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Degenhart AD, Hiremath SV, Yang Y, Foldes S, Collinger JL, Boninger M, Tyler-Kabara EC, Wang W. Remapping cortical modulation for electrocorticographic brain-computer interfaces: a somatotopy-based approach in individuals with upper-limb paralysis. J Neural Eng 2018; 15:026021. [PMID: 29160240 PMCID: PMC5841472 DOI: 10.1088/1741-2552/aa9bfb] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Brain-computer interface (BCI) technology aims to provide individuals with paralysis a means to restore function. Electrocorticography (ECoG) uses disc electrodes placed on either the surface of the dura or the cortex to record field potential activity. ECoG has been proposed as a viable neural recording modality for BCI systems, potentially providing stable, long-term recordings of cortical activity with high spatial and temporal resolution. Previously we have demonstrated that a subject with spinal cord injury (SCI) could control an ECoG-based BCI system with up to three degrees of freedom (Wang et al 2013 PLoS One). Here, we expand upon these findings by including brain-control results from two additional subjects with upper-limb paralysis due to amyotrophic lateral sclerosis and brachial plexus injury, and investigate the potential of motor and somatosensory cortical areas to enable BCI control. APPROACH Individuals were implanted with high-density ECoG electrode grids over sensorimotor cortical areas for less than 30 d. Subjects were trained to control a BCI by employing a somatotopic control strategy where high-gamma activity from attempted arm and hand movements drove the velocity of a cursor. MAIN RESULTS Participants were capable of generating robust cortical modulation that was differentiable across attempted arm and hand movements of their paralyzed limb. Furthermore, all subjects were capable of voluntarily modulating this activity to control movement of a computer cursor with up to three degrees of freedom using the somatotopic control strategy. Additionally, for those subjects with electrode coverage of somatosensory cortex, we found that somatosensory cortex was capable of supporting ECoG-based BCI control. SIGNIFICANCE These results demonstrate the feasibility of ECoG-based BCI systems for individuals with paralysis as well as highlight some of the key challenges that must be overcome before such systems are translated to the clinical realm. ClinicalTrials.gov Identifier: NCT01393444.
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Affiliation(s)
- Alan D. Degenhart
- Systems Neuroscience Institute, University of Pittsburgh, PA, USA
- Center for the Neural Basis of Cognition, Pittsburgh, PA, USA
| | - Shivayogi V. Hiremath
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Physical Therapy, Temple University, Philadelphia, PA, USA
| | - Ying Yang
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stephen Foldes
- Center for the Neural Basis of Cognition, Pittsburgh, PA, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Veterans Affairs Medical Center, Pittsburgh, PA, USA
| | - Jennifer L. Collinger
- Center for the Neural Basis of Cognition, Pittsburgh, PA, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Veterans Affairs Medical Center, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Boninger
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Veterans Affairs Medical Center, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, Pittsburgh, PA, USA
| | - Elizabeth C. Tyler-Kabara
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wei Wang
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, Pittsburgh, PA, USA
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
- Barnes-Jewish Hospital, St. Louis, MO, USA
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Rouse AG, Williams JJ, Wheeler JJ, Moran DW. Spatial co-adaptation of cortical control columns in a micro-ECoG brain-computer interface. J Neural Eng 2016; 13:056018. [PMID: 27651034 DOI: 10.1088/1741-2560/13/5/056018] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Electrocorticography (ECoG) has been used for a range of applications including electrophysiological mapping, epilepsy monitoring, and more recently as a recording modality for brain-computer interfaces (BCIs). Studies that examine ECoG electrodes designed and implanted chronically solely for BCI applications remain limited. The present study explored how two key factors influence chronic, closed-loop ECoG BCI: (i) the effect of inter-electrode distance on BCI performance and (ii) the differences in neural adaptation and performance when fixed versus adaptive BCI decoding weights are used. APPROACH The amplitudes of epidural micro-ECoG signals between 75 and 105 Hz with 300 μm diameter electrodes were used for one-dimensional and two-dimensional BCI tasks. The effect of inter-electrode distance on BCI control was tested between 3 and 15 mm. Additionally, the performance and cortical modulation differences between constant, fixed decoding using a small subset of channels versus adaptive decoding weights using the entire array were explored. MAIN RESULTS Successful BCI control was possible with two electrodes separated by 9 and 15 mm. Performance decreased and the signals became more correlated when the electrodes were only 3 mm apart. BCI performance in a 2D BCI task improved significantly when using adaptive decoding weights (80%-90%) compared to using constant, fixed weights (50%-60%). Additionally, modulation increased for channels previously unavailable for BCI control under the fixed decoding scheme upon switching to the adaptive, all-channel scheme. SIGNIFICANCE Our results clearly show that neural activity under a BCI recording electrode (which we define as a 'cortical control column') readily adapts to generate an appropriate control signal. These results show that the practical minimal spatial resolution of these control columns with micro-ECoG BCI is likely on the order of 3 mm. Additionally, they show that the combination and interaction between neural adaptation and machine learning are critical to optimizing ECoG BCI performance.
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Bundy DT, Pahwa M, Szrama N, Leuthardt EC. Decoding three-dimensional reaching movements using electrocorticographic signals in humans. J Neural Eng 2016; 13:026021. [PMID: 26902372 DOI: 10.1088/1741-2560/13/2/026021] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Electrocorticography (ECoG) signals have emerged as a potential control signal for brain-computer interface (BCI) applications due to balancing signal quality and implant invasiveness. While there have been numerous demonstrations in which ECoG signals were used to decode motor movements and to develop BCI systems, the extent of information that can be decoded has been uncertain. Therefore, we sought to determine if ECoG signals could be used to decode kinematics (speed, velocity, and position) of arm movements in 3D space. APPROACH To investigate this, we designed a 3D center-out reaching task that was performed by five epileptic patients undergoing temporary placement of ECoG arrays. We used the ECoG signals within a hierarchical partial-least squares (PLS) regression model to perform offline prediction of hand speed, velocity, and position. MAIN RESULTS The hierarchical PLS regression model enabled us to predict hand speed, velocity, and position during 3D reaching movements from held-out test sets with accuracies above chance in each patient with mean correlation coefficients between 0.31 and 0.80 for speed, 0.27 and 0.54 for velocity, and 0.22 and 0.57 for position. While beta band power changes were the most significant features within the model used to classify movement and rest, the local motor potential and high gamma band power changes, were the most important features in the prediction of kinematic parameters. SIGNIFICANCE We believe that this study represents the first demonstration that truly three-dimensional movements can be predicted from ECoG recordings in human patients. Furthermore, this prediction underscores the potential to develop BCI systems with multiple degrees of freedom in human patients using ECoG.
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Affiliation(s)
- David T Bundy
- Department of Biomedical Engineering, Washington University in St. Louis, Campus Box 8057, 660 South Euclid, St Louis, MO 63130, USA
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Ethier C, Miller LE. Brain-controlled muscle stimulation for the restoration of motor function. Neurobiol Dis 2015; 83:180-90. [PMID: 25447224 PMCID: PMC4412757 DOI: 10.1016/j.nbd.2014.10.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Revised: 10/14/2014] [Accepted: 10/20/2014] [Indexed: 12/21/2022] Open
Abstract
Loss of the ability to move, as a consequence of spinal cord injury or neuromuscular disorder, has devastating consequences for the paralyzed individual, and great economic consequences for society. Functional electrical stimulation (FES) offers one means to restore some mobility to these individuals, improving not only their autonomy, but potentially their general health and well-being as well. FES uses electrical stimulation to cause the paralyzed muscles to contract. Existing clinical systems require the stimulation to be preprogrammed, with the patient typically using residual voluntary movement of another body part to trigger and control the patterned stimulation. The rapid development of neural interfacing in the past decade offers the promise of dramatically improved control for these patients, potentially allowing continuous control of FES through signals recorded from motor cortex, as the patient attempts to control the paralyzed body part. While application of these 'brain-machine interfaces' (BMIs) has undergone dramatic development for control of computer cursors and even robotic limbs, their use as an interface for FES has been much more limited. In this review, we consider both FES and BMI technologies and discuss the prospect for combining the two to provide important new options for paralyzed individuals.
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Affiliation(s)
- Christian Ethier
- Department of Physiology, Feinberg School of Medicine, Northwestern University, 303 E. Chicago Ave., Chicago, IL 60611, USA
| | - Lee E Miller
- Department of Physiology, Feinberg School of Medicine, Northwestern University, 303 E. Chicago Ave., Chicago, IL 60611, USA; Department of Biomedical Engineering, Northwestern University, 2145 Sheridan Road Evanston, IL 60208, USA; Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, 345 E. Superior Ave., Chicago, IL 60611, USA.
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Tolstosheeva E, Gordillo-González V, Biefeld V, Kempen L, Mandon S, Kreiter AK, Lang W. A multi-channel, flex-rigid ECoG microelectrode array for visual cortical interfacing. SENSORS 2015; 15:832-54. [PMID: 25569757 PMCID: PMC4327052 DOI: 10.3390/s150100832] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 12/18/2014] [Indexed: 11/16/2022]
Abstract
High-density electrocortical (ECoG) microelectrode arrays are promising signal-acquisition platforms for brain-computer interfaces envisioned, e.g., as high-performance communication solutions for paralyzed persons. We propose a multi-channel microelectrode array capable of recording ECoG field potentials with high spatial resolution. The proposed array is of a 150 mm2 total recording area; it has 124 circular electrodes (100, 300 and 500 µm in diameter) situated on the edges of concentric hexagons (min. 0.8 mm interdistance) and a skull-facing reference electrode (2.5 mm2 surface area). The array is processed as a free-standing device to enable monolithic integration of a rigid interposer, designed for soldering of fine-pitch SMD-connectors on a minimal assembly area. Electrochemical characterization revealed distinct impedance spectral bands for the 100, 300 and 500 µm-type electrodes, and for the array's own reference. Epidural recordings from the primary visual cortex (V1) of an awake Rhesus macaque showed natural electrophysiological signals and clear responses to standard visual stimulation. The ECoG electrodes of larger surface area recorded signals with greater spectral power in the gamma band, while the skull-facing reference electrode provided higher average gamma power spectral density (γPSD) than the common average referencing technique.
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Affiliation(s)
- Elena Tolstosheeva
- Institute for Microsensors, Actuators and Systems (IMSAS), Microsystems Center Bremen (MCB), University of Bremen, Bremen 28359, Germany.
| | - Víctor Gordillo-González
- Institute for Brain Research, Center for Cognitive Sciences, University of Bremen, Bremen 28359, Germany.
| | - Volker Biefeld
- Institute for Microsensors, Actuators and Systems (IMSAS), Microsystems Center Bremen (MCB), University of Bremen, Bremen 28359, Germany.
| | - Ludger Kempen
- Institute for Microsensors, Actuators and Systems (IMSAS), Microsystems Center Bremen (MCB), University of Bremen, Bremen 28359, Germany.
| | - Sunita Mandon
- Institute for Brain Research, Center for Cognitive Sciences, University of Bremen, Bremen 28359, Germany.
| | - Andreas K Kreiter
- Institute for Brain Research, Center for Cognitive Sciences, University of Bremen, Bremen 28359, Germany.
| | - Walter Lang
- Institute for Microsensors, Actuators and Systems (IMSAS), Microsystems Center Bremen (MCB), University of Bremen, Bremen 28359, Germany.
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Martens S, Bensch M, Halder S, Hill J, Nijboer F, Ramos-Murguialday A, Schoelkopf B, Birbaumer N, Gharabaghi A. Epidural electrocorticography for monitoring of arousal in locked-in state. Front Hum Neurosci 2014; 8:861. [PMID: 25374532 PMCID: PMC4204459 DOI: 10.3389/fnhum.2014.00861] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 10/06/2014] [Indexed: 11/13/2022] Open
Abstract
Electroencephalography (EEG) often fails to assess both the level (i.e., arousal) and the content (i.e., awareness) of pathologically altered consciousness in patients without motor responsiveness. This might be related to a decline of awareness, to episodes of low arousal and disturbed sleep patterns, and/or to distorting and attenuating effects of the skull and intermediate tissue on the recorded brain signals. Novel approaches are required to overcome these limitations. We introduced epidural electrocorticography (ECoG) for monitoring of cortical physiology in a late-stage amytrophic lateral sclerosis patient in completely locked-in state (CLIS). Despite long-term application for a period of six months, no implant-related complications occurred. Recordings from the left frontal cortex were sufficient to identify three arousal states. Spectral analysis of the intrinsic oscillatory activity enabled us to extract state-dependent dominant frequencies at <4, ~7 and ~20 Hz, representing sleep-like periods, and phases of low and elevated arousal, respectively. In the absence of other biomarkers, ECoG proved to be a reliable tool for monitoring circadian rhythmicity, i.e., avoiding interference with the patient when he was sleeping and exploiting time windows of responsiveness. Moreover, the effects of interventions addressing the patient's arousal, e.g., amantadine medication, could be evaluated objectively on the basis of physiological markers, even in the absence of behavioral parameters. Epidural ECoG constitutes a feasible trade-off between surgical risk and quality of recorded brain signals to gain information on the patient's present level of arousal. This approach enables us to optimize the timing of interactions and medical interventions, all of which should take place when the patient is in a phase of high arousal. Furthermore, avoiding low-responsiveness periods will facilitate measures to implement alternative communication pathways involving brain-computer interfaces (BCI).
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Affiliation(s)
- Suzanne Martens
- Division of Functional and Restorative Neurosurgery and Division of Translational Neurosurgery, Department of Neurosurgery, Eberhard Karls University TuebingenTuebingen, Germany
- Neuroprosthetics Research Group, Werner Reichardt Center for Integrative Neuroscience, Eberhard Karls University TuebingenTuebingen, Germany
- Department of Empirical Inference, Max Planck Institute for Intelligent SystemsTuebingen, Germany
- Department of Medical Physics, University Medical Center Utrecht, Utrecht UniversityUtrecht, Netherlands
| | - Michael Bensch
- Department of Computer Engineering, Wilhelm-Schickard Institute for Computer Science, Eberhard Karls University TuebingenTuebingen, Germany
| | - Sebastian Halder
- Institute of Medical Psychology and Behavioral Neurobiology, Eberhard Karls University TuebingenTuebingen, Germany
- Institute of Psychology, University of WuerzburgWuerzburg, Germany
| | - Jeremy Hill
- Department of Empirical Inference, Max Planck Institute for Intelligent SystemsTuebingen, Germany
| | - Femke Nijboer
- Research Group Human Media Interaction, Department of Electrical Engineering, Mathematics and Computer Science, University of TwenteEnschede, Netherlands
| | - Ander Ramos-Murguialday
- Institute of Medical Psychology and Behavioral Neurobiology, Eberhard Karls University TuebingenTuebingen, Germany
- Health and Quality of life Unit, Fatronik-TecnaliaSan Sebastian, Spain
| | - Bernhard Schoelkopf
- Department of Empirical Inference, Max Planck Institute for Intelligent SystemsTuebingen, Germany
| | - Niels Birbaumer
- Institute of Medical Psychology and Behavioral Neurobiology, Eberhard Karls University TuebingenTuebingen, Germany
- Istituto di Ricovero e Cura a Carattere Scientifico, IRCCS Ospedale San CamilloVenezia, Italy
| | - Alireza Gharabaghi
- Division of Functional and Restorative Neurosurgery and Division of Translational Neurosurgery, Department of Neurosurgery, Eberhard Karls University TuebingenTuebingen, Germany
- Neuroprosthetics Research Group, Werner Reichardt Center for Integrative Neuroscience, Eberhard Karls University TuebingenTuebingen, Germany
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Mestais CS, Charvet G, Sauter-Starace F, Foerster M, Ratel D, Benabid AL. WIMAGINE: wireless 64-channel ECoG recording implant for long term clinical applications. IEEE Trans Neural Syst Rehabil Eng 2014; 23:10-21. [PMID: 25014960 DOI: 10.1109/tnsre.2014.2333541] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A wireless 64-channel ElectroCorticoGram (ECoG) recording implant named WIMAGINE has been designed for various clinical applications. The device is aimed at interfacing a cortical electrode array to an external computer for neural recording and control applications. This active implantable medical device is able to record neural activity on 64 electrodes with selectable gain and sampling frequency, with less than 1 μV(RMS) input referred noise in the [0.5 Hz - 300 Hz] band. It is powered remotely through an inductive link at 13.56 MHz which provides up to 100 mW. The digitized data is transmitted wirelessly to a custom designed base station connected to a PC. The hermetic housing and the antennae have been designed and optimized to ease the surgery. The design of this implant takes into account all the requirements of a clinical trial, in particular safety, reliability, and compliance with the regulations applicable to class III AIMD. The main features of this WIMAGINE implantable device and its architecture are presented, as well as its functional performances and long-term biocompatibility results.
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Bundy DT, Zellmer E, Gaona CM, Sharma M, Szrama N, Hacker C, Freudenburg ZV, Daitch A, Moran DW, Leuthardt EC. Characterization of the effects of the human dura on macro- and micro-electrocorticographic recordings. J Neural Eng 2014; 11:016006. [DOI: 10.1088/1741-2560/11/1/016006] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Ritaccio A, Brunner P, Crone NE, Gunduz A, Hirsch LJ, Kanwisher N, Litt B, Miller K, Moran D, Parvizi J, Ramsey N, Richner TJ, Tandon N, Williams J, Schalk G. Proceedings of the Fourth International Workshop on Advances in Electrocorticography. Epilepsy Behav 2013; 29:259-68. [PMID: 24034899 PMCID: PMC3896917 DOI: 10.1016/j.yebeh.2013.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 08/10/2013] [Indexed: 10/26/2022]
Abstract
The Fourth International Workshop on Advances in Electrocorticography (ECoG) convened in New Orleans, LA, on October 11-12, 2012. The proceedings of the workshop serves as an accurate record of the most contemporary clinical and experimental work on brain surface recording and represents the insights of a unique multidisciplinary ensemble of expert clinicians and scientists. Presentations covered a broad range of topics, including innovations in passive functional mapping, increased understanding of pathologic high-frequency oscillations, evolving sensor technologies, a human trial of ECoG-driven brain-machine interface, as well as fresh insights into brain electrical stimulation.
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Affiliation(s)
| | - Peter Brunner
- Albany Medical College, Albany, NY, USA, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Nathan E. Crone
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Nancy Kanwisher
- McGovern Institute for Brain Research at MIT, Cambridge, MA, USA
| | - Brian Litt
- University of Pennsylvania, Pittsburgh, PA, USA
| | | | | | | | - Nick Ramsey
- University Medical Center, Utrecht University, Utrecht, The Netherlands
| | | | - Niton Tandon
- University of Texas Health Science Center, Houston, TX, USA
| | | | - Gerwin Schalk
- Albany Medical College, Albany, NY, USA, Wadsworth Center, New York State Department of Health, Albany, NY, USA
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Yazdan-Shahmorad A, Kipke DR, Lehmkuhle MJ. High γ power in ECoG reflects cortical electrical stimulation effects on unit activity in layers V/VI. J Neural Eng 2013; 10:066002. [PMID: 24099908 DOI: 10.1088/1741-2560/10/6/066002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Cortical electrical stimulation (CES) has been used extensively in experimental neuroscience to modulate neuronal or behavioral activity, which has led this technique to be considered in neurorehabilitation. Because the cortex and the surrounding anatomy have irregular geometries as well as inhomogeneous and anisotropic electrical properties, the mechanism by which CES has therapeutic effects is poorly understood. Therapeutic effects of CES can be improved by optimizing the stimulation parameters based on the effects of various stimulation parameters on target brain regions. APPROACH In this study we have compared the effects of CES pulse polarity, frequency, and amplitude on unit activity recorded from rat primary motor cortex with the effects on the corresponding local field potentials (LFP), and electrocorticograms (ECoG). CES was applied at the surface of the cortex and the unit activity and LFPs were recorded using a penetrating electrode array, which was implanted below the stimulation site. ECoGs were recorded from the vicinity of the stimulation site. MAIN RESULTS Time-frequency analysis of LFPs following CES showed correlation of gamma frequencies with unit activity response in all layers. More importantly, high gamma power of ECoG signals only correlated with the unit activity in lower layers (V-VI) following CES. Time-frequency correlations, which were found between LFPs, ECoGs and unit activity, were frequency- and amplitude-dependent. SIGNIFICANCE The signature of the neural activity observed in LFP and ECoG signals provides a better understanding of the effects of stimulation on network activity, representative of large numbers of neurons responding to stimulation. These results demonstrate that the neurorehabilitation and neuroprosthetic applications of CES targeting layered cortex can be further improved by using field potential recordings as surrogates to unit activity aimed at optimizing stimulation efficacy. Likewise, the signatures of unit activity observed as changes in high gamma power in ECoGs suggest that future cortical stimulation studies could rely on less invasive feedback schemes that incorporate surface stimulation with ECoG reporting of stimulation efficacy.
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Charvet G, Foerster M, Chatalic G, Michea A, Porcherot J, Bonnet S, Filipe S, Audebert P, Robinet S, Josselin V, Reverdy J, D'Errico R, Sauter F, Mestais C, Benabid AL. A wireless 64-channel ECoG recording electronic for implantable monitoring and BCI applications: WIMAGINE. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2013; 2012:783-6. [PMID: 23366009 DOI: 10.1109/embc.2012.6346048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A wireless, low power, 64-channel data acquisition system named WIMAGINE has been designed for ElectroCorticoGram (ECoG) recording. This system is based on a custom integrated circuit (ASIC) for amplification and digitization on 64 channels. It allows the RF transmission (in the MICS band) of 32 ECoG recording channels (among 64 channels available) sampled at 1 kHz per channel with a 12-bit resolution. The device is powered wirelessly through an inductive link at 13.56 MHz able to provide 100mW (30mA at 3.3V). This integration is a first step towards an implantable device for brain activity monitoring and Brain-Computer Interface (BCI) applications. The main features of the WIMAGINE platform and its architecture will be presented, as well as its performances and in vivo studies.
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Affiliation(s)
- G Charvet
- CEA/LETI/CLINATEC, MINATEC Campus, Grenoble, France.
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Kelly JW, Degenhart AD, Siewiorek DP, Smailagic A, Wang W. Sparse linear regression with elastic net regularization for brain-computer interfaces. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2013; 2012:4275-8. [PMID: 23366872 DOI: 10.1109/embc.2012.6346911] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This paper demonstrates the feasibility of decoding neuronal population signals using a sparse linear regression model with an elastic net penalty. In offline analysis of real electrocorticographic (ECoG) neural data the elastic net achieved a timepoint decoding accuracy of 95% for classifying hand grasps vs. rest, and 82% for moving a cursor in 1-D space towards a target. These results were superior to those obtained using ℓ(2)-penalized and unpenalized linear regression, and marginally better than ℓ(1)-penalized regression. Elastic net and the ℓ(1)-penalty also produced sparse feature sets, but the elastic net did not eliminate correlated features, which could result in a more stable decoder for brain-computer interfaces.
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Affiliation(s)
- John W Kelly
- Department of Electrical and Computer Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA.
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Ashmore RC, Endler BM, Smalianchuk I, Degenhart AD, Hatsopoulos NG, Tyler-Kabara EC, Batista AP, Wang W. Stable online control of an electrocorticographic brain-computer interface using a static decoder. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2013; 2012:1740-4. [PMID: 23366246 DOI: 10.1109/embc.2012.6346285] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A brain computer interface (BCI) system was implemented by recording electrocorticographic signals (ECoG) from the motor cortex of a Rhesus macaque. These signals were used to control two-dimensional cursor movements in a standard center-out task, utilizing an optimal linear estimation (OLE) method. We examined the time course over which a monkey could acquire accurate control when operating in a co-adaptive training scheme. Accurate and maintained control was achieved after 4-5 days. We then held the decode parameters constant and observed stable control over the next 28 days. We also investigated the underlying neural strategy employed for control, asking whether neural features that were correlated with a given kinematic output (e.g. velocity in a certain direction) were clustered anatomically, and whether the features were coordinated or conflicting in their contributions to the control signal.
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Marathe AR, Taylor DM. Decoding continuous limb movements from high-density epidural electrode arrays using custom spatial filters. J Neural Eng 2013; 10:036015. [PMID: 23611833 DOI: 10.1088/1741-2560/10/3/036015] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Our goal was to identify spatial filtering methods that would improve decoding of continuous arm movements from epidural field potentials as well as demonstrate the use of the epidural signals in a closed-loop brain-machine interface (BMI) system in monkeys. APPROACH Eleven spatial filtering options were compared offline using field potentials collected from 64-channel high-density epidural arrays in monkeys. Arrays were placed over arm/hand motor cortex in which intracortical microelectrodes had previously been implanted and removed leaving focal cortical damage but no lasting motor deficits. Spatial filters tested included: no filtering, common average referencing (CAR), principle component analysis, and eight novel modifications of the common spatial pattern (CSP) algorithm. The spatial filtering method and decoder combination that performed the best offline was then used online where monkeys controlled cursor velocity using continuous wrist position decoded from epidural field potentials in real time. MAIN RESULTS Optimized CSP methods improved continuous wrist position decoding accuracy by 69% over CAR and by 80% compared to no filtering. Kalman decoders performed better than linear regression decoders and benefitted from including more spatially-filtered signals but not from pre-smoothing the calculated power spectra. Conversely, linear regression decoders required fewer spatially-filtered signals and were improved by pre-smoothing the power values. The 'position-to-velocity' transformation used during online control enabled the animals to generate smooth closed-loop movement trajectories using the somewhat limited position information available in the epidural signals. The monkeys' online performance significantly improved across days of closed-loop training. SIGNIFICANCE Most published BMI studies that use electrocorticographic signals to decode continuous limb movements either use no spatial filtering or CAR. This study suggests a substantial improvement in decoding accuracy could be attained by using our new version of the CSP algorithm that extends the traditional CSP method for use with continuous limb movement data.
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Affiliation(s)
- A R Marathe
- Department of Neurosciences, The Cleveland Clinic, Cleveland, OH 44195, USA
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15
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Ajiboye AB, Simeral JD, Donoghue JP, Hochberg LR, Kirsch RF. Prediction of imagined single-joint movements in a person with high-level tetraplegia. IEEE Trans Biomed Eng 2012; 59:2755-65. [PMID: 22851229 DOI: 10.1109/tbme.2012.2209882] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cortical neuroprostheses for movement restoration require developing models for relating neural activity to desired movement. Previous studies have focused on correlating single-unit activities (SUA) in primary motor cortex to volitional arm movements in able-bodied primates. The extent of the cortical information relevant to arm movements remaining in severely paralyzed individuals is largely unknown. We record intracortical signals using a microelectrode array chronically implanted in the precentral gyrus of a person with tetraplegia, and estimate positions of imagined single-joint arm movements. Using visually guided motor imagery, the participant imagined performing eight distinct single-joint arm movements, while SUA, multispike trains (MSP), multiunit activity, and local field potential time (LFPrms), and frequency signals (LFPstft) were recorded. Using linear system identification, imagined joint trajectories were estimated with 20-60% variance explained, with wrist flexion/extension predicted the best and pronation/supination the poorest. Statistically, decoding of MSP and LFPstft yielded estimates that equaled those of SUA. Including multiple signal types in a decoder increased prediction accuracy in all cases. We conclude that signals recorded from a single restricted region of the precentral gyrus in this person with tetraplegia contained useful information regarding the intended movements of upper extremity joints.
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Affiliation(s)
- A Bolu Ajiboye
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA.
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Flint RD, Lindberg EW, Jordan LR, Miller LE, Slutzky MW. Accurate decoding of reaching movements from field potentials in the absence of spikes. J Neural Eng 2012; 9:046006. [PMID: 22733013 DOI: 10.1088/1741-2560/9/4/046006] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The recent explosion of interest in brain-machine interfaces (BMIs) has spurred research into choosing the optimal input signal source for a desired application. The signals with highest bandwidth--single neuron action potentials or spikes--typically are difficult to record for more than a few years after implantation of intracortical electrodes. Fortunately, field potentials recorded within the cortex (local field potentials, LFPs), at its surface (electrocorticograms, ECoG) and at the dural surface (epidural, EFPs) have also been shown to contain significant information about movement. However, the relative performance of these signals has not yet been directly compared. Furthermore, while it is widely postulated, it has not yet been demonstrated that these field potential signals are more durable than spike recordings. The aim of this study was to address both of these questions. We assessed the offline decoding performance of EFPs, LFPs and spikes, recorded sequentially, in primary motor cortex (M1) in terms of their ability to decode the target of reaching movements, as well as the endpoint trajectory. We also examined the decoding performance of LFPs on electrodes that are not recording spikes, compared with the performance when they did record spikes. Spikes were still present on some of the other electrodes throughout this study. We showed that LFPs performed nearly as well as spikes in decoding velocity, and slightly worse in decoding position and in target classification. EFP performance was slightly inferior to that reported for ECoG in humans. We also provided evidence demonstrating that movement-related information in the LFP remains high regardless of the ability to record spikes concurrently on the same electrodes. This is the first study to provide evidence that LFPs retain information about movement in the absence of spikes on the same electrodes. These results suggest that LFPs may indeed remain informative after spike recordings are lost, thereby providing a robust, accurate signal source for BMIs.
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Affiliation(s)
- Robert D Flint
- Department of Neurology, Northwestern University, Chicago, IL 60611, USA
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Bundy DT, Wronkiewicz M, Sharma M, Moran DW, Corbetta M, Leuthardt EC. Using ipsilateral motor signals in the unaffected cerebral hemisphere as a signal platform for brain-computer interfaces in hemiplegic stroke survivors. J Neural Eng 2012; 9:036011. [PMID: 22614631 DOI: 10.1088/1741-2560/9/3/036011] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Brain-computer interface (BCI) systems have emerged as a method to restore function and enhance communication in motor impaired patients. To date, this has been applied primarily to patients who have a compromised motor outflow due to spinal cord dysfunction, but an intact and functioning cerebral cortex. The cortical physiology associated with movement of the contralateral limb has typically been the signal substrate that has been used as a control signal. While this is an ideal control platform in patients with an intact motor cortex, these signals are lost after a hemispheric stroke. Thus, a different control signal is needed that could provide control capability for a patient with a hemiparetic limb. Previous studies have shown that there is a distinct cortical physiology associated with ipsilateral, or same-sided, limb movements. Thus far, it was unknown whether stroke survivors could intentionally and effectively modulate this ipsilateral motor activity from their unaffected hemisphere. Therefore, this study seeks to evaluate whether stroke survivors could effectively utilize ipsilateral motor activity from their unaffected hemisphere to achieve this BCI control. To investigate this possibility, electroencephalographic (EEG) signals were recorded from four chronic hemispheric stroke patients as they performed (or attempted to perform) real and imagined hand tasks using either their affected or unaffected hand. Following performance of the screening task, the ability of patients to utilize a BCI system was investigated during on-line control of a one-dimensional control task. Significant ipsilateral motor signals (associated with movement intentions of the affected hand) in the unaffected hemisphere, which were found to be distinct from rest and contralateral signals, were identified and subsequently used for a simple online BCI control task. We demonstrate here for the first time that EEG signals from the unaffected hemisphere, associated with overt and imagined movements of the affected hand, can enable stroke survivors to control a one-dimensional computer cursor rapidly and accurately. This ipsilateral motor activity enabled users to achieve final target accuracies between 68% and 91% within 15 min. These findings suggest that ipsilateral motor activity from the unaffected hemisphere in stroke survivors could provide a physiological substrate for BCI operation that can be further developed as a long-term assistive device or potentially provide a novel tool for rehabilitation.
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Affiliation(s)
- David T Bundy
- Department of Biomedical Engineering, Washington University in St Louis, Campus Box 8057, 660 South Euclid, St Louis, MO 63130, USA
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Ritaccio A, Boatman-Reich D, Brunner P, Cervenka MC, Cole AJ, Crone N, Duckrow R, Korzeniewska A, Litt B, Miller KJ, Moran DW, Parvizi J, Viventi J, Williams J, Schalk G. Proceedings of the Second International Workshop on Advances in Electrocorticography. Epilepsy Behav 2011; 22:641-50. [PMID: 22036287 PMCID: PMC3847909 DOI: 10.1016/j.yebeh.2011.09.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 09/24/2011] [Indexed: 11/15/2022]
Abstract
The Second International Workshop on Advances in Electrocorticography (ECoG) was convened in San Diego, CA, USA, on November 11-12, 2010. Between this meeting and the inaugural 2009 event, a much clearer picture has been emerging of cortical ECoG physiology and its relationship to local field potentials and single-cell recordings. Innovations in material engineering are advancing the goal of a stable long-term recording interface. Continued evolution of ECoG-driven brain-computer interface technology is determining innovation in neuroprosthetics. Improvements in instrumentation and statistical methodologies continue to elucidate ECoG correlates of normal human function as well as the ictal state. This proceedings document summarizes the current status of this rapidly evolving field.
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Thongpang S, Richner TJ, Brodnick SK, Schendel A, Kim J, Wilson JA, Hippensteel J, Krugner-Higby L, Moran D, Ahmed AS, Neimann D, Sillay K, Williams JC. A micro-electrocorticography platform and deployment strategies for chronic BCI applications. Clin EEG Neurosci 2011; 42:259-65. [PMID: 22208124 PMCID: PMC3653975 DOI: 10.1177/155005941104200412] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over the past decade, electrocorticography (ECoG) has been used for a wide set of clinical and experimental applications. Recently, there have been efforts in the clinic to adapt traditional ECoG arrays to include smaller recording contacts and spacing. These devices, which may be collectively called "micro-ECoG" arrays, are loosely defined as intercranial devices that record brain electrical activity on the sub-millimeter scale. An extensible 3D-platform of thin film flexible micro-scale ECoG arrays appropriate for Brain-Computer Interface (BCI) application, as well as monitoring epileptic activity, is presented. The designs utilize flexible film electrodes to keep the array in place without applying significant pressure to the brain and to enable radial subcranial deployment of multiple electrodes from a single craniotomy. Deployment techniques were tested in non-human primates, and stimulus-evoked activity and spontaneous epileptic activity were recorded. Further tests in BCI and epilepsy applications will make the electrode platform ready for initial human testing.
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Affiliation(s)
- Sanitta Thongpang
- Department of Engineering, University of Wisconsin, Madison, 53706, USA
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20
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Vinjamuri R, Weber DJ, Mao ZH, Collinger JL, Degenhart AD, Kelly JW, Boninger ML, Tyler-Kabara EC, Wang W. Toward synergy-based brain-machine interfaces. ACTA ACUST UNITED AC 2011; 15:726-36. [PMID: 21708506 DOI: 10.1109/titb.2011.2160272] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This paper demonstrates a synergy-based brain-machine interface that uses low-dimensional command signals to control a high dimensional virtual hand. First, temporal postural synergies were extracted from the angular velocities of finger joints of five healthy subjects when they performed hand movements that were similar to activities of daily living. Two synergies inspired from the extracted synergies, namely, two-finger pinch and whole-hand grasp, were used in real-time brain control, where a virtual hand with 10 degrees of freedom was controlled to grasp or pinch virtual objects. These two synergies were controlled by electrocorticographic (ECoG) signals recorded from two electrodes of an electrode array that spanned motor and speech areas of an individual with intractable epilepsy, thus demonstrating closed loop control of a synergy-based brain-machine interface.
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Affiliation(s)
- Ramana Vinjamuri
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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21
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Slutzky MW, Jordan LR, Lindberg EW, Lindsay KE, Miller LE. Decoding the rat forelimb movement direction from epidural and intracortical field potentials. J Neural Eng 2011; 8:036013. [PMID: 21508491 DOI: 10.1088/1741-2560/8/3/036013] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Brain-machine interfaces (BMIs) use signals from the brain to control a device such as a computer cursor. Various types of signals have been used as BMI inputs, from single-unit action potentials to scalp potentials. Recently, intermediate-level signals such as subdural field potentials have also shown promise. These different signal types are likely to provide different amounts of information, but we do not yet know what signal types are necessary to enable a particular BMI function, such as identification of reach target location, control of a two-dimensional cursor or the dynamics of limb movement. Here we evaluated the performance of field potentials, measured either intracortically (local field potentials, LFPs) or epidurally (epidural field potential, EFPs), in terms of the ability to decode reach direction. We trained rats to move a joystick with their forepaw to control the motion of a sipper tube to one of the four targets in two dimensions. We decoded the forelimb reach direction from the field potentials using linear discriminant analysis. We achieved a mean accuracy of 69 ± 3% with EFPs and 57 ± 2% with LFPs, both much better than chance. Signal quality remained good up to 13 months after implantation. This suggests that using epidural signals could provide BMI inputs of high quality with less risk to the patient than using intracortical recordings.
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Affiliation(s)
- Marc W Slutzky
- Department of Neurology, Northwestern University Chicago, IL 60611, USA.
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Schalk G, Leuthardt EC. Brain-Computer Interfaces Using Electrocorticographic Signals. IEEE Rev Biomed Eng 2011; 4:140-54. [DOI: 10.1109/rbme.2011.2172408] [Citation(s) in RCA: 262] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Evolution of brain-computer interface: action potentials, local field potentials and electrocorticograms. Curr Opin Neurobiol 2010; 20:741-5. [PMID: 20952183 DOI: 10.1016/j.conb.2010.09.010] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 09/13/2010] [Accepted: 09/15/2010] [Indexed: 11/23/2022]
Abstract
Brain computer interfaces (BCIs) were originally developed to give severely motor impaired patients a method to communicate and interact with their environment. Initially most BCI systems were based on non-invasive electroencephalographic recordings from the surface of the scalp. To increase control speed, accuracy and complexity, researchers began utilizing invasive recording modalities. BCIs using multi-single unit action potentials have provided elegant multi-dimensional control of both computer cursors and robotic limbs in the last few years. However, long-term stability issues with single-unit arrays has lead researchers to investigate other invasive recording modalities such as high-frequency local field potentials and electrocorticography (ECoG). Although ECoG originally evolved as a replacement for single-unit BCIs, it has come full circle to become an effective tool for studying cortical neurophysiology.
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Slutzky MW, Jordan LR, Krieg T, Chen M, Mogul DJ, Miller LE. Optimal spacing of surface electrode arrays for brain-machine interface applications. J Neural Eng 2010; 7:26004. [PMID: 20197598 DOI: 10.1088/1741-2560/7/2/026004] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Brain-machine interfaces (BMIs) use signals recorded directly from the brain to control an external device, such as a computer cursor or a prosthetic limb. These control signals have been recorded from different levels of the brain, from field potentials at the scalp or cortical surface to single neuron action potentials. At present, the more invasive recordings have better signal quality, but also lower stability over time. Recently, subdural field potentials have been proposed as a stable, good quality source of control signals, with the potential for higher spatial and temporal bandwidth than EEG. Here we used finite element modeling in rats and humans and spatial spectral analysis in rats to compare the spatial resolution of signals recorded epidurally (outside the dura), with those recorded from subdural and scalp locations. Resolution of epidural and subdural signals was very similar in rats and somewhat less so in human models. Both were substantially better than signals recorded at the scalp. Resolution of epidural and subdural signals in humans was much more similar when the cerebrospinal fluid layer thickness was reduced. This suggests that the less invasive epidural recordings may yield signals of similar quality to subdural recordings, and hence may be more attractive as a source of control signals for BMIs.
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Affiliation(s)
- Marc W Slutzky
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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Leuthardt EC, Schalk G, Roland J, Rouse A, Moran DW. Evolution of brain-computer interfaces: going beyond classic motor physiology. Neurosurg Focus 2009; 27:E4. [PMID: 19569892 PMCID: PMC2920041 DOI: 10.3171/2009.4.focus0979] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The notion that a computer can decode brain signals to infer the intentions of a human and then enact those intentions directly through a machine is becoming a realistic technical possibility. These types of devices are known as brain-computer interfaces (BCIs). The evolution of these neuroprosthetic technologies could have significant implications for patients with motor disabilities by enhancing their ability to interact and communicate with their environment. The cortical physiology most investigated and used for device control has been brain signals from the primary motor cortex. To date, this classic motor physiology has been an effective substrate for demonstrating the potential efficacy of BCI-based control. However, emerging research now stands to further enhance our understanding of the cortical physiology underpinning human intent and provide further signals for more complex brain-derived control. In this review, the authors report the current status of BCIs and detail the emerging research trends that stand to augment clinical applications in the future.
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Affiliation(s)
- Eric C Leuthardt
- Department of Biomedical Engineering, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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