Method Article

A Multimodal Imaging- and Stimulation-based Method of Evaluating Connectivity-related Brain Excitability in Patients with Epilepsy

DOI:

10.3791/53727

November 13th, 2016

In This Article

Summary

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Resting-state functional-connectivity MRI has identified abnormalities in patients with a wide range of neuropsychiatric disorders, including epilepsy due to malformations of cortical development. Transcranial Magnetic Stimulation in combination with EEG can demonstrate that patients with epilepsy have cortical hyperexcitability in regions with abnormal connectivity.

Abstract

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Resting-state functional connectivity MRI (rs-fcMRI) is a technique that identifies connectivity between different brain regions based on correlations over time in the blood-oxygenation level dependent signal. rs-fcMRI has been applied extensively to identify abnormalities in brain connectivity in different neurologic and psychiatric diseases. However, the relationship among rs-fcMRI connectivity abnormalities, brain electrophysiology and disease state is unknown, in part because the causal significance of alterations in functional connectivity in disease pathophysiology has not been established. Transcranial Magnetic Stimulation (TMS) is a technique that uses electromagnetic induction to noninvasively produce focal changes in cortical activity. When combined with electroencephalography (EEG), TMS can be used to assess the brain's response to external perturbations. Here we provide a protocol for combining rs-fcMRI, TMS and EEG to assess the physiologic significance of alterations in functional connectivity in patients with neuropsychiatric disease. We provide representative results from a previously published study in which rs-fcMRI was used to identify regions with abnormal connectivity in patients with epilepsy due to a malformation of cortical development, periventricular nodular heterotopia (PNH). Stimulation in patients with epilepsy resulted in abnormal TMS-evoked EEG activity relative to stimulation of the same sites in matched healthy control patients, with an abnormal increase in the late component of the TMS-evoked potential, consistent with cortical hyperexcitability. This abnormality was specific to regions with abnormal resting-state functional connectivity. Electrical source analysis in a subject with previously recorded seizures demonstrated that the origin of the abnormal TMS-evoked activity co-localized with the seizure-onset zone, suggesting the presence of an epileptogenic circuit. These results demonstrate how rs-fcMRI, TMS and EEG can be utilized together to identify and understand the physiological significance of abnormal brain connectivity in human diseases.

Introduction

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Transcranial magnetic stimulation (TMS) is a means of noninvasively stimulating regions of cortex via electromagnetic induction. In TMS, a large but spatially restricted magnetic flux is used to induce an electrical field in a target cortical area, and thereby modulate the activity of the underlying neural tissue. TMS to motor cortex results in motor evoked potentials that can be measured peripherally via electromyography (EMG). When applied in pairs or triplets of pulses, TMS can be used to assess the activity of specific intracortical GABAergic and glutaminergic circuits1-3, and thus assess the balance of excitation and inhibition in vivo in huma....

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Protocol

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The protocol described here was approved by the institutional review boards of the Beth Israel Deaconess Medical Center and the Massachusetts Institute of Technology.

1. Subject Selection

  1. Patient selection for research protocol.
    1. Identify patients with active epilepsy (seizures within the past year) or a history of remote epilepsy (prior seizures, but with no seizures in the past five years either on or off medication) and periventricular nodular heterotopia on structural brain imaging.
    2. Exclude patients without any history of seizures. Also exclude patients with alternative possible etiologies for seizures ....

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Results

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Resting-state functional connectivity fMRI can be used to identify regions of cortex that demonstrate high functional connectivity with the heterotopic periventricular gray matter nodules (Figure 1), and control regions without such connectivity. To determine whether such abnormal functional connectivity has physiologic significance, the cortical region with correlated resting-state activity can be chosen as the "connected" target sites for neuronavigated TMS, and the evo.......

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Discussion

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Resting-state functional connectivity MRI has been used to identify network connectivity in the human brain, and to identify alterations of connectivity that occur in different disease states26,31,32. However, as fMRI functional connectivity is based on identifying correlations in the BOLD signal, and as blood oxygenation changes have a non-trivial relationship with underlying neural activity, the causal significance and physiological relevance of these fMRI connectivity findings is unclear. TMS enables spatia.......

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Disclosures

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MMS, SWG, CJC and BSC have nothing to disclose. APL serves on the scientific advisory boards for Nexstim, Neuronix, Starlab Neuroscience, Neuroelectrics, and Neosync, and is listed as an inventor on several issued and pending patents on the real-time integration of transcranial magnetic stimulation (TMS) with electroencephalography (EEG) and magnetic resonance imaging (MRI).

Acknowledgements

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The authors would like to thank Emily L. Thorn, B.A., for her assistance with the Source estimation of evoked electrical activity Section. MMS was supported by a KL2/Catalyst Medical Research Investigator Training award from Harvard Catalyst/The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award KL2 TR001100). CJC was supported by a grant from the National Institutes of Health (5K12NS066225). APL was supported in part by grants from the Sidney R. Baer Jr. Foundation, the National Institutes of Health (R01 HD069776, R01 NS073601, R21 ....

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Materials

List of materials used in this article
NameCompanyCatalog NumberComments
3T MRI scanner
MRI functional connectivity software
MRI image viewing softwareMRICron
Transcranial Magnetic StimulatorNexstimeXimia StimulatorCan use stimulators from other suppliers, e.g., Magventure, Magstim
MRI neuronavigation systemNexstimNBS v3.2.1Alternative MRI neuronavigation system, e.g., Brainsight, Localite
TMS-compatible EEG systemNexstimEximia EEGAlternatives: Brain Products, Synamps, ANT
MatlabMathworksR2012bAlternatives: Octave
EEGLab
Minimum Norm Estimate (MNE) software
FreeSurfer

References

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  1. Florian, J., Müller-Dahlhaus, M., Liu, Y., Ziemann, U. Inhibitory circuits and the nature of their interactions in the human motor cortex a pharmacological TMS study. J. Physiol. 586 (2), 495-514 (2008).
  2. Rotenberg, A.

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Tags

Resting State Functional ConnectivityTranscranial Magnetic StimulationElectroencephalography RecordingEpilepsy Brain ExcitabilityCortical Hyperexcitability AssessmentTMS Evoked EEG ActivityFunctional Connectivity MRINeuronavigation Guided StimulationIndependent Component AnalysisSeizure Onset Zone Localization

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