Stefan Rampp

A guideline for head volume conductor modeling in EEG and MEG

For accurate EEG/MEG source analysis it is necessary to model the head volume conductor as realistic as possible. This includes the distinction of the different conductive compartments in the human head. In this study, we investigated the influence of modeling/not modeling the conductive compartments skull spongiosa, skull compacta, cerebrospinal fluid (CSF), gray matter, and white matter and of the inclusion of white matter anisotropy on the EEG/MEG forward solution. Therefore, we created a highly realistic 6-compartment head model with white matter anisotropy and used a state-of-the-art finite element approach. Starting from a 3-compartment scenario (skin, skull, and brain), we subsequently refined our head model by distinguishing one further of the above-mentioned compartments. For each of the generated five head models, we measured the effect on the signal topography and signal magnitude both in relation to a highly resolved reference model and to the model generated in the previous refinement step. We evaluated the results of these simulations using a variety of visualization methods, allowing us to gain a general overview of effect strength, of the most important source parameters triggering these effects, and of the most affected brain regions. Thereby, starting from the 3-compartment approach, we identified the most important additional refinement steps in head volume conductor modeling. We were able to show that the inclusion of the highly conductive CSF compartment, whose conductivity value is well known, has the strongest influence on both signal topography and magnitude in both modalities. We found the effect of gray/white matter distinction to be nearly as big as that of the CSF inclusion, and for both of these steps we identified a clear pattern in the spatial distribution of effects. In comparison to these two steps, the introduction of white matter anisotropy led to a clearly weaker, but still strong, effect. Finally, the distinction between skull spongiosa and compacta caused the weakest effects in both modalities when using an optimized conductivity value for the homogenized compartment. We conclude that it is highly recommendable to include the CSF and distinguish between gray and white matter in head volume conductor modeling. Especially for the MEG, the modeling of skull spongiosa and compacta might be neglected due to the weak effects; the simplification of not modeling white matter anisotropy is admissible considering the complexity and current limitations of the underlying modeling approach.

Fast activity as a surrogate marker of epileptic network function

The detection of epileptiform discharges in electroencephalography recordings is a crucial part in diagnosing epilepsy. Thorough electrophysiologic evaluation yields information that allows for tailored surgical therapy in many cases, and thus improves treatment outcome. In recent years, fast activity (>60-80Hz) has been investigated for its diagnostic value in addition to well-known patterns such as epileptic transients. It was shown that these high frequency oscillations are highly specific for epileptic network function and might provide valuable information for localization of epileptic networks and understanding of their mechanisms. In this review, an overview of the electrophysiologic characteristics, putative cellular and network mechanisms in epilepsy is given. Recent studies are reviewed and interpreted in the context of a common hypothetical model.

Preservation of facial nerve function after postoperative vasoactive treatment in vestibular schwannoma surgery.

OBJECTIVE:Facial nerve paresis and hearing loss are common complications after vestibular schwannoma surgery. Experimental and clinical studies point to a beneficial effect of nimodipine and hydroxyethyl starch for preservation of cochlear nerve function. A retrospective analysis was undertaken to evaluate the effect of vasoactive treatment on facial nerve outcome. PATIENTS AND METHODS:Forty-five patients with vestibular schwannoma removal, intraoperative electromyographic monitoring, and postoperative deterioration of facial nerve function were evaluated. Twenty-five patients underwent vasoactive treatment consisting of nimodipine and hydroxyethyl starch for improvement of hearing outcome. Twenty patients did not receive such treatment. Facial nerve function was evaluated before and after surgery, as well as 1 year after the surgical procedure. Patients were comparable regarding age, tumor size, and preoperative facial nerve function. RESULTS:Long-term results of facial nerve function were significantly improved in those patients who experienced severe postoperative deterioration of facial nerve function and received vasoactive treatment as compared with patients who did not receive nimodipine and hydroxyethyl starch after surgery. Treated patients showed a significantly higher rate of complete recovery compared with patients without treatment. CONCLUSION:The study points to a potential effect of vasoactive treatment for facial nerve function after vestibular schwannoma surgery. In particular, patients with postoperative disfiguring facial nerve palsy clearly benefit from intravenous hydroxyethyl starch and nimodipine with respect to a long-term socially acceptable facial nerve function.

Lobar localization information in epilepsy patients: MEG—A useful tool in routine presurgical diagnosis

Epilepsy surgery is an established therapy for pharmacoresistant focal epilepsy. This study investigated the contribution of routinely used magnetoencepahlography (MEG) in addition to long term video-EEG-monitoring in presurgical evaluation. The distribution of localization results to anatomical lobes was compared with special focus to MEG spike localization results in cases without or with ambiguous EEG findings. A total of 105 consecutive patients with intractable focal epilepsy and epilepsy surgery after investigation by video-EEG-monitoring and MEG were included. The percentages of monolobar results were analysed and compared, especially with respect to the resection lobe. Postoperative outcome was used for further validation. No spikes were recorded on MEG in 30% (32 of 105). In cases with a diagnostic finding by the respective method, MEG localized in 82% (60 of 73 patients) within one anatomical lobe. Ictal EEG localized within one lobe in 72% (66 of 92 patients), interictal EEG in 60% (59 of 98 patients). In 25 of 105 patients (24%) no clear localization within one lobe was found either in interictal or in ictal EEG. In 11 of these cases MEG localized within the resection lobe. Six patients of these became seizure free, the other five had at least 50% reduction of their seizure rate 1 year after surgery. In summary MEG is a useful tool in the routine workup for epilepsy surgery contributing information to focus hypothesis in addition to video-EEG.

MEG-based identification of the epileptogenic zone in occult peri-insular epilepsy

INTRODUCTION Presurgical work-ups of patients with pharmacoresistant epileptic seizures can require multiple diagnostic methods if magnetic resonance imaging (MRI) combined with video-EEG monitoring fails to show an epileptogenic lesion. Yet, the added value of available methods is not clear. In particular, only a minority of epilepsy centres apply magnetoencephalography (MEG). This study explores the potential of MEG for patients whose previous sophisticated work-ups missed deep-seated, peri-insular epileptogenic lesions. PATIENTS AND METHODS Three patients with well documented, frequent, stereotypical hypermotor seizures without clear focus hypotheses after repeated presurgical work-ups including video-EEG-monitoring, 3Tesla (3T) magnetic resonance imaging (MRI), morphometric MRI analysis, PET and SPECT were referred to MEG source localisation. RESULTS In two out of three patients, MEG source localisation identified very subtle morphological abnormalities formerly missed in MRI or classified as questionable pathology. In the third patient, MEG was not reliable due to insufficient detection of epileptic patterns. Here, a 1 mm × 1 mm × 1 mm 3T fluid-attenuated inversion recovery (FLAIR) MRI revealed a potential epileptogenic lesion. A minimal invasive work-up via lesion-focused depth electrodes confirmed the intralesional seizure onset in all patients, and histology revealed dysplastic lesions. Seizure outcomes were Engel 1a in two patients, and Engel 1d in the third. DISCUSSION MEG can contribute to the identification of epileptogenic lesions even when multiple previous methods failed, and when the lesions are located in deep anatomical structures such as peri-insular cortex. For epilepsy centres without MEG capability, referral of patients with cryptogenic focal epilepsies to centres with MEG systems may be indicated.

Periventricular nodular heterotopia: A challenge for epilepsy surgery

Pharmacoresistant focal epilepsies due to periventricular nodular heterotopia are a diagnostic and therapeutic challenge because of the need of invasive presurgical diagnostics and the selection of an optimal surgical approach. Invasive investigations in previous studies showed that focal epileptic activity can be correlated predominantly either with one of the nodular heterotopia or with neocortical epileptogenic zones distant to the periventricular nodules. Up to now, invasive recordings were required for localization of epileptic activity and its correlation to heterotopia. The following case presentation reports on a non-invasive approach using magnetic source imaging (MSI) combined with intraoperative ECoG. MSI combines preoperative data from magnetic resonance imaging (MRI) with magnetoencephalography (MEG). The MSI data for definition of the localization of the epileptic activity and functional important areas were coregistered with the intraoperative high-field-MRI and diffusion tensor imaging-based fiber tracking (DTI) of the visual pathway using a neuronavigational system. A neuronavigation-guided surgical resection of the epileptogenic area was performed leaving the heterotopia and the visual tract fibers intact. Postoperatively preservation of the visual fields was documented and the frequency of seizures was markedly reduced.

Seizure onset determination.

Digital electroencephalography has greatly expanded the opportunities for data analysis. Although commercial software packages are available they seem not to be used as widely in the preoperative work-up of epilepsy patients as might be warranted. This review will demonstrate that seizure onset can be better defined by judicious use of post hoc filter settings, expanded electrode coverage, and special electrode montages. In scalp recordings, ictal baseline shifts and infraslow activity (ISA) can be evaluated with conventional EEG systems by opening the high-pass filter to 0.01 Hz; in intracranial recordings high-frequency activity (>60 Hz; HFA) can be observed in addition. Inasmuch as ISA and HFA have considerably smaller electrical fields than the conventional frequencies they may better define seizure onset than might be possible otherwise. It is recommended that to determine the clinical value of ISA and HFA for epilepsy surgery, retrospective analyses of seizure data, which include assessment of ISA and HFA, be performed from patients who have undergone surgical resections of epileptogenic tissue. These may yield information as to whether or not the epileptogenic areas of ISA and HFA had been included in the resected tissue and their relationship to surgical outcome can then be determined.

Combining EEG and MEG for the Reconstruction of Epileptic Activity Using a Calibrated Realistic Volume Conductor Model

To increase the reliability for the non-invasive determination of the irritative zone in presurgical epilepsy diagnosis, we introduce here a new experimental and methodological source analysis pipeline that combines the complementary information in EEG and MEG, and apply it to data from a patient, suffering from refractory focal epilepsy. Skull conductivity parameters in a six compartment finite element head model with brain anisotropy, constructed from individual MRI data, are estimated in a calibration procedure using somatosensory evoked potential (SEP) and field (SEF) data. These data are measured in a single run before acquisition of further runs of spontaneous epileptic activity. Our results show that even for single interictal spikes, volume conduction effects dominate over noise and need to be taken into account for accurate source analysis. While cerebrospinal fluid and brain anisotropy influence both modalities, only EEG is sensitive to skull conductivity and conductivity calibration significantly reduces the difference in especially depth localization of both modalities, emphasizing its importance for combining EEG and MEG source analysis. On the other hand, localization differences which are due to the distinct sensitivity profiles of EEG and MEG persist. In case of a moderate error in skull conductivity, combined source analysis results can still profit from the different sensitivity profiles of EEG and MEG to accurately determine location, orientation and strength of the underlying sources. On the other side, significant errors in skull modeling are reflected in EEG reconstruction errors and could reduce the goodness of fit to combined datasets. For combined EEG and MEG source analysis, we therefore recommend calibrating skull conductivity using additionally acquired SEP/SEF data.

Networks involved in seizure initiation A reading epilepsy case studied with EEG-fMRI and MEG

Objective: To define the ictal cortical/subcortical network of reading-induced seizures. Methods: We analyzed ictal magnetoencephalography (MEG) and EEG-correlated fMRI (EEG-fMRI) data in a unique patient with reading epilepsy (RE) affected by frequent perioral reflex myocloni triggered by reading silently. Results: Ictal MEG corroborated EEG localization and revealed activity extending precentrally into Brodmann area (BA) 6. fMRI blood oxygen level−dependent (BOLD) signal changes in the left deep piriform cortex (PFC) and left BA6 preceded seizures and occurred before BOLD changes were observed in thalamus and right inferior frontal gyrus (BA44). Dynamic causal modeling provided evidence of a causal link between hemodynamic changes in the left PFC and reading-evoked seizures. Conclusion: Our findings support the important role of deep cortical and subcortical structures, in particular the frontal PFC, as key regions in initiating and modulating seizure activity. In our patient with RE, BA6 appeared to be the area linking cognitive activation and seizure activity.

A real-time monitoring system for the facial nerve.

OBJECTIVEDamage to the facial nerve during surgery in the cerebellopontine angle is indicated by A-trains, a specific electromyogram pattern. These A-trains can be quantified by the parameter “traintime,” which is reliably correlated with postoperative functional outcome. The system presented was designed to monitor traintime in real-time. METHODSA dedicated hardware and software platform for automated continuous analysis of the intraoperative facial nerve electromyogram was specifically designed. The automatic detection of A-trains is performed by a software algorithm for real-time analysis of nonstationary biosignals. The system was evaluated in a series of 30 patients operated on for vestibular schwannoma. RESULTSA-trains can be detected and measured automatically by the described method for real-time analysis. Traintime is monitored continuously via a graphic display and is shown as an absolute numeric value during the operation. It is an expression of overall, cumulated length of A-trains in a given channel; a high correlation between traintime as measured by real-time analysis and functional outcome immediately after the operation (Spearman correlation coefficient [ρ] = 0.664, P < .001) and in long-term outcome (ρ = 0.631, P < .001) was observed. CONCLUSIONAutomated real-time analysis of the intraoperative facial nerve electromyogram is the first technique capable of reliable continuous real-time monitoring. It can critically contribute to the estimation of functional outcome during the course of the operative procedure.