (BFi) muscle induced by rapid voluntary arm movement and the typical phenomenon of APA were changed dependent on these illusory whole-body movements, with preceding EMG activities of BFi appearing earlier in vibration applied to TA and later in vibration applied to Sol muscle. In vibration applied to the back surface of neck muscle, preceding EMG activities of BFi appeared earlier, as with vibration applied to TA. On the contrary, in vibration applied to the front surface of neck muscles, preceding EMG activities of BFi appeared later, as with vibration applied to Sol. Based on these results, we discuss changes in the central processing of proprioceptive signals used for coding of the spatial orientation of the body and its contribution to postural stabilization.

The size of corpus callosum and functional connectivities of cortical regions in finger and shoulder movements

The correlations between the size of corpus callosum and the inter- and intra-hemispheric EEG coherence and the spatial EEG synchronization during finger and shoulder movements were analyzed in nine right-handed men. The cross-sectional surface areas of corpus callosum (CC) and of seven callosal regions were measured from the mid-sagittal slice of the anatomical MRI. Movement-related coherence between pairs of EEG electrodes overlying the central and parietal regions of both hemispheres was computed after spatially filtering EEG data by the Laplacian operator method. The spatial EEG synchronization was evaluated using omega-complexity, a novel measure which quantifies the number of independent sources of spontaneous EEG oscillations. The amplitude of coherence between the left and right S1/M1 areas after movement onset in the lower alpha band (7.8-9.8 Hz) correlated with the size of the callosal body in both types of movement. The size of the callosal body also correlated with the C3-Cz coherence in the 15.6-19.5 Hz band in finger movement, and in the 15.6-23.5 Hz band in shoulder movements. The size of the rostral, anterior intermediate and posterior intermediate truncus of CC correlated with omega-complexity in both types of movements indicating more foci of synchronized EEG oscillations in subjects with a large callosal truncus. The results suggest that the size of callosal truncus which is known to connect the primary sensorimotor and the supplementary motor areas of both hemispheres contributes to the coupling of EEG oscillations during voluntary finger and shoulder movements.

Somatotopy of the supplementary motor area: evidence from correlation of the extent of surgical resection with the clinical patterns of deficit

OBJECTIVE

This study, which aimed to confirm or invalidate the somatotopic organization of the supplementary motor area (SMA), correlates the pattern of clinical symptoms observed after SMA removal with the extent of resection.

METHODS

Eleven patients with medial precentral glioma underwent partial or complete tumoral resection of the SMA. Seven patients underwent preoperative functional magnetic resonance imaging that incorporated speech and motor tasks. During the operation, the primary motor and speech areas and pathways (in the dominant side) were identified by use of intraoperative direct cortical or subcortical stimulation, and these areas were respected.

RESULTS

SMA resection resulted in motor deficits, language deficits, or both; the deficits were always regressive, and they corresponded to the SMA syndrome. The topography and severity of these deficits were correlated to the extent of the SMA resection. The location of the deficit corresponded to SMA somatotopy: the representations of the lower limb, the upper limb, the face, and language (in the left-dominant SMA) were located from posterior to anterior. This somatotopy was also observed with functional magnetic resonance imaging.

CONCLUSION

Correlation between clinical patterns of deficit and the extent of SMA resection, guided by means of pre- and intraoperative functional methods, provides strong arguments in favor of somatotopy in this area. This knowledge should allow clinicians to base preoperative predictions of the pattern of postsurgical deficit and recovery on the planned resection, thus allowing them to inform patients accurately before the procedure.

Increased synchronization of cortical oscillatory activities between human supplementary motor and primary sensorimotor areas during voluntary movements

In human, both primary and nonprimary motor areas are involved in the control of voluntary movements. However, the dynamics of functional coupling among different motor areas has not been fully clarified yet. Because it has been proposed that the functional coupling among cortical areas might be achieved by the synchronization of oscillatory activity, we investigated the electrocorticographic coherence between the supplementary motor and primary sensorimotor areas (SMA and S1-M1) by means of event-related partial coherence analysis in 11 intractable epilepsy patients. We found premovement increase of coherence between the SMA proper and S1-M1 at the frequency of 0-33 Hz and between the pre-SMA and S1-M1 at 0-18 Hz. Coherence between the SMA proper and M1 started to increase 0.9 sec before the movement onset and peaked 0.3 sec after the movement. There was no systematic difference within the SMA (SMA proper vs pre-SMA) or within the S1-M1, in terms of the time course as well as the peak value of coherence. The phase spectra revealed near-zero phase difference in 57% (20 of 35) of region pairs analyzed, and the remaining pairs showed inconsistent results. This increase of synchronization between multiple motor areas in the preparation and execution of voluntary movements may reflect the multiregional functional interactions in human motor behavior.

Somatotopic organization of the medial wall of the cerebral hemispheres: a 3 Tesla fMRI study

Somatotopic organization of the human medial wall of the cerebral hemispheres was studied using functional MRI conducted at high field strength (3 T) with fine spatial resolution ( approximately 2 mm). Healthy subjects performed paced, repetitive movements of the fingers and toes. Within the supplementary motor area (SMA), two regions were identified: finger movements activated a region rostral and superior to that for toe movements. Two activation foci were also identified in the cingulate motor area: toe movements activated a region rostral and ventral to that activated by finger movements. All foci were located between the anterior and posterior commissures. Our results confirm previous human and non-human primate studies regarding the rostral-caudal organization of the SMA and CMA. The dorsal-ventral organization of the CMA, however, appears to be divergent from results derived from cortical stimulation studies conducted in non-human primates.

Kinesthetic illusion of wrist movement activates motor-related areas

We used positron emission tomography (PET) to test the hypothesis that illusory movement of the right wrist activates the motor-related areas that are activated by real wrist movements. We vibrated the tendons of the relaxed right wrist extensor muscles which elicits a vivid illusory palmar flexion. In a control condition, we vibrated the skin surface over the processes styloideus ulnae, which does not elicit the illusion, using the identical frequency (83 Hz). We provide evidence that kinesthetic illusory wrist movement activates the contralateral primary sensorimotor cortices, supplementary motor area (SMA) and cingulate motor area (CMA). These areas are also active when executing the limb movement.

Evidence for distinct beta resonance frequencies in human EEG related to specific sensorimotor cortical areas

OBJECTIVE

We studied event-related synchronization (ERS) of beta rhythms related to voluntary movement vs. stimulation of upper and lower limbs. The aim of this study was to investigate whether the frequency of the beta response is related to specific regions within the sensorimotor strip.

METHODS

Self-paced movement and electrical stimulation of the dominant hand and foot/leg was investigated in 10 right-handed volunteers. The electroencephalogram was recorded from closely spaced electrodes over central areas and processed time-locked to movement-offset or stimulation. In order to identify the dominant frequency of the induced beta oscillations, time-frequency maps were calculated using the continuous wavelet transformation. For the specific beta frequency bands, the band power time courses were analyzed by quantifying the event-related (de-)synchronization (ERD/ERS).

RESULTS

Both limb movement and somatosensory stimulation induced bursts of beta oscillations appearing within 1 s after movement/stimulation with a clear focus close to the corresponding sensorimotor representation area. The peak frequency was significantly lower over the hand area (below approximately 20 Hz) than at mid-central sites overlying the foot representation area (above approximately 20 Hz). But no difference was found between movement and stimulation of the respective limb.

CONCLUSIONS

Analyzing the frequency of induced beta activity revealed concomitant oscillations at slightly different frequencies over neighboring cortical areas. These oscillations might be indicative for a resonance-like behavior of connected sub-networks in sensorimotor areas.

Interictal and ictal magnetoencephalographic study in patients with medial frontal lobe epilepsy

PURPOSE

To determine whether magnetoencephalography (MEG) has any clinical value for the analysis of seizure discharges in patients with medial frontal lobe epilepsy (FLE).

METHODS

Four patients were studied with 74-channel MEG. Interictal and ictal electroencephalographic (EEG) and MEG recordings were obtained. The equivalent current dipoles (ECDs) of the MEG spikes were calculated.

RESULTS

In two patients with postural seizures, interictal EEG spikes occurred at Cz or Fz. The ECDs of interictal MEG spikes were localized around the supplementary motor area. In the other two patients with focal motor or oculomotor seizures, interictal EEG spikes occurred at Fz or Cz. The ECDs of interictal MEG spikes were localized at the top of the medial frontal region. The ECDs detected at MEG ictal onset were also localized in the same area as those of the interictal discharges.

CONCLUSIONS

In medial FLE patients, interictal and ictal MEG indicated consistent ECD localization that corresponded to the semiology of clinical seizures. Our findings demonstrate that MEG is a useful tool for detecting epileptogenic focus.

Lateralizing value of unilateral motor and somatosensory manifestations in frontal lobe seizures

PURPOSE

To evaluate the lateralizing value of unilateral somatosensory aura, unilateral tonic posturing, head version, non-forced head turning, ictal cloni, dystonic posturing, and postictal nose wiping in seizures originating in the frontal lobe.

METHODS

We included patients who had consecutively undergone presurgical evaluation with ictal video-EEG monitoring at our institution, had had resective epilepsy surgery involving the frontal lobe, and had remained seizure-free >1 year after operation. Twenty-seven patients aged 1-42 years (mean 18) met the inclusion criteria. Fifteen patients had right-sided, 12 patients had left-sided epileptogenic regions. Seizures recorded during EEG-video monitoring were re-evaluated by two investigators in order to identify lateralization signs in frontal lobe seizures. One of the investigators was blind to patients' clinical data.

RESULTS

We analyzed 153 seizures of 27 patients. The most common unilateral phenomenon was the unilateral tonic posturing occurring in 48% of all the patients and in 25% of all seizures. Somatosensory aura and head version appeared exclusively contralateral whereas clonus occurred in 92% and unilateral tonic posturing in 89% of seizures contralateral to the epileptogenic region. Ictal non-forced head turning and postictal nose wiping showed no lateralizing significance. Dystonic posturing did not occur.

CONCLUSIONS

Somatosensory aura, head version, ictal cloni, and tonic posturing are reliable lateralizing signs in frontal seizures. These signs may help in identifying the epileptogenic region during presurgical evaluation of patients suffering from frontal lobe epilepsy.

Stereotactic recordings of median nerve somatosensory-evoked potentials in the human pre-supplementary motor area

Median nerve somatosensory-evoked potentials (SEPs) have been recorded using intracortical electrodes stereotactically implanted in the frontal lobe of eight epileptic patients in order to assess the waveforms, latencies and surface-to-depth distributions of somatosensory responses generated in the anterior subdivision of supplementary motor areas (SMAs), the so-called pre-SMA. Intracortical responses were analysed in two latency ranges: 0--50 ms and 50--150 ms after stimulus. In all patients, we recorded in the first 50 ms after stimulus two positive P14 and P20 potentials followed by a N30 negativity. In the hemisphere contralateral to stimulation, the P20--N30 potentials showed a clear amplitude decrease from the outer to the inner aspect of the frontal lobe with minimal amplitudes in the pre-SMA. In the hemisphere ipsilateral to stimulus, P20 and N30 amplitudes were decreasing from mesial to lateral frontal cortex. In the 50--150 ms latency range, contacts implanted in the pre-SMA recorded a negative potential in the 60--70 ms latency range which, in five patients, was followed by a positive response peaking 80--110 ms after stimulus. These potentials were not picked up by more superficial contacts. We conclude that no early SEP is generated in pre-SMA in the first 50 ms after stimulation, while some potentials peaking in the 60--100 ms after stimulus are likely to originate from this cortical area. The latency of the pre-SMA responses recorded in our patients supports the hypothesis that the pre-SMA does not receive short-latency somatosensory inputs via direct thalamocortical projections. More probably the pre-SMA receives somatosensory inputs mediated by a polysynaptic transcortical transmission through functionally secondary motor and somatosensory areas.

Movement-related cortical potentials associated with progressive muscle fatigue in a grasping task

OBJECTIVE

The present research was aimed to further address the general empirical question regarding the behavioral and neurophysiological indices and mechanisms that contribute to and/or compensate for muscle fatigue. In particular, we examined isometric force production, EMG, and EEG correlates of progressive muscle fatigue while subjects performed a grasping task.

METHODS

Six neurologically healthy subjects were instructed to produce and maintain 70% of maximum voluntary contraction (MVC) for a total of 5 s in a sequence of 120 trials using a specially designed grip dynamometer. Three components of movement-related potentials (Bereitschaftspotential, BP, Motor potential, MP, and Movement-monitoring potential, MMP) were extracted from continuous EEG records and analyzed with reference to behavioral indicators of muscle fatigue.

RESULTS

Experimental manipulations induced muscle fatigue that was demonstrated by decreases in both MVC values and mean force levels produced concomitant to increases in EMG root mean square (RMS) amplitude with respect to baseline levels, and EMG slope. EEG data revealed a significant increase in MP amplitude at precentral (Cz and FCz) and contralateral (C3) electrode sites, and increases in BP amplitude at precentral (Cz and FCz) electrode sites.

CONCLUSIONS

The increases in EMG amplitude, EMG slope, and MP amplitudes suggest a possible link between the control signal originating in the motor cortex and activity level of the alpha-motoneuron pool as a function of progressive muscle fatigue. Overall, the data demonstrate that progressive muscle fatigue induced a systematic increase in the electrocortical activation over the supplementary motor and contralateral sensorimotor areas as reflected in the amplitude of movement-related EEG potentials.

Different activation of presupplementary motor area, supplementary motor area proper, and primary sensorimotor area, depending on the movement repetition rate in humans

In order to clarify the functional role of the supplementary motor area (SMA) and its rostral part (pre-SMA) in relation to the rate of repetitive finger movements, we recorded movement-related cortical potentials (MRCPs) directly from the surface of the mesial frontal lobe by using subdural electrode grids implanted in four patients with intractable partial epilepsy. Two subregions in the SMA were identified based on the anatomical location and the different response to cortical stimulation. In three of the four subjects, we also recorded MRCPs from the surface of the lateral convexity covering the primary sensorimotor areas (SI-MI), which were defined by cortical stimulation and SEP recording. The subjects extended the middle finger or opposed the thumb against other fingers of the same hand at a self-paced rate of 0.2 Hz (slow) and 2 Hz (rapid), each in separate sessions. As a result, pre-and postmovement potentials were clearly seen at the SI-MI in both slow- and rapid-rate movements. By contrast, in the SMA, especially in the pre-SMA, premovement potentials were not seen and postmovement potentials were seldom seen in the rapid rate movement. In the slow-rate condition, pre- and postmovement potentials were clearly seen in both the pre-SMA and the SMA proper. In conclusion, the SMA, especially the pre-SMA, is less activated electrophysiologically in the rapid-rate movements, while the SI-MI remains active regardless of the movement rate.

EEG correlates of wrist kinematics as revealed by averaging techniques and Morlet wavelet transforms

The question regarding the invariant movement properties the central nervous system may organize to accomplish different motor task demands as reflected in EEG remains unsolved. Surprisingly, no systematic electrocortical research in humans has related movement preparation with different movement distance, although this area has been widely investigated in the field of motor control. This study examined whether the amplitude of discrete wrist movements influences the various EEG components both in time and frequency domains. Time-domain averaging techniques and Morlet wavelet transforms of EEG single trials were applied in order to extract three components [BP(0), N1, and LPS] of movement related potentials (MRP) and to quantify changes in oscillatory activity of the movement-induced EEG waveforms accompanying 20, 40, and 60 unilateral wrist flexion movements. The experimental manipulations induced systematic changes in BP(0) and N1 amplitude along the midline (Fz, Cz, and Pz) with 20 movement showing the most negativity and 60 the least. The dominant energy within a 30-50 frequency cluster from bilateral precentral (C3, Cz, C4), frontal (F3, Fz, F4), and parietal (P3, Pz, P4) areas with maximum at vertex (Cz) also appeared to be sensitive to movement amplitude with the least power observed during 60 wrist flexion. This suggests that movement amplitude may be a controllable variable that is highly related with task-specific cortical activation primarily at frontocentral areas as reflected in EEG.

Functional MRI of the supplementary motor area: comparison of motor and sensory tasks

PURPOSE

The purpose of this work was to assess the activation of the supplementary motor area (SMA) during simple motor, complex motor, hot sensory, and touch sensory tasks.

METHOD

Functional MRI (fMRI) was performed in eight right-handed healthy volunteers. There were four tasks: simple motor, complex motor, hot sensory, and touch sensory. The number of pixels and the average percentage change of signal intensity in the activated SMA were obtained during the four tasks and then compared.

RESULTS

The SMA was consistently activated on fMRI during both motor and sensory tasks. The average number of activated pixels during the complex motor task was more than the number during the hot sensory task, but the difference was not statistically significant. The average number of activated pixels during the complex motor task was greater than during the simple motor task. The average number of activated pixels during the hot sensory task was greater than during the touch sensory task. The average percentage change of signal intensity was statistically significant between the simple motor and the complex motor task. The average percentage change of signal intensity was not statistically significant between the complex motor and the hot sensory task.

CONCLUSION

The SMA is activated in both motor and sensory tasks. The degree of activation of the SMA differs according to the type of task.

Single-unit analysis of the pallidum, thalamus and subthalamic nucleus in parkinsonian patients

Microelectrode-guided stereotactic operations performed in 29 parkinsonian patients allowed the recording of 86 cells located in the globus pallidus and 563 in thalamic nuclei. In the globus pallidus, the average firing rate was significantly higher in the internal (91+/-52 Hz) than in the external (60+/-21 Hz) subdivision. This difference was further accentuated when the average firing rate in the external subdivision was compared with that of the internal part of the internal subdivision (114+/-30 Hz). A rhythmic modulation in globus pallidus activities was observed in 19.7% of the cells, and this only during rest tremor episodes. In these cases, modulation frequency of unit activities was not statistically different from the rest tremor frequency (average: 4.6+/-0.5 vs 4. 4+/-0.4 Hz, respectively). In the medial thalamus, four types of unit activities could be defined. A sporadic type was mainly found in the parvocellular division of the mediodorsal nucleus (96.8% of the cells recorded) and in the centre median-parafascicular complex (74.2%). Two other types of activities characterized by random or rhythmic bursts fulfilling the extracellular criteria of low-threshold calcium spike bursts were concentrated in the central lateral nucleus (62.3%) and the paralamellar division of the mediodorsal nucleus (34.1%). These activities could be recorded independently of the presence of a rest tremor. When a tremor episode occurred, the rhythmic low-threshold calcium spike bursts had an interburst frequency similar to rest tremor frequency, although they were not synchronized with it. The fourth type, the so-called tremor locked, was also characterized by rhythmic bursts which, however, did not display low-threshold calcium spike burst properties. These bursts occurred only when a rest tremor was present and was in-phase with the electromyographic bursts. All tremor-locked cells were located in the centre median-parafascicular complex. In the lateral thalamus, cells exhibiting random or rhythmic low-threshold calcium spike bursts were found preponderantly in the ventral anterior nucleus (53.4%) and in the ventral lateral anterior nucleus (52.7%). Tremor-locked units were confined to the ventral division of the ventral lateral posterior nucleus (35.4%). None of the random or rhythmic low-threshold calcium spike bursting units responded to somatosensory stimuli or voluntary movements, either in the medial or in the lateral thalamus. The presence of low-threshold calcium spike bursts at the thalamic level, together with the paucity (8%) of responses to voluntary movements compared to what is found in normal non-human primates, demonstrate a pathological state of inhibition due to the overactivity of the internal subdivision of the globus pallidus units. Activities of the thalamic cells producing low-threshold calcium spike bursts are not synchronized with each other or with the tremor. However, this does not exclude a causal role of these activities in the generation of tremor. Indeed, it has been demonstrated that even random electrical stimulations of the rolandic cortex in parkinsonian patients induce tremor episodes, probably due to the triggering of rhythmic, low-threshold calcium spike-dependent, thalamocortical activities. Similarly, low-threshold calcium spike bursts could be at the origin of rigidity and dystonia through an activation of the supplementary motor area and of akinesia when reaching the pre-supplementary motor area. We conclude that the intrinsic oscillatory properties of individual neurons, combined with the dynamic properties of the thalamocortical circuitry, are responsible for the three cardinal parkinsonian symptoms.

Lateralizing value of asymmetric tonic limb posturing observed in secondarily generalized tonic-clonic seizures

PURPOSE

A striking asymmetry of limb posture occurs during secondarily generalized tonic-clonic (GTC) seizures wherein one elbow is extended while the other is flexed during the tonic phase of the GTC seizure. We have named this phenomenon asymmetric tonic limb posturing (ATLP) or the "Figure 4 Sign."

METHODS

Fifty-nine secondarily GTC seizures from 31 patients with partial epilepsy who underwent successful epilepsy surgery were analyzed, in addition to another group of 64 GTC and generalized clonic seizures from 26 patients collected prospectively over a 7-month period. Three observers reviewed these seizures blinded to the side of ictal EEG onset and other clinical data.

RESULTS

The extended elbow was contralateral to the side of ictal onset in 35 of 39 patients who had ATLP during their seizures. The kappa index, a measure of interobserver agreement, was calculated, and ATLP was found to have very good agreement between observers.

CONCLUSIONS

In secondarily generalized tonic-clonic seizures, ATLP (Figure 4 Sign) may sometimes be only available lateralizing sign.

Automatic activation in the human primary motor cortex synchronized with movement preparation

The human primary motor cortex during a unilateral finger reactive movement to visual stimuli was examined by magnetoencephalography (MEG) measurement. The brain activity related to movement execution (the motor activity contralateral to the movement side) was estimated based on movement onset conditions and reaction times. The movement onset conditions were: (1) a simple reaction time task with a visual stimulus, (2) a Go/NoGo task with different colored stimuli and (3) a Go/NoGo task with different position stimuli. Dipole source estimation was done, and the time course of the motor activity was calculated. The results showed that not only the visual response but also the contralateral motor activity was evoked by the stimulus in all cases, and even when the NoGo stimulus was given. The motor activity in the primary motor cortex was conjectured to consist of two dominant components: the first component for the movement preparation and the second component for the movement execution. Because the first component happened with a constant delay time from the stimulus even in the NoGo case, the first component, coming through a fast pathway for signals from visual stimulus processing to the motor cortex without any intervening cognitive processing, was conjectured to make the motor cortex prepare for the forthcoming movement onset automatically regardless of the stimulus instruction.

EEG correlates of finger movements with different inertial load conditions as revealed by averaging techniques

OBJECTIVE

The present study was aimed to further address the general empirical question regarding the sensitivity of EEG correlates toward specific kinematic and/or kinetic movement parameters. In particular, we examined whether adding different inertial loads to the index finger, while a subject produced various amplitudes of discrete finger movements, influenced the movement-related potentials (MRP).

METHODS

Our experimental design systematically controlled the angular displacement, velocity and acceleration (kinematic) profiles of finger movement while torque (kinetics) was varied by adding different external loads opposing finger flexion movement. We applied time-domain averaging of EEG single trials in order to extract three movement-related potentials (BP-600 to -500 BP-100 to 0 and N0 to 100) preceding and accompanying 25, 50 and 75 degrees unilateral finger movements with no inertial load, small (100 g) and large (200 g) loading.

RESULTS

It was shown that both inertial load and the degree of angular displacement of index finger flexion increased the amplitude of late components of MRP (BP-100 to 0 and N0 to 100) over frontal and precentral areas. In contrast, the external load and movement amplitude manipulations did not influence the earlier component of the MRP (BP- 600 to -500).

CONCLUSIONS

Overall, the data demonstrate that adding inertial load to the finger with larger angular displacements involves systematic increase in activation across frontal and precentral areas that are related to movement initiation as reflected in BP-100 to 0 and N0 to 100.

Secondary bilateral synchrony due to fronto-mesial lesions. An invasive recording study

Frontal lobe epilepsies may present difficulties in focus localization in the pre-operative work-up for epilepsy surgery. This is specially true in patients with normal MRIs. We report on a 16 years-old girl that started with seizures by the age of 8 years. They were brief nocturnal episodes with automatisms such as bicycling and boxing. Seizure frequency ranged from 4-10 per night. Scalp EEG showed few right frontal convexity spiking and intense secondary bilateral synchrony (SBS). High resolution MRI directed to the frontal lobes was normal. Ictal SPECT suggested a right fronto-lateral focus. Ictal video-EEG showed no focal onset. She was submitted to invasive recordings after subdural plates implantation. Electrodes covered all the frontal convexity and mesial surface bilaterally. Ictal recordings disclosed stereotyped seizures starting from the right mesial frontal. Using a high-resolution tool to measure intra and interhemispheric latencies, the timing and direction of seizure spread from the right fronto-mesial region were studied. Motor strip mapping was performed by means of electrical stimulation. She was submitted to a right frontal lobe resection, 1.5 cm ahead of the motor strip and has been seizure free since surgery (8 months). Pathological examination found a 4 mm area of cortical dysplasia. Invasive studies are needed to allow adequate localization in patients with non-localizatory non-invasive work-up and may lead to excellent results in relation to seizures after surgery.

Illusory arm movements activate cortical motor areas: a positron emission tomography study

Vibration at approximately 70 Hz on the biceps tendon elicits a vivid illusory arm extension. Nobody has examined which areas in the brain are activated when subjects perceive this kinesthetic illusion. The illusion was hypothesized to originate from activations of somatosensory areas normally engaged in kinesthesia. The locations of the microstructurally defined cytoarchitectonic areas of the primary motor (4a and 4p) and primary somatosensory cortex (3a, 3b, and 1) were obtained from population maps of these areas in standard anatomical format. The regional cerebral blood flow (rCBF) was measured with (15)O-butanol and positron emission tomography in nine subjects. The left biceps tendon was vibrated at 10 Hz (LOW), at 70 or 80 Hz (ILLUSION), or at 220 or 240 Hz (HIGH). A REST condition with eyes closed was included in addition. Only the 70 and 80 Hz vibrations elicited strong illusory arm extensions in all subjects without any electromyographic activity in the arm muscles. When the rCBF of the ILLUSION condition was contrasted to the LOW and HIGH conditions, we found two clusters of activations, one in the supplementary motor area (SMA) extending into the caudal cingulate motor area (CMAc) and the other in area 4a extending into the dorsal premotor cortex (PMd) and area 4p. When LOW, HIGH, and ILLUSION were contrasted to REST, giving the main effect of vibration, areas 4p, 3b, and 1, the frontal and parietal operculum, and the insular cortex were activated. Thus, with the exception of area 4p, the effects of vibration and illusion were associated with disparate cortical areas. This indicates that the SMA, CMAc, PMd, and area 4a were activated associated with the kinesthetic illusion. Thus, against our expectations, motor areas rather than somatosensory areas seem to convey the illusion of limb movement.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Preserved motor evoked potentials fail to predict functional outcome in quadriplegia because of bilateral lesions of the supplementary motor areas: a brief report

We present a patient with a lesion of the mesial frontal cortex, including the supplementary motor areas bilaterally, who on clinical examination revealed no spontaneous movements, although neurophysiological examination indicated integrity of the corticospinal tract to thenar and tibialis anterior muscles bilaterally. The patient was alert, speech was hesitant, and he was able to move his hands only on command. The role of the supplementary motor areas in planning, setting, and execution of skillful voluntary movements has been previously established by direct cortical electrical stimulation and studies of regional cerebral blood flow. The findings in our patient support the role of the supplementary motor areas in initiating movements. The presence of motor evoked potentials after acute insults to the brain is considered to be associated with a good functional outcome. This is in contrast to our patient who did not show improvement in motor performance, despite preserved motor evoked potentials. Hence, in the case of bilateral lesions to the supplementary motor areas sparing the corticospinal tract, the presence of motor evoked potentials may not predict functional recovery.

Lateralized human cortical activity for shifting visuospatial attention and initiating saccades

Lateralized human cortical activity for shifting visuospatial attention and initiating saccades. J. Neurophysiol. 80: 2900-2910, 1998. The relation between shifts of visual attention and saccade preparation was investigated by studying their electrophysiological correlates in human scalp-recorded electroencephalogram (EEG). Participants had to make saccades either to a saliently colored or to a gray circle, simultaneously presented in opposite visual hemifields, under different task instructions. EEG was measured within the short interval between stimulus onset and saccade, focusing on lateralized activity, contralateral either to the side of the relevant stimulus or to the direction of the saccade. Three components of lateralization were found: 1) activity contralateral to the relevant stimulus irrespective of saccade direction, peaking 250 ms after stimulus onset, largest above lateral parietal sites, 2) activity contralateral to the relevant stimulus if the stimulus was also the target of the saccade, largest 330-480 ms after stimulus onset, widespread over the scalp but with a focus again above lateral parietal sites, and 3) activity contralateral to saccade direction, beginning about 100 ms before the saccade, largest above mesial parietal sites, with some task-dependent fronto-central contribution. Because of their sensitivity to task variables, component 1 is interpreted as the shifting of attention to the relevant stimulus, component 2 is interpreted as reflecting the enhancement of the attentional shift if the relevant stimulus is also the saccade target, and component 3 is interpreted as the triggering signal for saccade execution. Thus human neurophysiological data provided evidence both for independent and interdependent processes of saccade preparation and shifts of visual attention.

Brain electrical source analysis of primary cortical components of the tibial nerve somatosensory evoked potential using regional sources

Tibial nerve somatosensory evoked potentials (SEPs) show higher amplitudes ipsilateral to the side of stimulation, whereas subdural recordings revealed a source in the foot area of the contralateral hemisphere. We now investigated this paradoxical lateralization by performing a brain electrical source analysis in the P40 time window (34-46 ms). The tibial nerve was stimulated behind the ankle (8 subjects). On each side, 2048 stimuli were applied twice. SEPs were recorded using 32 magnetic resonance imaging (MRI)-verified electrode positions (bandpass 0.5-500 Hz). In each case, the P40 amplitude was higher ipsilaterally (0.45 +/- 0.14 microV) than contralaterally (-0.49 +/- 0.16 microV). The best fitting regional source, however, was always located in the contralateral hemisphere with a mean distance of 8.2 +/- 4.3 mm from the midline. The positivity pointed ipsilaterally shifting from a frontal orientation (P37) to a parietal direction (P40). The P40 dipole moment was 2.5 times stronger than the dipole moment of P37, which makes P40 most prominent in EEG recordings. However, with its oblique dipole orientation compared to the tangential P37 dipole, it is systematically underestimated in MEG. Dipole orientations explained interindividual variability of scalp potential distribution. SEP amplitudes were smaller when generated in the dominant (left) hemisphere. This is explained by deeper located sources (5.4 +/- 1.6 mm) with a more tangential orientation (delta theta = 17.5 +/- 2.3 degrees) in the left hemisphere.

Inter-hemispheric lateralization of event related potentials; motoric versus non-motoric cortical activity

To study hemispheric lateralization of cortical potentials associated with motoric and non-motoric function, cortical activity was recorded accompanying either finger extension or saccadic eye movements in a contingent negative variation (CNV) paradigm. Subjects viewed computer-generated pacing stimuli, presented in the left visual hemi-field, and were instructed to either initiate or inhibit a motor response following an imperative signal. Motoric lateralization was assessed by means of the lateralized readiness potential (LRP). In addition, a measure complementary to the LRP was introduced to investigate non-motoric lateralization (NML). Contralateral inter-hemispheric lateralization was evident in the LRP preceding finger movement, but was absent prior to eye movements. However, pre-saccadic cortical response profiles did exhibit a right hemispheric, non-motoric lateralization (NML) during stimulus presentation. Comparable non-motoric lateralization was found for finger extension. Results of the present study suggest that non-motoric lateralization may be a contributing factor to the frequently reported inter-hemispheric asymmetry preceding self-initiated saccadic eye movements. Results of the present study also suggest that the latter may be related to a covert shift of visuospatial attention toward the saccadic target. Associated shifts of attention are suppressed in a CNV paradigm, where attentional focus is primarily on the CNV stimulus during the pre-saccade period.

Neuropsychological consequences of epilepsy surgery in frontal lobe epilepsy

The present study investigated the effect of frontal lobe surgery on "cognitive functions", which have previously been shown to be discriminative in the evaluation of non-resected patients with frontal lobe epilepsy (FLE). The cognitive outcome was evaluated with particular consideration of the side (left/right), the site (lateral, orbital, mesial, premotor/SMA), the type of surgery (resections vs resections plus Multiple Subpial Transections), and seizure outcome. The evaluation is based on 33 patients with left (n = 17) or right (n = 16) frontal surgery. Forty-five patients who underwent successful left (n = 21) or right (n = 24) temporal lobectomy served as controls. The neuropsychological examination covered speed/attention, motor sequencing/coordination, response maintenance/inhibition, short-term memory, and language. With the exception of short term memory, the chosen tests were discriminative in determining preoperative frontal lobe dysfunctions but they did not differentiate patients with a different lateralization or localization of the frontal focus. At the three month follow-up examination, patients with temporal lobectomy had improved frontal functions, while patients with frontal lobe surgery showed a mild deterioration. Within the frontally resected group, completely seizure free patients had significantly improved short-term memory. Further consideration of the side, site and the type of the frontal resection indicated that patients with premotor/SMA surgery and patients with precentral/central MST had additional impairment after surgery. Premotor/SMA resections led to a deterioration in response maintenance/inhibition and if performed left sided also to deteriorated language functions. The latter impairment could be clearly related to transient aphasia directly after surgery. Irrespective of pareses observed immediately after surgery, patients with MST's of precentral/central areas displayed additional problems in motor coordination at the follow-up examination. In this group the seizure outcome was also less favorable. In summing up, frontal lobe surgery does not cause any considerable additional impairment in the short term follow-up. However, caution is recommended when surgery or MST affect functional relevant cortex (here the prefrontal/SMA and precentral/central area). Finally, a release of functions associated to frontal areas not affected by surgery is suggested, when seizures are successfully controlled by surgery.

Motor and sensory mapping of the frontal and occipital lobes

In patients with intractable epilepsy, surgical resections are performed with the primary goal of improving seizure control. The risk is that the resections may also remove tissues crucial for normal activities. The goal of surgical planning is therefore to determine as accurately as possible the regions of seizure onset and the regions controlling important functions, so that one can determine what to remove and what to leave in place. Clinical functional localization has been performed using cortical stimulation for over half a century, using both intraoperative and extraoperative methods. Signal averaging also has been widely used. More recently, techniques based on analysis of EEG in the frequency domain have shown promise. The methods appear to accurately indicate the function of the region assessed but do not necessarily predict functional consequences of resection. We review these methods, their indications, and the results obtained by their use.

Lateral frontal lobe seizures

On the basis of cytoarchitectural and functional studies, the frontal lobe can be subdivided into the primary motor cortex, premotor cortex, prefrontal cortex, and the limbic and paralimbic cortices. However, we are still a long way from clearly identifying individual frontal lobe epilepsies. Instead, we are limited to a discussion of frontal lobe seizures arising from various regions of the frontal lobe. Supplementary motor area epilepsy and perirolandic epilepsy have been quite well defined, in contrast to syndromes involving other regions of the frontal lobe. Recent technological advances in neuroimaging, electroencephalography, magnetoencephalography and detailed videotape analysis of seizure semiology may enable us to delineate these frontal lobe syndromes with better accuracy, thereby improving outcome after epilepsy surgery.

Mesial frontal epilepsy

The mesiofrontal cortex comprises a number of distinct anatomic and functional areas. Structural lesions and cortical dysgenesis are recognized causes of mesial frontal epilepsy, but a specific gene defect may also be important, as seen in some forms of familial frontal lobe epilepsy. The predominant seizure manifestations, which are not necessarily strictly correlated with a specific ictal onset zone, are absence, hypermotor, and postural tonic seizures. Other seizure types also occur. The task of localization of the epileptogenic zone can be challenging, whether EEG or imaging methods are used. Successful localization can lead to a rewarding outcome after epilepsy surgery, particularly in those with an imaged lesion.

Dynamic functional coupling of high resolution EEG potentials related to unilateral internally triggered one-digit movements

Between-electrode cross-covariances of delta (0-3 Hz)- and theta (4-7 Hz)-filtered high resolution EEG potentials related to preparation, initiation. and execution of human unilateral internally triggered one-digit movements were computed to investigate statistical dynamic coupling between these potentials. Significant (P < 0.05, Bonferroni-corrected) cross-covariances were calculated between electrodes of lateral and median scalp regions. For both delta- and theta-bandpassed potentials, covariance modeling indicated a shifting functional coupling between contralateral and ipsilateral frontal-central-parietal scalp regions and between these two regions and the median frontal-central scalp region from the preparation to the execution of the movement (P < 0.05). A maximum inward functional coupling of the contralateral with the ipsilateral frontal-central-parietal scalp region was modeled during the preparation and initiation of the movement, and a maximum outward functional coupling during the movement execution. Furthermore, for theta-bandpassed potentials, rapidly oscillating inward and outward relationships were modeled between the contralateral frontal-central-parietal scalp region and the median frontal-central scalp region across the preparation, initiation, and execution of the movement. We speculate that these cross-covariance relationships might reflect an oscillating dynamic functional coupling of primary sensorimotor and supplementary motor areas during the planning, starting, and performance of unilateral movement. The involvement of these cortical areas is supported by the observation that averaged spatially enhanced delta- and theta-bandpassed potentials were computed from the scalp regions where task-related electrical activation of primary sensorimotor areas and supplementary motor area was roughly represented.

Localization of language-related cortex with 15O-labeled water PET in patients with gliomas

Measurement of relative cerebral blood flow (CBF) with 15O-labeled water PET has been widely used for brain mapping experiments on language functions in normal volunteers and patients with epilepsy. We focused on the question of whether PET during speech activation is an appropriate method for noninvasive determination of language-related cortex in patients with brain tumors. Furthermore, the suitability of the method for determination of hemispheric language dominance was examined and compared to the results of the Edinburgh Handedness Inventory. Ten right-handed and six left-handed patients with gliomas were examined prior to surgery while repeatedly performing word repetition and verb generation tasks. A set of volumes of interest (VOIs) was drawn on coregistered MRI in order to account for anatomic variability as well as anatomical alterations due to tumor mass effect. Repetition of nouns did not produce significant hemispheric differences. During stimulation by verb generation, reliable lateralized activations of Broca's area and supplementary motor area were detected in all right-handed patients. Of the left-handed patients, two showed clear right lateralization, two activated Broca's area bilaterally, and two had a pattern similar to that of right-handers. Patients with bilateral activations showed the strongest tendency toward bihandedness according to the handedness inventory. Lateralization of supplementary motor area in left-handers corresponded to lateralized activity in Broca's area. Tumors in the vicinity of language-related regions did not alter activation responses. In conclusion, measurement of CBF changes during verb generation permits identification of language-related areas in patients with gliomas with strong lateralization related to hemispheric dominance. These findings may be of particular clinical interest for left-handed patients.

Neuropsychological consequences of epilepsy surgery in frontal lobe epilepsy

The present study investigated the effect of frontal lobe surgery on "cognitive functions", which have previously been shown to be discriminative in the evaluation of non-resected patients with frontal lobe epilepsy (FLE). The cognitive outcome was evaluated with particular consideration of the side (left/right), the site (lateral, orbital, mesial, premotor/SMA), the type of surgery (resections vs. resections plus multiple subpial transections; MST), and seizure outcome. The evaluation is based on 33 patients with left (n = 17) or right (n = 16) frontal surgery. Forty-five patients who underwent successful left (n = 21) or right (n = 24) temporal lobectomy served as controls. The neuropsychological examination covered speed/attention, motor sequencing/coordination, response maintenance/inhibition, short-term memory, and language. With the exception of short-term memory, the chosen tests were discriminative in determining preoperative frontal lobe dysfunctions but they did not differentiate patients with a different lateralization or localization of the frontal focus. At the 3 month follow-up examination, patients with temporal lobectomy had improved frontal functions, whereas patients with frontal lobe surgery showed a mild deterioration. Within the frontally resected group, completely seizure-free patients had significantly improved short-term memory. Further consideration of the side, site and the type of the frontal resection indicated that patients with premotor/SMA surgery and patients with precentral/central MST had additional impairment after surgery. Premotor/SMA resections led to a deterioration in response maintenance/inhibition and if performed left sided also to deteriorated language functions. The latter impairment could be clearly related to transient aphasia directly after surgery. Irrespective of pareses observed immediately after surgery, patients with MSTs of the precentral/central areas displayed additional problems in motor coordination at the follow-up examination. In this group the seizure outcome was also less favourable. In summing up, frontal lobe surgery does not cause any considerable additional impairment in the short-term follow-up. However, caution is recommended when surgery or MST affect functional relevant cortex (here the prefrontal/SMA and precentral/central area). Finally, a release of functions associated with frontal areas not affected by surgery is suggested, when seizures are successfully controlled by surgery.