Efficacy and safety of transcranial direct current stimulation to the ipsilesional motor cortex in subacute stroke (NETS): a multicenter, randomized, double-blind, placebo-controlled trial

Background

Each year, five million people are left disabled after stroke. Upper-extremity (UE) dysfunction is a leading problem. Neuroplasticity can be enhanced by non-invasive brain stimulation (NIBS) but evidence from large, randomized multicenter trials is lacking. We aimed at demonstrating efficacy of NIBS to enhance motor recovery after ischemic stroke.

Methods

We randomly assigned patients to receive anodal transcranial direct current (tDCS, 1 mA, 20 min) or placebo stimulation ('control') over the primary motor cortex of the lesioned hemisphere in addition to standardized rehabilitative training over ten days in the subacute phase after stroke. The original study was planned to enrol 250 but, following a blinded interim analysis, ended with 123 participants. The primary outcome parameter was UE impairment, measured by UE-Fugl-Meyer-Assessment (UEFMA), one to seven days after the end of the treatment intervention (ClinicalTrials.gov, NCT00909714).

Findings

From 2009 to 2019, 123 patients were included, with 119 entering intention-to-treat analysis (ITT). The control group (N = 61) improved 8.9 (SD 7.7) UEFMA points, the tDCS group (N = 58) improved 9.0 (8.8) points. ITT was neutral with respect to the primary efficacy endpoint (p = 0.820). We found no difference in UEFMA change between active tDCS and control. The safety profile of tDCS was favorable. In particular, there were no seizures.

Interpretation

In patients with ischemic stroke, anodal tDCS applied to the motor cortex of the lesioned hemisphere over 10 days in the subacute phase was safe but did not improve the recovery of upper extremity function compared with placebo stimulation.

Funding

Deutsche Forschungsgemeinschaft (GE 844/4-1).

A role for retro-splenial cortex in the task-related P3 network

OBJECTIVE

The P3 is an event-related response observed in relation to task-relevant sensory events. Despite its ubiquitous presence, the neural generators of the P3 are controversial and not well identified.

METHODS

We compared source analysis of combined magneto- and electroencephalography (M/EEG) data with functional magnetic resonance imaging (fMRI) and simulation studies to better understand the sources of the P3 in an auditory oddball paradigm.

RESULTS

Our results suggest that the dominant source of the classical, postero-central P3 lies in the retro-splenial cortex of the ventral cingulate gyrus. A second P3 source in the anterior insular cortex contributes little to the postero-central maximum. Multiple other sources in the auditory, somatosensory, and anterior midcingulate cortex are active in an overlapping time window but can be functionally dissociated based on their activation time courses.

CONCLUSIONS

The retro-splenial cortex is a dominant source of the parietal P3 maximum in EEG.

SIGNIFICANCE

These results provide a new perspective for the interpretation of the extensive research based on the P3 response.

A role for retro-splenial cortex in the task-related P3 network

Objective

The P3 is an event-related response observed in relation to task-relevant sensory events. Despite its ubiquitous presence, the neural generators of the P3 are controversial and not well identified.

Methods

We compared source analysis of combined magneto- and electroencephalography (M/EEG) data with functional magnetic resonance imaging (fMRI) and simulation studies to better understand the sources of the P3 in an auditory oddball paradigm.

Results

Our results suggest that the dominant source of the classical, postero-central P3 lies in the retro-splenial cortex of the ventral cingulate gyrus. A second P3 source in the anterior insular cortex contributes little to the postero-central maximum. Multiple other sources in the auditory, somatosensory, and anterior midcingulate cortex are active in an overlapping time window but can be functionally dissociated based on their activation time courses.

Conclusion

The retro-splenial cortex is a dominant source of the parietal P3 maximum in EEG.

Significance

These results provide a new perspective for the interpretation of the extensive research based on the P3 response.

Management of Cerebral Venous Thrombosis Due to Adenoviral COVID-19 Vaccination

Objective

Cerebral venous thrombosis (CVT) caused by vaccine‐induced immune thrombotic thrombocytopenia (VITT) is a rare adverse effect of adenovirus‐based severe acute respiratory syndrome‐coronavirus 2 (SARS‐CoV‐2) vaccines. In March 2021, after autoimmune pathogenesis of VITT was discovered, treatment recommendations were developed. These comprised immunomodulation, non‐heparin anticoagulants, and avoidance of platelet transfusion. The aim of this study was to evaluate adherence to these recommendations and its association with mortality.

Methods

We used data from an international prospective registry of patients with CVT after the adenovirus‐based SARS‐CoV‐2 vaccination. We analyzed possible, probable, or definite VITT‐CVT cases included until January 18, 2022. Immunomodulation entailed administration of intravenous immunoglobulins and/or plasmapheresis.

Results

Ninety‐nine patients with VITT‐CVT from 71 hospitals in 17 countries were analyzed. Five of 38 (13%), 11 of 24 (46%), and 28 of 37 (76%) of the patients diagnosed in March, April, and from May onward, respectively, were treated in‐line with VITT recommendations (p < 0.001). Overall, treatment according to recommendations had no statistically significant influence on mortality (14/44 [32%] vs 29/55 [52%], adjusted odds ratio [OR] = 0.43, 95% confidence interval [CI] = 0.16–1.19). However, patients who received immunomodulation had lower mortality (19/65 [29%] vs 24/34 [70%], adjusted OR = 0.19, 95% CI = 0.06–0.58). Treatment with non‐heparin anticoagulants instead of heparins was not associated with lower mortality (17/51 [33%] vs 13/35 [37%], adjusted OR = 0.70, 95% CI = 0.24–2.04). Mortality was also not significantly influenced by platelet transfusion (17/27 [63%] vs 26/72 [36%], adjusted OR = 2.19, 95% CI = 0.74–6.54).

Conclusions

In patients with VITT‐CVT, adherence to VITT treatment recommendations improved over time. Immunomodulation seems crucial for reducing mortality of VITT‐CVT. ANN NEUROL 2022;92:562–573

A multicenter, randomized, double-blind, placebo-controlled trial to test efficacy and safety of transcranial direct current stimulation to the motor cortex after stroke (NETS): study protocol

Introduction

The WHO estimates that each year 5 million people are left permanently disabled after stroke. Adjuvant treatments to promote the effects of rehabilitation are urgently needed. Cortical excitability and neuroplasticity can be enhanced by non-invasive brain stimulation but evidence from sufficiently powered, randomized controlled multi-center clinical trials is absent.

Methods

Neuroregeneration enhanced by transcranial direct current stimulation (tDCS) in stroke (NETS) tested efficacy and safety of anodal tDCS to the primary motor cortex of the lesioned hemisphere in the subacute phase (day 5–45) after cerebral ischemia. Stimulation was combined with standardized rehabilitative training and repeatedly applied in 10 sessions over a period of 2 weeks in a planned sample of 120 patients. Primary outcome parameter was upper-extremity function at the end of the 2-weeks intervention period of active treatment or placebo (1:1 randomization), measured by the upper-extremity Fugl-Meyer assessment. Sustainability of the treatment effect was evaluated by additional follow-up visits after 30 and 90 days. Further secondary endpoints included metrics of arm and hand function, stroke impact scale, and the depression module of the patient health questionnaire.

Perspective

NETS was aimed at providing evidence for an effective and safe adjuvant treatment for patients after stroke.

Trial registration: ClinicalTrials.gov Identifier NCT00909714. Registered May 28, 2009.

Characteristics and Outcomes of Patients With Cerebral Venous Sinus Thrombosis in SARS-CoV-2 Vaccine-Induced Immune Thrombotic Thrombocytopenia

Importance

Thrombosis with thrombocytopenia syndrome (TTS) has been reported after vaccination with the SARS-CoV-2 vaccines ChAdOx1 nCov-19 (Oxford-AstraZeneca) and Ad26.COV2.S (Janssen/Johnson & Johnson).

Objective

To describe the clinical characteristics and outcome of patients with cerebral venous sinus thrombosis (CVST) after SARS-CoV-2 vaccination with and without TTS.

Design, Setting, and Participants

This cohort study used data from an international registry of consecutive patients with CVST within 28 days of SARS-CoV-2 vaccination included between March 29 and June 18, 2021, from 81 hospitals in 19 countries. For reference, data from patients with CVST between 2015 and 2018 were derived from an existing international registry. Clinical characteristics and mortality rate were described for adults with (1) CVST in the setting of SARS-CoV-2 vaccine-induced immune thrombotic thrombocytopenia, (2) CVST after SARS-CoV-2 vaccination not fulling criteria for TTS, and (3) CVST unrelated to SARS-CoV-2 vaccination.

Exposures

Patients were classified as having TTS if they had new-onset thrombocytopenia without recent exposure to heparin, in accordance with the Brighton Collaboration interim criteria.

Main Outcomes and Measures

Clinical characteristics and mortality rate.

Results

Of 116 patients with postvaccination CVST, 78 (67.2%) had TTS, of whom 76 had been vaccinated with ChAdOx1 nCov-19; 38 (32.8%) had no indication of TTS. The control group included 207 patients with CVST before the COVID-19 pandemic. A total of 63 of 78 (81%), 30 of 38 (79%), and 145 of 207 (70.0%) patients, respectively, were female, and the mean (SD) age was 45 (14), 55 (20), and 42 (16) years, respectively. Concomitant thromboembolism occurred in 25 of 70 patients (36%) in the TTS group, 2 of 35 (6%) in the no TTS group, and 10 of 206 (4.9%) in the control group, and in-hospital mortality rates were 47% (36 of 76; 95% CI, 37-58), 5% (2 of 37; 95% CI, 1-18), and 3.9% (8 of 207; 95% CI, 2.0-7.4), respectively. The mortality rate was 61% (14 of 23) among patients in the TTS group diagnosed before the condition garnered attention in the scientific community and 42% (22 of 53) among patients diagnosed later.

Conclusions and Relevance

In this cohort study of patients with CVST, a distinct clinical profile and high mortality rate was observed in patients meeting criteria for TTS after SARS-CoV-2 vaccination.

Diagnostic Accuracy in Teleneurological Stroke Consultations

Background: The accuracy of diagnosing acute cerebrovascular disease via a teleneurology service and the characteristics of misdiagnosed patients are insufficiently known. Methods: A random sample (n = 1500) of all teleneurological consultations conducted between July 2015 and December 2017 was screened. Teleneurological diagnosis and hospital discharge diagnosis were compared. Diagnoses were then grouped into two main categories: cerebrovascular disease (CVD) and noncerebrovascular disease. Test characteristics were calculated. Results: Out of 1078 consultations, 52% (n = 561) had a final diagnosis of CVD. Patients with CVD could be accurately identified via teleneurological consultation (sensitivity 95.2%, 95% CI 93.2–96.8), but we observed a tendency towards false-positive diagnosis (specificity 77.4%, 95% CI 73.6–80.8). Characteristics of patients with a false-negative CVD diagnosis were similar to those of patients with a true-positive diagnosis, but patients with a false-negative CVD diagnosis had ischemic heart disease less frequently. In retrospect, one patient would have been considered a candidate for intravenous thrombolysis (0.2%). Conclusions: Teleneurological consultations are accurate for identifying patients with CVD, and there is a very low rate of missed candidates for thrombolysis. Apart from a lower prevalence of ischemic heart disease, characteristics of “stroke chameleons” were similar to those of correctly identified CVD patients.

Auditory cortex activity related to perceptual awareness versus masking of tone sequences

Sequences of repeating tones can be masked by other tones of different frequency. When these tone sequences are perceived, nevertheless, a prominent neural response in the auditory cortex is evoked by each tone of the sequence. When the targets are detected based on their isochrony, participants know that they are listening to the target once they detected it. To explore if the neural activity is more closely related to this detection task or to perceptual awareness, this magnetoencephalography (MEG) study used targets that could only be identified with cues provided after or before the masked target. In experiment 1, multiple mono-tone streams with jittered inter-stimulus interval were used, and the tone frequency of the target was indicated by a cue. Results showed no differential auditory cortex activity between hit and miss trials with post-stimulus cues. A late negative response for hit trials was only observed for pre-stimulus cues, suggesting a task-related component. Since experiment 1 provided no evidence for a link of a difference response with tone awareness, experiment 2 was planned to probe if detection of tone streams was linked to a difference response in auditory cortex. Random-tone sequences were presented in the presence of a multi-tone masker, and the sequence was repeated without masker thereafter. Results showed a prominent difference wave for hit compared to miss trials in experiment 2 evoked by targets in the presence of the masker. These results suggest that perceptual awareness of tone streams is linked to neural activity in auditory cortex.

Context-dependent role of selective attention for change detection in multi-speaker scenes

Disappearance of a voice or other sound source may often go unnoticed when the auditory scene is crowded. We explored the role of selective attention for this change deafness with magnetoencephalography in multi-speaker scenes. Each scene was presented two times in direct succession, and one target speaker was frequently omitted in Scene 2. When listeners were previously cued to the target speaker, activity in auditory cortex time locked to the target speaker's sound envelope was selectively enhanced in Scene 1, as was determined by a cross-correlation analysis. Moreover, the response was stronger for hit trials than for miss trials, confirming that selective attention played a role for subsequent change detection. If selective attention to the streams where the change occurred was generally required for successful change detection, neural enhancement of this stream would also be expected without cue in hit compared to miss trials. However, when listeners were not previously cued to the target, no enhanced activity for the target speaker was observed for hit trials, and there was no significant difference between hit and miss trials. These results, first, confirm a role for attention in change detection for situations where the target source is known. Second, they suggest that the omission of a speaker, or more generally an auditory stream, can alternatively be detected without selective attentional enhancement of the target stream. Several models and strategies could be envisaged for change detection in this case, including global comparison of the subsequent scenes.

Auditory-cortex lesions impair contralateral tone-pattern detection under informational masking

Impaired hearing contralateral to unilateral auditory-cortex lesions is typically only observed under conditions of perceptual competition, such as dichotic presentation or speech in noise. It remains unclear, however, if the source of this effect is direct competition in frequency-specific neurons, or if enhanced processing load in more distant frequencies can also impair auditory detection. To evaluate this question, we studied a group of patients with unilateral auditory-cortex lesions (N = 14, six left-hemispheric (LH), eight right-hemispheric (RH); four females; age range 26-72 years) and a control group (N = 25; 15 females; age range 18-76 years) with a target-detection task in presence of a multi-tone masker, which can produce informational masking. The results revealed reduced sensitivity for monaural target streams presented contralateral to auditory-cortex lesions, with an approximately 10% higher error rate in the contra-lesional ear. A general, bilateral reduction of target detection was only observed in a subgroup of patients, who were classified as additionally suffering from auditory neglect. These results demonstrate that auditory-cortex lesions impair monaural, contra-lesional target detection under informational masking. The finding supports the hypothesis that neural mechanisms beyond direct competition in frequency-specific neurons can be a source of impaired hearing under perceptual competition in patients with unilateral auditory-cortex lesions.

Effects of Cross-modal Asynchrony on Informational Masking in Human Cortex

In many everyday listening situations, an otherwise audible sound may go unnoticed amid multiple other sounds. This auditory phenomenon, called informational masking (IM), is sensitive to visual input and involves early (50–250 msec) activity in the auditory cortex (the so-called awareness-related negativity). It is still unclear whether and how the timing of visual input influences the neural correlates of IM in auditory cortex. To address this question, we obtained simultaneous behavioral and neural measures of IM from human listeners in the presence of a visual input stream and varied the asynchrony between the visual stream and the rhythmic auditory target stream (in-phase, antiphase, or random). Results show effects of cross-modal asynchrony on both target detectability (RT and sensitivity) and the awareness-related negativity measured with EEG, which were driven primarily by antiphasic audiovisual stimuli. The neural effect was limited to the interval shortly before listeners' behavioral report of the target. Our results indicate that the relative timing of visual input can influence the IM of a target sound in the human auditory cortex. They further show that this audiovisual influence occurs early during the perceptual buildup of the target sound. In summary, these findings provide novel insights into the interaction of IM and multisensory interaction in the human brain.

Transient human auditory cortex activation during volitional attention shifting

While strong activation of auditory cortex is generally found for exogenous orienting of attention, endogenous, intra-modal shifting of auditory attention has not yet been demonstrated to evoke transient activation of the auditory cortex. Here, we used fMRI to test if endogenous shifting of attention is also associated with transient activation of the auditory cortex. In contrast to previous studies, attention shifts were completely self-initiated and not cued by transient auditory or visual stimuli. Stimuli were two dichotic, continuous streams of tones, whose perceptual grouping was not ambiguous. Participants were instructed to continuously focus on one of the streams and switch between the two after a while, indicating the time and direction of each attentional shift by pressing one of two response buttons. The BOLD response around the time of the button presses revealed robust activation of the auditory cortex, along with activation of a distributed task network. To test if the transient auditory cortex activation was specifically related to auditory orienting, a self-paced motor task was added, where participants were instructed to ignore the auditory stimulation while they pressed the response buttons in alternation and at a similar pace. Results showed that attentional orienting produced stronger activity in auditory cortex, but auditory cortex activation was also observed for button presses without focused attention to the auditory stimulus. The response related to attention shifting was stronger contralateral to the side where attention was shifted to. Contralateral-dominant activation was also observed in dorsal parietal cortex areas, confirming previous observations for auditory attention shifting in studies that used auditory cues.

A roadmap for the study of conscious audition and its neural basis

How and which aspects of neural activity give rise to subjective perceptual experience-i.e. conscious perception-is a fundamental question of neuroscience. To date, the vast majority of work concerning this question has come from vision, raising the issue of generalizability of prominent resulting theories. However, recent work has begun to shed light on the neural processes subserving conscious perception in other modalities, particularly audition. Here, we outline a roadmap for the future study of conscious auditory perception and its neural basis, paying particular attention to how conscious perception emerges (and of which elements or groups of elements) in complex auditory scenes. We begin by discussing the functional role of the auditory system, particularly as it pertains to conscious perception. Next, we ask: what are the phenomena that need to be explained by a theory of conscious auditory perception? After surveying the available literature for candidate neural correlates, we end by considering the implications that such results have for a general theory of conscious perception as well as prominent outstanding questions and what approaches/techniques can best be used to address them.This article is part of the themed issue 'Auditory and visual scene analysis'.

Neural Correlates of Auditory Perceptual Awareness and Release from Informational Masking Recorded Directly from Human Cortex: A Case Study

In complex acoustic environments, even salient supra-threshold sounds sometimes go unperceived, a phenomenon known as informational masking. The neural basis of informational masking (and its release) has not been well-characterized, particularly outside auditory cortex. We combined electrocorticography in a neurosurgical patient undergoing invasive epilepsy monitoring with trial-by-trial perceptual reports of isochronous target-tone streams embedded in random multi-tone maskers. Awareness of such masker-embedded target streams was associated with a focal negativity between 100 and 200 ms and high-gamma activity (HGA) between 50 and 250 ms (both in auditory cortex on the posterolateral superior temporal gyrus) as well as a broad P3b-like potential (between ~300 and 600 ms) with generators in ventrolateral frontal and lateral temporal cortex. Unperceived target tones elicited drastically reduced versions of such responses, if at all. While it remains unclear whether these responses reflect conscious perception, itself, as opposed to pre- or post-perceptual processing, the results suggest that conscious perception of target sounds in complex listening environments may engage diverse neural mechanisms in distributed brain areas.

Lateralization and Binaural Interaction of Middle-Latency and Late-Brainstem Components of the Auditory Evoked Response

We used magnetoencephalography to examine lateralization and binaural interaction of the middle-latency and late-brainstem components of the auditory evoked response (the MLR and SN10, respectively). Click stimuli were presented either monaurally, or binaurally with left- or right-leading interaural time differences (ITDs). While early MLR components, including the N19 and P30, were larger for monaural stimuli presented contralaterally (by approximately 30 and 36 % in the left and right hemispheres, respectively), later components, including the N40 and P50, were larger ipsilaterally. In contrast, MLRs elicited by binaural clicks with left- or right-leading ITDs did not differ. Depending on filter settings, weak binaural interaction could be observed as early as the P13 but was clearly much larger for later components, beginning at the P30, indicating some degree of binaural linearity up to early stages of cortical processing. The SN10, an obscure late-brainstem component, was observed consistently in individuals and showed linear binaural additivity. The results indicate that while the MLR is lateralized in response to monaural stimuli-and not ITDs-this lateralization reverses from primarily contralateral to primarily ipsilateral as early as 40 ms post stimulus and is never as large as that seen with fMRI.

Does the mismatch negativity operate on a consciously accessible memory trace?

The extent to which the contents of short-term memory are consciously accessible is a fundamental question of cognitive science. In audition, short-term memory is often studied via the mismatch negativity (MMN), a change-related component of the auditory evoked response that is elicited by violations of otherwise regular stimulus sequences. The prevailing functional view of the MMN is that it operates on preattentive and even preconscious stimulus representations. We directly examined the preconscious notion of the MMN using informational masking and magnetoencephalography. Spectrally isolated and otherwise suprathreshold auditory oddball sequences were occasionally random rendered inaudible by embedding them in random multitone masker "clouds." Despite identical stimulation/task contexts and a clear representation of all stimuli in auditory cortex, MMN was only observed when the preceding regularity (that is, the standard stream) was consciously perceived. The results call into question the preconscious interpretation of MMN and raise the possibility that it might index partial awareness in the absence of overt behavior.

Interaction of streaming and attention in human auditory cortex

Serially presented tones are sometimes segregated into two perceptually distinct streams. An ongoing debate is whether this basic streaming phenomenon reflects automatic processes or requires attention focused to the stimuli. Here, we examined the influence of focused attention on streaming-related activity in human auditory cortex using magnetoencephalography (MEG). Listeners were presented with a dichotic paradigm in which left-ear stimuli consisted of canonical streaming stimuli (ABA_ or ABAA) and right-ear stimuli consisted of a classical oddball paradigm. In phase one, listeners were instructed to attend the right-ear oddball sequence and detect rare deviants. In phase two, they were instructed to attend the left ear streaming stimulus and report whether they heard one or two streams. The frequency difference (ΔF) of the sequences was set such that the smallest and largest ΔF conditions generally induced one- and two-stream percepts, respectively. Two intermediate ΔF conditions were chosen to elicit bistable percepts (i.e., either one or two streams). Attention enhanced the peak-to-peak amplitude of the P1-N1 complex, but only for ambiguous ΔF conditions, consistent with the notion that automatic mechanisms for streaming tightly interact with attention and that the latter is of particular importance for ambiguous sound sequences.

Stimulus dependence of contralateral dominance in human auditory cortex

The auditory system is often considered to show little contralateral dominance but physiological reports on the contralateral dominance of activity evoked by monaural sound vary widely. Here, we show that part of this variation is stimulus-dependent: blood oxygen level dependent (BOLD) responses to 32 s of monaurally presented unmodulated noise (UN) showed activation in contralateral auditory cortex (AC) and deactivation in ipsilateral AC compared to nonstimulus baseline. Slow amplitude-modulated (AM) noise evoked strong contralateral activation and minimal ipsilateral activation. The contrast of AM-versus-UN was used to separate fMRI activity related to the slow amplitude modulation per se. This difference activation was bilateral although still stronger in contralateral AC. In magnetoencephalography (MEG), the response was dominated by the steady-state activity phase locked to the amplitude modulation. This MEG activity showed no consistent contralateral dominance across listeners. Subcortical BOLD activation was strongly contralateral subsequent to the superior olivary complex (SOC) and showed no significant difference between modulated and UN. An acallosal participant showed similar fMRI activation as the group, ruling transcallosal transmission an unlikely source of ipsilateral enhancement or ipsilateral deactivation. These results suggest that ascending activity subsequent to the SOC is strongly dominant contralateral to the stimulus ear. In contrast, the part of BOLD and MEG activity related to slow amplitude modulation is more bilateral and only observed in AC. Ipsilateral deactivation can potentially bias measures of contralateral BOLD dominance and should be considered in future studies.

Sustained selective attention to competing amplitude-modulations in human auditory cortex

Auditory selective attention plays an essential role for identifying sounds of interest in a scene, but the neural underpinnings are still incompletely understood. Recent findings demonstrate that neural activity that is time-locked to a particular amplitude-modulation (AM) is enhanced in the auditory cortex when the modulated stream of sounds is selectively attended to under sensory competition with other streams. However, the target sounds used in the previous studies differed not only in their AM, but also in other sound features, such as carrier frequency or location. Thus, it remains uncertain whether the observed enhancements reflect AM-selective attention. The present study aims at dissociating the effect of AM frequency on response enhancement in auditory cortex by using an ongoing auditory stimulus that contains two competing targets differing exclusively in their AM frequency. Electroencephalography results showed a sustained response enhancement for auditory attention compared to visual attention, but not for AM-selective attention (attended AM frequency vs. ignored AM frequency). In contrast, the response to the ignored AM frequency was enhanced, although a brief trend toward response enhancement occurred during the initial 15 s. Together with the previous findings, these observations indicate that selective enhancement of attended AMs in auditory cortex is adaptive under sustained AM-selective attention. This finding has implications for our understanding of cortical mechanisms for feature-based attentional gain control.

Functional imaging of auditory scene analysis

Our auditory system is constantly faced with the task of decomposing the complex mixture of sound arriving at the ears into perceptually independent streams constituting accurate representations of individual sound sources. This decomposition, termed auditory scene analysis, is critical for both survival and communication, and is thought to underlie both speech and music perception. The neural underpinnings of auditory scene analysis have been studied utilizing invasive experiments with animal models as well as non-invasive (MEG, EEG, and fMRI) and invasive (intracranial EEG) studies conducted with human listeners. The present article reviews human neurophysiological research investigating the neural basis of auditory scene analysis, with emphasis on two classical paradigms termed streaming and informational masking. Other paradigms - such as the continuity illusion, mistuned harmonics, and multi-speaker environments - are briefly addressed thereafter. We conclude by discussing the emerging evidence for the role of auditory cortex in remapping incoming acoustic signals into a perceptual representation of auditory streams, which are then available for selective attention and further conscious processing. This article is part of a Special Issue entitled Human Auditory Neuroimaging.

Time is of the essence for auditory scene analysis

Using computational models and stimuli that resemble natural acoustic signals, auditory scientists explore how we segregate competing streams of sound.

Role of pattern, regularity, and silent intervals in auditory stream segregation based on inter-aural time differences

Tone triplets separated by a pause (ABA_) are a popular tone-repetition pattern to study auditory stream segregation. Such triplets produce a galloping rhythm when integrated, but isochronous rhythms when segregated. Other patterns lacking a pause may produce less-prominent rhythmic differences but stronger streaming. Here, we evaluated whether this difference is readily explained by the presence of the pause and potentially associated with the reduction of adaptation, or whether there is contribution of tone pattern per se. Sequences with repetitive ABA_ and ABAA patterns were presented in magnetoencephalography. A and B tones were separated by differences in inter-aural time differences (ΔITD). Results showed that the stronger streaming of ABAA was associated with a more prominent release from the adaptation of the P(1)m in auditory cortex. We further compared behavioral streaming responses for patterns with and without pauses, and varied the position of the pause and pattern regularity. Results showed a major effect of the pauses' presence, but no prominent effects of tone pattern or pattern regularity. These results make a case for the existence of an early, primitive streaming mechanism that does not require an analysis of the tone pattern at later stages suggested by predictive-coding models of auditory streaming. The results are better explained by the simpler population-separation model and stress the previously observed role of neural adaptation for streaming perception.

Sustained BOLD and theta activity in auditory cortex are related to slow stimulus fluctuations rather than to pitch

Human functional MRI (fMRI) and magnetoencephalography (MEG) studies indicate a pitch-specific area in lateral Heschl's gyrus. Single-cell recordings in monkey suggest that sustained-firing, pitch-specific neurons are located lateral to primary auditory cortex. We reevaluated whether pitch strength contrasts reveal sustained pitch-specific responses in human auditory cortex. Sustained BOLD activity in auditory cortex was found for iterated rippled noise (vs. noise or silence) but not for regular click trains (vs. jittered click trains or silence). In contrast, iterated rippled noise and click trains produced similar pitch responses in MEG. Subsequently performed time-frequency analysis of the MEG data suggested that the dissociation of cortical BOLD activity between iterated rippled noise and click trains is related to theta band activity. It appears that both sustained BOLD and theta activity are associated with slow non-pitch-specific stimulus fluctuations. BOLD activity in the inferior colliculus was sustained for both stimulus types and varied neither with pitch strength nor with the presence of slow stimulus fluctuations. These results suggest that BOLD activity in auditory cortex is much more sensitive to slow stimulus fluctuations than to constant pitch, compromising the accessibility of the latter. In contrast, pitch-related activity in MEG can easily be separated from theta band activity related to slow stimulus fluctuations.

Transient bold activity locked to perceptual reversals of auditory streaming in human auditory cortex and inferior colliculus

Our auditory system separates and tracks temporally interleaved sound sources by organizing them into distinct auditory streams. This streaming phenomenon is partly determined by physical stimulus properties but additionally depends on the internal state of the listener. As a consequence, streaming perception is often bistable and reversals between one- and two-stream percepts may occur spontaneously or be induced by a change of the stimulus. Here, we used functional MRI to investigate perceptual reversals in streaming based on interaural time differences (ITD) that produce a lateralized stimulus perception. Listeners were continuously presented with two interleaved streams, which slowly moved apart and together again. This paradigm produced longer intervals between reversals than stationary bistable stimuli but preserved temporal independence between perceptual reversals and physical stimulus transitions. Results showed prominent transient activity synchronized with the perceptual reversals in and around the auditory cortex. Sustained activity in the auditory cortex was observed during intervals where the ΔITD could potentially produce streaming, similar to previous studies. A localizer-based analysis additionally revealed transient activity time locked to perceptual reversals in the inferior colliculus. These data suggest that neural activity associated with streaming reversals is not limited to the thalamo-cortical system but involves early binaural processing in the auditory midbrain, already.

Functional dissociation of transient and sustained fMRI BOLD components in human auditory cortex revealed with a streaming paradigm based on interaural time differences

A number of physiological studies suggest that feature-selective adaptation is relevant to the pre-processing for auditory streaming, the perceptual separation of overlapping sound sources. Most of these studies are focused on spectral differences between streams, which are considered most important for streaming. However, spatial cues also support streaming, alone or in combination with spectral cues, but physiological studies of spatial cues for streaming remain scarce. Here, we investigate whether the tuning of selective adaptation for interaural time differences (ITD) coincides with the range where streaming perception is observed. FMRI activation that has been shown to adapt depending on the repetition rate was studied with a streaming paradigm where two tones were differently lateralized by ITD. Listeners were presented with five different ΔITD conditions (62.5, 125, 187.5, 343.75, or 687.5 μs) out of an active baseline with no ΔITD during fMRI. The results showed reduced adaptation for conditions with ΔITD ≥ 125 μs, reflected by enhanced sustained BOLD activity. The percentage of streaming perception for these stimuli increased from approximately 20% for ΔITD = 62.5 μs to > 60% for ΔITD = 125 μs. No further sustained BOLD enhancement was observed when the ΔITD was increased beyond ΔITD = 125 μs, whereas the streaming probability continued to increase up to 90% for ΔITD = 687.5 μs. Conversely, the transient BOLD response, at the transition from baseline to ΔITD blocks, increased most prominently as ΔITD was increased from 187.5 to 343.75 μs. These results demonstrate a clear dissociation of transient and sustained components of the BOLD activity in auditory cortex.

Activity associated with stream segregation in human auditory cortex is similar for spatial and pitch cues

Streaming is a perceptual mechanism by which the brain segregates information from multiple sound sources in our environment and assigns them to distinct auditory streams. Examples for streaming cues are differences in frequency spectrum, pitch, or space, and potential neural correlates for streaming based on spectral and pitch cues have been identified in the auditory cortex. Here, magnetoencephalography (MEG) and functional magnetic resonance imaging (fMRI) were used to evaluate if response enhancement in auditory cortex associated with streaming represents a general pattern that is independent of the stimulus cue. Interaural time differences (ITDs) were used as a spatial streaming cue and were compared with streaming based on fundamental frequency (f(0)) differences. The MEG results showed enhancement of the P(1)m after 60-90 ms that was similar during streaming based on ITD and pitch. Sustained fMRI activity was enhanced at identical sites in Heschl's gyrus and planum temporale for both cues; no topographical specificity for space or pitch was found for the streaming-associated enhancement. These results support the hypothesis of an early convergence of the neural representation for auditory streams that is independent of the acoustic cue that the streaming is based on.

BOLD responses in human auditory cortex are more closely related to transient MEG responses than to sustained ones

Blood oxygen level dependent-functional magnetic resonance imaging (BOLD-fMRI) and magnetoencephalographic (MEG) signals are both coupled to postsynaptic potentials, although their relationship is incompletely understood. Here, the wide range of BOLD-fMRI and MEG responses produced by auditory cortex was exploited to better understand the BOLD-fMRI/MEG relationship. Measurements of BOLD and MEG responses were made in the same subjects using the same stimuli for both modalities. The stimuli, 24-s sequences of click trains, had duty cycles of 2.5, 25, 72, and 100%. For the 2.5% sequence, the BOLD response was elevated throughout the sequence, whereas for 100%, it peaked after sequence onset and offset and showed a diminished elevation in between. On the finer timescale of MEG, responses at 2.5% consisted of a complex of transients, including N(1)m, to each click train of the sequence, whereas for 100% the only transients occurred at sequence onset and offset between which there was a sustained elevation in the MEG signal (a sustained field). A model that separately estimated the contributions of transient and sustained MEG signals to the BOLD response best fit BOLD measurements when the transient contribution was weighted 8- to 10-fold more than the sustained one. The findings suggest that BOLD responses in the auditory cortex are tightly coupled to the neural activity underlying transient, not sustained, MEG signals.

A sustained deviance response evoked by the auditory oddball paradigm

OBJECTIVE

Previous studies have suggested that the MMN(m) is related to selective adaptation of the N(1m). Since selective adaptation has also been reported for the sustained field, we hypothesized a second deviance response in addition to the MMN(m). The present study evaluated the existence of this wave.

METHODS

Magnetoencephalography was used to record deviance responses for pure tones of 1000 and 1050Hz. Tone duration was 50, 150, or 600ms in separate sets. Our hypothesis was that a sustained deviance response would increase with tone duration.

RESULTS

The data revealed a sustained deviance response with a similar source configuration as the main MMN(m), but a distinct time course. The sustained deviance response increased with the tone duration, but less than the standard sustained field. Moreover, the sustained deviance response was already present for short (50ms) tones.

CONCLUSIONS

The MMN(m) is followed by a sustained deviance response in the oddball paradigm. While some characteristics of the response coincide with the sustained field, its growth with tone duration differs. The response could possibly be related to automatic orienting of attention, but further studies are required to explore its functional role.

SIGNIFICANCE

The sustained deviance response is a separate component--distinct from the MMN(m) and P3--that needs to be considered in the evaluation of data obtained with the auditory oddball paradigm.

Rate perception and the auditory 40-Hz steady-state fields evoked by two-tone sequences

The rate perception of tone sequences reflects the physical repetition rate for identical sound elements. More complex sequences are perceived at the physical rate or at lower rates, depending on perceptual organization. Here, we used magnetoencephalography and psychophysical studies to evaluate the possible relationship between rate perception of such rapid, 40-Hz tone trains and the 40-Hz steady-state response (SSR) in human primary auditory cortex. In Experiment 1, the 40-Hz SSR evoked by monotone sequences of 1000 and 600 Hz were compared to the response evoked by alternating-tone sequences of the same frequencies. The results showed that the 40-Hz SSR for the alternating-tones was attenuated compared to the monotones. In Experiment 2, frequency differences across a range of 25-300 Hz were studied. Compared to a 1000-Hz monotone sequence, the 40-Hz SSR was reduced. Amplitude reduction was most prominent for frequency differences of 200 Hz and more, which were generally perceived with half-the-physical rate. We discuss possible physiological mechanisms of this finding and its relationship to perception.

Neural correlates of auditory perceptual awareness under informational masking

Our ability to detect target sounds in complex acoustic backgrounds is often limited not by the ear's resolution, but by the brain's information-processing capacity. The neural mechanisms and loci of this "informational masking" are unknown. We combined magnetoencephalography with simultaneous behavioral measures in humans to investigate neural correlates of informational masking and auditory perceptual awareness in the auditory cortex. Cortical responses were sorted according to whether or not target sounds were detected by the listener in a complex, randomly varying multi-tone background known to produce informational masking. Detected target sounds elicited a prominent, long-latency response (50-250 ms), whereas undetected targets did not. In contrast, both detected and undetected targets produced equally robust auditory middle-latency, steady-state responses, presumably from the primary auditory cortex. These findings indicate that neural correlates of auditory awareness in informational masking emerge between early and late stages of processing within the auditory cortex.

The pulse-train auditory aftereffect and the perception of rapid amplitude modulations

Prolonged listening to a pulse train with repetition rates around 100 Hz induces a striking aftereffect, whereby subsequently presented sounds are heard with an unusually "metallic" timbre [Rosenblith et al., Science 106, 333-335 (1947)]. The mechanisms responsible for this auditory aftereffect are currently unknown. Whether the aftereffect is related to an alteration of the perception of temporal envelope fluctuations was evaluated. Detection thresholds for sinusoidal amplitude modulation (AM) imposed onto noise-burst carriers were measured for different AM frequencies (50-500 Hz), following the continuous presentation of a periodic pulse train, a temporally jittered pulse train, or an unmodulated noise. AM detection thresholds for AM frequencies of 100 Hz and above were significantly elevated compared to thresholds in quiet, following the presentation of the pulse-train inducers, and both induced a subjective auditory aftereffect. Unmodulated noise, which produced no audible aftereffect, left AM detection thresholds unchanged. Additional experiments revealed that, like the Rosenblith et al. aftereffect, the effect on AM thresholds does not transfer across ears, is not eliminated by protracted training, and can last several tens of seconds. The results suggest that the Rosenblith et al. aftereffect is related to a temporary alteration in the perception of fast temporal envelope fluctuations in sounds.

Representation of auditory-filter phase characteristics in the cortex of human listeners

Harmonic tone complexes with component phases, adjusted using a variant of a method proposed by Schroeder, can produce pure-tone masked thresholds differing by >20 dB. This phenomenon has been qualitatively explained by the phase characteristics of the auditory filters on the basilar membrane, which differently affect the flat envelopes of the Schroeder-phase maskers. We examined the influence of auditory-filter phase characteristics on the neural representation in the auditory cortex by investigating cortical auditory evoked fields (AEFs). We found that the P1m component exhibited larger amplitudes when a long-duration tone was presented in a repeating linearly downward sweeping (Schroeder positive, or m(+)) masker than in a repeating linearly upward sweeping (Schroeder negative, or m(-)) masker. We also examined the neural representation of short-duration tone pulses presented at different temporal positions within a single period of three maskers differing in their component phases (m(+), m(-), and sine phase m(0)). The P1m amplitude varied with the position of the tone pulse in the masker and depended strongly on the masker waveform. The neuromagnetic results in all cases were consistent with the perceptual data obtained with the same stimuli and with results from simulations of neural activity at the output of cochlear preprocessing. These findings demonstrate that phase effects in peripheral auditory processing are accurately reflected up to the level of the auditory cortex.

The effect of temporal context on the sustained pitch response in human auditory cortex

Recent neuroimaging studies have shown that activity in lateral Heschl's gyrus covaries specifically with the strength of musical pitch. Pitch strength is important for the perceptual distinctiveness of an acoustic event, but in complex auditory scenes, the distinctiveness of an event also depends on its context. In this magnetoencephalography study, we evaluate how temporal context influences the sustained pitch response (SPR) in lateral Heschl's gyrus. In 2 sequences of continuously alternating, periodic target intervals and a more irregular baseline interval, the distinctiveness of the target was decreased in 1 of 2 ways--either by increasing the pitch strength of the baseline or by decreasing the pitch strength of the target. The results show that the amplitude of the SPR increases monotonically with the distinctiveness of the target. Moreover, SPR amplitude is greater for the sequence, where the pitch strength of the target is varied, compared with the condition, where the baseline is varied. Two subsequent experiments show that the amplitude of the SPR increases as duty cycle decreases, in a pitch "strength" contrast and in a pitch "value" contrast. These results indicate that the SPR adapts to recent stimulus history, enhancing the response to rare and brief events.