Black blood MRI sequences in the acute management of ruptured and unruptured intracranial aneurysms

We present an illustrative case series in which high spatial resolution black blood (BB) MRI sequences were used as an adjunct in the acute management of intracranial aneurysms with diagnostic uncertainty regarding rupture status. Several acute management dilemmas are discussed including the surveillance of previously treated ruptured intracranial aneurysms, identifying culprit lesion(s) amongst multiple ruptured intracranial aneurysms, and risk stratifying incidental unruptured intracranial aneurysms. We present our experience which supports the evaluation of this vessel wall imaging technique in larger multi-centre observational studies. MR imaging was performed on a 3.0 Tesla Siemens Somatom Vida system and sequences used included: Susceptibility Weighted Imaging, Diffusion Weighted Imaging & 3D T1 pre- and post-contrast-enhanced BB sequences.

Outcomes of Fluorescence-Guided vs White Light Resection of Glioblastoma in a Single Institution

Background Glioblastoma (GBM) is the most common malignant primary brain tumour and confers a very poor prognosis. Maximal safe resection of tumour is the goal of neurosurgical intervention and may be more easily achieved through the use of surgical adjuncts such as fluorescence-guided surgery (FGS). 5-Aminolevulinic acid (5-ALA) accumulates in GBM tissue and fluoresce red, distinguishing tumour cells from the surrounding tissue and therefore making resection easier. 5-ALA-guided resection in GBM has been shown to increase resection rates and prolong progression-free survival without impacting post-operative morbidity. Radiotherapy and concomitant chemotherapy also improve survival in GBM. Other factors such as patient age and molecular status of the tumour also impact prognosis. Aims The aim of this study was to compare the outcomes of 5-ALA vs white light-guided resection for glioblastoma in the west of Scotland. Methods  This was a retrospective analysis of baseline characteristics (age, sex, tumour molecular markers, radiotherapy, chemotherapy, anatomical location of tumour and treatment group) and outcomes (mortality, survival, degree of resection and performance status) of 239 patients who underwent primary resection of glioblastoma over a four-year period (2017-2020). A variety of statistical methods were used to analyse the relationship between each variable and surgical technique; multivariate Cox regression and the Kaplan-Meier method were used in survival analysis. Results  5-ALA-guided resection substantially improved resection rates (74.0% vs 40.2%). Mortality at 15 months was 5.1% lower in the 5-ALA group (52.0% vs 57.1%, p = 0.53), and patients lived an average of 68 days longer compared to the white light group (444 days vs 376 days, p = 0.21). There were negligible differences between treatment groups in terms of post-operative performance status (PS) and post-operative complications. In our multivariate Cox regression model, six factors were statistically significant at a level of p ≤ 0.05: age, radiotherapy, chemotherapy, O(6)-methylguanine-DNA methyltransferase (MGMT) methylation, anatomical location and >90% resection. Receiving chemotherapy and radiotherapy, MGMT methylation and undergoing >90% resection conferred a survival benefit at 15 months. Older age and multi-focal disease were related to a worsened mortality rate. Undergoing radiotherapy and maximal resection were the two greatest predictors of improved survival, reducing mortality risk by 58% and 51%, respectively. Conclusion 5-ALA-guided resection improved resection rates without impacting post-operative morbidity. 5-ALA-guided resection was associated with improved survival and lower mortality rate, but this was not statistically significant. Receiving chemoradiotherapy, MGMT methylation and undergoing maximal resection conferred a survival benefit, whilst older age and multi-focal disease were associated with a poorer prognosis.

A survey of the radiological follow-up of unruptured intracranial aneurysms in the United Kingdom

OBJECTIVE

Unruptured intracranial aneurysms (UIA) are common. For many the treatment risks outweigh their risk of subarachnoid haemorrhage and patients undergo surveillance imaging. There is little data to inform if and how to monitor UIAs resulting in widely varying practices. This study aimed to determine the current practice of unruptured UIA surveillance in the United Kingdom.

METHODS

A questionnaire was designed to address the themes of surveillance protocols for UIA including when surveillance is initiated, how frequently it is performed, and when it is terminated. Additionally, how aneurysm growth is managed and how clinically meaningful growth is defined were explored. The questionnaire was distributed to members of the British Neurovascular Group using probability-based cluster and non-probability purposive sampling methods.

RESULTS

Responses were received from 30 of the 30 (100.0%) adult neurosurgical units in the United Kingdom of which 27 (90.0%) routinely perform surveillance for aneurysm growth. Only four units had a unit policy. The mean patient age up to which a unit would initiate follow-up of a low-risk UIA was 65.4 ± 9.0 years. The time points at which imaging is performed varied widely. There was an even split between whether units use a fixed duration of follow-up or an age threshold for terminating surveillance. Forty percent of units will follow-up patients more than 5 years from diagnosis. The magnitude in the change in size that was felt to constitute growth ranged from 1 to 3mm. No units routinely used vessel wall imaging although 27 had access to 3T MRI capable of performing it.

CONCLUSIONS

There is marked heterogeneity in surveillance practices between units in the United Kingdom. This study will help units better understand their practice relative to their peers and provide a framework forplanning further research on aneurysm growth.

Risk of Aneurysm Rupture (ROAR) study: protocol for a long-term, longitudinal, UK multicentre study of unruptured intracranial aneurysms

INTRODUCTION

Unruptured intracranial aneurysms (UIA) are common in the adult population, but only a relatively small proportion will rupture. It is therefore essential to have accurate estimates of rupture risk to target treatment towards those who stand to benefit and avoid exposing patients to the risks of unnecessary treatment. The best available UIA natural history data are the PHASES study. However, this has never been validated and given the known heterogeneity in the populations, methods and biases of the constituent studies, there is a need to do so. There are also many potential predictors not considered in PHASES that require evaluation, and the estimated rupture risk is largely based on short-term follow-up (mostly 1 year). The aims of this study are to: (1) test the accuracy of PHASES in a UK population, (2) evaluate additional predictors of rupture and (3) assess long-term UIA rupture rates.

METHODS AND ANALYSIS

The Risk of Aneurysm Rupture study is a longitudinal multicentre study that will identify patients with known UIA seen in neurosurgery units. Patients will have baseline demographics and aneurysm characteristics collected by their neurosurgery unit and then a single aggregated national cohort will be linked to databases of hospital admissions and deaths to identify all patients who may have subsequently suffered a subarachnoid haemorrhage. All matched admissions and deaths will be checked against medical records to confirm the diagnosis of aneurysmal subarachnoid haemorrhage. The target sample size is 20 000 patients. The primary outcome will be aneurysm rupture resulting in hospital admission or death. Cox regression models will be built to test each of the study's aims.

ETHICS AND DISSEMINATION

Ethical approval has been given by South Central Hampshire A Research Ethics Committee (21SC0064) and Confidentiality Advisory Group support (21CAG0033) provided under Section 251 of the NHS Act 2006. The results will be disseminated in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN17658526.

Radiological follow-up of endovascularly treated intracranial aneurysms: a survey of current practice in the UK and Ireland

PURPOSE

Due to the risk of intracranial aneurysm (IA) recurrence and the potential requirement for re-treatment following endovascular treatment (EVT), radiological follow-up of these aneurysms is necessary. There is little evidence to guide the duration and frequency of this follow-up. The aim of this study was to establish the current practice in neurosurgical units in the UK and Ireland.

METHODS

A survey was designed with input from interventional neuroradiologists and neurosurgeons. Neurovascular consultants in each of the 30 neurosurgical units providing a neurovascular service in the UK and Ireland were contacted and asked to respond to questions regarding the follow-up practice for IA treated with EVT in their department.

RESULTS

Responses were obtained from 28/30 (94%) of departments. There was evidence of wide variations in the duration and frequency of follow-up, with a minimum follow-up duration for ruptured IA that varied from 18 months in 5/28 (18%) units to 5 years in 11/28 (39%) of units. Young patient age, previous subarachnoid haemorrhage and incomplete IA occlusion were cited as factors that would prompt more intensive surveillance, although larger and broad-necked IA were not followed-up more closely in the majority of departments.

CONCLUSIONS

There is a wide variation in the radiological follow-up of IA treated with EVT in the UK and Ireland. Further standardisation of this aspect of patient care is likely to be beneficial, but further evidence on the behaviour of IA following EVT is required in order to inform this process.

Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Risk of Rupture After Intracranial Aneurysm Growth

Importance

Unruptured intracranial aneurysms not undergoing preventive endovascular or neurosurgical treatment are often monitored radiologically to detect aneurysm growth, which is associated with an increase in risk of rupture. However, the absolute risk of aneurysm rupture after detection of growth remains unclear.

Objective

To determine the absolute risk of rupture of an aneurysm after detection of growth during follow-up and to develop a prediction model for rupture.

Design, Setting, and Participants

Individual patient data were obtained from 15 international cohorts. Patients 18 years and older who had follow-up imaging for at least 1 untreated unruptured intracranial aneurysm with growth detected at follow-up imaging and with 1 day or longer of follow-up after growth were included. Fusiform or arteriovenous malformation-related aneurysms were excluded. Of the 5166 eligible patients who had follow-up imaging for intracranial aneurysms, 4827 were excluded because no aneurysm growth was detected, and 27 were excluded because they had less than 1 day follow-up after detection of growth.

Exposures

All included aneurysms had growth, defined as 1 mm or greater increase in 1 direction at follow-up imaging.

Main Outcomes and Measures

The primary outcome was aneurysm rupture. The absolute risk of rupture was measured with the Kaplan-Meier estimate at 3 time points (6 months, 1 year, and 2 years) after initial growth. Cox proportional hazards regression was used to identify predictors of rupture after growth detection.

Results

A total of 312 patients were included (223 [71%] were women; mean [SD] age, 61 [12] years) with 329 aneurysms with growth. During 864 aneurysm-years of follow-up, 25 (7.6%) of these aneurysms ruptured. The absolute risk of rupture after growth was 2.9% (95% CI, 0.9-4.9) at 6 months, 4.3% (95% CI, 1.9-6.7) at 1 year, and 6.0% (95% CI, 2.9-9.1) at 2 years. In multivariable analyses, predictors of rupture were size (7 mm or larger hazard ratio, 3.1; 95% CI, 1.4-7.2), shape (irregular hazard ratio, 2.9; 95% CI, 1.3-6.5), and site (middle cerebral artery hazard ratio, 3.6; 95% CI, 0.8-16.3; anterior cerebral artery, posterior communicating artery, or posterior circulation hazard ratio, 2.8; 95% CI, 0.6-13.0). In the triple-S (size, site, shape) prediction model, the 1-year risk of rupture ranged from 2.1% to 10.6%.

Conclusion and Relevance

Within 1 year after growth detection, rupture occurred in approximately 1 of 25 aneurysms. The triple-S risk prediction model can be used to estimate absolute risk of rupture for the initial period after detection of growth.

Spontaneous Resolution of Radiotherapy-induced Craniopharyngioma Cyst

Craniopharyngioma cyst enlargement after surgery and radiation therapy is often presumed to represent a treatment failure, instigating further management strategies. We present an eight-year-old girl with a small intrasellar residuum post-resection who then developed cystic enlargement post-radiotherapy. With close surveillance, the cyst spontaneously resolved.

The validity of EORTC GBM prognostic calculator on survival of GBM patients in the West of Scotland

OBJECTIVE

It is now accepted that the addition of temozolomide to radiotherapy in the treatment of patients with newly diagnosed glioblastoma multiforme (GBM) significantly improves survival. In 2008, a subanalysis of the original study data was performed, and an online "GBM Calculator" was made available on the European Organisation for Research and Treatment of Cancer (EORTC) website allowing users to estimate patients' survival outcomes. We tested this calculator against actual local survival data to validate its use in our patients.

MATERIALS AND METHODS

Prospectively collected clinical data were analysed on 105 consecutive patients receiving concurrent chemoradiotherapy following surgical treatment of GBM between December 2004 and February 2009. Using the EORTC online calculator, survival outcomes were generated for these patients and compared with their actual survival.

RESULTS

The median overall survival for the entire cohort was 15.3 months (range 2.8-50.5 months), with 1-year and 2-year overall survival of 65.7% and 19%, respectively. This is in comparison to the median overall predictive survival of 21.3 months, with 1-year and 2-year survival of 95% and 39.5%, respectively. Case by case analysis also showed that the survival was overestimated in nearly 80% of patients. Subgroup analyses showed similar overestimation of patients' survival, except calculator Model 3 which utilised MGMT status.

CONCLUSION

Use of the EORTC GBM prognostic calculator would have overestimated the survival of the majority of our patients with GBM. Uncertainty exists as to the cause of overestimation in the cohort although local socioeconomic factors might play a role. The different calculator models yielded different outcomes and the "best" predictor of survival for the cohort under study utilised the tumour MGMT status. We would strongly encourage similar local studies of validity testing prior to employing the online prognostic calculator for other population groups.

A survival analysis of GBM patients in the West of Scotland pre- and post-introduction of the Stupp regime

OBJECTIVE

It is now accepted that the concomitant administration of temozolomide with radiotherapy (Stupp regime), in the treatment of patients with newly diagnosed glioblastoma multiforme (GBM), significantly improves survival and this practice has been adopted locally since 2004. However, survival outcomes in cancer can vary in different population groups, and outcomes can be affected by a number of local factors including socioeconomic status. In the West of Scotland, we have one of the worse socioeconomic status and overall health record for a western European country. With the ongoing reorganisation and rationalisation in the National Health Service, the addition of prolonged courses of chemotherapy to patients' management significantly adds to the financial burden of a cash stripped NHS. A survival analysis in patients with GBM was therefore performed, comparing outcomes of pre- and post-introduction of the Stupp regime, to justify the current practice.

MATERIALS AND METHODS

Prospectively collected clinical data were analysed in 105 consecutive patients receiving concurrent chemoradiotherapy (Stupp regime) following surgical treatment of GBM between December 2004 and February 2009. This was compared to those of 106 consecutive GBM patients who had radical radiotherapy (pre-Stupp regime) post-surgery between January 2001 and February 2006.

RESULTS

The median overall survival for the post-Stupp cohort was 15.3 months (range, 2.83-50.5 months), with 1-year and 2-year overall survival rates of 65.7% and 19%, respectively. This was in comparison with the median overall pre-Stupp survival of 10.7 months, with 1-year and 2-year survival rates of 42.6% and 12%, respectively (log-rank test, p < 0.001). Multivariate Cox regression analysis showed that independent prognostic factors for better survival were younger age, greater extent of surgical resection and a post-operative chemoradiotherapy regime.

CONCLUSION

Significant survival benefit has been achieved, following the introduction of the Stupp regime, in GBM patients in the West of Scotland.

Developmental venous anomalies--two cases with venous thrombosis

Developmental venous anomalies (DVA) are generally considered the most common vascular anomalies. They are usually asymptomatic and display a benign clinical course. We report two cases of thrombosed developmental venous anomalies. Both patients developed venous infarcts with haemorrhagic transformation from the thrombosed DVA, and 1 patient needed decompressive craniectomy.

The differential diagnosis of longitudinally extensive transverse myelitis

Longitudinally extensive transverse myelitis refers to florid and widespread inflammation of the spinal cord causing T2 hyperintensity on spinal magnetic resonance imaging that is seen to extend over three or more vertebral segments. Whilst rare, longitudinally extensive transverse myelitis is clinically important as it can lead to catastrophic morbidity, and a group of these patients are at risk of further attacks. Early identification and establishment of the underlying aetiology is vital in order to initiate appropriate therapy and optimize outcomes. Whilst longitudinally extensive transverse myelitis is classically associated with neuromyelitis optica, there are many other causes. These include other inflammatory aetiologies, infection, malignancy and metabolic disturbance. Some of these are readily treatable. Laboratory and radiological investigations can help to differentiate these causes. Treatment of longitudinally extensive transverse myelitis hinges on distinguishing inflammatory and non-inflammatory aetiologies and identifying patients who are at high risk of a recurrent course.

Modeling spatiotemporal covariance for magnetoencephalography or electroencephalography source analysis

We propose a new model to approximate spatiotemporal noise covariance for use in neural electromagnetic source analysis, which better captures temporal variability in background activity. As with other existing formalisms, our model employs a Kronecker product of matrices representing temporal and spatial covariance. In our model, spatial components are allowed to have differing temporal covariances. Variability is represented as a series of Kronecker products of spatial component covariances and corresponding temporal covariances. Unlike previous attempts to model covariance through a sum of Kronecker products, our model is designed to have a computationally manageable inverse. Despite increased descriptive power, inversion of the model is fast, making it useful in source analysis. We have explored two versions of the model. One is estimated based on the assumption that spatial components of background noise have uncorrelated time courses. Another version, which gives closer approximation, is based on the assumption that time courses are statistically independent. The accuracy of the structural approximation is compared to an existing model, based on a single Kronecker product, using both Frobenius norm of the difference between spatiotemporal sample covariance and a model, and scatter plots. Performance of ours and previous models is compared in source analysis of a large number of single dipole problems with simulated time courses and with background from authentic magnetoencephalography data.

Dopaminergic modulation and rod contribution in the generation of oscillatory potentials in the tiger salamander retina

The roles of rod and cone input and of dopamine in the generation of oscillatory potentials were studied in tiger salamander retina. Under scotopic conditions, oscillations were elicited with a green, but not a red stimulus. With mesopic background illumination, both stimuli caused oscillations. Addition of quinpirole to a mesopic retina eliminated oscillations while SKF-38393 had no effect. Similarly, addition of sulpiride to a light-adapted retina elicited oscillatory activity, but SCH 22390 had no effect. These results suggest that oscillatory potentials are elicited through activation of the rod pathway and are modulated by dopamine through D2-receptors.

A high frequency resonance in the responses of retinal ganglion cells to rapidly modulated stimuli: a computer model

Brisk Y-type ganglion cells in the cat retina exhibit a high frequency resonance (HFR) in their responses to large, rapidly modulated stimuli. We used a computer model to test whether negative feedback mediated by axon-bearing amacrine cells onto ganglion cells could account for the experimentally observed properties of HFRs. Temporal modulation transfer functions (tMTFs) recorded from model ganglion cells exhibited HFR peaks whose amplitude, width, and locations were qualitatively consistent with experimental data. Moreover, the wide spatial distribution of axon-mediated feedback accounted for the observed increase in HFR amplitude with stimulus size. Model phase plots were qualitatively similar to those recorded from Y ganglion cells, including an anomalous phase advance that in our model coincided with the amplification of low-order harmonics that overlapped the HFR peak. When axon-mediated feedback in the model was directed primarily to bipolar cells, whose synaptic output was graded, or else when the model was replaced with a simple cascade of linear filters, it was possible to produce large HFR peaks but the region of anomalous phase advance was always eliminated, suggesting the critical involvement of strongly non-linear feedback loops. To investigate whether HFRs might contribute to visual processing, we simulated high frequency ocular tremor by rapidly modulating a naturalistic image. Visual signals riding on top of the imposed jitter conveyed an enhanced representation of large objects. We conclude that by amplifying responses to ocular tremor, HFRs may selectively enhance the processing of large image features.

Simultaneously detected biomagnetic signals and NMR

We have obtained 1H NMR spectra simultaneously with high temporal resolution biomagnetic signals such as the magnetocardiogram (MCG) and magnetomyogram (MMG). The NMR spectra are acquired at measurement fields of 2-50 microT, with corresponding proton Larmor frequencies of 80-2000 Hz. Our measurements demonstrate a method suitable for MR imaging with concurrent measurement of biomagnetic signals that can provide sub-millisecond temporal resolution. The narrow line widths, reduction in susceptibility noise and enhanced spectral resolution at ultra low fields provide a new and extremely sensitive measurement method that may enable direct imaging of biological currents by detecting the phase or frequency shifts produced by magnetic fields arising from those currents. The results of our simultaneous measurements of NMR with MCG and MMG are compared to results from a current phantom to investigate the exciting potential of direct MRI of bioelectric currents.

MUSIC seeded multi-dipole MEG modeling using the Constrained Start Spatio-Temporal modeling procedure

The Constrained Start Spatio-Temporal modeling program (CSST) is an objective multi-dipole, multi-start MEG/EEG analysis procedure that randomly selects from 100 to 100,000 initial dipole configurations, and runs a nonlinear simplex search on each of these configurations employing a reduced Chi-square statistic as the minimization criterion, to obtain a set of dipole configurations that best fit the data [Ranken, 2002]. A parallel version of CSST is implemented in IDL and MPI, making CSST usable on a single computer, or on a Linux cluster. We have now developed a multi-resolution version of MUSIC [Mosher, 1992] [Mosher, 1998] that provides an 80% or more reduction in the number of forward calculations needed to obtain results comparable to a 160,000 point MUSIC scan, on a 2 mm grid that defines a brain volume. The multi-resolution MUSIC scan provides an improved set of initial dipole estimates for the CSST analysis. In preliminary tests on real and simulated MEG data, with model orders ranging between 5 and 7 dipoles, the best performance improvements were obtained by mixing in 1 to 3 dipole locations randomly drawn from the best MUSIC locations, with randomly selected locations from the brain volume to complete the selected model order. We have also developed an improved method for sampling the brain volume for initial configurations. These improvements have led to a 75% reduction in the number of starting configurations required to obtain 5-10 best solutions with equal or lower reduced Chi-square values, when compared to the best solutions from the previous version of CSST.

The influence of brain tissue anisotropy on human EEG and MEG

The influence of gray and white matter tissue anisotropy on the human electroencephalogram (EEG) and magnetoencephalogram (MEG) was examined with a high resolution finite element model of the head of an adult male subject. The conductivity tensor data for gray and white matter were estimated from magnetic resonance diffusion tensor imaging. Simulations were carried out with single dipoles or small extended sources in the cortical gray matter. The inclusion of anisotropic volume conduction in the brain was found to have a minor influence on the topology of EEG and MEG (and hence source localization). We found a major influence on the amplitude of EEG and MEG (and hence source strength estimation) due to the change in conductivity and the inclusion of anisotropy. We expect that inclusion of tissue anisotropy information will improve source estimation procedures.

Scattered-light imaging in vivo tracks fast and slow processes of neurophysiological activation

We imaged fast optical changes associated with evoked neural activation in the dorsal brainstem of anesthetized rats, using a novel imaging device. The imager consisted of a gradient-index (GRIN) lens, a microscope objective, and a miniature charged-coupled device (CCD) video camera. We placed the probe in contact with tissue above cardiorespiratory areas of the nucleus of the solitary tract and illuminated the tissue with 780-nm light through flexible fibers around the probe perimeter. The focus depth was adjusted by moving the camera and microscope objective relative to the fixed GRIN lens. Back-scattered light images were relayed through the GRIN lens to the CCD camera. Video frames were digitized at 100 frames per second, along with tracheal pressure, arterial blood pressure, and electrocardiogram signals recorded at 1 kHz per channel. A macroelectrode placed under the GRIN lens recorded field potentials from the imaged area. Aortic, vagal, and superior laryngeal nerves were dissected free of surrounding tissue within the neck. Separate shocks to each dissected nerve elicited evoked electrical responses and caused localized optical activity patterns. The optical response was modeled by four distinct temporal components corresponding to putative physical mechanisms underlying scattered light changes. Region-of-interest analysis revealed image areas which were dominated by one or more of the different time-course components, some of which were also optimally recorded at different tissue depths. Two slow optical components appear to correspond to hemodynamic responses to metabolic demand associated with activation. Two fast optical components paralleled electrical evoked responses.

Continuous image and electrophysiological recording with real-time processing and control

Collecting continuous video together with multichannel electrophysiological data and other experimental modalities requires high bandwidth and storage capacities, as well as accurate synchronization to detect correlations between different recorded events. Often, experiments are highly complex, with many variables requiring immediate analysis and feedback during the course of the experiment. In addition, output channels require real-time control with high time resolution. We have explored several approaches to a system that can perform the above functions. The design of our system considered a number of issues, including time intervals between control and acquisition events, longest continuous recording period, data transfer bottleneck considerations, file archiving and format, and real-time display and processing. To demonstrate the system, we describe an experiment for characterizing rapid evoked scattered light changes in neural tissue, in vivo, using simultaneous electronic image acquisition and electrophysiological recording.

Conductivity tensor mapping of the human brain using diffusion tensor MRI

Knowledge of the electrical conductivity properties of excitable tissues is essential for relating the electromagnetic fields generated by the tissue to the underlying electrophysiological currents. Efforts to characterize these endogenous currents from measurements of the associated electromagnetic fields would significantly benefit from the ability to measure the electrical conductivity properties of the tissue noninvasively. Here, using an effective medium approach, we show how the electrical conductivity tensor of tissue can be quantitatively inferred from the water self-diffusion tensor as measured by diffusion tensor magnetic resonance imaging. The effective medium model indicates a strong linear relationship between the conductivity and diffusion tensor eigenvalues (respectively, final sigma and d) in agreement with theoretical bounds and experimental measurements presented here (final sigma/d approximately 0.844 +/- 0.0545 S small middle dots/mm(3), r(2) = 0.945). The extension to other biological transport phenomena is also discussed.

A focusing image probe for assessing neural activity in vivo

We describe a compact, focusing image probe to record rapid optical changes from neural tissue. A gradient index (GRIN) lens served as a relay lens from tissue to a microscope objective which projected an image onto a CCD camera. The microscope objective and camera assembly was adjusted independently from the GRIN lens, allowing focus changes without disturbing the probe/tissue interface; firm contact minimized movement and specular reflectance. Fiber optics around the probe perimeter provided diffuse illumination from a 780 nm laser, or 660 and 560 nm light emitting diodes. To characterize depth-of-field, we imaged a black suture through increasing tissue thicknesses. Light modulation by the suture remained detectable down to 900 microm using 780 nm illumination. We acquired images from cardiorespiratory areas of the rat dorsal medulla, at different depths and illumination wavelengths. Images illuminated at 560 nm were dominated by vasculature flow patterns, while 660 nm illumination revealed different spatial patterns which preceded vascular flow by 40 ms and may represent cardiac-related neural activity. Using 780 nm light, image sequences triggered by the cardiac R-wave showed vascular perfusion changes with delayed and broader responses at deeper levels. Electrical stimulation within the vagal bundle caused fast optical changes which track the electrical response, with a different spatial distribution from hemodynamic signals.

Bayesian inference applied to the electromagnetic inverse problem

We present a new approach to the electromagnetic inverse problem that explicitly addresses the ambiguity associated with its ill-posed character. Rather than calculating a single "best" solution according to some criterion, our approach produces a large number of likely solutions that both fit the data and any prior information that is used. Whereas the range of the different likely results is representative of the ambiguity in the inverse problem even with prior information present, features that are common across a large number of the different solutions can be identified and are associated with a high degree of probability. This approach is implemented and quantified within the formalism of Bayesian inference, which combines prior information with that of measurement in a common framework using a single measure. To demonstrate this approach, a general neural activation model is constructed that includes a variable number of extended regions of activation and can incorporate a great deal of prior information on neural current such as information on location, orientation, strength, and spatial smoothness. Taken together, this activation model and the Bayesian inferential approach yield estimates of the probability distributions for the number, location, and extent of active regions. Both simulated MEG data and data from a visual evoked response experiment are used to demonstrate the capabilities of this approach.

Diffusion imaging with hyperpolarized 3He Gas

We used MRI of hyperpolarized 3He to demonstrate some novel aspects of gas diffusion. Two different techniques were used. First, a slice was burned into a one-dimensional image by inverting the spins in the slice and diffusion was studied by measuring the magnetization as it filled the depleted slice. A diffusion coefficient was determined by the fit of these data. Second, one-dimensional diffusion images were made using a Stejskal-Tanner PGSE method. This was done with and without a temperature gradient present, showing that the effect of temperature can be dynamically monitored by such diffusion images. Copyright 1997 Academic Press. Copyright 1997Academic Press

Retinotopic organization of human visual cortex: departures from the classical model

Retinotopic mapping strategies similar to those used for invasive electrophysiological studies to identify multiple visual areas in monkeys have been adapted for noninvasive studies in humans, using magnetic recordings of brain activity in conjunction with anatomical magnetic resonance imaging. The retinotopic organization of the primary visual area (V1) in the left hemisphere of human subjects was examined by presenting a small patterned stimuli near the vertical and horizontal meridians in the lower right visual field. In contrast with the classical model of V1 retinotopy, our results suggest that the representation of the horizontal meridian does not necessarily correspond in a one-to-one manner with the base of the calcarine fissure and that some lower field stimuli can activate regions in the lower bank of the fissure. The results also indicate significant individual variability in the details of how V1 maps around the calcarine fissure.

Neuromagnetic source imaging with FOCUSS: a recursive weighted minimum norm algorithm

The paper describes a new algorithm for tomographic source reconstruction in neural electromagnetic inverse problems. Termed FOCUSS (FOCal Underdetermined System Solution), this algorithm combines the desired features of the two major approaches to electromagnetic inverse procedures. Like multiple current dipole modeling methods, FOCUSS produces high resolution solutions appropriate for the highly localized sources often encountered in electromagnetic imaging. Like linear estimation methods, FOCUSS allows current sources to assume arbitrary shapes and it preserves the generality and ease of application characteristic of this group of methods. It stands apart from standard signal processing techniques because, as an initialization-dependent algorithm, it accommodates the non-unique set of feasible solutions that arise from the neuroelectric source constraints. FOCUSS is based on recursive, weighted norm minimization. The consequence of the repeated weighting procedure is, in effect, to concentrate the solution in the minimal active regions that are essential for accurately reproducing the measurements. The FOCUSS algorithm is introduced and its properties are illustrated in the context of a number of simulations, first using exact measurements in 2- and 3-D problems, and then in the presence of noise and modeling errors. The results suggest that FOCUSS is a powerful algorithm with considerable utility for tomographic current estimation.

Mapping function in the human brain with magnetoencephalography, anatomical magnetic resonance imaging, and functional magnetic resonance imaging

Integrated analyses of human anatomical and functional measurements offer a powerful paradigm for human brain mapping. Magnetoencephalography (MEG) and EEG provide excellent temporal resolution of neural population dynamics as well as capabilities for source localization. Anatomical magnetic resonance imaging (MRI) provides excellent spatial resolution of head and brain anatomy, whereas functional MRI (fMRI) techniques provide an alternative measure of neural activation based on associated hemodynamic changes. These methodologies constrain and complement each other and can thereby improve our interpretation of functional neural organization. We have developed a number of computational tools and techniques for the visualization, comparison, and integrated analysis of multiple neuroimaging techniques. Construction of geometric anatomical models from volumetric MRI data allows improved models of the head volume conductor and can provide powerful constraints for neural electromagnetic source modeling. These approaches, coupled to enhanced algorithmic strategies for the inverse problem, can significantly enhance the accuracy of source-localization procedures. We have begun to apply these techniques for studies of the functional organization of the human visual system. Such studies have demonstrated multiple, functionally distinct visual areas that can be resolved on the basis of their locations, temporal dynamics, and differential sensitivity to stimulus parameters. Our studies have also produced evidence of internal retinotopic organization in both striate and extrastriate visual areas but have disclosed organizational departures from classical models. Comparative studies of MEG and fMRI suggest a reasonable but imperfect correlation between electrophysiological and hemodynamic responses. We have demonstrated a method for the integrated analysis of fMRI and MEG, and we outline strategies for improvement of these methods. By combining multiple measurement techniques, we can exploit the complementary strengths and transcend the limitations of the individual neuro-imaging methods.

Temporal dynamics of visual-evoked neuromagnetic sources: effects of stimulus parameters and selective attention

Results are reviewed from several neuromagnetic studies which characterize the temporal dynamics of neural sources contributing to the visual evoked response and effects of attention on these sources. Different types of pattern-onset stimuli (< or = 2 degrees) were presented sequentially to a number of field locations in the right visual field. Multiple dipole models were applied to a sequence of instantaneous field distributions constructed at 10 ms intervals. Best-fitting source parameters were superimposed on Magnetic Resonance images (MRI) of each subject to identify the anatomical structure(s) giving rise to the surface patterns. At least three sources, presumably corresponding to different visual areas, were routinely identified from 80-150 ms following the onset of visual stimulation. This observation was consistent across subjects and studies. The temporal sequence and strength of activation of these sources, however, were dependent upon the specific stimulus parameters used to evoke the response (e.g., eccentricity) and on the relevance of the stimulus to the subject. In addition, our results provide evidence for the recurrence of activity in striate and extrastriate regions, following the initial cycle of responses.

Reversible opening of the blood-brain barrier by anti-bacterial antibodies

The leukocyte adhesion molecule CR3 (CD11b/CD18, Mac-1) promotes leukocyte transmigration into tissues by engaging an unknown cognate ligand on the surface of vascular endothelial cells. Filamentous hemagglutinin (FHA), an adhesin of the bacterium Bordetella pertussis, binds to CR3. We hypothesized that FHA mimics the native ligand for the CR3 integrin on endothelial cells and predicted that anti-FHA antibodies should bind to endothelial cells, interfere with leukocyte recruitment, and induce endothelial permeability. Anti-FHA monoclonal antibodies bound to cerebral microvessels in sections from human brain and upon intravenous injection into rabbits. Antibody binding correlated with the ability to recognize two polypeptides in extracts of human cerebral vessels that were also bound by CD18. In vivo, antibody binding not only interfered with transmigration of leukocytes into cerebrospinal fluid but also induced a dose-dependent reversible increase in blood-brain barrier permeability sufficient to improve delivery of intravenously administered therapeutic agents to brain parenchyma.

Interactions between the subunits of transducin and cyclic GMP phosphodiesterase in Rana catesbiana rod photoreceptors

In bullfrog (Rana catesbiana) rods the activity of cyclic GMP (cGMP) phosphodiesterase was stimulated 10 times by washing disc membranes with an isotonic, GTP-containing buffer. This stimulation was maintained following hydrolysis of GTP and after removal of guanine nucleotides. At least 60-70% of the inhibitory gamma subunit of cGMP phosphodiesterase (P gamma) was physically released from membranes by these washing procedures. When cGMP phosphodiesterase was activated by a hydrolysis-resistant GTP analogue, P gamma was found in the supernatant complexed with the transducin alpha subunit (T alpha) using three chromatography systems. When GTP was used to activate cGMP phosphodiesterase, P gamma was also found in the supernatant complexed with GDP.T alpha. This complex was also isolated using the same three chromatography systems, indicating that P gamma remained tightly bound to T alpha even after bound GTP was hydrolyzed. Interaction with the beta,gamma subunits of transducin, which remained associated with disc membranes, was required for the release of P gamma from the GDP.T alpha complex, which resulted in the deactivation of active cGMP phosphodiesterase. We conclude that during activation of cGMP phosphodiesterase, P gamma is complexed with T alpha (both GTP and GDP forms) in the supernatant and that, following GTP hydrolysis, beta,gamma subunits of transducin are necessary for the release of P gamma from the complex and the resulting inactivation of cGMP phosphodiesterase in frog photoreceptors.

Control of Ca2+ in rod outer segment disks by light and cyclic GMP

Photons absorbed in vertebrate rods and cones probably cause electrochemical changes at the photoreceptor plasma membrane by changing the cytoplasmic concentration of a diffusible transmitter substance, reducing the Na+ current flowing into the outer segment of the cell in the dark, to produce the observed membrane hyperpolarization that is the initial excitatory response. Cyclic GMP has been proposed as the transmitter because a light-activated cyclic GMP phosphodiesterase (PDE) has been found in rod disk membranes and because intracellularly injected cyclic GMP reduces rod membrane potentials. Free Ca2+ has also been proposed because increasing external [Ca2+] quickly and reversibly reduces the dark current and divalent cationophores increase the Ca2+ sensitivity. Ca2+ efflux from rod outer segments (ROS) of intact retinas occurs simultaneously with light responses. Vesicles prepared from ROS disk membranes become more permeable on illumination, releasing trapped ions or molecules, but intact outer segment disks have not previously been found to store sufficient Ca2+ in darkness and to release enough in light to meet the theoretical requirements for control of the dark current by varying cytoplasmic Ca2+ (refs 14-18). We now report experiments that show the required Ca2+ storage and release from rod disk membranes suspended in media containing high-energy phosphate esters and electrolytes approximating the cytoplasmic composition of live rod cells. Cyclic GMP stimulates Ca2+ uptake by ROS disks in such media.

Intestinal parasitic infestation among parturients in Trinidad and Tobago

1. In this limited survey, 42.5% of parturients were found to be infested with intestinal parasites. 2. Hookworm, Trichuris and Entamoeba infestations were the most common. 3. Race, social class and locality influenced in the incidence of the different types of infestations. 4. Those infested with hookworm had longer labor, smaller babies and higher incidence of prematurity.