Quantitative Multimodal Mapping Of Seizure Networks In Drug-Resistant Epilepsy

Over 15 million people worldwide suffer from localization-related drug-resistant epilepsy. These patients are candidates for targeted surgical therapies such as surgical resection, laser thermal ablation, and neurostimulation. While seizure localization is needed prior to surgical intervention, this process is challenging, invasive, and often inconclusive. In this work, I aim to exploit the power of multimodal high-resolution imaging and intracranial electroencephalography (iEEG) data to map seizure networks in drug-resistant epilepsy patients, with a focus on minimizing invasiveness. Given compelling evidence that epilepsy is a disease of distorted brain networks as opposed to well-defined focal lesions, I employ a graph-theoretical approach to map structural and functional brain networks and identify putative targets for removal. The first section focuses on mesial temporal lobe epilepsy (TLE), the most common type of localization-related epilepsy. Using high-resolution structural and functional 7T MRI, I demonstrate that noninvasive neuroimaging-based network properties within the medial temporal lobe can serve as useful biomarkers for TLE cases in which conventional imaging and volumetric analysis are insufficient. The second section expands to all forms of localization-related epilepsy. Using iEEG recordings, I provide a framework for the utility of interictal network synchrony in identifying candidate resection zones, with the goal of reducing the need for prolonged invasive implants. In the third section, I generate a pipeline for integrated analysis of iEEG and MRI networks, paving the way for future large-scale studies that can effectively harness synergy between different modalities. This multimodal approach has the potential to provide fundamental insights into the pathology of an epileptic brain, robustly identify areas of seizure onset and spread, and ultimately inform clinical decision making

Functional network correlates of language and semiology in epilepsy

Epilepsy surgery is appropriate for 2-3% of all epilepsy diagnoses. The goal of the presurgical workup is to delineate the seizure network and to identify the risks associated with surgery. While interpretation of functional MRI and results in EEG-fMRI studies have largely focused on anatomical parameters, the focus of this thesis was to investigate canonical intrinsic connectivity networks in language function and seizure semiology. Epilepsy surgery aims to remove brain areas that generate seizures. Language dysfunction is frequently observed after anterior temporal lobe resection (ATLR), and the presurgical workup seeks to identify the risks associated with surgical outcome. The principal aim of experimental studies was to elaborate understanding of language function as expressed in the recruitment of relevant connectivity networks and to evaluate whether it has value in the prediction of language decline after anterior temporal lobe resection. Using cognitive fMRI, we assessed brain areas defined by parameters of anatomy and canonical intrinsic connectivity networks (ICN) that are involved in language function, specifically word retrieval as expressed in naming and fluency. fMRI data was quantified by lateralisation indices and by ICN_atlas metrics in a priori defined ICN and anatomical regions of interest. Reliability of language ICN recruitment was studied in 59 patients and 30 healthy controls who were included in our language experiments. New and established language fMRI paradigms were employed on a three Tesla scanner, while intellectual ability, language performance and emotional status were established for all subjects with standard psychometric assessment. Patients who had surgery were reinvestigated at an early postoperative stage of four months after anterior temporal lobe resection. A major part of the work sought to elucidate the association between fMRI patterns and disease characteristics including features of anxiety and depression, and prediction of postoperative language outcome. We studied the efficiency of reorganisation of language function associated with disease features prior to and following surgery. A further aim of experimental work was to use EEG-fMRI data to investigate the relationship between canonical intrinsic connectivity networks and seizure semiology, potentially providing an avenue for characterising the seizure network in the presurgical workup. The association of clinical signs with the EEG-fMRI informed activation patterns were studied using the data from eighteen patients’ whose seizures and simultaneous EEG-fMRI activations were reported in a previous study. The accuracy of ICN_atlas was validated and the ICN construct upheld in the language maps of TLE patients. The ICN construct was not evident in ictal fMRI maps and simulated ICN_atlas data. Intrinsic connectivity network recruitment was stable between sessions in controls. Amodal linguistic processing and the relevance of temporal intrinsic connectivity networks for naming and that of frontal intrinsic connectivity networks for word retrieval in the context of fluency was evident in intrinsic connectivity networks regions. The relevance of intrinsic connectivity networks in the study of language was further reiterated by significant association between some disease features and language performance, and disease features and activation in intrinsic connectivity networks. However, the anterior temporal lobe (ATL) showed significantly greater activation compared to intrinsic connectivity networks – a result which indicated that ATL functional language networks are better studied in the context of the anatomically demarked ATL, rather than its functionally connected intrinsic connectivity networks. Activation in temporal lobe networks served as a predictor for naming and fluency impairment after ATLR and an increasing likelihood of significant decline with greater magnitude of left lateralisation. Impairment of awareness served as a significant classifying feature of clinical expression and was significantly associated with the inhibition of normal brain functions. Canonical intrinsic connectivity networks including the default mode network were recruited along an anterior-posterior anatomical axis and were not significantly associated with clinical signs

Interrogating spatiotemporal patterns of resting state neuronal and hemodynamic activity in the awake mouse model

Since the advent of functional magnetic resonance imaging (fMRI) and the rise in popularity of its use for resting state functional connectivity mapping (rs-FCM) to non-invasively detect correlated networks of brain activity in human and animal models, many resting state FCM studies have reported differences in these networks under pathologies such as Alzheimer’s or schizophrenia, highlighting the potential for the method’s diagnostic relevance. A common underlying assumption of this analysis, however, is that the blood oxygen level dependent (BOLD) signal of fMRI is a direct measurement of local neural activity. The BOLD signal is in fact a measurement of the local changes in concentration of deoxy-hemoglobin (HbR). Thus, it is imperative that neurovascular coupling—the relationship between neuronal activity and subsequent hemodynamic activity—be better characterized to enable accurate interpretation of resting state fMRI in the context of clinical usage. This dissertation first describes the development and utility of WFOM paradigm for the robust and easily adaptable imaging of simultaneous neuronal and hemodynamic activity in awake mouse models of health or disease in strains with genetically encoded fluorescent calcium reporters. Subsequent exploration of resting state WFOM data collected in Thy1-GCaMP3 and Thy1-GCaMP6f mouse strains is then presented, namely the characterization of spatiotemporal patterns of neuronal and hemodynamic activity and different modulatory depths of neuronal activity via a toolbox of unsupervised blind source separation (e.g. k-means clustering) and supervised (e.g. non-negative least squares, Pearson correlation) analysis tools. The presence of these different modulatory depths of neuronal activity were then confirmed in another Thy1-jRGECO1a mouse strain using the same imaging scheme. Finally, the dissertation documents the application of the WFOM paradigm and select analysis tools to a novel mouse model of diffusely infiltrating glioma, through which neuronal and hemodynamic activity changes during diffusely infiltrating glioma development which impact temporal coherence of the tumor region activity relative to non-tumor regions activity were recorded and analyzed. The paradigm also allowed for recording of numerous spontaneous occurrences of interictal neuronal activity during which neurovascular coupling is modified in the tumor, as well as occurrences of non-convulsive generalized seizure activity (during which neurovascular is non-linear and cortex eventually suffers hypoxia). The detection of spatiotemporal patterns and different modulatory depths of activity in the awake mouse cortex, as well as observation of changes in functional activity in the context of diffusely infiltrating glioma, provide us with new insights into the possible mechanisms underlying variations in resting state connectivity networks found in resting state fMRI studies comparing health and disease states

Investigating resting-state functional connectivity in health and epilepsy using magnetonencephalography

It is now widely accepted that different areas of the brain are functionally connected even in the absence of explicit task demands, the so-called 'resting-state'. Differences in resting-state connectivity between groups are increasingly used as a marker of pathology in a number of neurological diseases and neuropsychiatric disorders. However, in order for a specific pattern of functional connectivity to represent a valid biomarker, it must be proven to be stable and reliably measurable in the absence of disease or disorder. Further, much is still unknown about the biological basis and purpose of resting-state activity, that may help to elucidate the functional relevance in patient groups. Magnetoencephalography (MEG) is a technique that is well suited to the study of resting-state connectivity because it provides a direct inference of synchronised neuronal activity. In chapter two of this thesis, the test-retest repeatability of two different approaches to assessing functional coupling of brain areas using MEG is examined. Having established a preferential analysis pipeline, chapter three compares frequency band-limited MEG connectivity with functional connectivity derived from BOLD-fMRI data. The connectivity pipeline is then used for two different applications. First, the approach is combined with pharmacological intervention in healthy subjects in order to investigate the role of AMPA receptors in the glutamate system on the MEG signal and functional connectivity (chapter four). The final experimental chapter focuses on comparing functional connectivity in a group of generalised epilepsy patients with age- and gender-matched healthy control subjects. Taken together, the results of this thesis have implications for the study of functional connectivity in the resting-state using MEG, particularly the sensitivity of the technique to microscale as well as macroscale change

A multimodal imaging approach for quantitative assessment of epilepsy

Le tecniche di coregistrazione elettroencefalogramma-risonanza magnetica funzionale (EEG-fMRI) ed EEG ad alta densità (hdEEG) consentono di mappare attivazioni cerebrali anomale evocate da processi epilettici. L’EEG-fMRI è una tecnica di imaging non invasivo che permette la localizzazione delle variazioni del livello di ossigenazione nel sangue presente nelle regioni irritative (segnale BOLD). Diversamente, l’analisi di sorgente stima, a partire da un potenziale elettrico misurato sullo scalpo (EEG), la densità di corrente della sorgente elettrica a livello corticale producendo una plausibile localizzazione del dipolo nelle regioni irritative. Lo scopo di questa tesi è quello di sviluppare un approccio multimodale attraverso l’uso di dati di coregistrazione EEG-fMRI e hdEEG al fine di localizzare l’attività epilettica e verificare l’affidabilità sia dell’attivazione BOLD che della localizzazione della sorgente. Nel Capitolo I si introduce il concetto di approccio multimodale. Il capitolo è suddiviso principalmente in due parti: la prima descrive la tecnica di coregistrazione EEG-fMRI e la seconda la tecnica di localizzazione della sorgente in epilessia. La prima parte consiste in una breve analisi delle basi fisiologiche del dato di coregistrazione EEG-fMRI, nella descrizione di tecniche di registrazione simultanea e nell’introduzione del metodo convenzionale di analisi dei dati. Sono inoltre descritti problemi tecnici, problemi di sicurezza, modalità di scansione e strategie di rimozione degli artefatti EEG. È quindi presentata una panoramica sullo stato dell’arte delle coregistrazioni EEG-fMRI con discussione dei problemi aperti riguardanti l’analisi convenzionale. La seconda parte introduce i principi di base della stima delle sorgenti da dati hdEEG ed i loro limiti. Il primo capitolo fornisce un quadro generale, mentre i due capitoli successivi sono dedicati ad introdurre approcci di tipo diverso. Nell’analisi convenzionale di dati EEG-fMRI, l’apparizione di eventi interictali (IED) guida l’analisi dei dati fMRI. Il neurologo identifica gli intervalli degli eventi IED, che sono rappresentati da un’onda quadra, e successivamente questo protocollo viene convoluto con una risposta emodinamica (HRF) canonica per la costruzione di un modello o regressore da impiegare nell’analisi con modelli lineari generalizzati (GLM). I problemi principali dell’analisi convenzionale consistono nel fatto che essa non è automatica, ossia soffre di soggettività nella classificazione degli IED, e che, se la scelta dell’HRF non è ottimale, l’attivazione può essere sovra o sotto stimata. Il nuovo metodo proposto integra nell’analisi GLM convenzionale due nuove funzioni: il regressore basato sul segnale EEG (Capitolo II), e l’individuazione di una risposta emodinamica individual-based (ibHRF) (Capitolo III). Nel Capitolo IV le prestazioni del nuovo metodo per l’analisi di dati EEG-fMRI sono validate su dati in silico. A questo scopo sono stati creati dati fMRI simulati per testare la scelta dell’HRF ottima tra cinque modelli: quattro standard ed un modello HRF individual-based. Le prestazioni del metodo sono state valutate utilizzando come selezione il criterio di Akaike. Le simulazioni dimostrano la superiorità del nuovo metodo rispetto a quelli convenzionali e mostrano come la variazione del modello HRF influisce sui risultati dell’analisi statistica. Il Capitolo V introduce un criterio automatico volto a separare le componenti del segnale fMRI relative a network interni dal rumore. Dopo il processo di decomposizione probabilistico delle componenti indipendenti (PICA), si seleziona il numero ottimale di componenti applicando un nuovo algoritmo che tiene conto, per ciascuna componente, dei valori medi delle mappe spaziali di attivazione seguito da passaggi di clustering, segmentazione ed analisi spettrale. Confrontando i risultati dell’identificazione visiva dei network neuronali con i risultati di quella automatica, l’algoritmo mostra elevata accuratezza e precisione. In questo modo, il metodo di selezione automatica permette di separare ed individuare i network in stato di riposo, riducendo la soggettività nella valutazione delle componenti indipendenti. Nel Capitolo VI sono descritti il design sperimentale e l’analisi dei dati reali. Il capitolo illustra i risultati di dodici pazienti epilettici, concentrandosi sull’attività BOLD, sulla localizzazione della sorgente e sulla concordanza con il quadro clinico del paziente. Lo scopo è quello di applicare un approccio multimodale che combini tecniche non invasive di acquisizione ed analisi. Sequenze di EEG standard e fMRI sono acquisite nel corso della stessa sessione di scansione. L’analisi dei dati EEG-fMRI è eseguita utilizzando l’approccio GLM tradizionale, il nuovo approccio e l’analisi PICA. La sorgente dell’attività epilettica è stimata a partire da tracciati EEG a 256-canali. L’attivazione BOLD è confrontata con la ricostruzione della sorgente EEG. Questi risultati sono infine confrontati con l’attività epilettica definita da EEG standard ed esiti clinici. La combinazione di tecniche multimodali ed i loro rispettivi metodi di analisi sono strumenti utili per creare un workup prechirurgico completo dell’epilessia, fornendo diversi metodi di localizzazione dello stesso focolaio epilettico. L’approccio non invasivo di integrazione multimodale di dati EEG-fMRI e hdEEG sembra essere uno strumento molto promettente per lo studio delle scariche epilettiche.Electroencephalography-functional magnetic resonance imaging (EEG-fMRI) coregistration and high density EEG (hdEEG) can be combined to noninvasively map abnormal brain activation elicited by epileptic processes. EEG-fMRI can provide information on the pathophysiological processes underlying interictal activity, since the hemodynamic changes are a consequence of the abnormal neural activity generating interictal epileptiform discharges (IEDs). The source analysis estimates the current density of the source that generates a measured electric potential and it yields a plausible dipole localization of irritative regions. The aim of this thesis is to develop a multimodal approach with hdEEG and EEG-fMRI coregistration in order to localize the epileptic activity and to verify the reliability of source localization and BOLD activation. In Chapter I the multimodal approach is introduced. The chapter is divided in two main parts: the first is based on EEG-fMRI coregistration and the second on the source localization in epilepsy. The first part consists of a brief review of the physiologic basis of EEG and fMRI and the technical basics of simultaneous recording, examining the conventional method for EEG-fMRI data. Technical challenges, safety issues, scanning modalities and EEG artifact removal strategies are also described. An overview of the state of EEG-fMRI is presented and the open problems of conventional analysis are discussed. The second part introduces the basic principles of the source estimation from EEG data in epilepsy and their limitations. The first chapter provides a general framework. The next two are devoted to introduce different approaches. Conventional analysis of EEG-fMRI data relies on spike-timing of epileptic activity: the neurologist identifies the intervals of the IEDs events, as represented by a square wave; this protocol is then convolved with a canonical hemodynamic response function (HRF) to construct a model for the general linear model (GLM) analysis. There are limitations to the technique, however. The conventional analysis is not automatic, suffers of subjectivity in IEDs classification, and using a suboptimal HRF to model the BOLD response the activation map may result over or under estimated. The novel method purposed integrates in the conventional GLM two new features: the regressor based on the EEG signal (Chapter II) and the individual-based hemodynamic response function (ibHRF) (Chapter III). In Chapter IV the performance of the novel method of EEG-fMRI data was tested on in silico data. Simulated fMRI datasets were created and used for the choice of the optimal HRF among five models: four standard and an individual-based HRF models. The performance of the method was evaluated using the Akaike information criterion as selection. Simulations would demonstrate the superiority of the novel method compared with the conventional ones and assess how the variations in HRF model affect the results of the statistical analysis. Chapter V introduces an automatic criterion aiming to separate in fMRI data the signal related to an internal network from the noise. After the decomposition process (probabilistic independent component analysis [PICA]), the optimal number of components was selected by applying a novel algorithm which takes into account, for each component, the mean values of the spatial activation maps followed by clustering, segmentation and spectral analysis steps. Comparing visual and automatic identification of the neuronal networks, the algorithm demonstrated high accuracy and precision. Thus, the automatic selection method allows to separate and detect the resting state networks reducing the subjectivity of the independent component assessment. In Chapter VI experimental design and analysis on real data are described. The chapter focuses on BOLD activity, source localization and agreement with the clinical history of twelve epileptic patients. The scope is to apply a multimodal approach combining noninvasive techniques of acquisition and analysis. Standard EEG and fMRI data were acquired during a single scanning session. The analysis of EEG-fMRI data was performed by using both the conventional GLM, the new GLM and the PICA. Source localization of IEDs was performed using 256-channels hdEEG. BOLD localizations were then compared to the EEG source reconstruction and to the expected epileptic activity defined by standard EEG and clinical outcome. The combination of multimodal techniques and their respectively methods of analysis are useful tools in the presurgical workup of epilepsy providing different methods of localization of the same epileptic foci. Furthermore, the combined use of EEG-fMRI and hdEEG offers a new and more complete approach to the study of epilepsy and may play an increasingly important role in the evaluation of patients with refractory focal epilepsy

Homotopic Coupling in Persons with Epilepsy using Movie-driven and Resting-state fMRI

For the 30-40% of persons with epilepsy (PWE) with refractory epilepsy, seizure freedom following surgery is affected by the localization of the epileptogenic zone (EZ). However, functional abnormalities can exist at a distance from the EZ, which may contribute to variable outcomes after surgery. Considering epilepsy as a network disorder (Pittau & Vulliemoz, 2015), and evaluating functional coupling among homotopic brain areas, may help predict cognitive outcomes. Homotopic areas are well connected anatomically and undoubtedly work synchronously to generate cognition. We evaluated 22 persons with focal epilepsy and 24 neurologically healthy controls using fMRI at rest and while watching a brief and engaging audiovisual film clip. The Glasser parcellation (Glasser et al., 2016), a surface-based atlas that divides each hemisphere into 180 cortical regions and 22 functionally distinct sections, was applied and a baseline distribution of homotopic connectivity between pairs of regions and sections was established based on a subset of controls. Regional distribution of homotopic coupling activity was investigated as well as the relationship with performance on neuropsychological measures. We demonstrate the combined utility of resting-state and movie-driven fMRI for detecting homotopic functional coupling abnormalities in persons with refractory temporal lobe epilepsy. In addition, we find evidence of patient-specific and widespread abnormal homotopic functional coupling in PWE within and outside the temporal lobe. Finally, we show that the relationship between homotopic coupling at rest and performance on neuropsychological assessments shows group differences. Our findings supplement evidence of altered functional connectivity in epilepsy using resting-state fMRI and demonstrate how the engaged brain is altered in focal epilepsy

Study of the Term Neonatal Brain Injury with combined Diffuse Optical Tomography and Electroencephalography

This thesis describes the application of combined diffuse optical tomography (DOT) and electroencephalography (EEG) in the investigation of neonatal term brain injury. With hypoxic ischaemic encephalopathy (HIE) and perinatal stroke being the most frequent contributors to brain injury in the term neonatal population, the first part of the thesis focuses on the description and ongoing requirement for their further investigation. In continuation to that, the characteristics and unique properties of both DOT and EEG are described and explored. The combination of these two modalities was utilised in elucidating the relationship between neuronal activity and cerebral haemodynamics both in physiological processes as well as in disease, by the infant’s cot side. This work differs to previous studies using near-infrared technologies and EEG, as a denser whole head array was used, offering the potential of 3-dimensional image reconstruction of the cortical haemodynamic events in relation to electro-cortical activity. These methods were applied in the study of critically ill infants presenting with seizures in the first few days of life. The relevant results are presented in three separate chapters of the thesis. Distinct neurophysiological phenomena such as seizures and burst suppression were detected and studied in association to underlying HIE. On the grounds of a pre-existing pilot study of our research group, distinct prolonged de-oxygenated cortical areas were identified following electrical seizure activity. Further exploration of infants with seizures provided limited supporting evidence. The investigation of burst suppression in HIE led to the first ever identification of repeated, waveform, cortical haemodynamic events in response to bursts of electrical activity with some spatial correlation to regions of brain injury. Further analysis of the low frequencies within the diffuse optical signal in cases of perinatal stroke, showed a consistent interhemispheric difference between the healthy and stroke-affected brain regions. The limitations, prospects and conclusions are presented in the final chapter. The use of simultaneous DOT and EEG offers a unique neuro-monitoring and neuro-investigating tool in the neonatal intensive care environment, which is safe, portable, and cost-effective, Ongoing research is required for the exploration and development of the methodology and its potential diagnostic properties