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#17IntraoperativeMappingTheCortexSOTERO

#17IntraoperativeMappingTheCortexSOTERO

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02/01/2013

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2/13/20111
Cortical Mapping
15 years doing it and still learning !
Marcio A. Sotero de Menezes, MDDirector, Pediatric EpilepsySwedish Neuroscience InstituteAssociate Professor in Neurology and PediatricsUniversity of Washington, Department of Neurology
Methods of Cortical FunctionDetermination
Somatosensory evoked potentials (SSEP’s)
Direct electrical cortical stimulation.
High frequency ECoG (>50-100 Hz)changes – Dr. Ritaccio
MEG functional mapping -*
fMRI -*
PET-** Not the subject of this lecture
SSEPs for the localization of somatossensory cortex(central sulcus)in Epilepsy and Tumoral SurgeryMedian Nerve SSEP Methods
Frequency 3.7-5.3 Hz
Do not use multiples/divisors of 60 Hz
Filter band 3 Hz to 3 KHz
Pulse Width 300 microsec
Stimulus intensity 10-20 mA (visible thumbtwitches)
Average of 300-400 stimuli
Recording – Grid or Strips
Somatosensory area = Cortical negativity with 19-20 msec latency
Cedzich: Neurosurgery, Volume 38(5).May 1996.962-970
 
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Kombos2008
Motor cortex“Positivity”Somatossensory cortex“Negativity”
CentralSulcus
Negativity 19 msec latency“Imperfect” phase reversal(positivity ~ 2 msec later)NoseMotorSensory
Motor and languagemapping inEpilepsy and TumoralSurgery
Aldini 1804 used decapitated lambs, cows and horses.Aldini came across a beheaded man: Left hemispherestimulation
right facial movements but he used a right earreference so direct effect cannot be ruled out. He created a“fashion’ that was prohibited by law in Prussia.Luigi Rolando 1809 produced similar effects in pigs.Fritsch noticed contra-lateral twitching when the hemisphereswere stimulated (irritated) “involuntarily” when he wasdressing a patient with head wounds during the Prussian-Danish War in 1864.Hitzig defined the motor cortex of the dog - circa 1824disproving Flourens’ equivalence theory of the brain.Fritsch and Hitzig 1870 publish “About Electrical Excitabilityof the cerebrum"
The Grotesque History of Brainfunction via Electrical Stimulation
http://www.torinoscienza.it/img/orig/it/s00/00/0011/00001194.jpgWeiser 2000
 
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1874 Bartholow a Professor of Medicine with feebleethics, gets consent from a feeble-minded girl (sic)with scalp ulcers to stimulate her brain with needlesdemonstrating the motor cortex in humans and alsocausing seizures, coma and death as well as anEthical revolution in the US and Europe.Ferrier 1872; Horsley 1888; Sherrington 1903 definecortical motor cortex and frontal eye fields,hippocampus-olfaction in primates.Ferrier 1876 localized (and destroyed) the hearingcortex of a monkey to the superior temporal gyrus.The Monkey became deaf.
History of Brain function viaElectrical Stimulation
Weiser 2000
Charles ScottSherrington
Horsely and Clarke come up with the stereotaxic method 1902Cushing 1909 – post-central gyrus = somatosensory cortex.1920’s the stimulators become more sophisticated and smallerKrause and Schum show the motor cortex in man (1931)
History of Brain function viaElectrical Stimulation
http://www.cerebromente.org.br/n18/history/stimulation_i.htm
Fedor Krause (1857-1937),pioneer of neurosurgeryand cortical mapping.
Foerster 1936 and Penfield 1937 define motor and sensorycortex, lateralization 1941; complex localization 1954; 1957;1959Stereo EEG with depth electrodes in 1969-19701990’s propofol anesthesia allows better “awake craniotomies”often a/w transient narcotic and local anesthesia
History of Brain function viaElectrical Stimulation
Weiser 2000http://www.cerebromente.org.br/n18/history/stimulation_i.htm
Why check cortical function
Wide variation of location and conformation ineloquent and motor cortex
Cortical dysplasia
Areas invaded by brain tumors can “push” functionalcortex– Ojemann 1996
Early insults like CVA’s before ages 1-6 y.o.
Diseased brain may have higher threshold for responses
Subcortical mapping tracts involved inconnectivity between eloquent areas and thosecarrying motor function.
Ojemann JG et al Neurosurgery 1996;39:253-9Schiffbauer Neurosurgery 2001 49(6):1313-1320Simon , Shield and Skandar 2010

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