Keith H. Chiappa

Variability of motor potentials evoked by transcranial magnetic stimulation

We studied the effect of stimulus intensity, coil size, mental alertness and prestimulus muscle contraction on the variability of motor evoked potentials (MEPs) produced by magnetic cortical stimulation (MCS). In 5 healthy subjects we delivered MCS either with a circular coil centered at the vertex or a figure-8 coil centered over the motor cortex hand area, recording from first dorsal interosseous. With the subject at rest or exerting 5% maximum voluntary contraction, 30 consecutive stimuli were given at 4 stimulus intensities (SIs) in 10% increments above resting motor threshold. Concurrent mental arithmetic constituted mental alertness. Spectral analysis was performed on data from 300 consecutive stimuli. The variability of MEP response size was inversely related to stimulus intensity, prestimulus voluntary muscle contraction, the recruitment of motoneurons and the size of the field generated by the magnetic coil. The MEP variability was larger than and not correlated with the variability of the H-reflex. Fast Fourier transformation and cross-correlation analysis did not identify a consistent dominant frequency, suggesting that the variability in MEP size is essentially random. We suggest that the variability in MEP response is caused by constant, rapid, spontaneous fluctuations in corticospinal and segmental motoneuron excitability levels. Any maneuver that raises this level or increases the probability of motoneuron firing will decrease MEP variability.

The EEG of Drowsiness in Normal Adults

The EEG of Drowsiness in Normal Adults Joan Santamaria;Keith Chiappa; Journal of Clinical Neurophysiology

Brainstem auditory and, shortrlatency somatosensory evoked responses in brain death

Thirty-five patients who met all clinical criteria for brain death and 53 patients who did not were tested with brainstem auditory (BAER) and short-latency somatosensory (SER) evoked resonses. Of the brain-dead patients, 77% had no waves present in the BAER, including wave I, whereas 69% had medulla components present in the SER. These data suggest that the SER has greater clinical utility in the brain-death setting, because it is important to have a wave present that establishes that the input signal has reached the central nervous system. No brain-dead patients had subsequent waves in either test. These results are correlated with neuropathologic findings and contrasted with data obtained in the comatose but riot brain-dead patients.

Motion and Ballistocardiogram Artifact Removal for Interleaved Recording of EEG and EPs during MRI

Artifacts generated by motion (e.g., ballistocardiac) of the head inside a high magnetic field corrupt recordings of EEG and EPs. This paper introduces a method for motion artifact cancellation. This method is based on adaptive filtering and takes advantage of piezoelectric motion sensor information to estimate the motion artifact noise. This filter estimates the mapping between motion sensor and EEG space, subtracting the motion-related noise from the raw EEG signal. Due to possible subject motion and changes in electrode impedance, a time-varying mapping of the motion versus EEG is required. We show that this filter is capable of removing both ballistocardiogram and gross motion artifacts, restoring EEG alpha waves (8-13 Hz), and visual evoked potentials (VEPs). This adaptive filter outperforms the simple band-pass filter for alpha detection because it is also capable of reducing noise within the frequency band of interest. In addition, this filter also removes the transient responses normally visible in the EEG window after echo planar image acquisition, observed during interleaved EEG/fMRI recordings. Our adaptive filter approach can be implemented in real-time to allow for continuous monitoring of EEG and fMRI during clinical and cognitive studies.

PERIODIC LATERALIZED EPILEPTIFORM DISCHARGES : A CRITICAL REVIEW

It is the purpose of this review to critically consider and organize the literature dealing with the ephemeral electroencephalographic (EEG) pattern periodic lateralized epileptiform discharges (PLEDs). Although the retrospective nature of these studies limits their ability to discuss accurately the clinical and pathophysiological aspects of this EEG entity, the available data strongly emphasize stroke as the dominant etiology and its high association with seizures. Recent evidence, particularly from functional neuroimaging studies, strongly suggests that PLEDs might reflect a key pattern for focal hyperexcitability in the penumbra zone of ischemic stroke. The authors prefer to consider PLEDs as an EEG signature of a dynamic pathophysiological state in which unstable neurobiological processes create an ictal-interictal continuum, with the nature of the underlying neuronal injury, the patients preexisting propensity to have seizures, and the co-existence of any acute metabolic derangements all contributing to whether seizures occur or not. This review underlines the need for further sophisticated prospective controlled studies implementing early continuous EEG monitoring in order to contribute to an understanding of the incidence, dynamics, and relevance of this pattern.

Functional magnetic resonance imaging and transcranial magnetic stimulation Complementary approaches in the evaluation of cortical motor function

Functional magnetic resonance imaging (fMRI) and transcranial magnetic stimulation (TMS) represent different approaches to mapping the motor cortex. fMRI identifies areas of hemodynamic changes during task performance while TMS provides electrophysiologic data concerning the localization and density of cortical motoneurons. Here we define the spatial correlation between fMRI and TMS maps and compared them with direct electrical cortical stimulation (ECS). We performed fMRI at 1.5 T on 3 normal subjects and 2 patients with mass lesions near the central sulcus using a multislice, asymmetric, spin-echo, echo-planar pulse sequence during the performance of a motor task. We also performed focal TMS with surface EMG recordings from the muscles primarily involved in the fMRI task. We coregistered the stimulation sites in real time with the fMRI maps using a frameless stereotactic system. In both patients we also performed ECS of the cortex during surgery under local anesthesia. fMRI maps were validated by the electro-physiologic data both pre- and intraoperatively. Our results suggest that regions of fMRI activation correspond spatially to areas of highest motoneuron density as demonstrated by electrophysiologic techniques.

Physiological motor asymmetry in human handedness: evidence from transcranial magnetic stimulation.

We hypothesized that human handedness might be associated with measurable differences in the excitability of the motor system. We compared the thresholds for electromyographic activation of the left and right abductor pollicis brevis (APB) and biceps muscles in 30 left-handers and 30 right-handers, by varying the direction of a brief monophasic pulse in a circular electromagnetic coil centered over the vertex of the scalp. In right-handers, we found that the threshold for activation of muscles in the right arm was lower than the threshold for activation of corresponding muscles in the left arm. In left-handers, the reverse was true. Threshold asymmetry was influenced significantly by the consistency with which each subject used the writing hand to perform other motor tasks, and was not significant between non-consistent left-handers and right-handers. Our results indicate that human handedness, and in particular, consistency of hand preference, are associated with lateralized differences in the excitability of motor system projections activated by transcranial magnetic stimulation. Our findings might reflect physiological differences in corticospinal tract function or cortical motor representation.

Pattern shift visual, brainstem auditory, and short‐latency somatosensory evoked potentials in multiple sclerosis

Pattern shift visual (PSVER), brainstem auditory (BAER), and short-latency somatosensory (SER) evoked potentials are practical and reliable clinical tests that provide objective measures of impulse conduction in the respective central nervous system (CNS) white matter tracts. In large groups of patients with multiple sclerosis (MS), the abnormality rates were 56, 32, and 60% (PSVER, BAER, and SER, respectively). Evidence of clinically unsuspected lesions was found in 42, 21, and 51%, respectively. Abnormality rates for a definite MS group alone were higher. The tests provide confirmatory and additional evidence for multiple lesions in CNS white matter. They may also provide an objective assessment of the efficacy of therapeutic regimens.

Hemispheric threshold differences for motor evoked potentials produced by magnetic coil stimulation

A brief monophasic pulse through an electromagnetic coil preferentially activates motor pathways of each hemisphere, depending on the direction of coil current flow. Using the preferred direction for each hemisphere, the minimum stimulus intensity (threshold) that evoked compound muscle action potentials in the contralateral abductor digiti minimi (ADM) muscle was significantly less for the left hemisphere than the right. Threshold for biceps on each side was significantly higher than ADM, but there was no side-to-side difference. Assessing handedness using a standard handedness index, those who had less tendency to use the right hand for everyday tasks had greater differences between hemispheres for ADM thresholds. The lower threshold of the left-hemisphere projection to hand muscles is probably related to the asymmetry of corticomotoneuronal monosynaptic connections; a greater number project to the motor neuron pool of the right- than left-hand muscles.

Transcranial magnetic stimulation identifies upper motor neuron involvement in motor neuron disease

Objective: To evaluate the sensitivity of transcranial magnetic stimulation (TMS) to identify upper motor neuron involvement in patients with motor neuron disease. Background: Diagnosis of ALS depends on upper and lower motor neuron involvement. Lower motor neuron involvement may be documented with electromyography, whereas definite evidence of upper motor neuron involvement may be elusive. A sensitive, noninvasive test of upper motor neuron function would be useful. Methods: TMS and clinical assessment in 121 patients with motor neuron disease. Results: TMS revealed evidence of upper motor neuron dysfunction in 84 of 121 (69%) patients, including 30 of 40 (75%) patients with only probable upper motor neuron signs and unsuspected upper motor neuron involvement in 6 of 22 (27%) patients who had purely lower motor neuron syndromes clinically. In selected cases, upper motor neuron involvement identified with TMS was verified in postmortem examination. Increased motor evoked potential threshold was the abnormality observed most frequently and was only weakly related to peripheral compound muscle action potential amplitude. In a subset of 12 patients reexamined after 11 ± 6 months, TMS showed progression of abnormalities, including progressive inexcitability of central motor pathways and loss of the normal inhibitory cortical stimulation silent period. Conclusions: TMS provides a sensitive means for the assessment and monitoring of excitatory and inhibitory upper motor neuron function in motor neuron disease.