A comparison of language mapping by preoperative navigated transcranial magnetic stimulation and direct cortical stimulation during awake surgery.
TL;DR: Good overall correlation between repetitive nTMS and DCS mapping during awake surgery for the identification of language areas in patients with left-sided cerebral lesions was observed, particularly with regard to negatively mapped regions.
Abstract: Background Navigated transcranial magnetic stimulation (nTMS) is increasingly used in presurgical brain mapping. Preoperative nTMS results correlate well with direct cortical stimulation (DCS) data in the identification of the primary motor cortex. Repetitive nTMS can also be used for mapping of speech-sensitive cortical areas. Objective The current cohort study compares the safety and effectiveness of preoperative nTMS with DCS mapping during awake surgery for the identification of language areas in patients with left-sided cerebral lesions. Methods Twenty patients with tumors in or close to left-sided language eloquent regions were examined by repetitive nTMS before surgery. During awake surgery, language-eloquent cortex was identified by DCS. nTMS results were compared for accuracy and reliability with regard to DCS by projecting both results into the cortical parcellation system. Results Presurgical nTMS maps showed an overall sensitivity of 90.2%, specificity of 23.8%, positive predictive value of 35.6%, and negative predictive value of 83.9% compared with DCS. For the anatomic Broca's area, the corresponding values were a sensitivity of 100%, specificity of 13.0%, positive predictive value of 56.5%, and negative predictive value of 100%, respectively. Conclusion Good overall correlation between repetitive nTMS and DCS was observed, particularly with regard to negatively mapped regions. Noninvasive inhibition mapping with nTMS is evolving as a valuable tool for preoperative mapping of language areas. Yet its low specificity in posterior language areas in the current study necessitates further research to refine the methodology.
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Paolo Maria Rossini1, David Burke2, Robert Chen3, L.G. Cohen, Zafiris J. Daskalakis4, R. Di Iorio1, V. Di Lazzaro5, Florinda Ferreri6, Florinda Ferreri5, Paul B. Fitzgerald7, Mark S. George8, Mark Hallett, Jean-Pascal Lefaucheur9, Berthold Langguth10, Hideyuki Matsumoto, Carlo Miniussi11, Michael A. Nitsche12, Alvaro Pascual-Leone13, Walter Paulus12, Simone Rossi14, John C. Rothwell15, Hartwig R. Siebner16, Yoshikazu Ugawa17, Vincent Walsh15, Ulf Ziemann18 •
The Catholic University of America1, Royal Prince Alfred Hospital2, University of Toronto3, Centre for Addiction and Mental Health4, Università Campus Bio-Medico5, University of Eastern Finland6, Monash University7, Medical University of South Carolina8, Paris 12 Val de Marne University9, University of Regensburg10, University of Brescia11, University of Göttingen12, Beth Israel Deaconess Medical Center13, University of Siena14, University College London15, Copenhagen University Hospital16, Fukushima Medical University17, University of Tübingen18
TL;DR: These guidelines provide an up-date of previous IFCN report on “Non-invasive electrical and magnetic stimulation of the brain, spinal cord and roots: basic principles and procedures for routine clinical application” and include some recent extensions and developments.
1,850 citations
Cites methods from "A comparison of language mapping by..."
...NBS mapping has been used and approved by the FDA, and in this context it has been shown that NBS can be used for mapping speechsensitive cortical areas as a valuable tool for in preoperative assessment (Picht et al., 2013)....
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Simone Rossi1, Andrea Antal2, Sven Bestmann3, Marom Bikson4, Carmen C. Brewer5, Jürgen Brockmöller2, Linda L. Carpenter6, Massimo Cincotta, Robert Chen7, Jeff D Daskalakis7, Vincenzo Di Lazzaro8, Michael D. Fox9, Mark S. George10, Donald L. Gilbert11, Vasilios K. Kimiskidis12, Giacomo Koch, Risto J. Ilmoniemi13, Jean Pascal Lefaucheur14, Letizia Leocani15, Sarah H. Lisanby5, Carlo Miniussi16, Frank Padberg17, Alvaro Pascual-Leone18, Walter Paulus2, Angel V. Peterchev19, Angelo Quartarone20, Alexander Rotenberg18, John C. Rothwell3, Paolo Maria Rossini, Emiliano Santarnecchi9, Mouhsin M. Shafi9, Hartwig R. Siebner21, Yoshikatzu Ugawa22, Eric M. Wassermann, Abraham Zangen23, Ulf Ziemann24, Mark Hallett5 •
University of Siena1, University of Göttingen2, UCL Institute of Neurology3, City College of New York4, National Institutes of Health5, Brown University6, University of Toronto7, Università Campus Bio-Medico8, Beth Israel Deaconess Medical Center9, Medical University of South Carolina10, Cincinnati Children's Hospital Medical Center11, Aristotle University of Thessaloniki12, Aalto University13, Paris 12 Val de Marne University14, Vita-Salute San Raffaele University15, University of Trento16, Ludwig Maximilian University of Munich17, Harvard University18, Duke University19, University of Messina20, Copenhagen University Hospital21, Fukushima Medical University22, Ben-Gurion University of the Negev23, University of Tübingen24
TL;DR: New operational guidelines are provided for safety in planning future trials based on traditional and patterned TMS protocols, as well as a summary of the minimal training requirements for operators, and a note on ethics of neuroenhancement.
387 citations
Cites background from "A comparison of language mapping by..."
..., 2011, 2009), while brief rTMS trains are used to induce speech arrest or errors for language mapping (Picht et al., 2013)....
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TL;DR: In this article, the authors compare the accuracy of navigated transcranial magnetic stimulation (nTMS) and magnetoencephalographic imaging (MEGI) with direct cortical stimulation (DCS).
181 citations
Cites background or methods from "A comparison of language mapping by..."
...In recent months, one other group has compared nTMS language mapping with DCS (Picht et al., 2013)....
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...Picht et al. (2013) use a simple anatomic cortical parcellation system, counting as co-positive any pair of nTMS and DCS points that fall within the same parcel....
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...First, we utilize an nTMS stimulation onset that is simultaneous with presentation of the object, while Picht et al. (2013) employ a 300 ms delay between object presentation and nTMS stimulation....
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...This methodological difference also accounts for the improved specificity in our study (98% vs. 24%): by improving our granularity to 10 mm, we avoided the large number of false-positives that decreased the specificity in the Picht et al. (2013) analysis....
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TL;DR: The adult central nervous system reorganizes motor and language areas in patients with glioma through neural circuit reorganization or activation of latent functional pathways, suggesting that adult neural plasticity may help to preserve motor andlanguage function in the presence of evolving structural lesions.
Abstract: OBJECT To avoid iatrogenic injury during the removal of intrinsic cerebral neoplasms such as gliomas, direct electrical stimulation (DES) is used to identify cortical and subcortical white matter pathways critical for language, motor, and sensory function. When a patient undergoes more than 1 brain tumor resection as in the case of tumor recurrence, the use of DES provides an unusual opportunity to examine brain plasticity in the setting of neurological disease. METHODS The authors examined 561 consecutive cases in which patients underwent DES mapping during surgery forglioma resection. "Positive" and "negative" sites-discrete cortical regions where electrical stimulation did (positive) or did not (negative) produce transient sensory, motor, or language disturbance-were identified prior to tumor resection and documented by intraoperative photography for categorization into functional maps. In this group of 561 patients, 18 were identified who underwent repeat surgery in which 1 or more stimulation sites overlapped with those tested during the initial surgery. The authors compared intraoperative sensory, motor, or language mapping results between initial and repeat surgeries, and evaluated the clinical outcomes for these patients. RESULTS A total of 117 sites were tested for sensory (7 sites, 6.0%), motor (9 sites, 7.7%), or language (101 sites, 86.3%) function during both initial and repeat surgeries. The mean interval between surgical procedures was 4.1 years. During initial surgeries, 95 (81.2%) of 117 sites were found to be negative and 22 (18.8%) of 117 sites were found to be positive. During repeat surgeries, 103 (88.0%) of 117 sites were negative and 14 (12.0%) of 117 were positive. Of the 95 sites that were negative at the initial surgery, 94 (98.9%) were also negative at the repeat surgery, while 1 (1.1%) site was found to be positive. Of the 22 sites that were initially positive, 13 (59.1%) remained positive at repeat surgery, while 9 (40.9%) had become negative for function. Overall, 6 (33.3%) of 18 patients exhibited loss of function at 1 or more motor or language sites between surgeries. Loss of function at these sites was not associated with neurological impairment at the time of repeat surgery, suggesting that neurological function was preserved through neural circuit reorganization or activation of latent functional pathways. CONCLUSIONS The adult central nervous system reorganizes motor and language areas in patients with glioma. Ultimately, adult neural plasticity may help to preserve motor and language function in the presence of evolving structural lesions. The insight gained from this subset of patients has implications for our understanding of brain plasticity in clinical settings.
143 citations
TL;DR: NTMS motor mapping is a reliable and clinically validated tool to identify functional areas belonging to both normal and lesioned primary motor cortex, and this is less clear for language-eloquent cortical areas identified by nTMS.
Abstract: Navigated transcranial magnetic stimulation (nTMS) is increasingly used for preoperative mapping of motor function, and clinical evidence for its benefit for brain tumor patients is accumulating. In respect to language mapping with repetitive nTMS, literature reports have yielded variable results, and it is currently not routinely performed for presurgical language localization. The aim of this project is to define a common protocol for nTMS motor and language mapping to standardize its neurosurgical application and increase its clinical value. The nTMS workshop group, consisting of highly experienced nTMS users with experience of more than 1500 preoperative nTMS examinations, met in Helsinki in January 2016 for thorough discussions of current evidence and personal experiences with the goal to recommend a standardized protocol for neurosurgical applications. nTMS motor mapping is a reliable and clinically validated tool to identify functional areas belonging to both normal and lesioned primary motor cortex. In contrast, this is less clear for language-eloquent cortical areas identified by nTMS. The user group agreed on a core protocol, which enables comparison of results between centers and has an excellent safety profile. Recommendations for nTMS motor and language mapping protocols and their optimal clinical integration are presented here. At present, the expert panel recommends nTMS motor mapping in routine neurosurgical practice, as it has a sufficient level of evidence supporting its reliability. The panel recommends that nTMS language mapping be used in the framework of clinical studies to continue refinement of its protocol and increase reliability.
141 citations
Cites background or methods from "A comparison of language mapping by..."
...mapping have been published to enhance the specificity and sensitivity of nTMS, [12, 13, 21, 22, 27, 30, 46]....
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...Detection of subtle disturbances is achieved by comparing the baseline response to the response during rTMS stimulation [5, 27]....
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References
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3,756 citations
"A comparison of language mapping by..." refers methods in this paper
...These methods were already used in the first half of the past century and were later refined by others.(2,3,6,30,31) In these studies, it has become evident that the classic language sites (areas of Broca and Wernicke) are merely parts of a complex and highly individualized language network....
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TL;DR: The localization of cortical sites essential for language was assessed by stimulation mapping in the left, dominant hemispheres of 117 patients as discussed by the authors, where stimulation at a current below the threshold for afterdischarge evoked repeated statistically significant errors in object naming.
Abstract: ✓ 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 patient's 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 locali...
1,315 citations
TL;DR: The composite language maps generated in this study suggest that current models of human language organization insufficiently account for observed language function, and allow most gliomas to be aggressively resected without language deficits.
Abstract: Background Language sites in the cortex of the brain vary among patients. Language mapping while the patient is awake is an intraoperative technique designed to minimize language deficits associated with brain-tumor resection. Methods To study language function after brain-tumor resection with language mapping, we examined 250 consecutive patients with gliomas. Positive language sites (i.e., language regions in the cortex of the brain, 1 cm by 1 cm, which were temporarily inactivated by means of a bipolar electrode) were identified and categorized into cortical language maps. The tumors were resected up to 1 cm from the cortical areas where intraoperative stimulation produced a disturbance in language. Our resection strategy did not require identification of the stimulation-induced language sites within the field of exposure. Results A total of 145 of the 250 patients (58.0%) had at least one site with an intraoperative stimulation-induced speech arrest, 82 patients had anomia, and 23 patients had alexia....
925 citations
"A comparison of language mapping by..." refers background or methods in this paper
...Also, planning the resection strategy based on the language-negative cortical map has been proposed for fMRI(33) as well as for intraoperative DCS-based language mapping.(6) The relationship between resection margins and functional outcome has been described in various reports....
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...The relationship between resection margins and functional outcome has been described in various reports.(3,6,28,34-38) Recently, efforts to identify true, generally essential hot spots—“minimal common brain”—have been undertaken....
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...These methods were already used in the first half of the past century and were later refined by others.(2,3,6,30,31) In these studies, it has become evident that the classic language sites (areas of Broca and Wernicke) are merely parts of a complex and highly individualized language network....
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...In stimulation with intensity below the after-discharge threshold, controlled for by electrocorticography, current spread is limited and DCS is considered to have an error margin of 10 mm in speech mapping.(4,6,52-54) For TMS, repetitive high-frequency trains maintain a current within the cortex, which is the prerequisite to induce a virtual lesion and allows analysis of a higher cognitive function such as language....
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TL;DR: This paper examines the many factors that influence the quality of acquired fMRI data and conducts a review of the existing literature to determine if some measure of agreement has emerged regarding the reliability of fMRI.
Abstract: Functional magnetic resonance imaging (fMRI) is one of the most important methods for in vivo investigation of cognitive processes in the human brain. Within the last two decades, an explosion of research has emerged using fMRI, revealing the underpinnings of everything from motor and sensory processes to the foundations of social cognition. While these results have revealed the potential of neuroimaging, important questions regarding the reliability of these results remain unanswered. In this paper, we take a close look at what is currently known about the reliability of fMRI findings. First, we examine the many factors that influence the quality of acquired fMRI data. We also conduct a review of the existing literature to determine if some measure of agreement has emerged regarding the reliability of fMRI. Finally, we provide commentary on ways to improve fMRI reliability and what questions remain unanswered. Reliability is the foundation on which scientific investigation is based. How reliable are the results from fMRI?
548 citations
"A comparison of language mapping by..." refers background in this paper
...The reliance on predefined and used statistical thresholds is the main limitation of all cluster overlap methods.(7) Moreover, intracerebral lesions such as gliomas induce edema and change oxygenation in the brain, which hampers the accuracy of fMRI....
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...Nevertheless, preoperative language mapping can be of great value because elucidation of functional cortical organization preoperatively enables better patient selection and consultation based on objective risk-benefit balancing.(7) Furthermore, it may allow smaller, more targeted craniotomies and faster and safer intraoperative mapping....
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TL;DR: The use of intraoperative electrophysiology leads to the extension of indications of LGG surgery within eloquent areas; to a decrease in the risk of sequelae; and to improvement of the quality of tumour resection, with an impact on survival.
Abstract: Objectives: Despite the growing use of intraoperative functional mapping in supratentorial low grade glioma (LGG) surgery, few studies have compared series of patients operated on without and with direct electrical stimulation (DES) by the same team. The present study compared the rate of LGG surgery performed in eloquent areas, the rate of postoperative sequelae, and the quality of resection during two consecutive periods in the same department—the first without and the second with the use of intraoperative electrophysiology. Methods: Between 1985 and 1996, 100 patients harbouring a supratentorial LGG underwent surgery with no functional mapping (S1). Between 1996 and 2003, 122 patients were operated on in the same department for a supratentorial LGG using intraoperative cortico-subcortical DES (S2). Results: Comparison between the two series showed that 35% of LGGs were operated on in eloquent areas in S1 versus 62% in S2 (p Conclusions: The results of the present study allow, for the first time, quantification of the contribution of intraoperative DES in LGG resection. Indeed, the use of this method leads to the extension of indications of LGG surgery within eloquent areas; to a decrease in the risk of sequelae; and to improvement of the quality of tumour resection, with an impact on survival.
537 citations