Search

Accurate assessment of motor function is critical, particularly in the context of presurgical functional mapping. There are a few noninvasive tools available for preoperative motor mapping in older children and adults undergoing surgery for brain tumor or refractory epilepsy including fMRI, magnetoencephalography (MEG), and transcranial magnetic stimulation (TMS).1,2 However, assessing motor function is challenging in very young children. Direct cortical stimulation, a standard procedure in adults, is associated with a high incidence of intraoperative seizures, and is often unsuccessful in young children.3,4 Alternately, noninvasive motor mapping using MEG and fMRI attempted during sleep or under sedation primarily localize the somatosensory cortex from which the location of motor cortex is inferred.5,6 Furthermore, these methods have a low success rate (∼25%) and have risks associated with sedation.6 However, TMS has the advantage of mapping the motor cortex directly without requiring sedation. We have previously reported on successful mapping of the motor cortex in young children aged between 17 and 35 months.7 Here we describe a case of an 11-month-old infant who is, to our knowledge, the youngest person to undergo successful presurgical motor mapping with TMS.

Objective:There are limited data evaluating the effect of post mechanical thrombectomy (MT) blood pressure (BP) levels on early outcomes of patients with large vessel occlusions (LVO). We sought to investigate the association of BP course following MT with early outcomes in LVO.Methods:Consecutive patients with LVO treated with MT during a 3-year period were evaluated. Hourly systolic BP (SBP) and diastolic BP (DBP) values were recorded for 24 hours following MT and maximum SBP and DBP levels were identified. LVO patients with complete reperfusion following MT were stratified in 3 groups based on post-MT achieved BP goals: Results:A total of 217 acute ischemic stroke patients with LVO were prospectively evaluated. A 10 mm Hg increment in maximum SBP documented during the first 24 hours post MT was independently (p = 0.001) associated with a lower likelihood of 3-month functional independence (odds ratio [OR] 0.70; 95% confidence interval [CI] 0.56–0.87) and a higher odds of 3-month mortality (OR 1.49; 95% CI 1.18–1.88) after adjusting for potential confounders. In addition, achieving a BP goal of p = 0.010) in comparison to permissive hypertension.Conclusions:High maximum SBP levels following MT are independently associated with increased likelihood of 3-month mortality and functional dependence in LVO patients. Moderate BP control is also related to lower odds of 3-month mortality in comparison to permissive hypertension.

The American Academy of Neurology (AAN) endorsement for the use of fMRI evaluation of hemispheric dominance for language in epilepsy surgery candidates1 appears as an odd and disconcerting sequel to the article by Eckland et al.,2 which reported that the clustering approach in functional MRI (fMRI) data processing may be responsible for an excessively high rate of false-positive findings. The latter report implied that up to 70% of the significant fMRI effects reported in approximately 40,000 peer-reviewed publications could represent no brain physiology facts, but type I statistical errors to the degree that they employed clustering of activated voxels.2 Consequently, it is fitting to suggest users of these popular fMRI software packages (SPM, FSL, AFNI) reconsider conclusions based on differences in activation levels of voxel clusters between task conditions. This raises the question of whether those who use the clustering procedure for the purpose of assessing hemisphere dominance for language should be alarmed for having made incorrect assessments in the past and refrain from using them for the same purpose in the future. Our answer is no, since language laterality judgments are typically made on the basis of laterality indices (i.e., the relative degree of activation defined as the ratio of left- and right-hemisphere activated voxels that are equally likely or unlikely to be activated). However, depending on how users of these automated software packages derive estimates of localization of the language network hubs (a practice not endorsed by the AAN),1 they may need to exercise more caution now that the shortcomings of these data reduction and analysis procedures were directly demonstrated and made widely known.

Objective: To determine if MRI is as effective as CT in identification of calcified subependymal nodules in tuberous sclerosis (TS) patients, so that the number of CT scans that TS patients undergo may be able to be reduced, leading to less radiation exposure and less cost. Background CT has been used to look for calcifications in TS patients, especially if they have enlarging subependymal nodules concerning for subependymal giant cell astrocytomas. However, CT has been found to be a source of significant radiation, and MRI techniques have advanced. Design/Methods: TS patients who underwent both a CT and MRI within a 120 day period were evaluated. CT and MR studies from the same patient were compared. CT was considered the gold standard in identification of calcification. Calcification on CT was considered a true positive (TP). Results: Neuroimaging from 9 patients has been reviewed. Patient ages ranged from 2 months to 7 7/12 years, with an average of 3.9 years. Only 2 patients had SWI sequences, which was a limitation of this study. Fifty-five subependymal nodules were identified. MRI overall detected 52 of 55 lesions. The sensitivity for detecting subependymal nodules was 94.5% for T2-weighted imaging, 85% for B0 sequences, and 87% for SWI. The overall sensitivity of CT for detecting subenpendymal nodules was 94.5%; however, most of the lesions were calcified. The sensitivity of CT for uncalcified subependymal nodules was 25%. Among the MRI sequences, the sensitivity for detecting calcifications on T2-weighted sequences was 78%, B0 sequences was 82%, and SWI was 87%. Conclusions: CT is more sensitive than MRI at detecting calcified subependymal nodules. However, it is not sensitive for uncalcified nodules. Traditional MRI (without SWI) tended to underestimate calcified subependymal nodules. However, addition of SWI, which appeared to be the most sensitive MRI sequence to calcification, may allow closer approximation to CT findings. Disclosure: Dr. McGregor has received royalty payments from MedHumor Publishing. Dr. Caron has nothing to disclose. Dr. Perkins has nothing to disclose. Dr. Wheless has received personal compensation for activities with Abbott, UCB, GSK, Novartis, Ortho-McNeil, Cyberonics, Abbott, Cyberonics, Inc., Novartis, Ovation Pharmaceuticals, Marinus Pharmaceuticals, Questcor, Valeant, Pfizer Inc as a consultant and/or participant on an advisory board. Dr. Wheless has received research support from Abbott Laboratories, Cyberonics, Inc., Ortho-McNeil Pharmaceuticals, Novartis, UCB Pharma and Ovation Pharmaceauticals. Dr. Choudhri has nothing to disclose.