Olfactory hallucinations elicited by electrical stimulation via subdural electrodes: effects of direct stimulation of olfactory bulb and tract

Abnormal visual and olfactory sensations during radiation therapy: a prospective study

PURPOSE

Patients sometimes report phosphene and phantosmia during radiation therapy (RT). However, the detail features and related factors are not well understood. Our prospective study aimed to investigate the characteristics of phantosmias and phosphenes, to identify factors that influence the occurrence, intensity and hedonic (pleasantness/unpleasantness) ratings of such sensations during RT.

METHODS

We included a total of 106 patients (37 women), who underwent RT in regions of the brain, ear, nose, throat (ENT), and other areas of the body for a duration of 43 ± 5 days. Medical history and treatment parameters were collected in a structured medical interview. Olfactory function was measured using the Sniffin' Stick Odor Identification Test at baseline. Phantosmia and phosphene were recorded weekly based on a self-report questionnaire.

RESULTS

There were 37% of the patients experiencing phantosmias, 51% experiencing phosphenes, and 29% simultaneously experiencing both sensations. Phosphenes were typically perceived as a flashily blue, white and/or purple light, phantosmias were typically perceived as a chemical-like, metallic or burnt smell. Younger age (F = 7.81, p < 0.01), radiation in the brain region (χ2 = 14.05, p = 0.02), absence of taste problems (χ2 = 10.28, p = 0.01), and proton RT (χ2 = 10.57, p = 0.01) were related to these abnormal sensations. History of chemical/dust exposure predicted lower intensity (B = -1.52, p = 0.02) and lower unpleasantness (B = 0.49, p = 0.03) of phantosmia. In contrast, disease (tumor) duration (B = 0.11, p < 0.01), food allergy (B = 2.77, p < 0.01), and epilepsy (B = -1.50, p = 0.02) influence phosphenes intensity. Analgesics intake predicted a higher pleasantness of the phosphenes (B = 0.47, p < 0.01).

CONCLUSIONS

Phantosmias and phosphenes are common during RT. The treatment settings and individual arousal level influence the occurrence, intensity and hedonic of such abnormal sensations. Phantosmias and phosphenes may involve more central neural than peripheral mechanism, and they could be elicited with activation of areas that are not regarded to be part of the olfactory or visual network.

Future therapeutic strategies for olfactory disorders: electrical stimulation, stem cell therapy, and transplantation of olfactory epithelium-an overview

Olfactory disorders may be temporary or permanent and can have various causes. Currently, many COVID-19 patients report a reduced or complete loss of olfactory function. A wide range of treatment options have been investigated in the past, such as olfactory training, acupuncture, medical therapy, transcranial magnetic stimulation, or surgical excision of olfactory epithelium, e.g., in severe qualitative smell disorders. The development of a bioelectric nose, e.g., in connection with direct electrical stimulation or transplantation of olfactory epithelium or stem cells, represent treatment options of the future. The basis of these developments and the state of knowledge is discussed in the following work.

Olfactory Function and Olfactory Disorders

The sense of smell is important. This became especially clear to patients with infection-related olfactory loss during the SARS-CoV-2 pandemic. We react, for example, to the body odors of other humans. The sense of smell warns us of danger, and it allows us to perceive flavors when eating and drinking. In essence, this means quality of life. Therefore, anosmia must be taken seriously. Although olfactory receptor neurons are characterized by regenerative capacity, anosmia is relatively common with about 5 % of anosmic people in the general population. Olfactory disorders are classified according to their causes (e. g., infections of the upper respiratory tract, traumatic brain injury, chronic rhinosinusitis, age) with the resulting different therapeutic options and prognoses. Thorough history taking is therefore important. A wide variety of tools are available for diagnosis, ranging from short screening tests and detailed multidimensional test procedures to electrophysiological and imaging methods. Thus, quantitative olfactory disorders are easily assessable and traceable. For qualitative olfactory disorders such as parosmia, however, no objectifying diagnostic procedures are currently available. Therapeutic options for olfactory disorders are limited. Nevertheless, there are effective options consisting of olfactory training as well as various additive drug therapies. The consultation and the competent discussion with the patients are of major importance.

Surgical Approaches for Possible Positions of an Olfactory Implant to Stimulate the Olfactory Bulb

INTRODUCTION

Current scientific developments seem to allow for an "olfactory implant" in analogy to cochlear implants. However, the position and surgical approaches for electrical stimulation of the olfactory system are unclear.

METHODS

In a human anatomic cadaver study, we investigated different endoscopic approaches to electrically stimulate the olfactory bulb (OB) based on the following considerations: (1) the stimulating electrode should be close to the OB. (2) The surgical procedure should be as non-invasive and safe as possible and (3) as easy as possible for an experienced ENT surgeon.

RESULTS

In summary, the endoscopic intracranial positioning of the electrode via a widened ostium of the fila olfactoria or a frontal sinus surgery like a Draf IIb procedure is a good option in terms of patients' risk, degree of difficulty for ENT surgeons, and position to the OB. Endoscopic intranasal positioning appeared to be the best option in terms of patient risk and the degree of difficulty for ENT surgeons. Although a bigger approach to the OB using a drill and the combined intranasal endoscopic and external approach enabled a close placement of the electrode to the OB, they do not seem relevant in practice due to their higher invasiveness.

CONCLUSION

The study suggested that an intranasal positioning of a stimulating electrode is possible, with placements beneath the cribriform plate, extra- or intracranially, applying elegant surgical techniques with low or medium risk to the patient and a close placement to OB.

Quantitative analysis of the olfactory system in pediatric epilepsy: a magnetic resonance imaging study

PURPOSE

Olfactory dysfunction is a well-known complication in epilepsy. Studies have demonstrated that olfactory bulb volume (OBV), olfactory tract length (OTL), and olfactory sulcus depth (OSD) can be reliably evaluated using magnetic resonance imaging (MRI). In this study, we compared the OBV, OTL, and OSD values of children with epilepsy and those of healthy children (controls) of similar age. Our aim was to determine the presence of olfactory dysfunction in children with epilepsy and demonstrate the effects of the epilepsy type and treatment on olfactory function in these patients.

METHODS

Cranial MRI images of 36 patients with epilepsy and 108 controls (3-17 years) were evaluated. The patients with epilepsy were divided into groups according to the type of disease and treatment method. Subsequently, OBV and OSD were measured from the coronal section and OTL from the sagittal section. The OBV, OTL, and OSD values were compared between the epilepsy group, subgroups, and controls.

RESULTS

OBV was significantly reduced in the children with epilepsy compared with the control group (P < 0.001). No significant difference between the healthy children and those with epilepsy was determined in terms of OTL and OSD. Although OBV was moderately positively correlated with age in the control group (r = 0.561, P < 0.001), it was poorly correlated with age in children with epilepsy (r = 0.393, P = 0.018).

CONCLUSION

The results of our study indicate that OBV decreases in children with epilepsy, but epilepsy type and treatment method do not affect OBV, OTL, or OSD (P > 0.05).

Responses of Chemosensory Perception to Stimulation of the Human Brain

OBJECTIVE

Significant advances have been made in our understanding of the neural substrates of human chemosensory processing, involving the piriform cortex, insula, and orbitofrontal cortex. However, the important and challenging issues are to localize the brain regions with high anatomic precision that can causally produce chemosensory perception and further delineate the topography of different classifications of chemosensory perception.

METHODS

We quantitatively measured subjective responses of chemosensory perception to intracranial electrical stimulation over the brain in neurosurgical patients (n = 302) with medically refractory epilepsy.

RESULTS

The chemosensory perceptions including olfaction, gustation, and chemesthesis were elicited in 21 of 302 patients (7%). Chemosensory responses were evoked in 53 (0.2%) of 21,661 stimulated sites. The highest response rate (1.8%) was in the insula (37/2,051 stimulated sites from 15/163 patients). The chemosensory perception emerged predominantly during stimulation of the insula along the central sulcus axis. Notably, there existed a distinct pattern that the anteroventral insula predominately represented orthonasal olfaction, whereas different chemosensory modalities converged in the mid-dorsal insula.

INTERPRETATION

This study provided a detailed characterization of chemosensory perception across the brain, especially in the insula. These results suggest that the cortex along the banks of the central sulcus of the insula may play a role in producing the supramodal sensation of flavor. It also indicates that dysfunction of the central insula should be considered during the evaluation of chemosensory-related epileptic seizures. ANN NEUROL 2023;93:175-183.

Seizure semiology: ILAE glossary of terms and their significance

This educational topical review and Task Force report aims to address learning objectives of the International League Against Epilepsy (ILAE) curriculum. We sought to extract detailed features involving semiology from video recordings and interpret semiological signs and symptoms that reflect the likely localization for focal seizures in patients with epilepsy. This glossary was developed by a working group of the ILAE Commission on Diagnostic Methods incorporating the EEG Task Force. This paper identifies commonly used terms to describe seizure semiology, provides definitions, signs and symptoms, and summarizes their clinical value in localizing and lateralizing focal seizures based on consensus in the published literature. Video-EEG examples are included to illustrate important features of semiology in patients with epilepsy.

Development and Study of Ezzence: A Modular Scent Wearable to Improve Wellbeing in Home Sleep Environments

Ezzence is the first smartphone-controlled olfactometer designed for both day and night conditions. We discuss the design and technical implementation of Ezzence and report on a study to evaluate the feasibility of using the device in home-based sleep environments. The study results (N = 40) show that participants were satisfied with the device and found it easy to use. Furthermore, participants reported a significant improvement in sleep quality when using the device with scent in comparison to the control condition (p = 0.003), as well as better mood the following morning (p = 0.038) and shorter time to sleep onset (p = 0.008). The device is integrated with a wearable EEG and real-time sleep staging algorithm to release scent during specific sleep stages (N1, N2, N3, and REM), which is important for certain use cases (e.g., to study the effect of scent on REM dreams, or to improve memory consolidation with a re-exposure of scent during N2 and N3). Ezzence can be used for several applications, including those that require scent triggered day and night. They include targeted memory reactivation, longitudinal health treatments, therapy, and mental or physical exercises. Finally, this article proposes an interaction framework to understand relationships between scents and environments based on proxemic dimensions and passive or active interactions during sleep.

An olfactory display for virtual reality glasses

Olfaction has not been explored in virtual reality environments to the same extent as the visual and auditory senses. Much less research has been done with olfactory devices, and very few of them can be easily integrated into virtual reality applications. The inclusion of odor into virtual reality simulations using a chemical device involves challenges such as possible diffusion into undesired areas, slow dissipation, the definition of various parameters (e.g., concentration, frequency, and duration), and an appropriate software solution for controlling the diffusion of the odor. This paper aims to present a non-intrusive, mobile, low cost and wearable olfactory display, and a software service that allows the developer to easily create applications that include olfactory stimuli integrated with virtual reality headset glasses. We also present a case study conducted with 32 people to evaluate their satisfaction when using the olfactory display. Our findings indicate that our solution works as expected, producing odor properly and being easy to integrate to applications.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s00530-022-00908-8.

[Future therapeutic strategies for olfactory disorders: electrical stimulation, stem cell therapy, and transplantation of olfactory epithelium-an overview]

Passagere oder permanente Riechstörungen können verschiedene Ursachen haben. Ganz aktuell berichtet eine Vielzahl von Patienten im Rahmen von COVID-19-Infektionen über ein fehlendes oder vermindertes Riechvermögen. In der Vergangenheit wurden vielfältige Therapieoptionen untersucht, diese variieren vom Riechtraining über Akupunktur und medikamentöse Therapien bis hin zur transkraniellen Magnetstimulation oder, z. B. bei ausgeprägten qualitativen Riechstörungen, der chirurgischen Resektion der Riechschleimhaut. Die Entwicklung einer bioelektrischen Nase, z. B. in Verbindung mit direkter elektrischer Stimulation des Bulbus olfactorius, oder die Transplantation von Riechschleimhaut oder von Stammzellen stellen Behandlungsmöglichkeiten der Zukunft dar. Die Grundlagen für diese Entwicklungen sowie der Stand des Wissens werden in der vorliegenden Arbeit erläutert.

Prevalence and correlates of parosmia and phantosmia among smell disorders

Among those many individuals who experience a reduced odor sensitivity (hyposmia/anosmia), some individuals also have disorders that lead to odor distortion, such as parosmia (i.e. distorted odor with a known source), or odor phantoms (i.e. odor sensation without an odor source). We surveyed a large population with at least one olfactory disorder (N = 2031) and found that odor distortions were common (46%), with respondents reporting either parosmia (19%), phantosmia (11%), or both (16%). In comparison to respondents with hyposmia or anosmia, respondents with parosmia were more likely to be female, young, and suffering from post-viral olfactory loss (P < 0.001), while respondents with phantosmia were more likely to be middle-aged (P < 0.01) and experiencing symptoms caused by head trauma (P < 0.01). In addition, parosmia, compared to phantosmia or anosmia/hyposmia, was most prevalent 3 months to a year after olfactory symptom onset (P < 0.001), which coincides with the timeline of physiological recovery. Finally, we observed that the frequency and duration of distortions negatively affects the quality of life, with parosmia showing a higher range of severity than phantosmia (P < 0.001). Previous research often grouped these distortions together, but our results show that they have distinct patterns of demographics, medical history, and loss in quality of life.

Electrical stimulation of the medial orbitofrontal cortex in humans elicits pleasant olfactory perceptions

BACKGROUND

Olfactory hallucinations can be part of epileptic seizures of orbitofrontal origin. Olfactory hallucinations, however, are rare and therefore the semiology, localization and lateralization characteristics are underdetermined. In addition, many discrepancies are found in the literature regarding olfactory processing and orbitofrontal (OF) functions and olfactory function. Particularly, the questions of laterality and affective component in coding of odors in the OF cortex remain controversial.

AIMS

This study explored whether cortical electrical stimulation of the OF and mesiotemporal brain can trigger olfactory hallucinations with special focus on olfactory percepts in terms of laterality and hedonics.

MATERIALS AND METHODS

Eight patients with temporal lobe epilepsy participated in the study, at the time of invasive exploration of their epilepsy. The most distal contact of the OF and anterior hippocampus depth electrodes were stimulated (50 Hz, 0.2 ms biphasic pulse; maximal stimulation 4 mA). Patients were instructed to report any kind of sensation they might experience. Intracranial depth electrodes were localized (iElectrodes): subject-specific brain mask, subcortical segmentation and cortical parcellation based on the Destrieux atlas (FreeSurfer) were superposed to the coregistered T1-weighted MRI and CT images (SPM). The center of mass of each electrode-artifact cluster determined the electrode localization. The electrode labeling was done in patient space. To obtain the electrode coordinates in Montreal Neurological Institute (MNI) space, the images obtained previously in the patient space were first segmented and normalized (SPM). Then, the localization procedure (iElectrodes) was run again with these new normalized images in MNI space.

RESULTS

No hallucination was evoked by stimulation, neither of the right nor the left hippocampus (8/8 patients). Pleasant olfactory hallucinations were evoked by OF stimulation in 5/8 patients in either hemisphere. Patients named the percept as the smell of lemon or coffee for example. Among those 5 patients, electrodes were localized in the cortex of the olfactory sulcus, medial orbital sulcus or medial OF gyrus. Increasing stimulation amplitude changed the olfactory percept identification in 3 out of those 5 patients. No affective judgement or change in perceived odor intensity was reported by the patients. No hallucination was evoked by the stimulation of the white matter of the medial OF brain in 3/8 patients independently of the hemisphere stimulated.

CONCLUSIONS

This study demonstrated that stimulation of the cortex of the medial OF brain and not of its white matter elicits specific pleasant olfactory hallucinations independently of the hemisphere stimulated, supporting one symmetrical olfactory processing in human.

Optimized Electrode Placements for Non-invasive Electrical Stimulation of the Olfactory Bulb and Olfactory Mucosa

The olfactory system is known to be dysfunctional in the early stages of Parkinson's disease (PD) and Alzheimer's disease (AD). It is also shown that intact olfactory function can be a key role player for regaining consciousness after brain injuries. Modulation of the olfactory regions has been attempted successfully with electrical stimulation over the years, either directly (transethmoidally, intraoperatively, internasally, etc.) or indirectly through the vagus nerve. We sought to develop a means of delivering optimized electrical stimulation to the olfactory region in a non-invasive fashion and in a way that is simpler, easier, and less cumbersome. The ultimate goal was to develop a system that would allow easier testing in future clinical trials presenting an opportunity to fully develop this potential treatment option. We devised six potential electrode placements leveraging commonly accepted facts of electrical stimulation, easier access through relatively higher conductive pathways into the brain, and practicality. Using an ultra-high-resolution finite element model, we screened each one of these montages for their ability to target the olfactory regions primarily and thereafter for select sub-cortical regions implicated in the pathogenesis of PD and AD. Modeling results indicate that some placements do result in inducing meaningful electric field magnitudes in the regions of interest. A practical headgear concept is proposed to realize the most ideal configuration. Our results pave the way for developing the first non-invasive electrical stimulation wearable system for targeting the olfactory regions which can help to alleviate the symptoms or suppress the progression of these neurological disorders.

Electrical stimulation of cranial nerves in cognition and disease

The cranial nerves are the pathways through which environmental information (sensation) is directly communicated to the brain, leading to perception, and giving rise to higher cognition. Because cranial nerves determine and modulate brain function, invasive and non-invasive cranial nerve electrical stimulation methods have applications in the clinical, behavioral, and cognitive domains. Among other neuromodulation approaches such as peripheral, transcranial and deep brain stimulation, cranial nerve stimulation is unique in allowing axon pathway-specific engagement of brain circuits, including thalamo-cortical networks. In this review we amalgamate relevant knowledge of 1) cranial nerve anatomy and biophysics; 2) evidence of the modulatory effects of cranial nerves on cognition; 3) clinical and behavioral outcomes of cranial nerve stimulation; and 4) biomarkers of nerve target engagement including physiology, electroencephalography, neuroimaging, and behavioral metrics. Existing non-invasive stimulation methods cannot feasibly activate the axons of only individual cranial nerves. Even with invasive stimulation methods, selective targeting of one nerve fiber type requires nuance since each nerve is composed of functionally distinct axon-types that differentially branch and can anastomose onto other nerves. None-the-less, precisely controlling stimulation parameters can aid in affecting distinct sets of axons, thus supporting specific actions on cognition and behavior. To this end, a rubric for reproducible dose-response stimulation parameters is defined here. Given that afferent cranial nerve axons project directly to the brain, targeting structures (e.g. thalamus, cortex) that are critical nodes in higher order brain networks, potent effects on cognition are plausible. We propose an intervention design framework based on driving cranial nerve pathways in targeted brain circuits, which are in turn linked to specific higher cognitive processes. State-of-the-art current flow models that are used to explain and design cranial-nerve-activating stimulation technology require multi-scale detail that includes: gross anatomy; skull foramina and superficial tissue layers; and precise nerve morphology. Detailed simulations also predict that some non-invasive electrical or magnetic stimulation approaches that do not intend to modulate cranial nerves per se, such as transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS), may also modulate activity of specific cranial nerves. Much prior cranial nerve stimulation work was conceptually limited to the production of sensory perception, with individual titration of intensity based on the level of perception and tolerability. However, disregarding sensory emulation allows consideration of temporal stimulation patterns (axon recruitment) that modulate the tone of cortical networks independent of sensory cortices, without necessarily titrating perception. For example, leveraging the role of the thalamus as a gatekeeper for information to the cerebral cortex, preventing or enhancing the passage of specific information depending on the behavioral state. We show that properly parameterized computational models at multiple scales are needed to rationally optimize neuromodulation that target sets of cranial nerves, determining which and how specific brain circuitries are modulated, which can in turn influence cognition in a designed manner.

History of Cranial Nerve-Implanted Stimulators in Otolaryngology

This article aims to clearly understand the historical development of cranial nerve-implanted stimulators in otolaryngology. The authors also discuss cranial nerve history; initial theory of the functional concept of animal spirit; electrical nerve impulse theory; first electrical otolaryngology cranial nerve stimulation devices; and the development of implanted stimulators.

Cranial Nerve Stimulation for Olfaction (Cranial Nerve 1)

Like sensory maps in other systems, the sense of smell has an organizational structure based on converging projections of olfactory receptor neurons containing unique odorant receptors onto the olfactory bulb in synaptic aggregations termed glomeruli. This organizational structure provides the potential for electrical stimulation and restoration of smell. Prior animal and human studies support the feasibility of an olfactory stimulation device, encouraging ongoing work in development of olfactory implants.

A Quantitative Meta-analysis of Olfactory Dysfunction in Epilepsy

Olfactory dysfunction in epilepsy is well-documented in several olfactory domains. However, the clinical specificity of these deficits remains unknown. The aim of this systematic meta-analysis was to determine which domains of olfactory ability were most impaired in individuals with epilepsy, and to assess moderating factors affecting olfactory ability. Extant peer-reviewed literature on olfaction in epilepsy were identified via a computerized literature search using PubMed, MEDLINE, PsycInfo, and Google Scholar databases. Twenty-one articles met inclusion criteria. These studies included a total of 912 patients with epilepsy and 794 healthy comparison subjects. Included studies measured olfaction using tests of odor identification, discrimination, memory, and detection threshold in patients with different types of epilepsy, including temporal lobe epilepsy (TLE), mixed frontal epilepsy (M-F), and mixed epilepsy (MIX). Olfactory deficits were robust in patients with epilepsy when compared to healthy individuals, with effect sizes in the moderate to large range for several olfactory domains, including odor identification (d = -1.59), memory (d = -1.10), discrimination (d = -1.04), and detection threshold (d = -0.58). Olfactory deficits were most prominent in patients with TLE and M-F epilepsy. Amongst patients with epilepsy, sex, age, smoking status, education, handedness, and age of illness onset were significantly related to olfactory performance. Overall, these meta-analytic findings indicate that the olfactory system is compromised in epilepsy and suggest that detailed neurobiological investigations of the olfactory system may provide further insight into this disorder.

Continuous Theta Burst Stimulation Over the Right Orbitofrontal Cortex Impairs Conscious Olfactory Perception

The right orbitofrontal cortex (rOFC) has been proposed as the region where conscious olfactory perception arises; however, evidence supporting this hypothesis has all been collected from neuroimaging and lesion studies in which only correlation and not a temporal pattern can be established. Continuous theta burst stimulation (cTBS) causes a reversible disruption of cortical activity and has been used successfully to disrupt orbitofrontal activity. To overcome intrinsic limitations of current experimental research, a crossover, double-blind, prospective and longitudinal study was carried out in which cTBS was applied over the rOFC to evaluate its effect on odorant stimuli detection. All subjects received real and sham cTBS. Experimental procedures were done in two different sessions with a separation of at least one week between them to avoid carryover and learning effects. A total of 15 subjects completed the experiment, and their data were included in the final analysis (10 women, 5 men, mean age 22.40 ± 3.41). Every session consisted of two different measures of the conscious olfactory perception task: A baseline measure and one 5 min after cTBS/sham. Compared to baseline, marks in the olfactory task during the sham cTBS session increased (p = 0.010), while marks during the real cTBS session decreased (p = 0.017). Our results support the hypothesis that rOFC is an important node of a complex network required for conscious olfactory perception to arise. However, the exact mechanism that explains our results is unclear and could be explained by the disruption of other cognitive functions related to the rOFC.

Induction of smell through transethmoid electrical stimulation of the olfactory bulb

BACKGROUND

Anosmia has an estimated prevalence of 5% of the general population. Outside of inflammatory causes, therapeutic options are limited despite research advances. Bypassing peripheral neuronal damage through central stimulation is a potential therapeutic option that has shown success in other sensory systems, most notably with hearing. We performed a pilot study to determine the feasibility of inducing smell through artificial electrical stimulation of the olfactory bulbs in humans.

METHODS

Subjects with a history of sinus surgery, including total ethmoidectomy, with intact ability to smell were enrolled. The ability to smell was confirmed with a 40-item smell identification test. Awake subjects underwent nasal endoscopy and either a monopolar or bipolar electrode was positioned at 3 areas along the lateral lamella of the cribriform plate within the ethmoid sinus cavity. A graded stimulation current of 1-20 mA at 3.17 Hz was administered while cortical evoked potential (CEP) recordings were collected. Subjective responses of perceived smell along with reports of discomfort were recorded. Subjects with artificially induced smell underwent repeat stimulation after medically induced anosmia.

RESULTS

Five subjects (age, 43-72 years) were enrolled. Three subjects reported smell perception smell with electrical stimulation. This was reproducible after inducing anosmia, but CEP recordings could not provide objective support. All subjects tolerated the study with minimal discomfort.

CONCLUSION

This is the first report of induced smell through transethmoid electrical stimulation of the olfactory bulb. These results provide a proof of concept for efforts in development of an olfactory implant system.

Orbitofrontal epilepsy: Case series and review of literature

BACKGROUND

Orbitofrontal epilepsy (OFE) is less known and is poorly characterized in comparison with temporal lobe epilepsy, partly because it is rare and possibly because it is unrecognized and therefore underestimated.

OBJECTIVE

This paper aimed to better characterize seizure semiology, presurgical findings, and surgical outcomes in patients with OFE.

METHODS

We retrospectively reviewed all confidently established OFE cases from six Canadian epilepsy monitoring units between 1988 and 2014, and in the literature between 1972 and 2017. Inclusion criteria were identification of an epileptogenic lesion localized in the OFC or if the patient was seizure-free after surgical removal of the OFC in nonlesional cases.

RESULTS

Sixteen cases were identified from our databases. Fifty percent had predominantly sleep-related seizures; 56% had no aura (the remaining had nonspecific or vegetative auras), and 62.5% featured hypermotor (mostly hyperkinetic) behaviors. Interictal epileptiform discharges over frontal and temporal derivations always allowed lateralization. Magnetic resonance imaging (MRI) identified an orbitofrontal lesion in 8/16, positron emission tomography (PET) identified a hypometabolism extending outside the orbital cortex in 4/9, ictal single-photon emission computed tomography (SPECT) identified an orbital hyperperfusion in 1/5, magnetoencephalography (MEG) identified lateral orbital sources in 2/4, and intracranial electroencephalography (EEG) identified an orbitofrontal onset in 9/10. Fourteen patients underwent surgery, all reaching a favorable outcome (71.4% Engel 1; 28.6% Engel 2; mean FU=5.6years). Pre- and postoperative neuropsychological assessments revealed heterogeneous findings. Our review of literature identified 71 possible cases of OFE, 32 with confident focus localization. Extracted data from these cumulated cases supported observations made from our case series.

CONCLUSIONS

Orbitofrontal epilepsy should be suspected with sleep-related, hyperkinetic seizures with no specific aura, and frontotemporal interictal discharges. Several patients have nonmotor seizures with or without auras which may resemble temporal lobe seizures. Postoperative seizure outcome was favorable, but there is inherent bias as we only included patients with a seizure-free outcome if the MRI was negative. A larger study is required to address identified gaps in knowledge such as identifying discriminative features between medial and lateral OFE, evaluating the value of more recent diagnostic tools, and assessing the neuropsychological outcome of orbital epilepsy surgery.

Three- and four-dimensional mapping of speech and language in patients with epilepsy

We have provided 3-D and 4D mapping of speech and language function based upon the results of direct cortical stimulation and event-related modulation of electrocorticography signals. Patients estimated to have right-hemispheric language dominance were excluded. Thus, 100 patients who underwent two-stage epilepsy surgery with chronic electrocorticography recording were studied. An older group consisted of 84 patients at least 10 years of age (7367 artefact-free non-epileptic electrodes), whereas a younger group included 16 children younger than age 10 (1438 electrodes). The probability of symptoms transiently induced by electrical stimulation was delineated on a 3D average surface image. The electrocorticography amplitude changes of high-gamma (70-110 Hz) and beta (15-30 Hz) activities during an auditory-naming task were animated on the average surface image in a 4D manner. Thereby, high-gamma augmentation and beta attenuation were treated as summary measures of cortical activation. Stimulation data indicated the causal relationship between (i) superior-temporal gyrus of either hemisphere and auditory hallucination; (ii) left superior-/middle-temporal gyri and receptive aphasia; (iii) widespread temporal/frontal lobe regions of the left hemisphere and expressive aphasia; and (iv) bilateral precentral/left posterior superior-frontal regions and speech arrest. On electrocorticography analysis, high-gamma augmentation involved the bilateral superior-temporal and precentral gyri immediately following question onset; at the same time, high-gamma activity was attenuated in the left orbitofrontal gyrus. High-gamma activity was augmented in the left temporal/frontal lobe regions, as well as left inferior-parietal and cingulate regions, maximally around question offset, with high-gamma augmentation in the left pars orbitalis inferior-frontal, middle-frontal, and inferior-parietal regions preceded by high-gamma attenuation in the contralateral homotopic regions. Immediately before verbal response, high-gamma augmentation involved the posterior superior-frontal and pre/postcentral regions, bilaterally. Beta-attenuation was spatially and temporally correlated with high-gamma augmentation in general but with exceptions. The younger and older groups shared similar spatial-temporal profiles of high-gamma and beta modulation; except, the younger group failed to show left-dominant activation in the rostral middle-frontal and pars orbitalis inferior-frontal regions around stimulus offset. The human brain may rapidly and alternately activate and deactivate cortical areas advantageous or obtrusive to function directed toward speech and language at a given moment. Increased left-dominant activation in the anterior frontal structures in the older age group may reflect developmental consolidation of the language system. The results of our functional mapping may be useful in predicting, across not only space but also time and patient age, sites specific to language function for presurgical evaluation of focal epilepsy.

Brain network dynamics in the human articulatory loop

OBJECTIVE

The articulatory loop is a fundamental component of language function, involved in the short-term buffer of auditory information followed by its vocal reproduction. We characterized the network dynamics of the human articulatory loop, using invasive recording and stimulation.

METHODS

We measured high-gamma activity_{70-110 Hz} recorded intracranially when patients with epilepsy either only listened to, or listened to and then reproduced two successive tones by humming. We also conducted network analyses, and analyzed behavioral responses to cortical stimulation.

RESULTS

Presentation of the initial tone elicited high-gamma augmentation bilaterally in the superior-temporal gyrus (STG) within 40ms, and in the precentral and inferior-frontal gyri (PCG and IFG) within 160ms after sound onset. During presentation of the second tone, high-gamma augmentation was reduced in STG but enhanced in IFG. The task requiring tone reproduction further enhanced high-gamma augmentation in PCG during and after sound presentation. Event-related causality (ERC) analysis revealed dominant flows within STG immediately after sound onset, followed by reciprocal interactions involving PCG and IFG. Measurement of cortico-cortical evoked-potentials (CCEPs) confirmed connectivity between distant high-gamma sites in the articulatory loop. High-frequency stimulation of precentral high-gamma sites in either hemisphere induced speech arrest, inability to control vocalization, or forced vocalization. Vocalization of tones was accompanied by high-gamma augmentation over larger extents of PCG.

CONCLUSIONS

Bilateral PCG rapidly and directly receives feed-forward signals from STG, and may promptly initiate motor planning including sub-vocal rehearsal for short-term buffering of auditory stimuli. Enhanced high-gamma augmentation in IFG during presentation of the second tone may reflect high-order processing of the tone sequence.

SIGNIFICANCE

The articulatory loop employs sustained reciprocal propagation of neural activity across a network of cortical sites with strong neurophysiological connectivity.

Interictal high-frequency oscillations generated by seizure onset and eloquent areas may be differentially coupled with different slow waves

OBJECTIVE

High-frequency oscillations (HFOs) can be spontaneously generated by seizure-onset and functionally-important areas. We determined if consideration of the spectral frequency bands of coupled slow-waves could distinguish between epileptogenic and physiological HFOs.

METHODS

We studied a consecutive series of 13 children with focal epilepsy who underwent extraoperative electrocorticography. We measured the occurrence rate of HFOs during slow-wave sleep at each electrode site. We subsequently determined the performance of HFO rate for localization of seizure-onset sites and undesirable detection of nonepileptic sensorimotor-visual sites defined by neurostimulation. We likewise determined the predictive performance of modulation index: MI(XHz)&(YHz), reflecting the strength of coupling between amplitude of HFOsXHz and phase of slow-waveYHz. The predictive accuracy was quantified using the area under the curve (AUC) on receiver-operating characteristics analysis.

RESULTS

Increase in HFO rate localized seizure-onset sites (AUC⩾0.72; p<0.001), but also undesirably detected nonepileptic sensorimotor-visual sites (AUC⩾0.58; p<0.001). Increase in MI(HFOs)&(3-4Hz) also detected both seizure-onset (AUC⩾0.74; p<0.001) and nonepileptic sensorimotor-visual sites (AUC⩾0.59; p<0.001). Increase in subtraction-MIHFOs [defined as subtraction of MI(HFOs)&(0.5-1Hz) from MI(HFOs)&(3-4Hz)] localized seizure-onset sites (AUC⩾0.71; p<0.001), but rather avoided detection of nonepileptic sensorimotor-visual sites (AUC⩽0.42; p<0.001).

CONCLUSION

Our data suggest that epileptogenic HFOs may be coupled with slow-wave3-4Hz more preferentially than slow-wave0.5-1Hz, whereas physiologic HFOs with slow-wave0.5-1Hz more preferentially than slow-wave3-4Hz during slow-wave sleep.

SIGNIFICANCE

Further studies in larger samples are warranted to determine if consideration of the spectral frequency bands of slow-waves coupled with HFOs can positively contribute to presurgical evaluation of patients with focal epilepsy.

Spatial-temporal patterns of electrocorticographic spectral changes during midazolam sedation

OBJECTIVE

To better understand 'when' and 'where' wideband electrophysiological signals are altered by sedation.

METHODS

We generated animation movies showing electrocorticography (ECoG) amplitudes at eight spectral frequency bands across 1.0-116 Hz, every 0.1s, on three-dimensional surface images of 10 children who underwent epilepsy surgery. We measured the onset, intensity, and variance of each band amplitude change at given nonepileptic regions separately from those at affected regions. We also determined the presence of differential ECoG changes depending on the brain anatomy.

RESULTS

Within 20s following injection of midazolam, beta (16-31.5 Hz) and sigma (12-15.5 Hz) activities began to be multifocally augmented with increased variance in amplitude at each site. Beta-sigma augmentation was most prominent within the association neocortex. Augmentation of low-delta activity (1.0-1.5 Hz) was relatively modest and confined to the somatosensory-motor region. Conversely, injection of midazolam induced attenuation of theta (4.0-7.5 Hz) and high-gamma (64-116 Hz) activities.

CONCLUSIONS

Our observations support the notion that augmentation beta-sigma and delta activities reflects cortical deactivation or inactivation, whereas theta and high-gamma activities contribute to maintenance of consciousness. The effects of midazolam on the dynamics of cortical oscillations differed across regions.

SIGNIFICANCE

Sedation, at least partially, reflects a multi-local phenomenon at the cortical level rather than global brain alteration homogeneously driven by the common central control structure.

Upright face-preferential high-gamma responses in lower-order visual areas: evidence from intracranial recordings in children

Behavioral studies demonstrate that a face presented in the upright orientation attracts attention more rapidly than an inverted face. Saccades toward an upright face take place in 100-140 ms following presentation. The present study using electrocorticography determined whether upright face-preferential neural activation, as reflected by augmentation of high-gamma activity at 80-150 Hz, involved the lower-order visual cortex within the first 100 ms post-stimulus presentation. Sampled lower-order visual areas were verified by the induction of phosphenes upon electrical stimulation. These areas resided in the lateral-occipital, lingual, and cuneus gyri along the calcarine sulcus, roughly corresponding to V1 and V2. Measurement of high-gamma augmentation during central (circular) and peripheral (annular) checkerboard reversal pattern stimulation indicated that central-field stimuli were processed by the more polar surface whereas peripheral-field stimuli by the more anterior medial surface. Upright face stimuli, compared to inverted ones, elicited up to 23% larger augmentation of high-gamma activity in the lower-order visual regions at 40-90 ms. Upright face-preferential high-gamma augmentation was more highly correlated with high-gamma augmentation for central than peripheral stimuli. Our observations are consistent with the hypothesis that lower-order visual regions, especially those for the central field, are involved in visual cues for rapid detection of upright face stimuli.

The piriform cortex and human focal epilepsy

It is surprising that the piriform cortex, when compared to the hippocampus, has been given relatively little significance in human epilepsy. Like the hippocampus, it has a phylogenetically preserved three-layered cortex that is vulnerable to excitotoxic injury, has broad connections to both limbic and cortical areas, and is highly epileptogenic – being critical to the kindling process. The well-known phenomenon of early olfactory auras in temporal lobe epilepsy highlights its clinical relevance in human beings. Perhaps because it is anatomically indistinct and difficult to approach surgically, as it clasps the middle cerebral artery, it has, until now, been understandably neglected. In this review, we emphasize how its unique anatomical and functional properties, as primary olfactory cortex, predispose it to involvement in focal epilepsy. From recent convergent findings in human neuroimaging, clinical epileptology, and experimental animal models, we make the case that the piriform cortex is likely to play a facilitating and amplifying role in human focal epileptogenesis, and may influence progression to epileptic intractability.

Localization of specific language pathways using diffusion-weighted imaging tractography for presurgical planning of children with intractable epilepsy

OBJECTIVE

To examine whether diffusion-weighted imaging (DWI) tractography can detect multiple white matter pathways connected to language cortices, we employed a maximum a posteriori probability (MAP) classification method, which has been recently validated for the corticospinal tract.

METHODS

DWI was performed in 12 normally developing children and 17 children with intractable focal epilepsy who underwent subsequent two-stage epilepsy surgery with intracranial functional mapping. First, whole-brain DWI tractography was performed to identify unique pathways originating from Broca's area, premotor area, and Wernicke's area on functional magnetic resonance imaging (fMRI) of normal children and intracranial electrical stimulation mapping (ESM) of children with epilepsy. Group averaging of these pathways based on fMRI was performed to construct the probability maps of language areas in standard MRI space. These maps were finally used to design a DWI-MAP classifier, which can automatically sort individual fibers originating from fMRI language areas as well as ESM language areas.

RESULTS

In normally developing children, the DWI-MAP classifier predicted language-activation areas on fMRI with up to 77% accuracy. In children with focal epilepsy, the DWI-MAP classifier also showed high accuracy (up to 82%) for the fibers terminating in proximity to essential language areas determined by ESM. Decreased volumes in DWI-MAP-defined pathways after epilepsy surgery were associated with postoperative language deficits.

SIGNIFICANCE

This study encourages further investigations to determine if DWI-MAP analysis can serve as a noninvasive diagnostic tool during pediatric presurgical planning by estimating not only the location of essential language cortices, but also the underlying fibers connecting these cortical areas.

Contribution of research on 'Epilepsy & behavior' to the refinement of functional brain atlas in four dimensions

Intracranial stimulation mapping by Penfield et al. largely contributed to our current knowledge of the functional organization of motor, sensory, and language systems. The functional maps were generated and printed in two dimensions, based on the summary results of direct cortical stimulation of which locations varied across patients. Intracranial measurement of electrocorticographic changes elicited by a task can localize the regions involved in or participating to the given task. Augmentation of high-gamma activity at >80 Hz is considered to reflect in situ cortical activation at each moment. In the late 2000s, the spatial-temporal profiles of event-related high-gamma activity began to be published as a video material in journals. We have referred to our animation movie as ‘in-vivo animation of event-related high-gamma activity’, that demonstrates ‘when’ and ‘where’ cortical regions are activated in a self-explanatory fashion. Summation of event-related high-gamma measures derived from a large cohort of patients, as previously performed by Penfield et al, is expected to generate unique four-dimensional functional brain atlas covering the whole cerebral cortex.

Roles of olfactory system dysfunction in depression

The olfactory system is involved in sensory functions, emotional regulation and memory formation. Olfactory bulbectomy in rat has been employed as an animal model of depression for antidepressant discovery studies for many years. Olfaction is impaired in animals suffering from chronic stress, and patients with clinical depression were reported to have decreased olfactory function. It is believed that the neurobiological bases of depression might include dysfunction in the olfactory system. Further, brain stimulation, including nasal based drug delivery could provide novel therapies for management of depression.

Slow-wave sleep-imposed replay modulates both strength and precision of memory

Odor perception is hypothesized to be an experience-dependent process involving the encoding of odor objects by distributed olfactory cortical ensembles. Olfactory cortical neurons coactivated by a specific pattern of odorant evoked input become linked through association fiber synaptic plasticity, creating a template of the familiar odor. In this way, experience and memory play an important role in odor perception and discrimination. In other systems, memory consolidation occurs partially via slow-wave sleep (SWS)-dependent replay of activity patterns originally evoked during waking. SWS is ideal for replay given hyporesponsive sensory systems, and thus reduced interference. Here, using artificial patterns of olfactory bulb stimulation in a fear conditioning procedure in the rat, we tested the effects of imposed post-training replay during SWS and waking on strength and precision of pattern memory. The results show that imposed replay during post-training SWS enhanced the subsequent strength of memory, whereas the identical replay during waking induced extinction. The magnitude of this enhancement was dependent on the timing of imposed replay relative to cortical sharp-waves. Imposed SWS replay of stimuli, which differed from the conditioned stimulus, did not affect conditioned stimulus memory strength but induced generalization of the fear memory to novel artificial patterns. Finally, post-training disruption of piriform cortex intracortical association fiber synapses, hypothesized to be critical for experience-dependent odor coding, also impaired subsequent memory precision but not strength. These results suggest that SWS replay in the olfactory cortex enhances memory consolidation, and that memory precision is dependent on the fidelity of that replay.

Same same but different: the case of olfactory imagery

In the present work we present an overview of experimental findings corroborating olfactory imagery observations with the visual and auditory modalities. Overall, the results indicate that imagery of olfactory information share many features with those observed in the primary senses although some major differences are evident. One such difference pertains to the considerable individual differences observed, with the majority being unable to reproduce olfactory information in their mind. Here, we highlight factors that are positively related to an olfactory imagery capacity, such as semantic knowledge, perceptual experience, and olfactory interest that may serve as potential moderators of the large individual variation.

Electrocorticographic correlates of overt articulation of 44 English phonemes: intracranial recording in children with focal epilepsy

OBJECTIVE

We determined the temporal-spatial patterns of electrocorticography (ECoG) signal modulation during overt articulation of 44 American English phonemes.

METHODS

We studied two children with focal epilepsy who underwent extraoperative ECoG recording. Using animation movies, we delineated 'when' and 'where' gamma- (70-110 Hz) and low-frequency-band activities (10-30 Hz) were modulated during self-paced articulation.

RESULTS

Regardless of the classes of phoneme articulated, gamma-augmentation initially involved a common site within the left inferior Rolandic area. Subsequently, gamma-augmentation and/or attenuation involved distinct sites within the left oral-sensorimotor area with a timing variable across phonemes. Finally, gamma-augmentation in a larynx-sensorimotor area took place uniformly at the onset of sound generation, and effectively distinguished voiced and voiceless phonemes. Gamma-attenuation involved the left inferior-frontal and superior-temporal regions simultaneously during articulation. Low-frequency band attenuation involved widespread regions including the frontal, temporal, and parietal regions.

CONCLUSIONS

Our preliminary results support the notion that articulation of distinct phonemes recruits specific sensorimotor activation and deactivation. Gamma attenuation in the left inferior-frontal and superior-temporal regions may reflect transient functional suppression in these cortical regions during automatic, self-paced vocalization of phonemes containing no semantic or syntactic information.

SIGNIFICANCE

Further studies are warranted to determine if measurement of event-related modulations of gamma-band activity, compared to that of the low-frequency-band, is more useful for decoding the underlying articulatory functions.

Olfactory Hallucinations without Clinical Motor Activity: A Comparison of Unirhinal with Birhinal Phantosmia

Olfactory hallucinations without subsequent myoclonic activity have not been well characterized or understood. Herein we describe, in a retrospective study, two major forms of olfactory hallucinations labeled phantosmias: one, unirhinal, the other, birhinal. To describe these disorders we performed several procedures to elucidate similarities and differences between these processes. From 1272, patients evaluated for taste and smell dysfunction at The Taste and Smell Clinic, Washington, DC with clinical history, neurological and otolaryngological examinations, evaluations of taste and smell function, EEG and neuroradiological studies 40 exhibited cyclic unirhinal phantosmia (CUP) usually without hyposmia whereas 88 exhibited non-cyclic birhinal phantosmia with associated symptomology (BPAS) with hyposmia. Patients with CUP developed phantosmia spontaneously or after laughing, coughing or shouting initially with spontaneous inhibition and subsequently with Valsalva maneuvers, sleep or nasal water inhalation; they had frequent EEG changes usually ipsilateral sharp waves. Patients with BPAS developed phantosmia secondary to several clinical events usually after hyposmia onset with few EEG changes; their phantosmia could not be initiated or inhibited by any physiological maneuver. CUP is uncommonly encountered and represents a newly defined clinical syndrome. BPAS is commonly encountered, has been observed previously but has not been clearly defined. Mechanisms responsible for phantosmia in each group were related to decreased gamma-aminobutyric acid (GABA) activity in specific brain regions. Treatment which activated brain GABA inhibited phantosmia in both groups.