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Macdonald-Laurs E, Dzau W, Warren AEL, Coleman M, Mignone C, Stephenson SEM, Howell KB. Identification and treatment of surgically-remediable causes of infantile epileptic spasms syndrome. Expert Rev Neurother 2024; 24:661-680. [PMID: 38814860 DOI: 10.1080/14737175.2024.2360117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Infantile epileptic spasms syndrome (IESS) is a common developmental and epileptic encephalopathy with poor long-term outcomes. A substantial proportion of patients with IESS have a potentially surgically remediable etiology. Despite this, epilepsy surgery is underutilized in this patient group. Some surgically remediable etiologies, such as focal cortical dysplasia and malformation of cortical development with oligodendroglial hyperplasia in epilepsy (MOGHE), are under-diagnosed in infants and young children. Even when a surgically remediable etiology is recognised, for example, tuberous sclerosis or focal encephalomalacia, epilepsy surgery may be delayed or not considered due to diffuse EEG changes, unclear surgical boundaries, or concerns about operating in this age group. AREAS COVERED In this review, the authors discuss the common surgically remediable etiologies of IESS, their clinical and EEG features, and the imaging techniques that can aid in their diagnosis. They then describe the surgical approaches used in this patient group, and the beneficial impact that early epilepsy surgery can have on developing brain networks. EXPERT OPINION Epilepsy surgery remains underutilized even when a potentially surgically remediable cause is recognized. Overcoming the barriers that result in under-recognition of surgical candidates and underutilization of epilepsy surgery in IESS will improve long-term seizure and developmental outcomes.
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Affiliation(s)
- Emma Macdonald-Laurs
- Department of Neurology, The Royal Children's Hospital, Parkville, VIC, Australia
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Winston Dzau
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Aaron E L Warren
- Department of Medicine (Austin Health), The University of Melbourne, Melbourne, VIC, Australia
- Brigham and Women's Hospital, Harvard Medical School, Massachusetts, USA
| | - Matthew Coleman
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Cristina Mignone
- Department of Medical Imaging, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Sarah E M Stephenson
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Katherine B Howell
- Department of Neurology, The Royal Children's Hospital, Parkville, VIC, Australia
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
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Ntemou E, Jonkers R, Reisch K, Böttcher F, Burchert F, Picht T, Rofes A. The cortical representation of transitivity: Insights from tractography-based inhibitory nTMS. Neuropsychologia 2024; 201:108940. [PMID: 38876372 DOI: 10.1016/j.neuropsychologia.2024.108940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 02/07/2024] [Accepted: 06/11/2024] [Indexed: 06/16/2024]
Abstract
Navigated Transcranial Magnetic Stimulation (nTMS) is commonly used to causally identify cortical regions involved in language processing. Combining tractography with nTMS has been shown to increase induced error rates by targeting stimulation of cortical terminations of white matter fibers. According to functional Magnetic Resonance Imaging (fMRI) data, bilateral cortical areas connected by the arcuate fasciculus (AF) have been implicated in the processing of transitive compared to unergative verbs. To test this connection between transitivity and bilateral perisylvian regions, we administered a tractography-based inhibitory nTMS protocol during action naming of finite transitive (The man reads) and unergative (The man sails) verbs. After tracking the left and right AF, we stimulated the cortical terminations of the tract in frontal, parietal and temporal regions in 20 neurologically healthy native speakers of German. Results revealed that nTMS induced more errors during transitive compared to unergative verb naming when stimulating the left (vs right) AF terminations. This effect was specific to the left temporal terminations of the AF, whereas no differences between the two verb types were identified when stimulating inferior parietal and frontal AF terminations. Induced errors for transitive verbs over left temporal terminations mostly manifested as access errors (i.e., hesitations). Given the inhibitory nature of our nTMS protocol, these results suggest that temporal regions of the left hemisphere play a crucial role in argument structure processing. Our findings align with previous data on the role of left posterior temporal regions in language processing and by providing further evidence from a language production experiment using tractography-based inhibitory nTMS.
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Affiliation(s)
- Effrosyni Ntemou
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany; Brain Language Laboratory, Department of Philosophy and Humanities, Freie Universität Berlin, Germany
| | - Roel Jonkers
- Center for Language and Cognition (CLCG), University of Groningen, Groningen, the Netherlands
| | - Klara Reisch
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Franziska Böttcher
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Burchert
- Department of Linguistics, University of Potsdam, Potsdam, Germany
| | - Thomas Picht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany; Cluster of Excellence: "Matters of Activity. Image Space Material", Humboldt University, Berlin, Germany
| | - Adrià Rofes
- Center for Language and Cognition (CLCG), University of Groningen, Groningen, the Netherlands.
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Young F, Aquilina K, Seunarine KK, Mancini L, Clark CA, Clayden JD. Fibre orientation atlas guided rapid segmentation of white matter tracts. Hum Brain Mapp 2024; 45:e26578. [PMID: 38339907 PMCID: PMC10826637 DOI: 10.1002/hbm.26578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 12/14/2023] [Accepted: 12/19/2023] [Indexed: 02/12/2024] Open
Abstract
Fibre tract delineation from diffusion magnetic resonance imaging (MRI) is a valuable clinical tool for neurosurgical planning and navigation, as well as in research neuroimaging pipelines. Several popular methods are used for this task, each with different strengths and weaknesses making them more or less suited to different contexts. For neurosurgical imaging, priorities include ease of use, computational efficiency, robustness to pathology and ability to generalise to new tracts of interest. Many existing methods use streamline tractography, which may require expert neuroimaging operators for setting parameters and delineating anatomical regions of interest, or suffer from as a lack of generalisability to clinical scans involving deforming tumours and other pathologies. More recently, data-driven approaches including deep-learning segmentation models and streamline clustering methods have improved reproducibility and automation, although they can require large amounts of training data and/or computationally intensive image processing at the point of application. We describe an atlas-based direct tract mapping technique called 'tractfinder', utilising tract-specific location and orientation priors. Our aim was to develop a clinically practical method avoiding streamline tractography at the point of application while utilising prior anatomical knowledge derived from only 10-20 training samples. Requiring few training samples allows emphasis to be placed on producing high quality, neuro-anatomically accurate training data, and enables rapid adaptation to new tracts of interest. Avoiding streamline tractography at the point of application reduces computational time, false positives and vulnerabilities to pathology such as tumour deformations or oedema. Carefully filtered training streamlines and track orientation distribution mapping are used to construct tract specific orientation and spatial probability atlases in standard space. Atlases are then transformed to target subject space using affine registration and compared with the subject's voxel-wise fibre orientation distribution data using a mathematical measure of distribution overlap, resulting in a map of the tract's likely spatial distribution. This work includes extensive performance evaluation and comparison with benchmark techniques, including streamline tractography and the deep-learning method TractSeg, in two publicly available healthy diffusion MRI datasets (from TractoInferno and the Human Connectome Project) in addition to a clinical dataset comprising paediatric and adult brain tumour scans. Tract segmentation results display high agreement with established techniques while requiring less than 3 min on average when applied to a new subject. Results also display higher robustness than compared methods when faced with clinical scans featuring brain tumours and resections. As well as describing and evaluating a novel proposed tract delineation technique, this work continues the discussion on the challenges surrounding the white matter segmentation task, including issues of anatomical definitions and the use of quantitative segmentation comparison metrics.
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Affiliation(s)
- Fiona Young
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- Department of Medical Physics and Biomedical EngineeringUniversity College LondonLondonUK
| | - Kristian Aquilina
- Department of NeurosurgeryGreat Ormond Street Hospital for ChildrenLondonUK
| | - Kiran K. Seunarine
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- Department of RadiologyGreat Ormond Street Hospital for ChildrenLondonUK
| | - Laura Mancini
- Lysholm Department of Neuroradiology, The National Hospital for Neurology and NeurosurgeryUniversity College London Hospitals NHS Foundation TrustLondonUK
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Chris A. Clark
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - Jonathan D. Clayden
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
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Reisch K, Böttcher F, Tuncer MS, Schneider H, Vajkoczy P, Picht T, Fekonja LS. Tractography-based navigated TMS language mapping protocol. Front Oncol 2022; 12:1008442. [PMID: 36568245 PMCID: PMC9780436 DOI: 10.3389/fonc.2022.1008442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction This study explores the feasibility of implementing a tractography-based navigated transcranial magnetic stimulation (nTMS) language mapping protocol targeting cortical terminations of the arcuate fasciculus (AF). We compared the results and distribution of errors from the new protocol to an established perisylvian nTMS protocol that stimulated without any specific targeting over the entire perisylvian cortex. Methods Sixty right-handed patients with language-eloquent brain tumors were examined in this study with one half of the cohort receiving the tractographybased protocol and the other half receiving the perisylvian protocol. Probabilistic tractography using MRtrix3 was performed for patients in the tractography-based group to identify the AF's cortical endpoints. nTMS mappings were performed and resulting language errors were classified into five psycholinguistic groups. Results Tractography and nTMS were successfully performed in all patients. The tractogram-based group showed a significantly higher median overall ER than the perisylvian group (3.8% vs. 2.9% p <.05). The median ER without hesitation errors in the tractogram-based group was also significantly higher than the perisylvian group (2.0% vs. 1.4%, p <.05). The ERs by error type showed no significant differences between protocols except in the no response ER, with a higher median ER in the tractogram-based group (0.4% vs. 0%, p <.05). Analysis of ERs based on the Corina cortical parcellation system showed especially high nTMS ERs over the posterior middle temporal gyrus (pMTG) in the perisylvian protocol and high ERs over the middle and ventral postcentral gyrus (vPoG), the opercular inferior frontal gyrus (opIFG) and the ventral precentral gyrus (vPrG) in the tractography-based protocol. Discussion By considering the white matter anatomy and performing nTMS on the cortical endpoints of the AF, the efficacy of nTMS in disrupting patients' object naming abilities was increased. The newly introduced method showed proof of concept and resulted in AF-specific ERs and noninvasive cortical language maps, which could be applied to additional fiber bundles related to the language network in future nTMS studies.
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Affiliation(s)
- Klara Reisch
- Image Guidance Lab, Department of Neurosurgery, Charité – University Hospital, Berlin, Germany
| | - Franziska Böttcher
- Image Guidance Lab, Department of Neurosurgery, Charité – University Hospital, Berlin, Germany
| | - Mehmet S. Tuncer
- Image Guidance Lab, Department of Neurosurgery, Charité – University Hospital, Berlin, Germany
| | - Heike Schneider
- Image Guidance Lab, Department of Neurosurgery, Charité – University Hospital, Berlin, Germany
| | - Peter Vajkoczy
- Image Guidance Lab, Department of Neurosurgery, Charité – University Hospital, Berlin, Germany
| | - Thomas Picht
- Image Guidance Lab, Department of Neurosurgery, Charité – University Hospital, Berlin, Germany
- Cluster of Excellence: “Matters of Activity. Image Space Material”, Humboldt University, Berlin, Germany
| | - Lucius S. Fekonja
- Image Guidance Lab, Department of Neurosurgery, Charité – University Hospital, Berlin, Germany
- Cluster of Excellence: “Matters of Activity. Image Space Material”, Humboldt University, Berlin, Germany
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