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Spitzer H, Ripart M, Whitaker K, D’Arco F, Mankad K, Chen AA, Napolitano A, De Palma L, De Benedictis A, Foldes S, Humphreys Z, Zhang K, Hu W, Mo J, Likeman M, Davies S, Güttler C, Lenge M, Cohen NT, Tang Y, Wang S, Chari A, Tisdall M, Bargallo N, Conde-Blanco E, Pariente JC, Pascual-Diaz S, Delgado-Martínez I, Pérez-Enríquez C, Lagorio I, Abela E, Mullatti N, O’Muircheartaigh J, Vecchiato K, Liu Y, Caligiuri ME, Sinclair B, Vivash L, Willard A, Kandasamy J, McLellan A, Sokol D, Semmelroch M, Kloster AG, Opheim G, Ribeiro L, Yasuda C, Rossi-Espagnet C, Hamandi K, Tietze A, Barba C, Guerrini R, Gaillard WD, You X, Wang I, González-Ortiz S, Severino M, Striano P, Tortora D, Kälviäinen R, Gambardella A, Labate A, Desmond P, Lui E, O’Brien T, Shetty J, Jackson G, Duncan JS, Winston GP, Pinborg LH, Cendes F, Theis FJ, Shinohara RT, Cross JH, Baldeweg T, Adler S, Wagstyl K. Interpretable surface-based detection of focal cortical dysplasias: a Multi-centre Epilepsy Lesion Detection study. Brain 2022; 145:3859-3871. [PMID: 35953082 PMCID: PMC9679165 DOI: 10.1093/brain/awac224] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/22/2022] [Accepted: 05/26/2022] [Indexed: 11/13/2022] Open
Abstract
One outstanding challenge for machine learning in diagnostic biomedical imaging is algorithm interpretability. A key application is the identification of subtle epileptogenic focal cortical dysplasias (FCDs) from structural MRI. FCDs are difficult to visualize on structural MRI but are often amenable to surgical resection. We aimed to develop an open-source, interpretable, surface-based machine-learning algorithm to automatically identify FCDs on heterogeneous structural MRI data from epilepsy surgery centres worldwide. The Multi-centre Epilepsy Lesion Detection (MELD) Project collated and harmonized a retrospective MRI cohort of 1015 participants, 618 patients with focal FCD-related epilepsy and 397 controls, from 22 epilepsy centres worldwide. We created a neural network for FCD detection based on 33 surface-based features. The network was trained and cross-validated on 50% of the total cohort and tested on the remaining 50% as well as on 2 independent test sites. Multidimensional feature analysis and integrated gradient saliencies were used to interrogate network performance. Our pipeline outputs individual patient reports, which identify the location of predicted lesions, alongside their imaging features and relative saliency to the classifier. On a restricted 'gold-standard' subcohort of seizure-free patients with FCD type IIB who had T1 and fluid-attenuated inversion recovery MRI data, the MELD FCD surface-based algorithm had a sensitivity of 85%. Across the entire withheld test cohort the sensitivity was 59% and specificity was 54%. After including a border zone around lesions, to account for uncertainty around the borders of manually delineated lesion masks, the sensitivity was 67%. This multicentre, multinational study with open access protocols and code has developed a robust and interpretable machine-learning algorithm for automated detection of focal cortical dysplasias, giving physicians greater confidence in the identification of subtle MRI lesions in individuals with epilepsy.
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Affiliation(s)
- Hannah Spitzer
- Institute of Computational Biology, Helmholtz Center Munich, Munich 85764, Germany
| | - Mathilde Ripart
- Department of Developmental Neuroscience, UCL Great Ormond Street Institute for Child Health, London WC1N 1EH, UK
| | | | - Felice D’Arco
- Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, UK
| | - Kshitij Mankad
- Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, UK
| | - Andrew A Chen
- Penn Statistics in Imaging and Visualization Center, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA 19104, USA
- Center for Biomedical Image Computing and Analytics, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Antonio Napolitano
- Medical Physics Department, Bambino Gesù Children’s Hospital, Rome 00165, Italy
| | - Luca De Palma
- Rare and Complex Epilepsies, Department of Neurosciences, Bambino Gesù Children’s Hospital, IRCCS, Rome 00165, Italy
| | - Alessandro De Benedictis
- Neurosurgery Unit, Department of Neurosciences, Bambino Gesù Children’s Hospital, IRCCS, Rome 00165, Italy
| | - Stephen Foldes
- Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, AZ 85016, USA
| | - Zachary Humphreys
- Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, AZ 85016, USA
| | - Kai Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100054, China
| | - Wenhan Hu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100054, China
| | - Jiajie Mo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100054, China
| | - Marcus Likeman
- Bristol Royal Hospital for Children, Bristol BS2 8BJ, UK
| | - Shirin Davies
- School of Psychology, Cardiff University Brain Research Imaging Centre, Cardiff CF24 4HQ, UK
- The Welsh Epilepsy Unit, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff CF14 4XW, UK
| | | | - Matteo Lenge
- Neuroscience Department, Children’s Hospital Meyer-University of Florence, Florence 50139, Italy
| | - Nathan T Cohen
- Center for Neuroscience, Children’s National Hospital, Washington, DC 20012, USA
| | - Yingying Tang
- Department of Neurology, West China Hospital of Sichuan University, Chengdu 610093, China
- Epilepsy Center, Cleveland Clinic, Cleveland, OH 44106, USA
| | - Shan Wang
- Epilepsy Center, Cleveland Clinic, Cleveland, OH 44106, USA
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Aswin Chari
- Department of Developmental Neuroscience, UCL Great Ormond Street Institute for Child Health, London WC1N 1EH, UK
- Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, UK
| | - Martin Tisdall
- Department of Developmental Neuroscience, UCL Great Ormond Street Institute for Child Health, London WC1N 1EH, UK
- Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, UK
| | - Nuria Bargallo
- Department of Neuroradiology, Hospital Clinic Barcelona and Magnetic Resonance Imaging, Core Facility, IDIBAPS, Barcelona 08036, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid 28029, Spain
| | | | | | - Saül Pascual-Diaz
- Magnetic Resonance Imaging, Core Facility, IDIBAPS, Barcelona 08036, Spain
| | | | | | | | - Eugenio Abela
- Center for Neuropsychiatry and Intellectual Disability, Psychiatrische Dienste Aargau AG, Windisch 5120, Switzerland
| | - Nandini Mullatti
- Institute of Psychiatry, Psychology and Neuroscience, King’s College, London SE5 8AF, UK
| | - Jonathan O’Muircheartaigh
- Institute of Psychiatry, Psychology and Neuroscience, King’s College, London SE5 8AF, UK
- Department of Perinatal Imaging and Health, St. Thomas’ Hospital, King’s College London, London SE1 7EH, UK
| | - Katy Vecchiato
- Department of Perinatal Imaging and Health, St. Thomas’ Hospital, King’s College London, London SE1 7EH, UK
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London SE5 8AF, UK
| | - Yawu Liu
- Department of Neurology, University of Eastern Finland, Kuopio 70210, Finland
| | - Maria Eugenia Caligiuri
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro 88100, Italy
| | - Ben Sinclair
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC 3004, Australia
| | - Lucy Vivash
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC 3004, Australia
- Department of Neurology, Monash University, Melbourne, VIC 3004, Australia
| | - Anna Willard
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC 3004, Australia
| | - Jothy Kandasamy
- Royal Hospital for Children and Young People, Edinburgh EH16 4TJ, UK
| | - Ailsa McLellan
- Royal Hospital for Children and Young People, Edinburgh EH16 4TJ, UK
| | - Drahoslav Sokol
- Royal Hospital for Children and Young People, Edinburgh EH16 4TJ, UK
| | - Mira Semmelroch
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC 3052, Australia
| | - Ane G Kloster
- Neurobiology Research Unit, Copenhagen University Hospital—Rigshospitalet, Copenhagen 2100, Denmark
| | - Giske Opheim
- Neurobiology Research Unit, Copenhagen University Hospital—Rigshospitalet, Copenhagen 2100, Denmark
- Department of Neuroradiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen 2100, Denmark
| | - Letícia Ribeiro
- Department of Neurology, University of Campinas, Campinas 13083-888, Brazil
- Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), University of Campinas, Campinas 13083-888, Brazil
| | - Clarissa Yasuda
- Department of Neurology, University of Campinas, Campinas 13083-888, Brazil
- Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), University of Campinas, Campinas 13083-888, Brazil
| | | | - Khalid Hamandi
- School of Psychology, Cardiff University Brain Research Imaging Centre, Cardiff CF24 4HQ, UK
- The Welsh Epilepsy Unit, University Hospital of Wales, Cardiff CF14 4XW, UK
| | - Anna Tietze
- Charité University Hospital, Berlin 10117, Germany
| | - Carmen Barba
- Neuroscience Department, Children’s Hospital Meyer-University of Florence, Florence 50139, Italy
| | - Renzo Guerrini
- Neuroscience Department, Children’s Hospital Meyer-University of Florence, Florence 50139, Italy
| | | | - Xiaozhen You
- Center for Neuroscience, Children’s National Hospital, Washington, DC 20012, USA
| | - Irene Wang
- Epilepsy Center, Cleveland Clinic, Cleveland, OH 44106, USA
| | - Sofía González-Ortiz
- Department of Neuroradiology, Hospital del Mar, Barcelona 08003, Spain
- Magnetic Resonance Imaging Core Facility, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain
| | | | - Pasquale Striano
- IRCCS Istituto Giannina Gaslini, Genova 16147, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | | | - Reetta Kälviäinen
- Department of Neurology, University of Eastern Finland, Kuopio 70210, Finland
- Kuopio Epilepsy Center, Neurocenter, Kuopio University Hospital, Kuopio 70210, Finland
| | - Antonio Gambardella
- Institute of Neurology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro 88100, Italy
| | - Angelo Labate
- Neurology Unit, Department of BIOMORF, University of Messina, Messina 98168, Italy
| | - Patricia Desmond
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC 3050, Australia
| | - Elaine Lui
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC 3050, Australia
| | - Terence O’Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC 3004, Australia
- Department of Medicine, The Royal Melbourne Hospital, Parkville, VIC, 3052, Australia
| | - Jay Shetty
- Royal Hospital for Children and Young People, Edinburgh EH16 4TJ, UK
| | - Graeme Jackson
- The Florey Institute of Neuroscience and Mental Health, Austin Campus, Heidelberg, VIC 3071, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC 3084, Australia
| | - John S Duncan
- UCL Queen Square Institute of Neurology, London WC1N 3BG, UK
| | - Gavin P Winston
- UCL Queen Square Institute of Neurology, London WC1N 3BG, UK
- Department of Medicine, Division of Neurology, Queen’s University, Kingston, ON, Canada K7L 3N6
| | - Lars H Pinborg
- Neurobiology Research Unit, Copenhagen University Hospital—Rigshospitalet, Copenhagen 2100, Denmark
- Epilepsy Clinic, Department of Neurology, Copenhagen University Hospital—Rigshopsitalet, Copenhagen 2100, Denmark
| | - Fernando Cendes
- Department of Neurology, University of Campinas, Campinas 13083-888, Brazil
- Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), University of Campinas, Campinas 13083-888, Brazil
| | - Fabian J Theis
- Institute of Computational Biology, Helmholtz Center Munich, Munich 85764, Germany
- Department of Mathematics, Technical University of Munich, Garching 85748, Germany
| | - Russell T Shinohara
- Penn Statistics in Imaging and Visualization Center, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - J Helen Cross
- Department of Developmental Neuroscience, UCL Great Ormond Street Institute for Child Health, London WC1N 1EH, UK
- Young Epilepsy, Lingfield, Surrey RH7 6PW, UK
| | - Torsten Baldeweg
- Department of Developmental Neuroscience, UCL Great Ormond Street Institute for Child Health, London WC1N 1EH, UK
- Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, UK
| | - Sophie Adler
- Department of Developmental Neuroscience, UCL Great Ormond Street Institute for Child Health, London WC1N 1EH, UK
| | - Konrad Wagstyl
- Department of Developmental Neuroscience, UCL Great Ormond Street Institute for Child Health, London WC1N 1EH, UK
- Wellcome Centre for Human Neuroimaging, University College London, London WC1N 3AR, UK
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Wagstyl K, Whitaker K, Raznahan A, Seidlitz J, Vértes PE, Foldes S, Humphreys Z, Hu W, Mo J, Likeman M, Davies S, Lenge M, Cohen NT, Tang Y, Wang S, Ripart M, Chari A, Tisdall M, Bargallo N, Conde‐Blanco E, Pariente JC, Pascual‐Diaz S, Delgado‐Martínez I, Pérez‐Enríquez C, Lagorio I, Abela E, Mullatti N, O'Muircheartaigh J, Vecchiato K, Liu Y, Caligiuri M, Sinclair B, Vivash L, Willard A, Kandasamy J, McLellan A, Sokol D, Semmelroch M, Kloster A, Opheim G, Yasuda C, Zhang K, Hamandi K, Barba C, Guerrini R, Gaillard WD, You X, Wang I, González‐Ortiz S, Severino M, Striano P, Tortora D, Kalviainen R, Gambardella A, Labate A, Desmond P, Lui E, O'Brien T, Shetty J, Jackson G, Duncan JS, Winston GP, Pinborg L, Cendes F, Cross JH, Baldeweg T, Adler S. Atlas of lesion locations and postsurgical seizure freedom in focal cortical dysplasia: A MELD study. Epilepsia 2022; 63:61-74. [PMID: 34845719 PMCID: PMC8916105 DOI: 10.1111/epi.17130] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/07/2021] [Accepted: 11/08/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Drug-resistant focal epilepsy is often caused by focal cortical dysplasias (FCDs). The distribution of these lesions across the cerebral cortex and the impact of lesion location on clinical presentation and surgical outcome are largely unknown. We created a neuroimaging cohort of patients with individually mapped FCDs to determine factors associated with lesion location and predictors of postsurgical outcome. METHODS The MELD (Multi-centre Epilepsy Lesion Detection) project collated a retrospective cohort of 580 patients with epilepsy attributed to FCD from 20 epilepsy centers worldwide. Magnetic resonance imaging-based maps of individual FCDs with accompanying demographic, clinical, and surgical information were collected. We mapped the distribution of FCDs, examined for associations between clinical factors and lesion location, and developed a predictive model of postsurgical seizure freedom. RESULTS FCDs were nonuniformly distributed, concentrating in the superior frontal sulcus, frontal pole, and temporal pole. Epilepsy onset was typically before the age of 10 years. Earlier epilepsy onset was associated with lesions in primary sensory areas, whereas later epilepsy onset was associated with lesions in association cortices. Lesions in temporal and occipital lobes tended to be larger than frontal lobe lesions. Seizure freedom rates varied with FCD location, from around 30% in visual, motor, and premotor areas to 75% in superior temporal and frontal gyri. The predictive model of postsurgical seizure freedom had a positive predictive value of 70% and negative predictive value of 61%. SIGNIFICANCE FCD location is an important determinant of its size, the age at epilepsy onset, and the likelihood of seizure freedom postsurgery. Our atlas of lesion locations can be used to guide the radiological search for subtle lesions in individual patients. Our atlas of regional seizure freedom rates and associated predictive model can be used to estimate individual likelihoods of postsurgical seizure freedom. Data-driven atlases and predictive models are essential for evidence-based, precision medicine and risk counseling in epilepsy.
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Appavu B, Temkit M'H, Foldes S, Burrows BT, Kuwabara M, Jacobson A, Adelson PD. Association of Outcomes with Model-Based Indices of Cerebral Autoregulation After Pediatric Traumatic Brain Injury. Neurocrit Care 2021; 35:640-650. [PMID: 34268644 DOI: 10.1007/s12028-021-01279-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/17/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We investigated whether model-based indices of cerebral autoregulation (CA) are associated with outcomes after pediatric traumatic brain injury. METHODS This was a retrospective analysis of a prospective clinical database of 56 pediatric patients with traumatic brain injury undergoing intracranial pressure monitoring. CA indices were calculated, including pressure reactivity index (PRx), wavelet pressure reactivity index (wPRx), pulse amplitude index (PAx), and correlation coefficient between intracranial pressure pulse amplitude and cerebral perfusion pressure (RAC). Each CA index was used to compute optimal cerebral perfusion pressure (CPP). Time of CPP below lower limit of autoregulation (LLA) or above upper limit of autoregulation (ULA) were computed for each index. Demographic, physiologic, and neuroimaging data were collected. Primary outcome was determined using Pediatric Glasgow Outcome Scale Extended (GOSE-Peds) at 12 months, with higher scores being suggestive of unfavorable outcome. Univariate and multiple linear regression with guided stepwise variable selection was used to find combinations of risk factors that can best explain the variability of GOSE-Peds scores, and the best fit model was applied to the age strata. We hypothesized that higher GOSE-Peds scores were associated with higher CA values and more time below LLA or above ULA for each index. RESULTS At the univariate level, CPP, dose of intracranial hypertension, PRx, PAx, wPRx, RAC, percent time more than ULA derived for PAx, and percent time less than LLA derived for PRx, PAx, wPRx, and RAC were all associated with GOSE-Peds scores. The best subset model selection on all pediatric patients identified that when accounting for CPP, increased dose of intracranial hypertension and percent time less than LLA derived for wPRx were independently associated with higher GOSE-Peds scores. Age stratification of the best fit model identified that in children less than 2 years of age or 8 years of age or more, percent time less than LLA derived for wPRx represented the sole independent predictor of higher GOSE-Peds scores when accounting for CPP and dose of intracranial hypertension. For children 2 years or younger to less than 8 years of age, dose of intracranial hypertension was identified as the sole independent predictor of higher GOSE-Peds scores when accounting for CPP and percent time less than LLA derived for wPRx. CONCLUSIONS Increased dose of intracranial hypertension, PRx, wPRx, PAx, and RAC values and increased percentage time less than LLA based on PRx, wPRx, PAx, and RAC are associated with higher GOSE-Peds scores, suggestive of unfavorable outcome. Reducing intracranial hypertension and maintaining CPP more than LLA based on wPRx may improve outcomes and warrants prospective investigation.
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Affiliation(s)
- Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA. .,Department of Child Health, University of Arizona College of Medicine, Phoenix, 550 E. Van Buren Street, Phoenix, AZ, USA.
| | - M 'Hamed Temkit
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA
| | - Stephen Foldes
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA.,Department of Child Health, University of Arizona College of Medicine, Phoenix, 550 E. Van Buren Street, Phoenix, AZ, USA
| | - Brian T Burrows
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA
| | - Michael Kuwabara
- Department of Child Health, University of Arizona College of Medicine, Phoenix, 550 E. Van Buren Street, Phoenix, AZ, USA.,Department of Radiology, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, USA
| | - Austin Jacobson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA
| | - P David Adelson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA.,Department of Child Health, University of Arizona College of Medicine, Phoenix, 550 E. Van Buren Street, Phoenix, AZ, USA
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Appavu B, Foldes S, Fox J, Shetty S, Oh A, Bassal F, Marku I, Mangum T, Boerwinkle V, Neilson D, Kruer M. Treatment Timing, EEG, Neuroimaging, and Outcomes After Acute Necrotizing Encephalopathy in Children. J Child Neurol 2021; 36:517-524. [PMID: 33393838 DOI: 10.1177/0883073820984063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute necrotizing encephalopathy (ANE) is a rare condition associated with rapid progression to coma and high incidence of morbidity and mortality. METHODS Clinical, electroencephalographic (EEG), and brain magnetic resonance imaging (MRI) characteristics and immunomodulatory therapy timing were retrospectively analyzed in children with ANE. ANE severity scores (ANE-SS) and MRI scores were also assessed. The associations of patient characteristics with 6-month modified Rankin scale (mRS) and length of hospitalization were determined using either univariate linear regression or one-way analysis of variance. RESULTS 7 children were retrospectively evaluated. Normal EEG sleep spindles (P = .024) and early treatment (R2 = .57, P = .030) were associated with improved outcomes (ie, decreased mRS). Higher ANE-SS (R2 = .79, P = .011), higher age (R2 = .62, P = .038), and presence of brainstem lesions (P = .015) were associated with longer length of hospitalization. Other patient characteristics were not significantly associated with mRS or length of hospitalization. CONCLUSION Early immunomodulatory therapy and normal sleep spindles are associated with better functional outcome in children with ANE.
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Affiliation(s)
- Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Stephen Foldes
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Jordana Fox
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Sheetal Shetty
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Ann Oh
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Freddy Bassal
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Iris Marku
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Tara Mangum
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Varina Boerwinkle
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Derek Neilson
- Department of Genetics, Phoenix Children's Hospital, 42283University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Michael Kruer
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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Appavu B, Foldes S, Burrows BT, Jacobson A, Abruzzo T, Boerwinkle V, Willyerd A, Mangum T, Gunnala V, Marku I, Adelson PD. Multimodal Assessment of Cerebral Autoregulation and Autonomic Function After Pediatric Cerebral Arteriovenous Malformation Rupture. Neurocrit Care 2020; 34:537-546. [PMID: 32748209 DOI: 10.1007/s12028-020-01058-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Management after cerebral arteriovenous malformation (AVM) rupture aims toward preventing hemorrhagic expansion while maintaining cerebral perfusion to avoid secondary injury. We investigated associations of model-based indices of cerebral autoregulation (CA) and autonomic function (AF) with outcomes after pediatric cerebral AVM rupture. METHODS Multimodal neurologic monitoring data from the initial 3 days after cerebral AVM rupture were retrospectively analyzed in children (< 18 years). AF indices included standard deviation of heart rate (HRsd), root-mean-square of successive differences in heart rate (HRrmssd), low-high frequency ratio (LHF), and baroreflex sensitivity (BRS). CA indices include pressure reactivity index (PRx), wavelet pressure reactivity indices (wPRx and wPRx-thr), pulse amplitude index (PAx), and correlation coefficient between intracranial pressure pulse amplitude and cerebral perfusion pressure (RAC). Percent time of cerebral perfusion pressure (CPP) below lower limits of autoregulation (LLA) was also computed for each CA index. Primary outcomes were determined using Pediatric Glasgow Outcome Score Extended-Pediatrics (GOSE-PEDs) at 12 months and acquired epilepsy. Association of biomarkers with outcomes was investigated using linear regression, Wilcoxon signed-rank, or Chi-square. RESULTS Fourteen children were analyzed. Lower AF indices were associated with poor outcomes (BRS [p = 0.04], HRsd [p = 0.04], and HRrmssd [p = 0.00]; and acquired epilepsy (LHF [p = 0.027]). Higher CA indices were associated with poor outcomes (PRx [p = 0.00], wPRx [p = 0.00], and wPRx-thr [p = 0.01]), and acquired epilepsy (PRx [p = 0.02] and wPRx [p = 0.00]). Increased time below LLA was associated with poor outcome (percent time below LLA based on PRx [p = 0.00], PAx [p = 0.04], wPRx-thr [p = 0.03], and RAC [p = 0.01]; and acquired epilepsy (PRx [p = 0.00], PAx [p = 0.00], wPRx-thr [p = 0.03], and RAC [p = 0.01]). CONCLUSIONS After pediatric cerebral AVM rupture, poor outcomes are associated with AF and CA when applying various neurophysiologic model-based indices. Prospective work is needed to assess these indices of CA and AF in clinical decision support.
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Affiliation(s)
- Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA.
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA.
| | - Stephen Foldes
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Brian T Burrows
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
| | - Austin Jacobson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
| | - Todd Abruzzo
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Varina Boerwinkle
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Anthony Willyerd
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Tara Mangum
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Vishal Gunnala
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Iris Marku
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - P D Adelson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
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6
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Appavu B, Burrows BT, Foldes S, Adelson PD. Approaches to Multimodality Monitoring in Pediatric Traumatic Brain Injury. Front Neurol 2019; 10:1261. [PMID: 32038449 PMCID: PMC6988791 DOI: 10.3389/fneur.2019.01261] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 11/13/2019] [Indexed: 02/04/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Improved methods of monitoring real-time cerebral physiology are needed to better understand when secondary brain injury develops and what treatment strategies may alleviate or prevent such injury. In this review, we discuss emerging technologies that exist to better understand intracranial pressure (ICP), cerebral blood flow, metabolism, oxygenation and electrical activity. We also discuss approaches to integrating these data as part of a multimodality monitoring strategy to improve patient care.
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Affiliation(s)
- Brian Appavu
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
| | - Brian T Burrows
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Stephen Foldes
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
| | - P David Adelson
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
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7
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Eldeeb S, Akcakaya M, Sybeldon M, Foldes S, Santarnecchi E, Pascual-Leone A, Sethi A. EEG-based functional connectivity to analyze motor recovery after stroke: A pilot study. Biomed Signal Process Control 2019. [DOI: 10.1016/j.bspc.2018.12.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Degenhart AD, Hiremath SV, Yang Y, Foldes S, Collinger JL, Boninger M, Tyler-Kabara EC, Wang W. Remapping cortical modulation for electrocorticographic brain-computer interfaces: a somatotopy-based approach in individuals with upper-limb paralysis. J Neural Eng 2018; 15:026021. [PMID: 29160240 PMCID: PMC5841472 DOI: 10.1088/1741-2552/aa9bfb] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Brain-computer interface (BCI) technology aims to provide individuals with paralysis a means to restore function. Electrocorticography (ECoG) uses disc electrodes placed on either the surface of the dura or the cortex to record field potential activity. ECoG has been proposed as a viable neural recording modality for BCI systems, potentially providing stable, long-term recordings of cortical activity with high spatial and temporal resolution. Previously we have demonstrated that a subject with spinal cord injury (SCI) could control an ECoG-based BCI system with up to three degrees of freedom (Wang et al 2013 PLoS One). Here, we expand upon these findings by including brain-control results from two additional subjects with upper-limb paralysis due to amyotrophic lateral sclerosis and brachial plexus injury, and investigate the potential of motor and somatosensory cortical areas to enable BCI control. APPROACH Individuals were implanted with high-density ECoG electrode grids over sensorimotor cortical areas for less than 30 d. Subjects were trained to control a BCI by employing a somatotopic control strategy where high-gamma activity from attempted arm and hand movements drove the velocity of a cursor. MAIN RESULTS Participants were capable of generating robust cortical modulation that was differentiable across attempted arm and hand movements of their paralyzed limb. Furthermore, all subjects were capable of voluntarily modulating this activity to control movement of a computer cursor with up to three degrees of freedom using the somatotopic control strategy. Additionally, for those subjects with electrode coverage of somatosensory cortex, we found that somatosensory cortex was capable of supporting ECoG-based BCI control. SIGNIFICANCE These results demonstrate the feasibility of ECoG-based BCI systems for individuals with paralysis as well as highlight some of the key challenges that must be overcome before such systems are translated to the clinical realm. ClinicalTrials.gov Identifier: NCT01393444.
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Affiliation(s)
- Alan D. Degenhart
- Systems Neuroscience Institute, University of Pittsburgh, PA, USA
- Center for the Neural Basis of Cognition, Pittsburgh, PA, USA
| | - Shivayogi V. Hiremath
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Physical Therapy, Temple University, Philadelphia, PA, USA
| | - Ying Yang
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stephen Foldes
- Center for the Neural Basis of Cognition, Pittsburgh, PA, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Veterans Affairs Medical Center, Pittsburgh, PA, USA
| | - Jennifer L. Collinger
- Center for the Neural Basis of Cognition, Pittsburgh, PA, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Veterans Affairs Medical Center, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Boninger
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Veterans Affairs Medical Center, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, Pittsburgh, PA, USA
| | - Elizabeth C. Tyler-Kabara
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wei Wang
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, Pittsburgh, PA, USA
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
- Barnes-Jewish Hospital, St. Louis, MO, USA
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Alhourani A, Pathak SK, Randazzo MJ, Wozny T, Kondylis E, Walls S, Ward M, Foldes S, Krieger D, Okonkwo DO, Richardson RM, Niranjan A. 183 MEG Identification of Reduced Functional Connectivity Following Concussion. Neurosurgery 2015. [DOI: 10.1227/01.neu.0000467147.89009.8b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Hiremath SV, Chen W, Wang W, Foldes S, Yang Y, Tyler-Kabara EC, Collinger JL, Boninger ML. Brain computer interface learning for systems based on electrocorticography and intracortical microelectrode arrays. Front Integr Neurosci 2015; 9:40. [PMID: 26113812 PMCID: PMC4462099 DOI: 10.3389/fnint.2015.00040] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 05/20/2015] [Indexed: 12/20/2022] Open
Abstract
A brain-computer interface (BCI) system transforms neural activity into control signals for external devices in real time. A BCI user needs to learn to generate specific cortical activity patterns to control external devices effectively. We call this process BCI learning, and it often requires significant effort and time. Therefore, it is important to study this process and develop novel and efficient approaches to accelerate BCI learning. This article reviews major approaches that have been used for BCI learning, including computer-assisted learning, co-adaptive learning, operant conditioning, and sensory feedback. We focus on BCIs based on electrocorticography and intracortical microelectrode arrays for restoring motor function. This article also explores the possibility of brain modulation techniques in promoting BCI learning, such as electrical cortical stimulation, transcranial magnetic stimulation, and optogenetics. Furthermore, as proposed by recent BCI studies, we suggest that BCI learning is in many ways analogous to motor and cognitive skill learning, and therefore skill learning should be a useful metaphor to model BCI learning.
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Affiliation(s)
- Shivayogi V Hiremath
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Pittsburgh, PA, USA ; Department of Veterans Affairs, Human Engineering Research Laboratories Pittsburgh, PA, USA
| | - Weidong Chen
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Pittsburgh, PA, USA ; Qiushi Academy for Advanced Studies (QAAS), Zhejiang University Hangzhou, China
| | - Wei Wang
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Pittsburgh, PA, USA ; Department of Bioengineering, University of Pittsburgh Pittsburgh, PA, USA ; Clinical and Translational Science Institute, University of Pittsburgh Pittsburgh, PA, USA ; Center for the Neural Basis of Cognition, Carnegie Mellon University and the University of Pittsburgh Pittsburgh, PA, USA
| | - Stephen Foldes
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Pittsburgh, PA, USA ; Department of Veterans Affairs, Human Engineering Research Laboratories Pittsburgh, PA, USA ; Center for the Neural Basis of Cognition, Carnegie Mellon University and the University of Pittsburgh Pittsburgh, PA, USA
| | - Ying Yang
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Pittsburgh, PA, USA ; Center for the Neural Basis of Cognition, Carnegie Mellon University and the University of Pittsburgh Pittsburgh, PA, USA
| | - Elizabeth C Tyler-Kabara
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Pittsburgh, PA, USA ; Department of Bioengineering, University of Pittsburgh Pittsburgh, PA, USA ; Department of Neurological Surgery, University of Pittsburgh Pittsburgh, PA, USA
| | - Jennifer L Collinger
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Pittsburgh, PA, USA ; Department of Veterans Affairs, Human Engineering Research Laboratories Pittsburgh, PA, USA ; Department of Bioengineering, University of Pittsburgh Pittsburgh, PA, USA ; Center for the Neural Basis of Cognition, Carnegie Mellon University and the University of Pittsburgh Pittsburgh, PA, USA
| | - Michael L Boninger
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Pittsburgh, PA, USA ; Department of Veterans Affairs, Human Engineering Research Laboratories Pittsburgh, PA, USA ; Department of Bioengineering, University of Pittsburgh Pittsburgh, PA, USA ; Clinical and Translational Science Institute, University of Pittsburgh Pittsburgh, PA, USA
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Abstract
CONTEXT Spinal cord injury (SCI) results in a loss of function and sensation below the level of the lesion. Neuroprosthetic technology has been developed to help restore motor and autonomic functions as well as to provide sensory feedback. FINDINGS This paper provides an overview of neuroprosthetic technology that aims to address the priorities for functional restoration as defined by individuals with SCI. We describe neuroprostheses that are in various stages of preclinical development, clinical testing, and commercialization including functional electrical stimulators, epidural and intraspinal microstimulation, bladder neuroprosthesis, and cortical stimulation for restoring sensation. We also discuss neural recording technologies that may provide command or feedback signals for neuroprosthetic devices. CONCLUSION/CLINICAL RELEVANCE Neuroprostheses have begun to address the priorities of individuals with SCI, although there remains room for improvement. In addition to continued technological improvements, closing the loop between the technology and the user may help provide intuitive device control with high levels of performance.
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