MEG localization of interictal epileptic focal activity and concomitant stereotactic radiosurgery. A non-invasive approach for patients with focal epilepsy

Stereotactic radiosurgery for epilepsy and functional disorders

Stereotactic radiosurgery is used for many indications. In functional neurosurgery, it is used to modulate the function of axons, neurons, and related brain circuits. In this article, indications, current techniques, and outcomes are discussed.

Trends and importance of radiosurgery for the development of functional neurosurgery

Functional neurosurgery includes surgery conducted to ablate, augment, or modulate targets that lead to improvement in neurological function or behavior. Surgical approaches for this purpose include destructive lesioning with different mechanical or biologic agents or energy sources, non-destructive electrical modulation, and cellular or chemical augmentation. Our purpose was to review the role of stereotactic radiosurgery used for functional indications and to discuss future applications and potential techniques. Imaging and neurophysiological research will enable surgeons to consider new targets and circuits that may be clinically important. Radiosurgery is one minimal access approach to those targets.

The surgery of epilepsy

The idea of surgical treatment for epilepsy is not new. However, widespread use and general acceptance of this treatment has only been achieved during the past three decades. A crucial step in this direction was the development of video electroencephalographic monitoring. Improvements in imaging resulted in an increased ability for preoperative identification of intracerebral and potentially epileptogenic lesions. High resolution magnetic resonance imaging plays a major role in structural and functional imaging; other functional imaging techniques (e.g., positron emission tomography and single-photon emission computed tomography) provide complementary data and, together with corresponding electroencephalographic findings, result in a hypothesis of the epileptogenic lesion, epileptogenic zone, and the functional deficit zone. The development of microneurosurgical techniques was a prerequisite for the general acceptance of elective intracranial surgery. New less invasive and safer resection techniques have been developed, and new palliative and augmentative techniques have been introduced. Today, epilepsy surgery is more effective and conveys a better seizure control rate. It has become safer and less invasive, with lower morbidity and mortality rates. This article summarizes the various developments of the past three decades and describes the present tools for presurgical evaluation and surgical strategy, as well as ideas and future perspectives for epilepsy surgery.

Stereotactic radiosurgery for functional disorders

✓ Stereotactic radiosurgery (SRS) with the Gamma Knife and linear accelerator has revolutionized neurosurgery over the past 20 years. The most common indications for radiosurgery today are tumors and arteriovenous malformations of the brain. Functional indications such as treatment of movement disorders or intractable pain only contribute a small percentage of treated patients. Although SRS is the only noninvasive form of treatment for functional disorders, it also has some limitations: neurophysiological confirmation of the target structure is not possible, and one therefore must rely exclusively on anatomical targeting. Furthermore, lesion sizes may vary, and shielding adjacent radiosensitive neural structures may be difficult or impossible.

The most common indication for functional SRS is the treatment of trigeminal neuralgia. Radiosurgical treatment for epilepsy and certain psychiatric illnesses is performed in several centers as part of strict research protocols, and radiosurgical pallidotomy or medial thalamotomy is no longer recommended due to the high risk of complications. Radiosurgical ventrolateral thalamotomy for the treatment of tremor in patients with Parkinson disease or multiple sclerosis, as well as in the treatment of essential tremor, may be indicated for a select group of patients with advanced age, significant medical conditions that preclude treatment with open surgery, or patients who must receive anticoagulation therapy. A promising new application of SRS is high-dose radiosurgery delivered to the pituitary stalk. This treatment has already been successfully performed in several centers around the world to treat severe pain in patients with end-stage cancer.

Effects of language experience: Neural commitment to language-specific auditory patterns

Linguistic experience alters an individual's perception of speech. We here provide evidence of the effects of language experience at the neural level from two magnetoencephalography (MEG) studies that compare adult American and Japanese listeners' phonetic processing. The experimental stimuli were American English /ra/ and /la/ syllables, phonemic in English but not in Japanese. In Experiment 1, the control stimuli were /ba/ and /wa/ syllables, phonemic in both languages; in Experiment 2, they were non-speech replicas of /ra/ and /la/. The behavioral and neuromagnetic results showed that Japanese listeners were less sensitive to the phonemic /r-l/ difference than American listeners. Furthermore, processing non-native speech sounds recruited significantly greater brain resources in both hemispheres and required a significantly longer period of brain activation in two regions, the superior temporal area and the inferior parietal area. The control stimuli showed no significant differences except that the duration effect in the superior temporal cortex also applied to the non-speech replicas. We argue that early exposure to a particular language produces a "neural commitment" to the acoustic properties of that language and that this neural commitment interferes with foreign language processing, making it less efficient.

The use of stereotactic radiosurgery to treat intractable childhood partial epilepsy

PURPOSE

Although conventional surgery is presently used to treat seizures of temporolimbic and neocortical origin, deep-seated lesions are often associated with morbidity. Stereotactic radiosurgery is a noninvasive procedure that effectively treats patients with vascular malformations and brain tumors, but its efficacy for epileptogenic foci is limited, especially in children.

METHODS

Between 1995 and 1999, four candidates who had medically uncontrolled seizures and localized seizure foci were selected for stereotactic radiosurgery, with a mean age of 9.75 years at the time of surgery (range, 4-17 years). Seizure foci were identified on the basis of ictal and interictal video-EEG. Magnetic resonance (MR) images were obtained before and after surgery. Ictal single-photon emission computed tomography (SPECT) was performed by using stabilized hexamethyl-propyleneamine oxime (HMPAO; 300 microcuries/kg) with early injection after electrographic ictal onset. The clinical features of the patients are given. All radiosurgical procedures were performed with the gamma knife unit with the Leksell stereotactic frame, stereotactic MRI imaging, and the Gamma Plan workstation. Seizure outcome was scored according to Engel's classification.

RESULTS

Two patients had hypothalamic hamartoma (HH), and two had neocortical epilepsy. At mean follow-up of 39.2 months (range, 26-69 months), two patients were seizure free, one with a HH and one with a suggestive developmental tumor in the insular cortex by MRI findings. The other patient with HH had 90% reduction of seizures. One patient with a widespread seizure focus that involved the motor strip was unimproved. The two patients with HH also exhibited markedly improved neurobehavioral status after surgery. There were no significant complications of radiosurgical therapy.

CONCLUSIONS

Our findings suggest that gamma knife surgery is a potentially valuable treatment modality for children with medically intractable epilepsy due to a well-localized seizure focus that is difficult to excise by conventional techniques or for whom they are deemed unsuitable. More widespread application in childhood epilepsy should be investigated in larger series.

Applicability of the single equivalent point dipole model to represent a spatially distributed bio-electrical source

Although the single equivalent point dipole model has been used to represent well-localised bio-electrical sources, in realistic situations the source is distributed. Consequently, position estimates of point dipoles determined by inverse algorithms suffer from systematic error due to the non-exact applicability of the inverse model. In realistic situations, this systematic error cannot be avoided, a limitation that is independent of the complexity of the torso model used. This study quantitatively investigates the intrinsic limitations in the assignment of a location to the equivalent dipole due to distributed electrical source. To simulate arrhythmic activity in the heart, a model of a wave of depolarisation spreading from a focal source over the surface of a spherical shell is used. The activity is represented by a sequence of concentric belt sources (obtained by slicing the shell with a sequence of parallel plane pairs), with constant dipole moment per unit length (circumferentially) directed parallel to the propagation direction. The distributed source is represented by N dipoles at equal arc lengths along the belt. The sum of the dipole potentials is calculated at predefined electrode locations. The inverse problem involves finding a single equivalent point dipole that best reproduces the electrode potentials due to the distributed source. The inverse problem is implemented by minimising the chi2 per degree of freedom. It is found that the trajectory traced by the equivalent dipole is sensitive to the location of the spherical shell relative to the fixed electrodes. It is shown that this trajectory does not coincide with the sequence of geometrical centres of the consecutive belt sources. For distributed sources within a bounded spherical medium, displaced from the sphere's centre by 40% of the sphere's radius, it is found that the error in the equivalent dipole location varies from 3 to 20% for sources with size between 5 and 50% of the sphere's radius. Finally, a method is devised to obtain the size of the distributed source during the cardiac cycle.

The effects of continuous and single-dose radiation on choline uptake in organotypic tissue slice cultures of rabbit hippocampus

The objective of the present study was to determine the time-dependent course of choline uptake in mature organotypic slice cultures of rabbit hippocampal formation and to assess the effects of continuous and single high-dose irradiation on choline uptake in cultivated slices in vitro. Transverse slices of hippocampus were dynamically incubated in a cerebrospinal fluid-like culture medium for 72 h. To study the changes in choline uptake longitudinally, the slice cultures were processed with 0.1 microM [3H]-choline, and tritium accumulation was counted. Two different gamma irradiation sources (125I seeds and a clinical 60Co source) were used as representative models of interstitial radiosurgery and other radiosurgical techniques. A total dose of approximately 6000 cGy was delivered to the brain slices in one session or in a continuous, relatively low-dose rate fashion, and their effects on high-affinity choline uptake were examined. In another set of experiments with 125I, 5 microM hemicholinium-3 was used in choline uptake procedures as a competitive high-affinity choline uptake inhibitor. The results can be summarized as follows: (1) in the control group of the hippocampal tissue culture, there was a significant increase in tritium accumulation values from 0 to 48 h and a decrease thereafter; (2) continuous 125I irradiation caused a highly significant depression of the accumulation of tritium compared to that observed in the control group throughout its application for 72 h; (3) there was no significant change in the accumulation of tritium in the slices after single high-dose rate irradiation with a 60Co source; and (4) 5 microM hemicholinium significantly depressed the accumulation of tritium in both the control and the 125I-irradiated groups, and there was no longer a difference between 125I-irradiated and control groups when both groups were treated with hemicholinium. These results demonstrate that the delivery of continuous but relatively low-dose rate gamma irradiation is more efficacious than single high-dose external irradiation on high-affinity choline uptake in hippocampal nervous tissue. The results also indicate that continuous irradiation specifically affected the high-affinity energy-dependent choline uptake mechanism, whereas nonspecific choline uptake did not seem to be disturbed.

Subnecrotic stereotactic radiosurgery controlling epilepsy produced by kainic acid injection in rats

OBJECT

Any analysis of the potential role of stereotactic radiosurgery for epilepsy requires the experimental study of its potential antiepileptogenic, behavioral, and histological effects. The authors hypothesized that radiosurgery performed using subnecrotic tissue doses would reduce or abolish epilepsy without causing demonstrable behavioral side effects. The kainic acid model in rats was chosen to test this hypothesis.

METHODS

Chronic epilepsy was successfully created by stereotactic injection of kainic acid (8 microg) into the rat hippocampus. Epileptic rats were divided into three groups: high-dose radiosurgery (60 Gy, 16 animals), low-dose (30 Gy, 15 animals), and controls. After chronic epilepsy was confirmed by observation of the seizure pattern and by using electroencephalography (EEG), radiosurgery was performed on Day 10 postinjection. Serial seizure and behavior observation was supplemented by weekly EEG sessions performed for the next 11 weeks. To detect behavioral deficits, the Morris water maze test was performed during Week 12 to study spatial learning and memory. Tasks involved a hidden platform, a visible platform, and a probe trial. After radiosurgery, the incidence of observed and EEG-defined seizures was markedly reduced in rats from either radiosurgically treated group. A significant reduction was noted after high-dose (60 Gy) radiosurgery in Weeks 5 to 9 (p < 0.003). After low-dose (30 Gy) radiosurgery, a significant reduction was found after 7 to 9 weeks (p < 0.04). During the task involving the hidden platform, kainic acid-injected rats displayed significantly prolonged latencies compared with those of control animals (p < 0.05). Hippocampal radiosurgery did not worsen this performance. The probe trial showed that kainic acid-injected rats that did not undergo radiosurgery spent significantly less time than control rats in the target quadrant (p = 0.03). Rats that had undergone radiosurgery displayed no difference compared with control rats and demonstrated better performance than rats that received kainic acid alone (p = 0.04). Radiosurgery caused no adverse histological effects.

CONCLUSIONS

In a rat model, radiosurgery performed with subnecrotic tissue doses controlled epilepsy without causing subsequent behavioral impairment.

Radiosurgery: where we were, are, and may be in the third millennium

Radiosurgery will celebrate its Golden Jubilee in the year 2001. More than 100,000 patients throughout the world have undergone radiosurgery since Lars Leksell first described the technique in 1951. Rapid developments in neuroimaging and even robotic technology in the past decade have contributed to improved outcomes and wider applications for radiosurgery. A variety of different radiosurgical techniques have been developed in the past two decades. Numerous studies have examined the benefits and risks of radiosurgery performed with various devices. The long-term results of radiosurgery are now available, and these results have established radiosurgery as an effective noninvasive treatment method for intracranial vascular malformations and many tumors. Additional applications of radiosurgery for the treatment of malignant tumors and functional disorders are being assessed. Radiosurgery is an impressive combination of minimally invasive technologies administered by a multidisciplinary team of surgeons, oncologists, medical physicists, and engineers.

Functional radiosurgery

Although the application of stereotactic radiosurgery for the management of functional brain disorders began in 1951, almost 50 years elapsed before it received appropriate attention. Radiosurgical techniques are used to create image-guided, physiological inactivity or focally destructive brain lesions without neurophysiological guidance. The lack of neurophysiological guidance remains the greatest argument against the use of radiosurgery for selected disorders. Current anatomic targets include the trigeminal nerve (for trigeminal neuralgia), the thalamus (for tremor or pain), the cingulate gyrus or anterior internal capsule (for pain or psychiatric illness), the globus pallidus (for symptoms of Parkinson's disease), and the hippocampus (for epilepsy). The use of radiosurgery as a "lesion generator" is based on extensive animal studies that defined the dose, volume, and temporal response of the irradiated tissue. The usefulness of radiosurgery has been compared with that of microsurgical, percutaneous, and electrode-based techniques used for functional neurological disorders. At present, the long-term results after functional radiosurgery procedures remain to be documented. The current indications and expected outcomes after radiosurgery are discussed.

Three-dimensional localization of subclinical ictal activity by magnetoencephalography: correlation with invasive monitoring

BACKGROUND

Although magnetoencephalography (MEG) provides accurate information on the spatial distribution and temporal patterns of the "interictal" epileptic activities, it is interictal in nature and therefore also prone to all the problems associated with interictal data.

METHODS

We investigated the subclinical "ictal" epileptic activity with a 37-channel, large-array biomagnetometer and mapped the data onto a three-dimensional image in a patient with intractable frontal lobe epilepsy. Dipole source localization was calculated based on magnetic fields for both the interictal and subclinical ictal activities.

RESULTS

The current dipoles of the interictal MEG spikes (MEG irritative zone) were revealed to be scattered in the left anterior frontal lobe, whereas that of the subclinical ictal onset (MEG subclinical ictal onset zone) was surrounded by the interictal dipole cluster. The dipole source localization of the propagating activities was not calculated with a single dipole model. The MEG subclinical ictal onset zone correlated well with the ictal onset zone subsequently recorded by invasive subdural electrophysiological monitoring. After multiple subpial transection of the deduced epileptogenic area, a dramatic reduction of the seizures occurred.

CONCLUSION

These results illustrate the potential of MEG for localizing the epileptogenic foci with high spatial and temporal resolution.

Magnetocardiographic localization of arrhythmia substrates: a methodology study with accessory pathway ablation as reference

In magnetocardiographic (MCG) localization of arrhythmia substrates, a model of the thorax as volume conductor is a crucial component of the calculations. In this study, we investigated different models of the thorax, to determine the most suitable to use in the computations. Our methods and results are as follows. We studied 11 patients with overt Wolff-Parkinson-White syndrome, scheduled for catheter ablation. The MCG registrations were made with a 37-channel "superconducting quantum interference device" system. The underlying equivalent current dipole was computed for the delta-wave. Three models of the thorax were used: the infinite halfspace, a sphere and a box. For anatomical correlation and to define the suitable sphere and box, magnetic resonance images were obtained. As reference we used the position of the tip of the catheter, at successful radio-frequency-ablation, documented by cine-fluoroscopy. Nine patients could be evaluated. The mean errors (range) when using the infinite halfspace, the sphere and the box were 96 (49-125), 21 (5-39), and 36 mm (20-58 mm), respectively (p < 0.0001). In conclusion, the sphere was significantly better suited than the other models tested in this study, but even with this model the accuracy of MCG localization must further improve to be clinically useful. More realistic models of the thorax are probably required to achieve this goal.

Accuracy of an experimental stereotactic system for MRI-based gamma knife irradiation in the rat

Stereotactic devices for experimental Gamma Knife irradiation and magnetic resonance imaging (MRI) have recently been developed for experimental studies using rats [6,7]. The present study examined the accuracy of these devices using the following two approaches. In the first approach, Gamma Knife irradiation was performed using the stereotactic device with targets based on a standard stereotactic atlas. Gadolinium-enhanced T1-weighted magnetic resonance imaging was performed using the MRI stereotactic device. Animals were then sacrificed after Evans blue injection, and the rat brain was sliced using an attachment to the stereotactic device. The center coordinates of the gadolinium-enhanced area from the MRI and Evans blue-stained area from the tissue sections were obtained using a computer-assisted image analysis system. These coordinates were compared with the target coordinates planned from the stereotactic atlas. In the second approach, a thermoluminescence dosimeter was implanted in the rat brain. Stereotactic MRI was performed using the stereotactic MRI device, and the coordinates of the implant were obtained. Gamma Knife irradiation was then performed at this target using the stereotactic device. The absorbed dose was measured and compared with the planning dose. These experiments demonstrated a spatial error of 0.6 mm (standard error +/- 0.07) between Gamma Knife irradiation based on a comparison of the atlas coordinates and the lesion, and a spatial error of 1.0 mm (standard error +/- 0.13) based on a comparison of the stereotactic MR images and the lesion. Gamma Knife irradiation based on MR images using the stereotactic device demonstrated a maximum error of 10% in absorbed dose at the target center. Together, the stereotactic devices for Gamma Knife irradiation and magnetic resonance imaging provide useful tools for Gamma Knife research in an animal model.

Localisation of epileptic foci with multichannel magnetoencephalography, MEG

With the development of multichannel magnetoencephalographs biomagnetic signals can be recorded over large areas at the same time. It allows determination of the magnetic field outside the head generated by spontaneous epileptic discharges. From the maxima of outward and inward magnetic fluxes the locations of the sources of epileptic discharges can be calculated. The biomagnetic signals originating from an epileptic discharge is, however, mixed with biomagnetic signals generated by the background activity of the brain. A localisation based on a single discharge will therefore be influenced by the background activity. To diminish this influence, the biomagnetic signals during repeated identical epileptic discharges have been averaged. It gives a source localisation common to all discharges instead of a widely spread cluster of dipole sources. The error of epileptic dipole source localisations varies with the site of the dipole in the head as judged from studies with implanted dipole sources but also with the direction of the dipole as seen in studies with artificial dipoles in real head volumes. The error is relatively small in areas where the head has a spherical surface if the dipole direction is tangential. At other sites or dipole directions, the error can be very large. Since the site and direction of an epileptic dipole source is unknown it is not possible to estimate the error of localisations except by using models of individual head volumes.

Point and distributed current density analysis of interictal epileptic activity recorded by magnetoencephalography

Equivalent current dipole (ECD) analysis and fully three-dimensional distributed source solutions have been applied to interictal multichannel magnetoencephalographic recordings of a patient with complex partial epilepsy (CPE). Averaged signals were used. At certain instances ECD solutions could be found with a very high cross-correlation coefficient between the measurements and the field, produced by the current dipole solution, typically in excess of 0.97. At these instances a highly localized distribution, very close to the ECD location, was obtained from the distributed source analysis. The ECD solution started to move when the distributed source solution began to develop activity at more than one centre. This clearly contrasted with the way the activity of the distributed source solutions changed, which turned out to be highly stable. Stringent selection criteria for using the different solutions therefore seem mandatory, especially in identifying pathological areas and volumes of the human brain.