Ettore Lettich

CORTICAL LANGUAGE LOCALIZATION IN LEFT, DOMINANT HEMISPHERE. AN ELECTRICAL STIMULATION MAPPING INVESTIGATION IN 117 PATIENTS

The localization of cortical sites essential for language was assessed by stimulation mapping in the left, dominant hemispheres of 117 patients. Sites were related to language when stimulation at a current below the threshold for afterdischarge evoked repeated statistically significant errors in object naming. The language center was highly localized in many patients to form several mosaics of 1 to 2 sq cm, usually one in the frontal and one or more in the temporoparietal lobe. The area of individual mosaics, and the total area related to language was usually much smaller than the traditional Broca-Wernicke areas. There was substantial individual variability in the exact location of language function, some of which correlated with the patients sex and verbal intelligence. These features were present for patients as young as 4 years and as old as 80 years, and for those with lesions acquired in early life or adulthood. These findings indicate a need for revision of the classical model of language localization. The combination of discrete localization in individual patients but substantial individual variability between patients also has major clinical implications for cortical resections of the dominant hemisphere, for it means that language cannot be reliably localized on anatomic criteria alone. A maximal resection with minimal risk of postoperative aphasia requires individual localization of language with a technique like stimulation mapping.

Brain Mapping Techniques to Maximize Resection, Safety, and Seizure Control in Children with Brain Tumors

Intraoperative brain mapping techniques were used to localize language cortex, sensorimotor pathways, and seizure foci in children with supratentorial brain tumors. The methods of direct cortical and subcortical stimulation, in addition to electrocorticography, enabled us to maximize tumor resection, minimize morbidity, and eradicate epileptogenic zones which were always adjacent to, but not involving, the tumor nidus. Language localization was found to be quite variable in the children tested and anatomically unpredictable based on the preoperative neurological or radiological examination. Physiological mapping techniques, therefore, appear to be safe, reliable, and very useful for operations on tumors located within or adjacent to eloquent brain regions in the pediatric population.

Ten Percent Electrode System for Topographic Studies of Spontaneous and Evoked EEG Activities

ABSTRACT.An 81-electrode system is described which is designed for topographic studies of spontaneous and evoked EEG activities. This method combines the standard leads of the International 10–20 System with supplementary electrodes applied midway between leads of the 10–20 system or electrodes in turn situated between 10–20 leads. Auxiliary electrode designations refer to the underlying brain areas and to adjacent leads of the 10–20 method. The utilization of this “10% system” is suggested to promote standardization.

Neuronal activity in the human lateral temporal lobe. I. Responses to speech.

SummarySingle and multiple unit neuronal activity was recorded from the cortex of the lateral temporal lobe in conscious humans during open brain surgery for the treatment of epilepsy. Recordings were obtained from the right and left superior, middle and inferior temporal gyrus of 34 patients (41 recording sites). Recordings were restricted to regions to be resected during subsequent surgery. This excluded recordings from language areas proper. Neuronal responses to words and sentences presented over a loudspeaker and during free conversation were recorded. No significant differences between the right and left hemisphere were obvious. All neurons in the superior temporal gyrus responded to various aspects of spoken language with temporally well defined activation/inhibition patterns, but not or only little to non-linguistic noises or tones. Excitatory responses were typically short or prolonged (up to several hundred ms) bursts of discharges at rates above 20/sec, reaching peak rates of 50–100/s. Such responses could be specifically related to certain combinations of consonants suggesting a function in categorization, they could depend on word length, could differentiate between polysyllabic and compound words of the same length or could be unspecifically related to language as such. No formant specific responses were found, but the prolonged excitations across syllables suggest that consonant/vowel combinations may play a role for some activation patterns. Responses of some neurons (or neuronal populations) depended on the attention paid to the words and sentences, or the task connected with them (repeat words, speech addressed to the patient demanding something). Neurons in the middle and inferior temporal gyrus were only little affected by listening to single words or sentences, but some were unspecifically activated by words or while listening to sentences. Excitatory responses varied within a limited range of discharge rates usually below 5–10/s. Phonetic distortion of spoken language could reduce responses in superior temporal gyrus neurons, but also the slight changes in discharge rate of middle temporal neurons could be absent during distorted and uncomprehensible speech sounds. We conclude that superior temporal gyrus neuron responses reflect some general phonetic but not semantic aspects of spoken language. Middle and inferior temporal gyrus neurons do not signal phonetic aspects of language, but may be involved in understanding language under certain conditions.

Functional Cortex and Subcortical White Matter Located within Gliomas

Some neurosurgeons state that intra-axial tumors may be resected with a low risk of neurological deficit if the tumor removal stays within the confines of the grossly abnormal tissue. This is thought to be so even when the lesion is presumably located in a functional area, providing that the adjacent normal-appearing cortex and subcortical white matter are not disturbed. This retrospective analysis presents evidence that this view is not always correct, because functioning motor, sensory, or language tissue can be located within a grossly obvious tumor or the surrounding infiltrated brain. Intraoperative stimulation mapping techniques identified 28 patients, ranging in age between 22 and 73 years, who showed evidence of functional tissue within the boundaries of infiltrative gliomas, as identified by correlation with computed tomography and magnetic resonance imaging scans, intraoperative ultrasound, gross visualization, and histological confirmation. Direct stimulation mapping of cortical and subcortical portions of the tumor during resections identified motor, sensory, naming, reading, or speech arrest function. Nineteen patients had new or worsened neurological deficits immediately after the operation, but after 3 months, only 6 continued to show new deficits whereas 18 showed no deficits and 2 improved. These results demonstrate that regardless of the degree of tumor infiltration, swelling, apparent necrosis, and gross distortion by the mass, functional cortex and subcortical white matter may be located within the tumor or the adjacent infiltrated brain. Therefore, to safely maximize glioma resection in these functional areas, intraoperative stimulation mapping may be used to identify functional cortical or subcortical tissue within, as well as adjacent to, the tumor, thus avoiding permanent injury.

Neuronal activity in the human lateral temporal lobe. II: Responses to the subjects own voice

SummaryWe have recorded neuronal responses in the lateral temporal lobe of man to overt speech during open brain surgery for epilepsy. Tests included overt naming of objects and reading words or short sentences shown on a projector screen, repetition of tape recorded words or sentences presented over a loudspeaker, and free conversation. Neuronal activity in the dominant and non-dominant temporal lobe were about equally affected by overt speech. As during listening to language (see Creutzfeldt et al. 1989), responses differed between recordings from sites in the superior and the middle or inferior temporal gyrus. In the superior temporal gyrus all neurons responded clearly and each in a characteristic manner. Activation could be related to phonemic aspects, to segmentation or to the length of spoken words or sentences. However, neurons were mostly differently affected by listening to words and language as compared to overt speaking. In neuronal populations recorded simultaneously with one or two microelectrodes, some neurons responded predominantly to one or the other type of speech. Excitatory responses during overt speaking were always auditory. In the middle temporal gyrus more neurons (about 2/3) responded to overt speaking than to listening alone. Activations elicited during overt speech were seen in about 1/3 of our sample, but they were more sluggish than those recorded in the superior gyrus. A prominent feature was suppression of on-going activity, which we found in about 1/3 of middle and in some superior temporal gyrus neurons. This suppression could preced vocalization by up to a few hundred ms, and could outlast it by up to 1 s. Evoked ECoG-potentials to words heard or spoken were different, and those to overt speech were more widespread.

Cerebral responses to electrical tooth pulp stimulation in man An objective correlate of acute experimental pain

The pulp of individual teeth of 17 normal adult volunteers was electrically stimulated via pairs of electrodes implanted into dentine. Computer-summated responses recorded from the surface of the head were composed of two concurrent sequences of events, one of which was seen maximally over midline areas and the other over the lower portions of the postcentral regions. Appropriate tests demonstrated that these wave forms represented cerebral tooth pulp-evoked potentials. Because tooth pulp-evoked potentials represent objective, quantifiable, nonverbal concomitants of central events associated with the perception of noxious stimuli, they may prove helpful in investigating acute experimental pain in man.

Increased gamma-range activity in human sensorimotor cortex during performance of visuomotor tasks.

OBJECTIVE We documented changes in spectral power of human electrocorticograms (ECoG) during performance of sensorimotor tasks. METHODS In 6 human subjects, ECoGs were recorded simultaneously from 14 subdural cortical sites in forearm sensorimotor cortex. The subjects performed 3 visuomotor tasks: tracking a moving visual target with a joystick-controlled cursor, threading pieces of tubing, and pinching the fingers sequentially against the thumb. Control conditions consisted of passive resting and active extension of the wrist. For each site the spectral power of the ECoG during these behaviors was computed for 5 10 Hz ranges between 10 and 60 Hz. RESULTS All subjects showed power decreases in the range of 11-20 Hz and power increases in the 31-60 Hz range during performance of the visuomotor tasks, at sites in forearm sensorimotor cortex and adjacent areas. Simple wrist movements often produced little change in power. Three subjects showed episodes of explicit gamma oscillations during the visuomotor tasks. Different sites showed increases in gamma-range power for different tasks, indicating that the spatial distribution of the gamma activity is specific to the tasks. Cross-spectra showed that gamma activity could become synchronized between separate sites during particular tasks. CONCLUSIONS Synchronized gamma-range activity in human sensorimotor cortex increases with performance of manipulative visuomotor tasks, supporting the hypothesis that coherent gamma oscillations may play a role in sensorimotor integration or attention.

Modified nomenclature for the "10%" electrode system.

A modified nomenclature for designating the auxiliary electrodes of the 10% system is described.

Use of propofol (Diprivan) for awake craniotomies: Technical note

We describe the use of propofol (Diprivan) to provide patient comfort during the initial stages of awake craniotomies.