Solving the Orientation Specific Constraints in Transcranial Magnetic Stimulation by Rotating Fields

Transcranial Magnetic Stimulation (TMS) is a promising technology for both neurology and psychiatry. Positive treatment outcome has been reported, for instance in double blind, multi-center studies on depression. Nonetheless, the application of TMS towards studying and treating brain disorders is still limited by inter-subject variability and lack of model systems accessible to TMS. The latter are required to obtain a deeper understanding of the biophysical foundations of TMS so that the stimulus protocol can be optimized for maximal brain response, while inter-subject variability hinders precise and reliable delivery of stimuli across subjects. Recent studies showed that both of these limitations are in part due to the angular sensitivity of TMS. Thus, a technique that would eradicate the need for precise angular orientation of the coil would improve both the inter-subject reliability of TMS and its effectiveness in model systems. We show here how rotation of the stimulating field relieves the angular sensitivity of TMS and provides improvements in both issues. Field rotation is attained by superposing the fields of two coils positioned orthogonal to each other and operated with a relative phase shift in time. Rotating field TMS (rfTMS) efficiently stimulates both cultured hippocampal networks and rat motor cortex, two neuronal systems that are notoriously difficult to excite magnetically. This opens the possibility of pharmacological and invasive TMS experiments in these model systems. Application of rfTMS to human subjects overcomes the orientation dependence of standard TMS. Thus, rfTMS yields optimal targeting of brain regions where correct orientation cannot be determined (e.g., via motor feedback) and will enable stimulation in brain regions where a preferred axonal orientation does not exist

Cortical lamina-dependent blood volume changes in human brain at 7T

Cortical layer-dependent high (sub-millimeter) resolution functional magnetic resonance imaging (fMRI) in human or animal brain can be used to address questions regarding the functioning of cortical circuits, such as the effect of different afferent and efferent connectivities on activity in specific cortical layers. The sensitivity of gradient echo (GE) blood oxygenation level-dependent (BOLD) responses to large draining veins reduces its local specificity and can render the interpretation of the underlying laminar neural activity impossible. The application of the more spatially specific cerebral blood volume (CBV)-based fMRI in humans has been hindered by the low sensitivity of the noninvasive modalities available. Here, a vascular space occupancy (VASO) variant, adapted for use at high field, is further optimized to capture layer-dependent activity changes in human motor cortex at sub-millimeter resolution. Acquired activation maps and cortical profiles show that the VASO signal peaks in gray matter at 0.8–1.6 mm depth, and deeper compared to the superficial and vein-dominated GE-BOLD responses. Validation of the VASO signal change versus well-established iron-oxide contrast agent based fMRI methods in animals showed the same cortical profiles of CBV change, after normalization for lamina-dependent baseline CBV. In order to evaluate its potential of revealing small lamina-dependent signal differences due to modulations of the input-output characteristics, layer-dependent VASO responses were investigated in the ipsilateral hemisphere during unilateral finger tapping. Positive activation in ipsilateral primary motor cortex and negative activation in ipsilateral primary sensory cortex were observed. This feature is only visible in high-resolution fMRI where opposing sides of a sulcus can be investigated independently because of a lack of partial volume effects. Based on the results presented here, we conclude that VASO offers good reproducibility, high sensitivity and lower sensitivity than GE-BOLD to changes in larger vessels, making it a valuable tool for layer-dependent fMRI studies in humans

Early cortical surface plasticity relates to basic mathematical learning

Children lay the foundation for later academic achievement by acquiring core mathematical abilities in the first school years. Neural reorganization processes associated with individual differences in early mathematical learning, however, are still poorly understood. To fill this research gap, we followed a sample of 5-6-year-old children longitudinally to the end of second grade in school (age 7–8 years) combining magnetic resonance imaging (MRI) with comprehensive behavioral assessments. We report significant links between the rate of neuroplastic change of cortical surface anatomy, and children's early mathematical skills. In particular, most of the behavioral variance (about 73%) of children's visuospatial abilities was explained by the change in cortical thickness in the right superior parietal cortex. Moreover, half of the behavioral variance (about 55%) of children's arithmetic abilities was explained by the change in cortical folding in the right intraparietal sulcus. Additional associations for arithmetic abilities were found for cortical thickness change of the right temporal lobe, and the left middle occipital gyrus. Visuospatial abilities were related to right precentral and supramarginal thickness, as well as right medial frontal gyrus folding plasticity. These effects were independent of other individual differences in IQ, literacy and maternal education. Our findings highlight the critical role of cortical plasticity during the acquisition of fundamental mathematical abilities

Auditory brainstem measures and genotyping boost the prediction of literacy : a longitudinal study on early markers of dyslexia

Literacy acquisition is impaired in children with developmental dyslexia resulting in lifelong struggle to read and spell. Proper diagnosis is usually late and commonly achieved after structured schooling started, which causes delayed interventions. Legascreen set out to develop a preclinical screening to identify children at risk of developmental dyslexia. To this end we examined 93 preliterate German children, half of them with a family history of dyslexia and half of them without a family history. We assessed standard demographic and behavioral precursors of literacy, acquired saliva samples for genotyping, and recorded speech-evoked brainstem responses to add an objective physiological measure. Reading and spelling was assessed after two years of structured literacy instruction. Multifactorial regression analyses considering demographic information, genotypes, and auditory brainstem encoding, predicted children’s literacy skills to varying degrees. These predictions were improved by adding the standard psychometrics with a slightly higher impact on spelling compared to reading comprehension. Our findings suggest that gene-brain-behavior profiling has the potential to determine the risk of developmental dyslexia. At the same time our results imply the need for a more sophisticated assessment to fully account for the disparate cognitive profiles and the multifactorial basis of developmental dyslexia

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Kortikale und subkortikale Mechanismen bei persistentemStottern

Die dem Stottern zugrunde liegenden Ursachen und Pathomechanismen sind nach wie vor ungeklärt. Jüngste bildgebende Studien weisen auf veränderte kortikale und subkortikale Morphologien und einer damit einhergehenden, beeinträchtigten neuronalen Verarbeitung senso-motorischer Informationen beim Stottern hin. Betroffen ist sowohl die Verarbeitung sprachlicher als auch die Verarbeitung nicht-sprachlicher Informationen. Die drei Studien der vorliegenden Dissertation erweitern die Wissensgrundlage über Pathophysiologien und Pathomechanismen bei persistentem Stottern. In Studie eins konnte gezeigt werden, dass bei Erwachsenen, die stottern, der linke dorsolaterale prämotorische Cortex eine Fehlfunktion bei der Steuerung von Fingerbewegungen aufweist und dass der rechte dorsolaterale prämototrische Cortex für diese Leistung eine kompensatorische Rolle ausübt. Bisher lieferten bildgebende Studien Hinweise auf veränderte Aktivierungsmuster für fingermotorische Fähigkeiten. Ob die beobachtete Mehraktivierung der rechten Hemisphäre jedoch kompensatorische Mechanismen oder eine Fehlanpassung widerspiegelt, blieb ungeklärt. Mittels repetitiver transkranieller Magnetstimulation konnten wir erstmals direkt nachweisen, dass der Beitrag der rechten Hemisphäre tatsächlich eine Kompensation und keine Fehlanpassung darstellt. In Studie zwei untersuchten wir neurophysiologische Veränderungen des primär motorischen Cortex der Zungenrepräsentation der rechten und der linken Hemisphäre von stotternden Erwachsenen. Hierfür wurde die Methode, motorische Potentiale von der Zungenmuskulatur abzuleiten, im Labor etabliert. Dies ermöglichte es erstmals, die intrakortikale Erregbarkeit des Zungenareals bei stotternden Erwachsenen zu untersuchen und Veränderungen der TMS-induzierten Erregbarkeitsmodulation bei stotternden Erwachsenen zu beschreiben. Der starke Einfluss der Audition auf die Sprechflüssigkeit bei persistentem Stottern motivierte uns zu Studie drei, die Sprachwahrnehmung auf sublexikalischer Ebene zu testen. Wir prüften die Trennschärfe, mit der stotternde Erwachsene den Stimmhaftigkeits-Kontrast von Plosivlauten wahrnehmen. Hierfür kreierten wir zwei Silben-Kontinua (/be/-/pe/, /de/-/te/) mit einer Zunahme der voice onset time in 1-ms-Schritten. Die Daten der Identifikationsleistungen von 20 stotternden und 20 nicht-stotternden Erwachsenen wurden mit psychometrischen Funktionen gefittet, um die Breite des Bereichs der ambivalenten Wahrnehmung zu bestimmen. Stotternde Teilnehmer wiesen für beide Kontinua einen breiteren Unsicherheitsbereich und somit eine verminderte Trennschärfe auf. Aus dieser Beobachtung schließen wir, dass bei Erwachsenen mit persistentem Stottern phonematische Perzepte unzuverlässig sind. Unsere Daten unterstützen aktuelle Theorien der engen Interaktion von Sprachproduktion und wahrnehmung und untermauern Hypothesen eines gestörten sprechmotorischen Kontrollsystems beim Stottern

Dissecting structural connectivity of the left and right inferior frontal cortex in children who stutter

Inferior frontal cortex pars opercularis (IFCop) features a distinct cerebral dominance and vast functional heterogeneity. Left and right IFCop are implicated in developmental stuttering. Weak left IFCop connections and divergent connectivity of hyperactive right IFCop regions have been related to impeded speech. Here, we reanalyzed diffusion magnetic resonance imaging data from 83 children (41 stuttering). We generated connection probability maps of functionally segregated area 44 parcels and calculated hemisphere-wise analyses of variance. Children who stutter showed reduced connectivity of executive, rostral-motor, and caudal-motor corticostriatal projections from the left IFCop. We discuss this finding in the context of tracing studies from the macaque area 44, which leads to the need to reconsider current models of speech motor control. Unlike the left, the right IFCop revealed increased connectivity of the inferior posterior ventral parcel and decreased connectivity of the posterior dorsal parcel with the anterior insula, particularly in stuttering boys. This divergent connectivity pattern in young children adds to the debate on potential core deficits in stuttering and challenges the theory that right hemisphere differences might exclusively indicate compensatory changes that evolve from lifelong exposure. Instead, early right prefrontal connectivity differences may reflect additional brain signatures of aberrant cognition-emotion-action influencing speech motor control

Differentiation of brain metastases from small and non-small lung cancers using apparent diffusion coefficient (ADC) maps

Background!#!Brain metastases are particularly common in patients with small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC), with NSCLC showing a less  aggressive clinical course and lower chemo- and radio sensitivity compared to SCLC. Early adequate therapy is highly desirable and depends on a reliable classification of tumor type. The apparent diffusion coefficient is a noninvasive neuroimaging marker with the potential to differentiate between major histological subtypes. Here we determine the sensitivity and specificity of the apparent diffusion coefficient to distinguish between NSCLC and SCLC.!##!Methods!#!We enrolled all NSCLC and SCLC patients diagnosed between 2008 and 2019 at the University Medical Center Göttingen. Cranial MR scans were visually inspected for brain metastases and the ratio of the apparent diffusion coefficient (ADC) was calculated by dividing the ADC measured within the solid part of a metastasis by a reference ADC extracted from an equivalent region in unaffected tissue on the contralateral hemisphere.!##!Results!#!Out of 411 enrolled patients, we detected 129 patients (83 NSCLC, 46 SCLC) with sufficiently large brain metastases with histologically classified lung cancer and no hemorrhage. We analyzed 185 brain metastases, 84 of SCLC and 101 of NSCLC. SCLC brain metastases showed an ADC ratio of 0.68 ± 0.12 SD, and NSCLC brain metastases showed an ADC ratio of 1.47 ± 0.31 SD. Receiver operating curve statistics differentiated brain metastases of NSCLC from SCLC with an area under the curve of 0.99 and a 95% CI of 0.98 to 1, p < 0.001. Youden's J cut-point is 0.97 at a sensitivity of 0.989 and a specificity of 0.988.!##!Conclusions!#!In patients with lung cancer and brain metastases with solid tumor parts, ADC ratio enables an ad hoc differentiation of SCLC and NSCLC, easily achieved during routine neuroradiological examination. Non-invasive MR imaging enables an early-individualized management of brain metastases from lung cancer.!##!Trial registration!#!The study was registered in the German Clinical Trials Register (DRKS00023016)