Localization of sensorimotor cortex: the influence of Sherrington and Cushing on the modern concept

Multisensory integration processing during olfactory-visual stimulation-An fMRI graph theoretical network analysis

In this study, we aimed to understand how whole-brain neural networks compute sensory information integration based on the olfactory and visual system. Task-related functional magnetic resonance imaging (fMRI) data was obtained during unimodal and bimodal sensory stimulation. Based on the identification of multisensory integration processing (MIP) specific hub-like network nodes analyzed with network-based statistics using region-of-interest based connectivity matrices, we conclude the following brain areas to be important for processing the presented bimodal sensory information: right precuneus connected contralaterally to the supramarginal gyrus for memory-related imagery and phonology retrieval, and the left middle occipital gyrus connected ipsilaterally to the inferior frontal gyrus via the inferior fronto-occipital fasciculus including functional aspects of working memory. Applied graph theory for quantification of the resulting complex network topologies indicates a significantly increased global efficiency and clustering coefficient in networks including aspects of MIP reflecting a simultaneous better integration and segregation. Graph theoretical analysis of positive and negative network correlations allowing for inferences about excitatory and inhibitory network architectures revealed-not significant, but very consistent-that MIP-specific neural networks are dominated by inhibitory relationships between brain regions involved in stimulus processing.

Intracortical Microstimulation Maps of Motor, Somatosensory, and Posterior Parietal Cortex in Tree Shrews (Tupaia belangeri) Reveal Complex Movement Representations

Long-train intracortical microstimulation (LT-ICMS) is a popular method for studying the organization of motor and posterior parietal cortex (PPC) in mammals. In primates, LT-ICMS evokes both multijoint and multiple-body-part movements in primary motor, premotor, and PPC. In rodents, LT-ICMS evokes complex movements of a single limb in motor cortex. Unfortunately, very little is known about motor/PPC organization in other mammals. Tree shrews are closely related to both primates and rodents and could provide insights into the evolution of complex movement domains in primates. The present study investigated the extent of cortex in which movements could be evoked with ICMS and the characteristics of movements elicited using both short train (ST) and LT-ICMS in tree shrews. We demonstrate that LT-ICMS and ST-ICMS maps are similar, with the movements elicited with ST-ICMS being truncated versions of those elicited with LT-ICMS. In addition, LT-ICMS-evoked complex movements within motor cortex similar to those in rodents. More complex movements involving multiple body parts such as the hand and mouth were also elicited in motor cortex and PPC, as in primates. Our results suggest that complex movement networks present in PPC and motor cortex were present in mammals prior to the emergence of primates.

From the idea to its realization: the evolution of minimally invasive techniques in neurosurgery

Minimally invasive techniques in neurosurgery evolved in two steps. Many minimally invasive concepts like neuronavigation, endoscopy, or frame based stereotaxy were developed by the pioneers of neurosurgery, but it took decades till further technical developments made the realization and broad clinical application of these early ideas safe and possible. This thesis will be demonstrated by giving examples of the evolution of four minimally invasive techiques: neuronavigation, transsphenoidal pituitary surgery, neuroendoscopy and stereotaxy. The reasons for their early failure and also the crucial steps for the rediscovery of these minimally invasive techniques will be analysed. In the 80th of the 20th century endoscopy became increasingly applied in different surgical fields. The abdominal surgeons coined as first for their endoscopic procedures the term minimally invasive surgery in contrast to open surgery. In neurrosurgery the term minimally invasive surgery stood not in opposiotion to open procedures but was understood as a general concept and philosophy using the modern technology such as neuronavigation, endoscopy and planing computer workstations with the aim to make the procedures less traumatic.

Lower motor neuron findings after upper motor neuron injury: insights from postoperative supplementary motor area syndrome

Hypertonia and hyperreflexia are classically described responses to upper motor neuron injury. However, acute hypotonia and areflexia with motor deficit are hallmark findings after many central nervous system insults such as acute stroke and spinal shock. Historic theories to explain these contradictory findings have implicated a number of potential mechanisms mostly relying on the loss of descending corticospinal input as the underlying etiology. Unfortunately, these simple descriptions consistently fail to adequately explain the pathophysiology and connectivity leading to acute hyporeflexia and delayed hyperreflexia that result from such insult. This article highlights the common observation of acute hyporeflexia after central nervous system insults and explores the underlying anatomy and physiology. Further, evidence for the underlying connectivity is presented and implicates the dominant role of supraspinal inhibitory influence originating in the supplementary motor area descending through the corticospinal tracts. Unlike traditional explanations, this theory more adequately explains the findings of postoperative supplementary motor area syndrome in which hyporeflexia motor deficit is observed acutely in the face of intact primary motor cortex connections to the spinal cord. Further, the proposed connectivity can be generalized to help explain other insults including stroke, atonic seizures, and spinal shock.

The discovery of the pyramidal neurons: Vladimir Betz and a new era of neuroscience

As a consequence of nascent technology, the 19th century witnessed a profound change in orientation to the nervous system. For example, improved microscopy in the first half of the 19th century allowed high magnification without blurring. The subsequent observation of nucleated cells led to the identification of individual brain cells. Philosophical changes in approach to the natural sciences took their lead from those applied to physical observations. The Ukrainian anatomist and histologist, Vladimir Alekseyevich Betz (1834-94) played a pivotal role in reshaping scientific and philosophical approaches to the brain, connecting cerebral localization, function and brain microstructure. Betz revolutionized methods of cell fixation and staining. Sometimes his efforts yielded enormously complicated technological improvements. Betz's greatest contribution, however, was connecting his discovery of the function of giant pyramidal neurons of the primary motor cortex ('cells of Betz') with the cortical organization. Considering cortical cytoarchitectonics in relation with physiological function, Betz recognized this organization in two areas: motor and sensory. He defined a functional area on histological grounds and thereby opened the way to study precise cortical areas. Betz participated in the scientific transformation of cytoarchitectonics based on macro- and microscopic studies of the cortical surface, enabling him to view the paths of nerve cells in the brain. Betz's influence allowed systemization of scattered scientific findings. The discovery of pyramidal cells was a turning point in the prevailing philosophical and scientific approach to the brain, linking cytoarchitecture, neurophysiology and cerebral localization.

Harvey Cushing's contributions to motor mapping: 1902-1912

This review examined Dr. Harvey Cushing's cases in the surgical records of Johns Hopkins Hospital, from 1896 to 1912. 41 patients who underwent cortical stimulation for intra-operative motor mapping were selected for further analysis. We demonstrate that Cushing used cortical stimulation to define primary motor and sensory cortices in the treatment of tumors, trauma, and epilepsy, within adult and pediatric populations. In addition, he performed stimulation of sub-cortical white matter during 4 of these surgeries, setting the stage for contemporary use of this technique in improving post-operative outcomes. This review of Cushing's early intra-operative motor mapping illuminates his contributions, and clarifies his influence on the evolution of cortical mapping from an experimental technique to a staple of contemporary neurosurgery.

Transformations in oscillatory activity and evoked responses in primary somatosensory cortex in middle age: a combined computational neural modeling and MEG study

Oscillatory brain rhythms and evoked responses are widely believed to impact cognition, but relatively little is known about how these measures are affected by healthy aging. The present study used MEG to examine age-related changes in spontaneous oscillations and tactile evoked responses in primary somatosensory cortex (SI) in healthy young (YA) and middle-aged (MA) adults. To make specific predictions about neurophysiological changes that mediate age-related MEG changes, we applied a biophysically realistic model of SI that accurately reproduces SI MEG mu rhythms, containing alpha (7-14 Hz) and beta (15-30 Hz) components, and evoked responses. Analyses of MEG data revealed a significant increase in prestimulus mu power in SI, driven predominately by greater mu-beta dominance, and a larger and delayed M70 peak in the SI evoked response in MA. Previous analysis with our computational model showed that the SI mu rhythm could be reproduced with a stochastic sequence of rhythmic approximately 10 Hz feedforward (FF) input to the granular layers of SI (representative of lemniscal thalamic input) followed nearly simultaneously by approximately 10 Hz feedback (FB) input to the supragranular layers (representative of input from high order cortical or non-specific thalamic sources) (Jones et al., 2009). In the present study, the model further predicted that the rhythmic FF and FB inputs become stronger with age. Further, the FB input is predicted to arrive more synchronously to SI on each cycle of the 10 Hz input in MA. The simulated neurophysiological changes are sufficient to account for the age-related differences in both prestimulus mu rhythms and evoked responses. Thus, the model predicts that a single set of neurophysiological changes intimately links these age-related changes in neural dynamics.

Quantitative analysis and biophysically realistic neural modeling of the MEG mu rhythm: rhythmogenesis and modulation of sensory-evoked responses

Variations in cortical oscillations in the alpha (7-14 Hz) and beta (15-29 Hz) range have been correlated with attention, working memory, and stimulus detection. The mu rhythm recorded with magnetoencephalography (MEG) is a prominent oscillation generated by Rolandic cortex containing alpha and beta bands. Despite its prominence, the neural mechanisms regulating mu are unknown. We characterized the ongoing MEG mu rhythm from a localized source in the finger representation of primary somatosensory (SI) cortex. Subjects showed variation in the relative expression of mu-alpha or mu-beta, which were nonoverlapping for roughly 50% of their respective durations on single trials. To delineate the origins of this rhythm, a biophysically principled computational neural model of SI was developed, with distinct laminae, inhibitory and excitatory neurons, and feedforward (FF, representative of lemniscal thalamic drive) and feedback (FB, representative of higher-order cortical drive or input from nonlemniscal thalamic nuclei) inputs defined by the laminar location of their postsynaptic effects. The mu-alpha component was accurately modeled by rhythmic FF input at approximately 10-Hz. The mu-beta component was accurately modeled by the addition of approximately 10-Hz FB input that was nearly synchronous with the FF input. The relative dominance of these two frequencies depended on the delay between FF and FB drives, their relative input strengths, and stochastic changes in these variables. The model also reproduced key features of the impact of high prestimulus mu power on peaks in SI-evoked activity. For stimuli presented during high mu power, the model predicted enhancement in an initial evoked peak and decreased subsequent deflections. In agreement, the MEG-evoked responses showed an enhanced initial peak and a trend to smaller subsequent peaks. These data provide new information on the dynamics of the mu rhythm in humans and the model provides a novel mechanistic interpretation of this rhythm and its functional significance.

Osler vindicated: glioma of the leg center with Jacksonian epilepsy; removal and cure, with a 50-year follow-up. Historical vignette

On December 14, 1883, William Osler, then pathologist at the Montreal General Hospital, presented the specimen of a brain with an almond-sized glioma beneath the right motor cortex to the Montreal Medico-Chirurgical Society. The brain specimen was from a young woman who had suffered from intermittent Jacksonian seizures for 14 years and had eventually died in status epilepticus. Aware of the pioneering removal of a tumor from the cortex reported on in 1885 by Bennett and Godlee, Osler wrote of his case, "this was an instance in which operation would have been justifiable and possibly have been the means of saving life." In 1953, a young man with Jacksonian attacks that began in his foot underwent removal of a Grade I glioma from the central fissure. The operation was performed in an awake craniotomy during which cortical mapping was used to define the motor and sensory cortices. Treatment with focal radiation followed, and afterward the patient became seizure-free, stopped taking anticonvulsant medication, and has led an active life over the past 50 years. Reference is made to the experiences of Sherrington, Cushing, and Penfield with cortical stimulation in the awake patient under regional anesthesia as an effective aid to surgery for epileptogenic lesions, tumors, and vascular malformations. Their technique allows for maximal resection with minimal neurological deficits. Over the past 20 years, this approach has been adopted effectively in many neurosurgical centers.

Short-term variations in response distribution to cortical stimulation

Patterns of responses in the cerebral cortex can vary, and are influenced by pre-existing cortical function, but it is not known how rapidly these variations can occur in humans. We investigated how rapidly response patterns to electrical stimulation can vary in intact human brain. We also investigated whether the type of functional change occurring at a given location with stimulation would help predict the distribution of responses elsewhere over the cortex to stimulation at that given location. We did this by studying cortical afterdischarges following electrical stimulation of the cortex in awake humans undergoing evaluations for brain surgery. Response occurrence and location could change within seconds, both nearby to and distant from stimulation sites. Responses might occur at a given location during one trial but not the next. They could occur at electrodes adjacent or not adjacent to those directly stimulated or to other electrodes showing afterdischarges. The likelihood of an afterdischarge at an individual site after stimulation was predicted by spontaneous electroencephalographic activity at that specific site just prior to stimulation, but not by overall cortical activity. When stimulation at a site interrupted motor, sensory or language function, afterdischarges were more likely to occur at other sites where stimulation interrupted similar functions. These results show that widespread dynamic changes in cortical responses can occur in intact cortex within short periods of time, and that the distribution of these responses depends on local brain states and functional brain architecture at the time of stimulation. Similar rapid variations may occur during normal intracortical communication and may underlie changes in the cortical organization of function. Possibly these variations, and the occurrence and distribution of responses to cortical stimulation, could be predicted. If so, interventions such as stimulation might be used to alter spread of epileptogenic activity, accelerate learning or enhance cortical reorganization after brain injury.

Update on epilepsy and cerebral localization

The field of epilepsy has contributed significantly to localization of neurologic function, particularly in the neocortex. Methodologies such as cortical stimulation, positron emission tomography, functional MRI, trans-cranial magnetic stimulation, surgical resection, and magnetoencephalography have been used successfully in patients with epilepsy to locate specific functions, primarily for the purpose of defining eloquent cortex before surgical resections. The left hemisphere serves language-related functions and verbal memory in most people, whereas the right hemisphere serves some language function in addition to perceiving most components of music and other forms of nonverbal material. Both hemispheres cooperate in understanding spatial relationships. Studies in patients with developmental abnormalities have enriched our understanding of localization of function within the cortex. Future studies may help us understand the sequence in which specific regions are activated during specific tasks and determine which regions are necessary for tasks and which are supplementary. The ability to predict preoperatively the effect of removal of specific tissues would benefit surgical planning for all patients who undergo cortical resections, including those with epilepsy.

Neural correlates of tactile detection: a combined magnetoencephalography and biophysically based computational modeling study

Previous reports conflict as to the role of primary somatosensory neocortex (SI) in tactile detection. We addressed this question in normal human subjects using whole-head magnetoencephalography (MEG) recording. We found that the evoked signal (0-175 ms) showed a prominent equivalent current dipole that localized to the anterior bank of the postcentral gyrus, area 3b of SI. The magnitude and timing of peaks in the SI waveform were stimulus amplitude dependent and predicted perception beginning at approximately 70 ms after stimulus. To make a direct and principled connection between the SI waveform and underlying neural dynamics, we developed a biophysically realistic computational SI model that contained excitatory and inhibitory neurons in supragranular and infragranular layers. The SI evoked response was successfully reproduced from the intracellular currents in pyramidal neurons driven by a sequence of lamina-specific excitatory input, consisting of output from the granular layer (approximately 25 ms), exogenous input to the supragranular layers (approximately 70 ms), and a second wave of granular output (approximately 135 ms). The model also predicted that SI correlates of perception reflect stronger and shorter-latency supragranular and late granular drive during perceived trials. These findings strongly support the view that signatures of tactile detection are present in human SI and are mediated by local neural dynamics induced by lamina-specific synaptic drive. Furthermore, our model provides a biophysically realistic solution to the MEG signal and can predict the electrophysiological correlates of human perception.

Optimizing parameters for terminating cortical afterdischarges with pulse stimulation

PURPOSE

We previously reported that brief pulses of electrical stimulation (BPSs) can terminate afterdischarges (ADs) during cortical stimulation. We investigated conditions under which BPS is more likely to suppress ADs.

METHODS

We analyzed parameters altering BPS effectiveness on 200 ADs in seven patients with implanted subdural electrodes.

RESULTS

The odds of BPSs stopping ADs was 8.6 times greater at primary sites (directly stimulated electrodes) than at secondary sites (adjacent electrodes) (p = 0.016). BPS applied within 4.5 s after onset of AD had 2 times greater odds of stopping ADs (p = 0.014). BPS applied when AD voltage was negative was 1.9 times more likely to stop ADs (p = 0.012). ADs with rhythmic pattern responded best (p < 0.0001). BPS stopped 100% of ADs not starting immediately after localization stimulus (LS) versus 29% of those starting immediately (p < 0.0001).

CONCLUSIONS

BPS is more likely to terminate ADs at primary electrodes, if given early, if applied to the negative peak of the AD waveform, if AD has a rhythmic pattern, and if AD did not start immediately after LS.

Localisation of the sensorimotor cortex during surgery for brain tumours: feasibility and waveform patterns of somatosensory evoked potentials

OBJECTIVE

Intraoperative localisation of the sensorimotor cortex using the phase reversal of somatosensory evoked potentials (SEPs) is an essential tool for surgery in and around the perirolandic gyri, but unsuccessful and perplexing results have been reported. This study examines the effect of tumour masses on the waveform characteristics and feasibility of SEP compared with functional neuronavigation and electrical motor cortex mapping.

METHODS

In 230 patients with tumours of the sensorimotor region the SEP phase reversal of N20-P20 was recorded from the exposed cortex using a subdural grid or strip electrode. In one subgroup of 80 patients functional neuronavigation was performed with motor and sensory magnetic source imaging and in one subgroup of 40 patients the motor cortex hand area was localised by electrical stimulation mapping.

RESULTS

The intraoperative SEP method was successful in 92% of all patients, it could be shown that the success rate rather depended on the location of the lesion than on preoperative neurological deficits. In 13% of the patients with postcentral tumours no N20-P20 phase reversal was recorded but characteristic polyphasic and high amplitude waves at 25 ms and later made the identification of the postcentral gyrus possible nevertheless. Electrical mapping of the motor cortex took up to 30 minutes until a clear result was obtained. It was successful in 37 patients, but failed in three patients with precentral and central lesions. Functional neuronavigation indicating the tumour margins and the motor and sensory evoked fields was possible in all patients.

CONCLUSION

The SEP phase reversal of N20-P20 is a simple and reliable technique, but the success rate is much lower in large central and postcentral tumours. With the use of polyphasic late waveforms the sensorimotor cortex may be localised. By contrast with motor electrical mapping it is less time consuming. Functional neuronavigation is a desirable tool for both preoperative surgical planning and intraoperative use during surgery on perirolandic tumours, but compensation for brain shift, accuracy, and cost effectiveness are still a matter for discussion.

Space-occupying lesions of the sensori-motor region

Successful surgery of the sensori-motor region requires precise pre- and intraoperative localization of the sensori-motor region and pyramidal tract. Important aids are the landmarks of cranio-cerebral topography, coronal suture and bregma and the sulcal anatomy of the sensori-motor region, which can be identified in CT or MR images. Due to considerable displacement and distortion of the anatomical structures, elicited by mass lesions, these aids often fail to render reliable support. In this situation, identification of the motor area can be achieved by electrical stimulation of the precentral gyrus in association with the recording of somatosensory evoked potentials of the pre- and postcentral gyrus. The localisation of the "motor mosaics" in relation to the lesion, enable determination of the direction of displacement of the motor strip and the fan of the pyramidal tract. Based on this information the most appropriate route of access to the lesion is selected, either transcortical or transsulcal. Lesion-specific operative techniques as well as location-specific approaches are discussed. With consequent application of these principles the risk of a new persistent motor deficit was as low as 4%. Thus, the indication for surgery in this area can now be set with greater confidence and far more generously than in the past.