Presurgical localization of functional cortex using magnetic source imaging

Invasive versus non-invasive mapping of the motor cortex

Precise and comprehensive mapping of somatotopic representations in the motor cortex is clinically essential to achieve maximum resection of brain tumours whilst preserving motor function, especially since the current gold standard, that is, intraoperative direct cortical stimulation (DCS), holds limitations linked to the intraoperative setting such as time constraints or anatomical restrictions. Non‐invasive techniques are increasingly relevant with regard to pre‐operative risk‐assessment. Here, we assessed the congruency of neuronavigated transcranial magnetic stimulation (nTMS) and functional magnetic resonance imaging (fMRI) with DCS. The motor representations of the hand, the foot and the tongue regions of 36 patients with intracranial tumours were mapped pre‐operatively using nTMS and fMRI and by intraoperative DCS. Euclidean distances (ED) between hotspots/centres of gravity and (relative) overlaps of the maps were compared. We found significantly smaller EDs (11.4 ± 8.3 vs. 16.8 ± 7.0 mm) and better spatial overlaps (64 ± 38% vs. 37 ± 37%) between DCS and nTMS compared with DCS and fMRI. In contrast to DCS, fMRI and nTMS mappings were feasible for all regions and patients without complications. In summary, nTMS seems to be the more promising non‐invasive motor cortex mapping technique to approximate the gold standard DCS results.

Comparison of three-shell and simplified volume conductor models in magnetoencephalography

Experimental MEG source imaging studies have typically been carried out with either a spherically symmetric head model or a single-shell boundary-element (BEM) model that is shaped according to the inner skull surface. The concepts and comparisons behind these simplified models have led to misunderstandings regarding the role of skull and scalp in MEG. In this work, we assess the forward-model errors due to different skull/scalp approximations and due to differences and errors in model geometries. We built five anatomical models of a volunteer using a set of T1-weighted MR scans and three common toolboxes. Three of the models represented typical models in experimental MEG, one was manually constructed, and one contained a major segmentation error at the skull base. For these anatomical models, we built forward models using four simplified approaches and a three-shell BEM approach that has been used as reference in previous studies. Our reference model contained in addition the skull fine-structure (spongy bone). We computed signal topographies for cortically constrained sources in the left hemisphere and compared the topographies using relative error and correlation metrics. The results show that the spongy bone has a minimal effect on MEG topographies, and thus the skull approximation of the three-shell model is justified. The three-shell model performed best, followed by the corrected-sphere and single-shell models, whereas the local-spheres and single-sphere models were clearly worse. The three-shell model was the most robust against the introduced segmentation error. In contrast to earlier claims, there was no noteworthy difference in the computation times between the realistically-shaped and sphere-based models, and the manual effort of building a three-shell model and a simplified model is comparable. We thus recommend the realistically-shaped three-shell model for experimental MEG work. In cases where this is not possible, we recommend a realistically-shaped corrected-sphere or single-shell model.

Decreased inhibitory neuronal activity in patients with frontal lobe brain tumors with seizure presentation: Preliminary study using magnetoencephalography

BACKGROUND

Although 30-50 % of patients with brain tumors experience epileptic seizure as the presenting clinical symptom, and another 10-30 % are at risk for developing epilepsy in the later stages of the disease, the mechanisms of tumor-related epileptogenesis are poorly understood. We used magnetoencephalography (MEG) to investigate sensory evoked fields (SEFs) in patients with frontal lobe brain tumors as a means of evaluating the neuronal activity of peri-tumoral cortex.

METHODS

Twelve patients with frontal lobe brain tumors underwent MEG. We calculated the equivalent current dipole strength of two components of the primary sensory cortical response (N20m and P35m) and compared the P35m/N20m ratio in the tumor hemisphere vs. the normal hemisphere. There were two subsets of patients: group I, in which P35m/N20m was higher in the tumor hemisphere (n= 7), and group II, in which P35m/N20m was higher in the normal hemisphere (n=5). We looked for associations between clinical factors and P35m/N20m within each group.

RESULTS

All patients with seizure presentation were in group I, whereas only two patients without seizure presentation were in group I (Fisher exact test, p=0.028). No other clinical factors were related to P35m/N20m. The mean ratio of P35m/N20m equivalent current dipole strength in patients with seizure presentation was 4.07 ± 2.38 in the tumor hemisphere and 2.00 ± 0.55 in the normal hemisphere. This difference was statistically significant (Mann-Whitney test, p=0.030).

CONCLUSION

The paradoxical increase in P35m/N20m in patients with seizure presentation suggests that decreased inhibitory neuronal activity is a potential cause of tumorrelated epilepsy.

Slow brain activity (ISA/DC) detected by MEG

Infraslow activity (ISA), direct coupled (DC), and direct current (DC) are the terms used to describe brain activity that occurs in frequencies below 0.1 Hz. Infraslow activity amplitude increase is also associated with epilepsy, traumatic brain injuries, strokes, tumors, and migraines and has been studied since the early 90s at the Henry Ford Hospital MEG Laboratory. We have used a DC-based magnetoencephalography (MEG) system to validate and characterize the ISA from animal models of cortical spreading depression thought to be the underlying mechanism of migraine and other cortical spreading depression-like events seen during ischemia, anoxia, and epilepsy. Magnetoencephalography characterizes these slow shifts easier than electroencephalography because there is no attenuation of these signals by the skull. In the current study, we report on ISA MEG signals of 12 patients with epilepsy in the preictal and postictal states. In the minutes just before the onset of a seizure, large-amplitude ISA MEG waveforms were detected, signaling the onset of the seizure. It is suggested that MEG assessment of ISA, in addition to activity in the conventional frequency band, can at times be useful in the lateralization of epileptic seizures.

Concordance of MEG and fMRI patterns in adolescents during verb generation

In this study we focused on direct comparison between the spatial distributions of activation detected by functional magnetic resonance imaging (fMRI) and localization of sources detected by magnetoencephalography (MEG) during identical language tasks. We examined the spatial concordance between MEG and fMRI results in 16 adolescents performing a three-phase verb generation task that involves repeating the auditorily presented concrete noun and generating verbs either overtly or covertly in response to the auditorily presented noun. MEG analysis was completed using a synthetic aperture magnetometry (SAM) technique, while the fMRI data were analyzed using the general linear model approach with random-effects. To quantify the agreement between the two modalities, we implemented voxel-wise concordance correlation coefficient (CCC) and identified the left inferior frontal gyrus and the bilateral motor cortex with high CCC values. At the group level, MEG and fMRI data showed spatial convergence in the left inferior frontal gyrus for covert or overt generation versus overt repetition, and the bilateral motor cortex when overt generation versus covert generation. These findings demonstrate the utility of the CCC as a quantitative measure of spatial convergence between two neuroimaging techniques.

Comparison of three methods for localizing interictal epileptiform discharges with magnetoencephalography

PURPOSE

To compare three methods of localizing the source of epileptiform activity recorded with magnetoencephalography: equivalent current dipole, minimum current estimate, and dynamic statistical parametric mapping (dSPM), and to evaluate the solutions by comparison with clinical symptoms and other electrophysiological and neuroradiological findings.

METHODS

Fourteen children of 3 to 15 years were studied. Magnetoencephalography was collected with a whole-head 204-channel helmet-shaped sensor array. We calculated equivalent current dipoles and made minimum current estimate and dSPM movies to estimate the cortical distribution of interictal epileptiform discharges in these patients.

RESULTS

The results for four patients with localization-related epilepsy and one patient with Landau-Kleffner Syndrome were consistent among all the three analysis methods. In the rest of the patients, minimum current estimate and dSPM suggested multifocal or widespread activity; in these patients, the equivalent current dipole results were so scattered that interpretation of the results was not possible. For 9 patients with localization-related epilepsy and generalized epilepsy, the epileptiform discharges were wide spread or only slow waves, but dSPM suggested a possible propagation path of the interictal epileptiform discharges.

CONCLUSION

Minimum current estimate and dSPM could identify the propagation of epileptiform activity with high temporal resolution. The results of dSPM were more stable because the solutions were less sensitive to background brain activity.

Localisation of the central sulcus region in glioma patients with three-dimensional fluid-attenuated inversion recovery and volume rendering: comparison with functional and conventional magnetic resonance

PURPOSE

Volume rendering (VR) of three-dimensional (3D) fluid-attenuated inversion recovery (FLAIR) magnetic resonance (MR) images shows regional intensity differences, reflecting the central sulcus (CS) region and occipital cortex. The purpose of this study was to determine whether 3D FLAIR with VR could be used as an alternative method to localise the CS region in comparison with functional and conventional MR-imaging in patients with perirolandic glioma.

METHODS

Eleven patients with intracranial gliomas were studied with single-slab 3D FLAIR including VR and conventional T1-weighted imaging. In all patients, preoperative functional magnetic resonance imaging (fMRI) was performed with a motor paradigm of the hand. The hypo-intense central gyri on 3D FLAIR with VR were interpreted as the CS area. Localisation of the motor hand knob on anatomical images and fMRI results were used for identification of the primary motor cortex.

RESULTS

Anatomical localisation of the motor hand knob on T1-weighted images was possible in 91% of both hemispheres. In 73% of the affected hemispheres (AH) and 91% of the unaffected hemispheres (UH) the hand knob and CS region could be identified on 3D FLAIR axial and VR images, respectively. With one exception, fMRI activation confirmed the CS region as observed with 3D FLAIR with VR.

CONCLUSIONS

Volume rendering of 3D FLAIR MR images shows central hypo-intensities frequently corresponding with the CS region. Two-dimensional localisation of the CS region on conventional T1-weighted images and fMRI seems favourable compared to 3D FLAIR. However, in selected cases, especially where fMRI is not possible or feasible, volume rendering with 3D FLAIR may enhance the 3D visualisation of gliomas in relation to the CS region which can be used as an alternative method in the presurgical structural and functional evaluation of neurosurgical patients.

Image guidance and neuromonitoring in neurosurgery

INTRODUCTION

The localization of tumors and epileptogenic foci within the somatosensory or language cortex of the brain of a child poses unique neurosurgical challenges. In the past, lesions in these regions were not treated aggressively for fear of inducing neurological deficits. As a result, while function may have been preserved, the underlying disease may not have been optimally treated, and repeat neurosurgical procedures were frequently required. Today, with the advent of preoperative brain mapping, image guidance or neuronavigation, and intraoperative monitoring, peri-Rolandic and language cortex lesions can be approached directly and definitively with a high degree of confidence that neurosurgical function will be maintained.

METHODS AND RESULTS

The preoperative brain maps can now be achieved with magnetic resonance imaging (MRI), functional MRI, magnetoencephalography, and diffusion tensor imaging. Image guidance systems have improved significantly and include the use of the intraoperative MRI. Somatosensory, motor, and brainstem auditory-evoked potentials are used as standard neuromonitoring techniques in many centers around the world. Added to this now is the use of continuous train-of-five monitoring of the integrity of the corticospinal tract while operating in the peri-Rolandic region.

CONCLUSION

We are in an era where continued advancements can be expected in mapping additional pathways such as visual, memory, and hearing pathways. With these new advances, neurosurgeons can expect to significantly improve their surgical outcomes further.

The role of magnetoencephalography in epilepsy surgery

Epilepsy surgery requires the precise localization of the epileptogenic zone and the anatomical localization of eloquent cortex so that these areas can be preserved during cortical resection. Magnetoencephalography (MEG) is a technique that maps interictal magnetic dipole sources onto MR imaging to produce a magnetic source image. Magneto-encephalographic spike sources can be used to localize the epileptogenic zone and be part of the workup of the patient for epilepsy surgery in conjunction with data derived from an analysis of seizure semiology, scalp video electroencephalography, PET, functional MR imaging, and neuropsychological testing. In addition, magnetoencephalographic spike sources can be linked to neuronavigation platforms for use in the neurosurgical field. Finally, paradigms have been developed so that MEG can be used to identify functional areas of the cerebral cortex including the somatosensory, motor, language, and visual evoked fields.

The authors review the basic principles of MEG and the utility of MEG for presurgical planning as well as intra-operative mapping and discuss future applications of MEG technology.

Utility of neuronavigation and neuromonitoring in epilepsy surgery

The management of medically refractory epilepsy poses both a valuable therapeutic opportunity and a formidable technical challenge to epilepsy surgeons. Recent decades have produced significant advancements in the capabilities and availability of adjunctive tools in epilepsy surgery. In particular, image-based neuronavigation and electrophysiological neuromonitoring represent versatile and informative modalities that can assist a surgeon in performing safe and effective resections. In the present article the authors discuss these 2 subjects with reference to how they can be applied and what evidence supports their use. As technologies evolve with demonstrated and potential utility, it is important for all clinicians who deal with epilepsy to understand where neuronavigation and neuromonitoring stand in the present and what avenues for improvement exist for the future.

Preoperative localization of hand motor cortex by adaptive spatial filtering of magnetoencephalography data

Object

The goal of this study was to examine the sensitivity and specificity in preoperative localization of hand motor cortex by imaging regional event-related desynchronization (ERD) of brainwaves in the β frequency band (15–25 Hz) involved in self-paced movement.

Methods

Using magnetoencephalography (MEG), the authors measured ERD that occurred before self-paced unilateral index finger flexion in 66 patients with brain tumors, epilepsy, and arteriovenous malformations.

Results

The authors applied an adaptive spatial filtering algorithm to MEG data and found that peaks of the tomographic distribution of β-band ERD sources reliably localized hand motor cortex compared with electrical cortical stimulation. They also observed high specificity in estimating contralateral hand motor cortical representations relative to somatosensory cortex. Neither presence nor location of tumor changed the qualitative or quantitative location of motor cortex relative to somatosensory cortex.

Conclusions

An imaging protocol using ERD obtained by adaptive spatial filtering of MEG data can be used for extremely reliable preoperative localization of hand motor cortex.

Advances in brain tumor surgery

Advances in the fields of molecular and translational research, oncology, and surgery have emboldened the medical community to believe that intrinsic brain tumors may be treatable. Intraoperative imaging and brain mapping allow operations adjacent to eloquent cortex and more radical resection of tumors with increased confidence and safety. Despite these advances, the infiltrating edge of a neoplasm and distant microscopic satellite lesions will never be amendable to a surgical cure. Indeed, it is continued research into the delivery of an efficacious chemobiologic agent that will eventually allows us to manage this primary cause of treatment failure.

Intraoperative confirmation of hand motor area identified preoperatively by magnetoencephalography

BACKGROUND

Presurgical functional mapping using magnetoencephalography (MEG) has been performed for somatosensory, auditory and visual functions; however, the traditional analysis method utilizing dipole source analysis has some inherent limitations when applied to the mapping of cortical motor areas. Recently, a novel source reconstruction algorithm [event-related synthetic aperture magnetometry (erSAM)] has demonstrated success for the localization of motor function in healthy adults. We applied this technique to preoperatively map motor function in a young patient. We then confirmed our mapping with direct cortical stimulation intraoperatively.

METHODS

This is a case report of an 8-year-old girl with right hand and arm weakness and poor right hand motor control secondary to a left peri-rolandic tumor. Preoperatively, whole-head MEG was recorded while the patient performed a self-paced button pressing task. Cortical activity associated with the onset of movement was localized to the right hand precentral gyrus superior and medial to the tumor using erSAM, while sensory function was localized posterior to the tumor on the postcentral gyrus.

RESULTS

Intraoperative direct cortical stimulation of the motor area identified by MEG resulted in electromyographic activation of intrinsic muscles of the contralateral hand exclusively.

CONCLUSIONS

This is the first report of a case where direct cortical stimulation has confirmed a motor cortical location identified by the erSAM method.

Surgery Insight: the role of surgery in the management of low-grade gliomas

The benefits of surgery for the management of low-grade gliomas have been difficult to determine from the literature. This difficulty might be explained by the inconsistency of the published data, and also by advances in both neuroimaging and neurosurgical techniques, which have made surgical intervention a safer and more viable option than it has been in the past, making the earlier studies less applicable to modern care. In this article, we critically analyze the utility of surgery in the management of low-grade gliomas, including the value of observation without surgical intervention, the relative risks and benefits of biopsy versus craniotomy and resection, and recent advances that have made surgery safer and gross total resection a more realistic proposition. As we will discuss, the literature provides modest evidence that surgery leads to improved outcomes through a reduction in tumor burden. As a result of advances in surgical techniques, the time might now be right to effectively and accurately assess the influence of aggressive surgical resection on the prognosis of low-grade gliomas.

MAGNETOENCEPHALOGRAPHIC STUDY OF POSTERIOR TIBIAL NERVE STIMULATION IN PATIENTS WITH INTRACRANIAL LESIONS AROUND THE CENTRAL SULCUS

OBJECTIVE

To study interhemispheric differences of somatosensory evoked field (SEF) characteristics and the spatial distribution of equivalent current dipole sources in patients with unilateral hemispheric lesions around the central sulcus region.

METHODS

In 17 patients with perirolandic lesions, averaged somatosensory responses after posterior tibial nerve stimulation at the ankle were recorded with magnetoencephalography. Dipole source solutions in the affected (AH) and unaffected (UH) hemispheres were analyzed and compared for latency, equivalent current dipole strength, root mean square, and spatial distribution in relation to clinical findings.

RESULTS

Three main SEF components, P45m, N60m, and P75m, were identified in the hemisphere contralateral to the stimulated nerve. Dipole strength for the P45m component was significantly higher in the AH compared with the UH. SEF characteristics in the AH and UH showed no significant differences with respect to component latency or dipole strength of the N60m and P75m components. Interdipole location asymmetries exceeded 1.0 cm in 71% of the patients. Comparison of the posterior tibial nerve evoked responses (P45m and N60m) in patients with motor deficits and patients without deficits showed that these responses are enlarged in the AH when perirolandic lesions are present. Patients with motor deficits also showed an increased response for P45m in the UH.

CONCLUSION

The results of posterior tibial nerve SEFs suggest spatial and functional changes in the somatosensory network as a result of perirolandic lesions with a possible relationship with clinical symptoms. The results can provide further basis for the evaluation of cortical changes in the presence of perirolandic lesions.

Event-related beamforming: a robust method for presurgical functional mapping using MEG

OBJECTIVE

We describe the application of a new spatial filtering technique--event-related beamforming (ERB)--for presurgical functional mapping of primary sensory areas using MEG. This method provides an alternative to equivalent current dipole (ECD) modeling that potentially eliminates problems of intracranial magnetic artifacts due to movement of ferromagnetic materials (e.g., orthodontic braces) or eye movements.

METHODS

We compared localization results for ERB and ECD localization of primary somatosensory (M20) and auditory (M100) evoked responses in 12 healthy control subjects and four subjects with metallic dental implants. Data were recorded with a 151-channel CTF MEG system using standard presurgical mapping protocols.

RESULTS

We found a high level of agreement between the two methods in control subjects (overall localization difference was 5.9+/-2.2 mm for M20 and 10.4+/-5.6 mm for M100). Subjects with dental implants showed severely distorted evoked responses that could not be analyzed using ECD, whereas the ERB method localized sources to expected anatomical locations.

CONCLUSIONS

MEG functional mapping may be carried out without removal of orthodontic or other metallic implants using event-related beamformer analysis.

SIGNIFICANCE

Spatial filtering methods can overcome some of the limitations associated with MEG expanding its applicability, particularly in pediatric clinical environments.

Functional brain mapping and its applications to neurosurgery

Functional brain mapping may be useful for both preoperative planning and intraoperative neurosurgical decision making. "Gold standard" functional studies such as direct electrical stimulation and recording are complemented by newer, less invasive techniques such as functional magnetic resonance imaging. Less invasive techniques allow more areas of the brain to be mapped in more subjects (including healthy subjects) more often (including pre- and postoperatively). Expansion of the armamentarium of tools allows convergent evidence from multiple brain mapping techniques to bear on pre- and intraoperative decision making. Functional imaging techniques are used to map motor, sensory, language, and memory areas in neurosurgical patients with conditions as diverse as brain tumors, vascular lesions, and epilepsy. In the future, coregistration of high resolution anatomic and physiological data from multiple complementary sources will be used to plan more neurosurgical procedures, including minimally invasive procedures. Along the way, new insights on fundamental processes such as the biology of tumors and brain plasticity are likely to be revealed.

Motor field sensitivity for preoperative localization of motor cortex

OBJECT

In this study the role of magnetic source imaging for preoperative motor mapping was evaluated by using a single-dipole localization method to analyze motor field data in 41 patients.

METHODS

Data from affected and unaffected hemispheres were collected in patients performing voluntary finger flexion movements. Somatosensory evoked field (SSEF) data were also obtained using tactile stimulation. Dipole localization using motor field (MF) data was successful in only 49% of patients, whereas localization with movement-evoked field (MEF) data was successful in 66% of patients. When the spatial distribution of MF and MEF dipoles in relation to SSEF dipoles was analyzed, the motor dipoles were not spatially distinct from somatosensory dipoles.

CONCLUSIONS

The findings in this study suggest that single-dipole localization for the analysis of motor data is not sufficiently sensitive and is nonspecific, and thus not clinically useful.

Sensorimotor Cortex Localization: Comparison of Magnetoencephalography, Functional MR Imaging, and Intraoperative Cortical Mapping

PURPOSE

To prospectively evaluate magnetoencephalography (MEG) and functional magnetic resonance (MR) imaging, as compared with intraoperative cortical mapping, for identification of the central sulcus.

MATERIALS AND METHODS

Fifteen patients (six men, nine women; age range, 25-58 years) with a lesion near the primary sensorimotor cortex (13 gliomas, one cavernous hemangioma, and one meningioma) were examined after institutional review board approval and written informed consent from each patient were obtained. At MEG, evoked magnetic fields to median nerve stimulation were recorded; at functional MR imaging, hemodynamic responses to self-paced palmar flexion of the wrist were imaged. General linear model analysis with contextual clustering (P < .01) was used to analyze functional MR imaging data, and dipole modeling was used to analyze MEG data. MEG and functional MR localizations were compared with intraoperative cortical mappings. The distance from the area of functional MR imaging activation to the tumor margin was compared between the patients with discordant and those with concordant intraoperative mapping findings by using unpaired t testing.

RESULTS

MEG depicted the central sulcus correctly in all 15 patients, as verified at intraoperative mapping. The functional MR imaging localization results agreed with the intraoperative mappings in 11 patients. In all four patients with a false localization, the primary activation was in the postcentral sulcus region, but it did not differ significantly from the primary activation in the patients with correct localization with respect to proximity to the tumor (P = .38). Furthermore, at functional MR imaging, multiple nonprimary areas were activated, with considerable interindividual variation.

CONCLUSION

Although both MEG and functional MR imaging can provide useful information for neurosurgical planning, in the present study, MEG proved to be superior for locating the central sulcus. Activation of multiple nonprimary cerebral areas may confound the interpretation of functional MR imaging results.

Spatial dynamics of population activities at S1 after median and ulnar nerve stimulation revisited: An MEG study

In a number of studies, magnetoencephalography (MEG) has been successfully employed in localizing cortical neural population activities after stimulation of peripheral nerves. Little attention has been paid, however, to the spatiotemporal dynamics of these activations within the primary somatosensory cortex (SI). Here we report on the activation sequence at the right SI after left median and ulnar nerve stimulation. The results show that at least three macroscopically separable sources within or near SI are activated within 100 ms after the stimulus, corresponding to the somatosensory evoked field (SEF) deflections N20m, P35m and P60m. As P60m was localized significantly more posteriorly and also tended to be deeper than the two earlier deflections, its underlying source may be more extensive than during N20m and P35m, and it may get contribution from the postcentral gyrus and sulcus, possibly Brodmann areas 1 and 2. The source separation between the neural populations activated by the 2 nerves was 12 mm during N20m, 6 mm during P35m and 4 mm during P60m. Thus, at longer latencies, the centers of gravity of the activations were closer to each other for the 2 nerves. We argue that this reflects spreading of the activation with time from the site of initial excitation to encompass larger and more overlapping neural populations at longer latencies.

Magnetoencephalography in Neurosurgery

OBJECTIVE:

To present applications of magnetoencephalography (MEG) in studies of neurosurgical patients.

METHODS:

MEG maps magnetic fields generated by electric currents in the brain, and allows the localization of brain areas producing evoked sensory responses and spontaneous electromagnetic activity. The identified sources can be integrated with other imaging modalities, e.g., with magnetic resonance imaging scans of individual patients with brain tumors or intractable epilepsy, or with other types of brain imaging data.

RESULTS:

MEG measurements using modern whole-scalp instruments assist in tailoring individual therapies for neurosurgical patients by producing maps of functionally irretrievable cortical areas and by identifying cortical sources of interictal and ictal epileptiform activity. The excellent time resolution of MEG enables tracking of complex spaciotemporal source patterns, helping, for example, with the separation of the epileptic pacemaker from propagated activity. The combination of noninvasive mapping of subcortical pathways by magnetic resonance imaging diffusion tensor imaging with MEG source localization will, in the near future, provide even more accurate navigational tools for preoperative planning. Other possible future applications of MEG include the noninvasive estimation of language lateralization and the follow-up of brain plasticity elicited by central or peripheral neural lesions or during the treatment of chronic pain.

CONCLUSION:

MEG is a mature technique suitable for producing preoperative “road maps” of eloquent cortical areas and for localizing epileptiform activity.

Retrospective review of MEG visual evoked hemifield responses prior to resection of temporo-parieto-occipital lesions

Visual evoked cortical magnetic field (VEF) waveforms were recorded from both hemifields in 21 patients with temporo-parieto-occipital mass lesions to identify preserved visual pathways. Fifteen patients had visual symptoms pre-operatively. Magnetoencephalographic (MEG) VEF responses were detected, using single equivalent current dipole (ECD), in 17/21 patients studied. Displaced or abnormal responses were seen in 15 patients with disruption of pathway in one patient. Three of 21 patients had alterations in the surgical approach or the planned resection based on the MEG findings. The surgical outcome for these three patients suggests that the MEG study may have played a useful role in pre-surgical planning.

Three-dimensionally reconstructed magnetic source imaging and neuronavigation in pediatric epilepsy: technical note

OBJECTIVE

To determine the role of reconstructing three-dimensional magnetic source imaging (MSI) data on cortical resections for children undergoing epilepsy surgery using neuronavigation.

METHODS

Magnetoencephalographic recordings were analyzed in 16 children under 18 years of age with intractable epilepsy. The data were transferred to the neuronavigation workstation for intraoperative localization of MSI spike sources in selected patients. With the aid of neuronavigation, the MSI spike sources were resected. Intraoperative electrocorticography was then used to survey the surrounding field for residual epileptiform activity.

RESULTS

MSI spike sources were obtained in 13 of 16 patients. MSI spike sources localized the cortical and subcortical discharges before intraoperative electrocorticography in nine patients and before extraoperative subdural grid electroencephalographic monitoring in four patients. The localization of MSI spikes sources was characterized by clustered spike sources in 10 patients. By use of neuronavigation, the clustered spike sources were correlated to the interictal zone indicated by intraoperative electrocorticography in six patients and to the ictal onset zone shown on extraoperative subdural grid electroencephalography in three patients. Cortical excision of the spike cluster focus was then performed in these six patients. The technique used here to resect MSI spike source clusters that correlate with the ictal onset zone by invasive subdural grid monitoring is illustrated in one patient who underwent cortical resection for epilepsy surgery.

CONCLUSION

Three-dimensional reconstruction of MSI data linked to neuronavigation is a promising technique to facilitate resections around eloquent cortex in children with epilepsy.

Characterizing magnetic spike sources by using magnetoencephalography-guided neuronavigation in epilepsy surgery in pediatric patients

OBJECT

The authors sought to validate magnetoencephalography spike sources (MEGSSs) in neuronavigation during epilepsy surgery in pediatric patients.

METHODS

The distributions of MEGSSs in 16 children were defined and classified as clusters (Class I), greater than or equal to 20 MEGSSs with 1 cm or less between MEGSSs; small clusters (Class II), 6 to 19 with 1 cm or less between; and scatters (Class III), less than 6 or greater than 1 cm between spike sources. Using neuronavigation, the MEGSSs were correlated to epileptic zones from intra- and extraoperative electrocorticography (ECoG), surgical procedures, disease entities, and seizure outcomes. Thirteen patients underwent MEGSSs: nine had clusters; two had small clusters, one with and one without clusters; and three had scatters alone. All 13 had scatters. Clusters localized within and extended from areas of cortical dysplasia and at margins of tumors or cystic lesions. All clusters were colocalized to ECoG-defined epileptic zones. Four of 10 patients with clusters and/or small clusters underwent complete excisions, and six underwent partial excision with or without multiple subpial transections. In the three patients with scatters alone, ECoG revealed epileptic zones buried within MEGSS areas; these regions of scatters were completely excised and treated with multiple subpial transections. Coexisting scatters were left untreated in nine of 10 patients. Postoperatively, nine of 13 patients were seizure free; the four patients with residual seizures had clusters in unresected eloquent cortex. Three patients in whom no MEGSSs were demonstrated underwent lesionectomies and were seizure free.

CONCLUSIONS

Magnetoencephalography spike source clusters indicate an epileptic zone requiring complete excision. Coexisting scatters remote from clusters are nonepileptogenic and do not require excision. Scatters alone, however, should be examined by ECoG; an epileptic zone may exist within these distributions.

Magnetoencephalography in Epilepsy

Magnetoencephalography (MEG)-also known as magnetic source imaging when combined with magnetic resonance imaging-has developed to the point that it has now entered routine clinical application. Epilepsy MEG studies show that it can accurately localize spike sources--both ictal and interictal--as compared to both direct (intracranial EEG) and indirect (imaging abnormalities) measures. Challenges remain with difficulties in detecting complex or deep sources when recording spontaneous cerebral activity. Magnetoencephalography not only provides a novel tool to localize and characterize epileptiform disturbances, it also has an important role in determining the significance of abnormalities seen on both structural and functional imaging. Combined with mapping of normal or eloquent brain function, MEG should ultimately play a major role in the totally noninvasive epilepsy surgery evaluation.

An integrative MEG-fMRI study of the primary somatosensory cortex using cross-modal correspondence analysis

We develop a novel approach of cross-modal correspondence analysis (CMCA) to address whether brain activities observed in magnetoencephalography (MEG) and functional magnetic resonance imaging (fMRI) represent a common neuronal subpopulation, and if so, which frequency band obtained by MEG best fits the common brain areas. Fourteen adults were investigated by whole-head MEG using a single equivalent current dipole (ECD) and synthetic aperture magnetometry (SAM) approaches and by fMRI at 1.5 T using linear time-invariant modeling to generate statistical maps. The same somatosensory stimulus sequences consisting of tactile impulses to the right sided: digit 1, digit 4 and lower lip were used in both neuroimaging modalities. To evaluate the reproducibility of MEG and fMRI results, one subject was measured repeatedly. Despite different MEG dipole locations and locations of maximum activation in SAM and fMRI, CMCA revealed a common subpopulation of the primary somatosensory cortex, which displays a clear homuncular organization. MEG activity in the frequency range between 30 and 60 Hz, followed by the ranges of 20-30 and 60-100 Hz, explained best the defined subrepresentation given by both MEG and fMRI. These findings have important implications for improving and understanding of the biophysics underlying both neuroimaging techniques, and for determining the best strategy to combine MEG and fMRI data to study the spatiotemporal nature of brain activity.

Controversies in neurophysiology. MEG is superior to EEG in localization of interictal epileptiform activity: Pro

Both EEG and magnetoencephalography (MEG), with a time resolution of 1 ms or less, provide unique neurophysiologic data not obtainable by other neuroimaging techniques. MEG and EEG have often been compared to each other now although the two are complementary. Now that MEG has emerged as a mature clinical technology, it is worthwhile to compare the relative strengths of each for the localization of interictal epileptiform activity and to describe the strengths of MEG relative to EEG in the localization of interictal epileptiform activity. The sources of MEG and EEG signals will first be reviewed. Issues relevant to solving the forward problem and the inverse problem in MEG and EEG will be addressed followed by a comparison of research concerning the detection and localization of interictal epileptiform activity by MEG and EEG. The emphasis will be upon techniques and software routinely used in clinical applications but some emerging areas of MEG research which are entering clinical practice will also be reviewed.

SIGNIFICANCE

MEG is a new noninvasive neurophysiologic technique which provides unique information for the clinical evaluation of patients with epilepsy, revealing aspects of neuronal function that previously could only be obtained by invasive EEG monitoring, and giving a new window for research of neuronal activity.

Functional neuronavigation and intraoperative MRI

Our concept of computer assisted surgery is based on the combination of intraoperative magnetic resonance (MR) imaging with microscope-based neuronavigation, providing anatomical and functional guidance simultaneously. Intraoperative imaging evaluates the extent of a resection, while the additional use of functional neuronavigation, which displays the position of eloquent brain areas in the operative field, prevents increasing neurological deficits, which would otherwise result from extended resections. Up to mid 2001 we performed intraoperative MR imaging using a low-field 0.2 Tesla scanner in 330 patients. The main indications were the evaluation of the extent of resection in gliomas, pituitary tumours, and in epilepsy surgery. Intraoperative MR imaging proved to serve as intraoperative quality control with the possibility of an immediate modification of the surgical strategy, i.e. extension of the resection. Integrated use of functional neuronavigation prevented increased neurological deficits. Compared to routine pre- or postoperative imaging being performed with high-Tesla machines, intraoperative image quality and sequence spectrum could not compete. This led to the development of the concept to adapt a high-field MR scanner to the operating environment, preserving the benefits of using standard microsurgical equipment and microscope-based neuronavigational guidance with integrated functional data, which was successfully implemented by April 2002. Up to the end of 2002, 95 patients were investigated with the new setup. Improved image quality, intraoperative workflow, as well as enhanced sophisticated intraoperative imaging possibilities are the major benefits of the high-field setup.

Magnetoencephalographic representation of the sensorimotor hand area in cases of intracerebral tumour

OBJECTIVE

To assess the clinical value of magnetoencephalography (MEG) in localising the primary hand motor area and evaluating cortical distortion of the sensorimotor cortices in patients with intracerebral tumour.

METHODS

10 normal volunteers (controls) and 14 patients with an intracerebral tumour located around the central region were studied. Somatosensory evoked magnetic fields (SEFs) following median nerve stimulation, and movement related cerebral magnetic fields (MRCFs) following index finger extension, were measured in all subjects and analysed by the equivalent current dipole (ECD) method to ascertain the neuronal sources of the primary sensory and motor components (N20m and MF, respectively). These ECD locations were defined as the primary hand sensory and motor areas and the positional relations between these two functional areas in controls and patients were investigated.

RESULTS

The standard range of ECD locations of MF to N20m was determined in controls. In 11 of the 14 patients, MRCFs could identify the primary motor hand area. ECD locations of MF were significantly closer to the N20m in the medial-lateral direction in patients than in controls. In patients with a tumour located below the sensorimotor hand area, relative ECD locations of MF to N20m moved anteriorly over the standard range determined in the control subjects. These MEG findings correlated well with radiological tumour locations. The mean estimated ECD strength of MF was significantly lower in patients than in controls.

CONCLUSIONS

MRCF was useful in localising the primary motor hand area in patients with intracerebral tumour. The relative ECD locations of MF to N20m describe the anatomical distortion of the sensorimotor cortex.

Preoperative magnetic source imaging for brain tumor surgery: a quantitative comparison with intraoperative sensory and motor mapping

Object

The aim of this study was to compare quantitatively the methods of preoperative magnetic source (MS) imaging and intraoperative electrophysiological cortical mapping (ECM) in the localization of sensorimotor cortex in patients with intraaxial brain tumors.

Methods

Preoperative magnetoencephalography (MEG) was performed while patients received painless tactile somatosensory stimulation of the lip, hand, and foot. The early somatosensory evoked field was modeled using a single equivalent current dipole approach to estimate the spatial source of the response. Three-dimensional magnetic resonance image volume data sets with fiducials were coregistered with the MEG recordings to form the MS image. These individualized functional brain maps were integrated into a neuronavigation system. Intraoperative mapping of somatosensory and/or motor cortex was performed and sites were compared.

In two subgroups of patients we compared intraoperative somatosensory and motor stimulation sites with MS imaging–based somatosensory localizations. Mediolateral projection of the MS imaging source localizations to the cortical surface reduced systematic intermodality discrepancies. The distance between two corresponding points determined using MS imaging and ECM was 12.5 ± 1.3 mm for somatosensory–somatosensory and 19 ± 1.3 mm for somatosensory–motor comparisons. The observed 6.5 mm increase in site separation was systematically demonstrated in the anteroposterior direction, as expected from actual anatomy. In fact, intraoperative sites at which stimulation evoked the same patient response exhibited a spatial variation of 10.7 ± 0.7 mm.

Conclusions

Preoperative MS imaging and intraoperative ECM show a favorable degree of quantitative correlation. Thus, MS imaging can be considered a valuable and accurate planning adjunct in the treatment of patients with intraaxial brain tumors.

MEG and EEG in epilepsy

Both EEG and magnetoencephalogram (MEG), with a time resolution of 1 ms or less, provide unique neurophysiologic data not obtainable by other neuroimaging techniques. MEG has now emerged as a mature clinical technology. While both EEG and MEG can be performed with more than 100 channels, MEG recordings with 100 to 300 channels are more easily done because of the time needed to apply a large number of EEG electrodes. EEG has the advantage of the long-term video EEG recordings, which facilitates extensive temporal sampling across all periods of the sleep/wake cycle. MEG and EEG seem to complement each other for the detection of interictal epileptiform discharges, because some spikes can be recorded only on MEG but not on EEG and vice versa. Most studies indicate that MEG seems to be more sensitive for neocortical spike sources. Both EEG and MEG source localizations show excellent agreement with invasive electrical recordings, clarify the spatial relationship between the irritative zone and structural lesions, and finally, attribute epileptic activity to lobar subcompartments in temporal lobe and to a lesser extent in extratemporal epilepsies. In temporal lobe epilepsy, EEG and MEG can differentiate between patients with mesial, lateral, and diffuse seizure onsets. MEG selectively detects tangential sources. EEG measures both radial and tangential activity, although the radial components dominate the EEG signals at the scalp. Thus, while EEG provides more comprehensive information, it is more complicated to model due to considerable influences of the shape and conductivity of the volume conductor. Dipole localization techniques favor MEG due to the higher accuracy of MEG source localization compared to EEG when using the standard spherical head shape model. However, if special care is taken to address the above issues and enhance the EEG, the localization accuracy of EEG and MEG actually are comparable, although these surface EEG analytic techniques are not typically approved for clinical use in the United States. MEG dipole analysis is approved for clinical use and thus gives information that otherwise usually requires invasive intracranial EEG monitoring. There are only a few dozen whole head MEG units in operation in the world. While EEG is available in every hospital, specialized EEG laboratories capable of source localization techniques are nearly as scarce as MEG facilities. The combined use of whole-head MEG systems and multichannel EEG in conjunction with advanced source modeling techniques is an area of active development and will allow a better noninvasive characterization of the irritative zone in presurgical epilepsy evaluation. Finally, additional information on epilepsy may be gathered by either MEG or EEG analysis of data beyond the usual bandwidths used in clinical practice, namely by analysis of activity at high frequencies and near-DC activity.

Computer-aided navigation in neurosurgery

The article comprises three main parts: a historical review on navigation, the mathematical basics for calculation and the clinical applications of navigation devices. Main historical steps are described from the first idea till the realisation of the frame-based and frameless navigation devices including robots. In particular the idea of robots can be traced back to the Iliad of Homer, the first testimony of European literature over 2500 years ago. In the second part the mathematical calculation of the mapping between the navigation and the image space is demonstrated, including different registration modalities and error estimations. The error of the navigation has to be divided into the technical error of the device calculating its own position in space, the registration error due to inaccuracies in the calculation of the transformation matrix between the navigation and the image space, and the application error caused additionally by anatomical shift of the brain structures during operation. In the third part the main clinical fields of application in modern neurosurgery are demonstrated, such as localisation of small intracranial lesions, skull-base surgery, intracerebral biopsies, intracranial endoscopy, functional neurosurgery and spinal navigation. At the end of the article some possible objections to navigation-aided surgery are discussed.

Usefulness of intraoperative electrical subcortical mapping during surgery for low-grade gliomas located within eloquent brain regions: functional results in a consecutive series of 103 patients

OBJECT

Although a growing number of authors currently advocate surgery to treat low-grade gliomas, controversy still persists, especially because of the risk of inducing neurological sequelae when the tumor is located within eloquent brain areas. Many researchers performing preoperative neurofunctional imaging and intraoperative electrophysiological methods have recently reported on the usefulness of cortical functional mapping. Despite the frequent involvement of subcortical structures by these gliomas, very few investigators have specifically raised the subject of fiber tracking. The authors in this report describe the importance of mapping cortical and subcortical functional regions by using intraoperative real-time direct electrical stimulations during resection of low-grade gliomas.

METHODS

Between 1996 and 2001, 103 patients harboring a corticosubcortical low-grade glioma in an eloquent area, with no or only mild deficit, had undergone surgery during which intraoperative electrical mapping of functional cortical sites and subcortical pathways was performed throughout the procedure. Both eloquent cortical areas and corresponding white fibers were systematically detected and preserved, thus defining the resection boundaries. Despite an 80% rate of immediate postoperative neurological worsening, 94% of patients recovered their preoperative status within 3 months--10% even improved--and then returned to a normal socioprofessional life. Eighty percent of resections were classified as total or subtotal based on control magnetic resonance images.

CONCLUSIONS

The use of functional mapping of the white matter together with cortical mapping allowed the authors to optimize the benefit/risk ratio of surgery of low-grade glioma invading eloquent regions. Given that preoperative fiber tracking with the aid of neuroimaging is not yet validated, we used intraoperative real-time cortical and subcortical stimulations as a valuable adjunct to the other mapping methods.

Magnetoencephalographic validation parameters for clinical evaluation of interictal epileptic activity

The authors demonstrate that the confidence volume (the spatial volume that encompasses the 95% probability of source localization) of the single equivalent current dipole is helpful in validating magnetoencephalographic epileptic spike mapping. Such mapping involves distinguishing spikes from other neuronal events. The usual criteria for validating dipole fit reliability involve four parameters-correlation coefficient (R > or =0.98), goodness of fit (> or =0.95), root mean square magnetic field value (>400 fT), and dipole moment (Q value > 200 nAm)-but other parameters (direction of dipole moment, location of dipole, and confidence volume) can be considered. In 21 patients with epilepsy, the average correlation coefficient for 608 epileptic spikes was 0.99; average goodness of fit, 0.98; average root mean square, 1,198 fT; and the average Q value, 370 nAm. The mean average confidence volume was 0.30 +/- 0.27 cm3. Correlation coefficient values for quiet brain activity were less than 0.90; goodness of fit values, less than 0.85; and confidence volumes were large (>5 cm3); and for noise runs (no subject) they were even larger (>100 cm3), although correlation coefficient values were more than 0.80 and goodness of fit values were more than 0.85. Confidence volumes for noise data are large-for background brain activity even larger-but confidence volumes for epileptic spikes are small. Confidence volume, in conjunction with other parameters, may be a robust parameter for spike selection.

Preoperative magnetic source imaging for brain tumor surgery: a quantitative comparison with intraoperative sensory and motor mapping

OBJECT

The aim of this study was to compare quantitatively the methods of preoperative magnetic source (MS) imaging and intraoperative electrophysiological cortical mapping (ECM) in the localization of sensorimotor cortex in patients with intraaxial brain tumors.

METHODS

Preoperative magnetoencephalography (MEG) was performed while patients received painless tactile somatosensory stimulation of the lip, hand, and foot. The early somatosensory evoked field was modeled using a single equivalent current dipole approach to estimate the spatial source of the response. Three-dimensional magnetic resonance image volume data sets with fiducials were coregistered with the MEG recordings to form the MS image. These individualized functional brain maps were integrated into a neuronavigation system. Intraoperative mapping of somatosensory and/or motor cortex was performed and sites were compared. In two subgroups of patients we compared intraoperative somatosensory and motor stimulation sites with MS imaging-based somatosensory localizations. Mediolateral projection of the MS imaging source localizations to the cortical surface reduced systematic intermodality discrepancies. The distance between two corresponding points determined using MS imaging and ECM was 12.5 +/- 1.3 mm for somatosensory-somatosensory and 19 +/- 1.3 mm for somatosensory-motor comparisons. The observed 6.5 mm increase in site separation was systematically demonstrated in the anteroposterior direction, as expected from actual anatomy. In fact, intraoperative sites at which stimulation evoked the same patient response exhibited a spatial variation of 10.7 +/- 0.7 mm.

CONCLUSIONS

Preoperative MS imaging and intraoperative ECM show a favorable degree of quantitative correlation. Thus, MS imaging can be considered a valuable and accurate planning adjunct in the treatment of patients with intraaxial brain tumors.

Usefulness of somatosensory evoked magnetic field dipole measurements by magnetoencephalography for assessing spinal cord function

OBJECT

Objective assessment of sensory function disorders is difficult. In the present study, the authors investigated the possibility of assessing cervical myelopathy-induced sensory disorders by using magnetoencephalography (MEG) to measure somatosensory evoked magnetic fields (SSEMFs).

METHODS

In 12 patients with cervical myelopathy, SSEMFs were measured before and after surgery by using a 160-channel helmet-type MEG system to stimulate the median nerve, and the intensity and latency of N20m (first response occurring 20 msec after stimulation) were then determined. Additionally, the severity of the sensory disorder was assessed before and after surgery by obtaining sensory scores determined using the Neurosurgical Cervical Spine Scale. Furthermore, in 11 healthy individuals (control group), the intensity and latency of N20m were measured in the same fashion. Analysis of the results showed that the preoperative intensity of N20m in the 12 patients with cervical myelopathy was significantly lower than that demonstrated in the control patients (p < 0.005, Student t-test). In addition, of six patients in whom sensory scores improved postoperatively, there were significant increases in the intensity of N20m (p < 0.005, paired t-test). Furthermore, there was a significant correlation between sensory scores and dipole intensity (p < 0.001, Spearman correlation coefficient by rank test).

CONCLUSIONS

Somatosensory evoked magnetic field measurements determined by MEG are useful in objectively and noninvasively assessing sensory disorders caused by cervical myelopathy.

Intraoperative mapping of the subcortical language pathways using direct stimulations. An anatomo-functional study

Functional neuroimaging has improved pre-planning of surgery in eloquent cortical areas, but remains unable to map white matter. Thus, tumour resection in functional subcortical regions still presents a high risk of sequelae. The authors successfully used intraoperative electrical stimulations to perform subcortical language pathway mapping in order to avoid postoperative definitive deficit, and correlated these functional findings with the anatomical location of the eloquent bundles detected using postoperative MRI. At the same time, this also improved knowledge of fibre connectivity. Thirty patients harbouring a cortico-subcortical low-grade glioma in the left dominant hemisphere were operated on whilst awake using intraoperative electrical functional mapping during surgical resection. Language cortical sites and subcortical pathways were clearly identified and preserved in the 30 cases. The anatomo-functional correlations between data obtained using intraoperative subcortical mapping and postoperative MRI revealed the existence in all patients of common pathways which seem essential to language. This was shown by inducing reproducible speech disturbances during stimulations as follows: the subcallosal fasciculus (initiation disorders), the periventricular white matter (dysarthria), the arcuate fasciculus and the insular connections (anomia). Clinically, all patients except three presented a transient postoperative dysphasia, which resolved within 3 months. On control MRI, 14 resections were total and 16 subtotal due to infiltration of functional bundles described above. It is recommended that the combination of the techniques as described could prove ideal for future non-invasive reliable subcortical mapping both in healthy volunteers and in patients harbouring a (cortico)subcortical lesion in order to optimize surgical pre-planning.

MEG predicts epileptic zone in lesional extrahippocampal epilepsy: 12 pediatric surgery cases

PURPOSE

To discover whether the spatial distribution of spike sources determined by magnetoencephalography (MEG) provides reliable information for planning surgery and predicting outcomes in pediatric patients with lesional extrahippocampal epilepsy.

METHODS

We retrospectively studied 12 children with extrahippocampal epilepsy secondary to cortical dysplasia (CD), tumor, or porencephalic cyst. We compared interictal MEG spike source locations and somatosensory evoked fields derived from equivalent-current dipole modeling with intraoperative or extraoperative electrocorticography (ECoG).

RESULTS

MEG spike sources were found in proximity to the lesion in all patients and extended from lesions in five patients with CD. Marginal spike sources were noted in three patients with tumors, one patient with a cyst, and one with CD, and extramarginal sources in three patients with tumors. Three patients with tumors underwent lesionectomy only; two had further cortical excisions. One patient with CD underwent lesionectomy only, three had lesionectomy and cortical excisions, and two had lesionectomy and multiple subpial transection. Asymmetric MEG spike sources correlated with ECoG findings in all patients. Residual epileptiform discharges on postexcisional ECoG corresponded to spike sources in three patients with tumors and one patient with a cyst. Eleven patients have been seizure free for 1-6 years (mean, 4 years). One patient had residual seizures after incomplete excision of right temporal CD.

CONCLUSIONS

MEG delineated asymmetric epileptogenicity surrounding lesions and the eloquent cortex. Complete tumor resection produced favorable outcomes despite residual postexcisional ECoG spikes and extramarginal MEG spike sources. CD characterized by clusters of MEG spike sources within and extending from lesions seen on magnetic resonance imaging (MRI) should be removed to prevent seizures.

Functional activity within brain tumors: a magnetic source imaging study

OBJECTIVE

To determine whether low-grade gliomas contain functional cortical activity more often than high-grade gliomas within radiologically defined abnormal tissue.

METHODS

Patients with intra-axial cerebral lesions located in the vicinity of eloquent brain cortex preoperatively underwent magnetic source imaging. A dual 37-channel biomagnetometer was used to perform the imaging. Evoked magnetic fields were analyzed using the single-equivalent dipole representation to ascertain the neuronal source. Stimuli included painless tactile somatosensory stimulation of fingers, toes, and lips and auditory presentation of pure sinusoidal tones.

RESULTS

A retrospective analysis of 106 nonconsecutively treated patients, who had undergone preoperative magnetic source imaging between February 1996 and December 1999, revealed that 24.5% of the patients had been at risk for neurological deficits, because functionally active tissue was located within or at the border of the tumor. Functional activity was found within the radiologically defined lesion in 18% of Grade 2 tumors, in 17% of Grade 3 tumors, and in 8% of Grade 4 tumors.

CONCLUSION

The results confirm that, regardless of tumor grade, intra-axial brain tumors may involve or directly border on functional cortex. The degree of involvement of functionally viable cortex appeared greater for low-grade tumors than for high-grade lesions. On the other hand, high-grade lesions were more likely to be associated with functional cortex at their margins or within peritumoral edema. To safely maximize tumor resection, preoperative functional imaging and intraoperative electrophysiological mapping of the cerebral cortex and the white matter tracts are deemed necessary.

Correlation of sensorimotor activation with functional magnetic resonance imaging and magnetoencephalography in presurgical functional imaging: a spatial analysis

In this study we investigated the spatial heterotopy of MEG and fMRI localizations after sensory and motor stimulation tasks. Both methods are frequently used to study the topology of the primary and secondary motor cortex, as well as a tool for presurgical brain mapping. fMRI was performed with a 1.5T MR system, using echo-planar imaging with a motor and a sensory task. Somatosensory and motor evoked fields were recorded with a biomagnetometer. fMRI activation was determined with a cross-correlation analysis. MEG source localization was performed with a single equivalent current dipole model and a current density localization approach. Distances between MEG and fMRI activation sites were measured within the same anatomical 3-D-MR image set. The central region could be identified by MEG and fMRI in 33 of 34 cases. However, MEG and fMRI localization results showed significantly different activation sites for the motor and sensory task with a distance of 10 and 15 mm, respectively. This reflects the different neurophysiological mechanisms: direct neuronal current flow (MEG) and secondary changes in cerebral blood flow and oxygenation level of activated versus non activated brain structures (fMRI). The result of our study has clinical implications when MEG and fMRI localizations are used for pre- and intraoperative brain mapping. Although both modalities are useful for the estimation of the motor cortex, a single modality may err in the exact topographical labeling of the motor cortex. In some unclear cases a combination of both methods should be used in order to avoid neurological deficits.

Movement-related magnetic fields to tongue protrusion

Movement-related magnetic fields (MRFs) associated with tongue protrusion were measured in five normal subjects using a helmet-shaped magnetoencephalography system. Bihemispherical two-dipolar patterns appeared from approximately -2000 or -1000 to 0 ms to the trigger signal indicating when protrusion of the tongue tip reached the frontal part of the palate. Equivalent current dipoles (ECDs) for the MRFs were localized on the central sulcus, 14.4 +/- 6.1 mm inferior (P < 0.0001) and 7.6 +/- 6.9 mm anterior (P < 0.01) to the ECD for the N20m in the somatosensory evoked fields for median nerve stimuli. The ECD orientations of MRFs were anterior and perpendicular to the central sulcus. These results correspond to the movement-related potentials for tongue protrusion previously recorded from subdural electrodes in patients with epilepsy. Magnetoencephalography can be applied to analyze cortical functions related to tongue movement with high resolution in time and space in normal subjects.

Brain plasticity for sensory and linguistic functions: a functional imaging study using magnetoencephalography with children and young adults

In this report, the newest of the functional imaging methods, magnetoencephalography, is described, and its use in addressing the issue of brain reorganization for basic sensory and linguistic functions is documented in a series of 10 children and young adults. These patients presented with a wide variety of conditions, ranging from tumors and focal epilepsy to reading disability. In all cases, clear evidence of reorganization of the brain mechanisms of either somatosensory or linguistic functions or both was obtained, demonstrating the utility of magnetoencephalography in studying, completely noninvasively, the issue of plasticity in the developing brain.

Three-dimensional integration of brain anatomy and function to facilitate intraoperative navigation around the sensorimotor strip

We studied 12 patients with brain tumors in the vicinity of the sensorimotor region to provide a preoperative three-dimensional visualization of the functional anatomy of the rolandic cortex. We also evaluated the role of cortex-muscle coherence analysis and anatomical landmarks in identifying the sensorimotor cortex. The functional landmarks were based on neuromagnetic recordings with a whole-scalp magnetometer, coregistred with magnetic resonance images. Evoked fields to median and tibial nerve and lip stimuli were recorded to identify hand, foot and face representations in the somatosensory cortex. Oscillatory cortical activity, coherent with surface electromyogram during isometric muscle contraction, was analyzed to reveal the hand and foot representations in the precentral motor cortex. The central sulcus was identified also by available anatomical landmarks. The source locations, calculated from the neuromagnetic data, were displayed on 3-D surface reconstructions of the individual brains, including the veins. The preoperative data were verified during awake craniotomy by cortical stimulation in 7 patients and by cortical somatosensory evoked potentials in 5 patients. Sources of somatosensory evoked fields identified correctly the postcentral gyrus in all patients. Useful corroborative information was obtained from anatomical landmarks in 11 patients and from cortex-muscle correlograms in 8 patients. The preoperative visualization of the functional anatomy of the sensorimotor strip assisted in designing the operational strategy, facilitated orientation of the neurosurgeon during the operation, and speeded up the selection of sites for intraoperative stimulation or mapping, thereby helping to prevent damage of eloquent brain areas during surgery.

Pain-related somatosensory evoked magnetic fields induced by controlled ballistic mechanical impacts

The purpose of this study was to investigate cortical processing of painful compared with tactile mechanical stimulation by means of magnetoencephalography (MEG) using the novel technique of mechanical impact loading. A light, hard projectile is accelerated pneumatically in a guiding barrel and elicits a brief sensation of pain when hitting the skin in free flight. Controllable noxious and innocuous impact velocities facilitate the generation of different, predetermined stimulus intensities. The authors applied painful as well as tactile mechanical impacts to the dorsum of the second, third, and fourth digit of the nondominant hand. Pain-related somatosensory evoked magnetic fields (SSEFs) were compared with those following tactile stimulation in seven healthy volunteers. Contralateral primary sensory cortical area activation was observed within the first 70 msec after tactile as well as painful stimulus intensities. Only painful impacts elicited SSEF responses assigned to the bilateral secondary sensory cortical regions and to the middle part of the contralateral cingulate gyrus, which were active at latency ranges of 55 to 155 msec and 90 to 220 msec respectively. Additional long-latency responses occurred in these cortical areas as long as 280 msec after painful stimulation in three subjects. In contrast to tactile stimulation, painful mechanical impacts elicited SSEF responses in cortical areas demonstrated to be involved in central pain processing by previous MEG and neuroimaging studies. Because of its similarity to natural noxious stimuli and the possibility of adjustable painful and tactile impact velocities, the technique of mechanical impact loading provides a useful method for the neurophysiologic evaluation of cortical pain perception.