What the Referring Physician Needs to Know About ...
Transcript of What the Referring Physician Needs to Know About ...
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What the Referring Physician Needs to Know
About Magnetoencephalography (MEG)
Richard C. Burgess, MD, PhD
Director, Magnetoencephalography Laboratory
Cleveland Clinic Epilepsy Center
An American Clinical MEG Society Educational Webinar
November 21, 2013
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Green dots =
Subdural electrode
positions.
Green cylinders =
What is MEG?
Coregistration of MEG dipole sources and invasive electrodes
Green cylinders =
Depth electrode
positions.
Blue lollipops =
MEG dipoles, where
sphere is locaton
and stem is
orientation.
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Based on recording of incredibly small magnetic fields (10 -12 T).
Easy acquisition of very high density (100-300channels),
wideband (DC – 2000 hz) recordings
What is MEG?Neurophysiological Principles
wideband (DC – 2000 hz) recordings
of currents within the brain.
Magnetic fields, as opposed to electrical currents, suffer
minimum attenuation and distortion from the different tissues
that they have to cross to reach the scalp surface.
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What is MEG?
MEG is a localization tool.
Based on solid theoretical reasons, MEG has localization accuracy better than the scalp EEG.
Greater number of sensors typically employed� Greater number of sensors typically employed
� Simpler source modeling and calculation
� Anatomical co-registration with 3D-MRI
MEG is a neurophysiological technique, not an imaging method.
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What do we know about MEG?
MEG provides additional localizing information.
� (Wheless et al, 1999; Stefan et al, 2003; Pataraia
et al, 2004)
MEG results change the electrode coverage MEG results change the electrode coverage
decisions for intracranial EEG.
� (Knowlton et al, 2009)
The yield of MEG is higher than scalp EEG.
� (Yoshinaga et al, 2002; Iwasaki et al, 2005)
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MEG is a valuable component of
the presurgical epilepsy evaluation
Evaluation goals in potential epilepsy surgery candidates:� Locate the epileptogenic zone.� Assess whether it can be resected to achieve seizure freedom.
Multi-modality investigative tools:Video-EEG monitoring +/- sphenoidals� Video-EEG monitoring +/- sphenoidals
� MRI� PET/SPECT� Neuropsychology� Wada/fMRI� MEG source localization� Invasive Monitoring
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1. What should the referring physician expect from a MEG study?
2. What are the basic MEG modalities, clinical indications, and capabilities?
3. For patients with epilepsy, how can MEG help?
What Are the Main Questions from Epileptologists?
4. What can epileptologists expect from MEG in the future?
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1) Where do you send patients for clinical diagnostic MEG studies?
a) MEG lab in my own institution.
b) MEG lab at another institution.
c) I do not have convenient access to any MEG lab for my patients.
d) I do not currently request MEG testing.
2) What clinical indications do you currently use MEG for, or would you like to use MEG for?
a) Epileptogenic zone localization.
Some polling questions for the audience
b) Sensory and/or motor evoked fields.
c) Language assessment.
d) Both epilepsy localization and eloquent cortex mapping.
3) What has been the greatest limitation of MEG testing in your patients?
a) Results have been negative or provide no new information.
b) Results are discordant with the rest of the clinical picture.
c) Contents of the reports are confusing or not clinically relevant.
d) I have generally been satisfied with the results of clinical MEG testing
and the reports that I receive.
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Genesis of EEG and MEG Signals:
A current dipole creates a magnetic field
What is the MEG signal?
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Dipolar representation of brain currentsThe signals picked up by scalp electrodes or MEG sensors are generated by synchronized activity from many neurons
� Postsynaptic potentials produce intracellular laminar currents
� Neocortical pyramidal neurons arranged in a palisade structure
� Typically seen as a current dipole perpendicular to the cortical surface
Dipolar models are based on the assumption that a small number of current sources (multiple dipoles) in the brain can adequately model surface measurements.
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EEG and MEG WaveformsEEG
MEG
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Electric fields and magnetic fields
generated by a current dipole
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MEG Instrumentation
SQUID
Flux transformers
How is MEG recorded?
Shielded room
Head position
indicator
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SQUID and Flux Transformer
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Patient PreparationSystem / Patient
SetupData Recording Data Analysis
MEG Procedures
How is MEG recorded?
HPI measurement
Fiducial measurement
“Cloud” of scalp
points
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Careful Attention to Postion of
Fiducials, Landmarks, HPI Coils
Use of HPI (head position indicator)
coils:
•Number: 5
•Positions: Widely spaced over
scalp but well inside array
Alignment of scalp with MRI and MEG
array:
•Three fiducials (LPA, RPA, Naison)
•Digitize 80-120 additional scalp
points for coregistration with MRI
16
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MEG Procedures
Patient PreparationSystem / Patient
SetupData Recording Data Analysis
Simultaneous EEG and video monitoring Simultaneous EEG and video monitoring
with MEG
On-line marker entry
Feedback noise compensation
Continuous head-position monitoring
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Alignment of Subject in MEG ArrayGeneration of alignment image in real-time to insure good position
Location of HPI coils monitored
continuously.
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MEG Procedures
Patient PreparationSystem / Patient
SetupData Recording Data Analysis
Review of markersReview of markers
Review of video
Visual / manual analysis of every
channel of MEG and EEG
Montages
Single ECD analysis at core
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What are the Advantages of MEG?Why use MEG in epilepsy patients?
1. Inherently higher source resolution.
2. Direct connection to patient (i.e. pasting electrodes on) is not required.
3. Reference – free.
4. Signals not attenuated or distorted by bone and scalp, or other
inhomogeneities that exist between brain and surface.inhomogeneities that exist between brain and surface.
5. Therefore for source analysis, the head modelling problem is
significantly simpler.
6. Easy to obtain multichannel, whole-head, high spatial-density
recordings.
7. No exposure to radiation, magnetic field, or other active device.
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High temporal and spatial
resolution
Patient with parietal lobe seizures
Scalp video-EEG localization unclear
71674282
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Polyspikes Originating from Left parietal
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Propagation of Polyspike Activity to Left Parietal
Left inferior parietal
Left basal temporo-occpital
37 msec
Left middle temporal
161 msec
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Representative interictal dipoles
LEFT
LEFT
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High temporal and spatial
resolution
Patient with non-localizable,
non-lateralizable scalp video-EEG
71674282
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Run I EEG
EEG: Polyspikes, Vertex
#1 #2
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Left parietal sensors
MEG: Polyspikes, Left > Right parietal sensors
#1 #2
Right parietal sensors
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All interictal dipoles: Left frontal
CS
LEFT
CS
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Why does MEG have a
higher yield than EEG?
EEG and MEG are complementary.
MEG not only sees some different source, but sees more sources.
Geography:
• MEG is more sensitive to tangential sources, while EEG is more sensitive to radial sources.
• Approximately 2/3 of cortex lies in sulci, i.e. more tangential sources.• Approximately 2/3 of cortex lies in sulci, i.e. more tangential sources.
Resolution:
• MEG has an inherently higher resolution.
• Requires only ~4 cm2 vs 6 cm2 of synchronized discharging cortex.(Oishi M, Otsubo H et al. Epileptic spikes: Magnetoencephalography vs simultaneous electrocorticography. Epilepsia 43: 1290-1295; 2002.)
(Agirre-Arrizubieta Z et al. Brain 132, 3060-07; 2009)
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Differences and Similarities:
EEG and MEG
Similarities� Record the same phenomenon
• Same time-resolution
• Spontaneous activities (epileptic spikes, non-epileptiform physiological),
evoked responses (SEP, VEP, AEP)
� Sensitivity to brain volume and depth
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Differences and Similarities:
EEG and MEG
Similarities� Record the same phenomenon
• Same time-resolution
• Spontaneous activities (epileptic spikes, non-epileptiform physiological),
evoked responses (SEP, VEP, AEP)
� Sensitivity to brain volume and depth
Differences� Sensitivity to the current dipole orientation� Sensitivity to the current dipole orientation
• Tangential or vertical to the scalp surface
� Complexity of the forward model• Feasibility of the computerized source estimation
� Analysis
� MEG is reference-free
� Number of sensors
� Duration of the recording
� Different sensitivity to external noises
� Cost
� Established knowledge
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Primary Clinical Applications
Sensory Mapping
� Usually in relation to a lesion
Mapping often done prior to resection� Mapping often done prior to resection
Epileptic Spike Localization
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What are the Indications for MEG
in Epilepsy?
Localization tool for interictal spikes
Planning of intracranial investigations: grid placement, sEEG, etc.
Normal MRI or discordance between other non-invasive studies
Pre-existing cranial defects (reoperations)
Extensive lesionsExtensive lesions
Multiple lesions
Functional mapping
Bilateral synchrony
Normal EEG
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MEG:
Interictal
ICEEG:
Seizure
Onset
Correlation of MEG Localization of Interictal Discharges
to ICEEEG Ictal Activity
Interictal
Dipoles
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Patient Examples
MEG localization is especially useful in patients with
previous neurosurgery or other skull defects.
Head shape, deformities, or position in the sensor
array do not interfere.
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Patient #1: MRI and EEG negative
History
• 34 year old male
• Right-handed
• One febrile seizure at age 2.5
• Onset: 10 years old• Onset: 10 years old
• Current seizures, up to 30/day, consist of a spasm in the neck and throat, sometimes accompanied by head turning to left, eye closure and facial grimacing
• Most recent GTC seizure was 15 years ago.
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• 1987 VEEG monitoring: 16 episodes recorded, none with any EEG change
• 1988 VEEG monitoring: 1 seizure lateralized to right
• 1989 Threee multihour EEG: No epileptiform abnormalities
• 1993 Routine EEG: Normal
• 1995 Routine EEG: Normal
Patient #1 EEG and VEEG evaluations
• 1995 Routine EEG: Normal
• 2002 Routine EEG: Normal
• 2011 Routine EEG: Normal
• 2011 (February) 6 day VEEG monitoring: Many seizures with no EEG change, Two seizures with EEG patterns at the vertex, slightly higher on left
• 2011 (March) MEG
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Spike, regional right temporal (Unique to MEG, not
seen on EEG)
Run I: Double banana bipolar EEG
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MEG Left temporal sensors
Spike, regional right temporal on MEG
MEG Right temporal sensors
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Right temporal spike dipole source localization
RL
R RLeftL
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Representative spike dipoles
R L
Right side
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History:
55 year old, right handed male with onset of epilepsy at age 25.
Mostly nocturnal seizures, sometimes in clusters, consisting of asymmetrical tonic posturing.
Patient #2: Scalp EEG Negative Case
Example
consisting of asymmetrical tonic posturing.
Previous EEGs have been negative.
MRI negative.
Ictal SPECT showed bilateral frontal activation.
VEEG monitoring showed extremely rare bifrontal spikes and non-localizable seizures.
(MR# 57564962)
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Run I EEG (Bipolar double bananna)
EEG: Intermittent slow, FP1/F3
1 sec 100 uV
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Left frontal sensors
MEG: Run of sharp waves, Left frontal sensors
(consistent localization)1 sec 500 fT/cm
Right frontal sensors
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MEG Sources: Left middle frontal gyrus and superior frontal sulcus
LEFT LEFTLEFTLEFT
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Ictal Onset ( ) & CS seizure ( )Ictal Onset ( ) & CS seizure ( )
X’10
X’12
X’11
11 Spontaneous seizures captured with onset at X’10,11,12
X’12
X’11
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MEG in EEG-Negative Patients
Routine MEGs:� 358 Patients, 375 Studies
� Feb 2008 – Jan 2012
Previous Routine EEG: 145 Patients (40.5%)Previous Routine EEG: 145 Patients (40.5%)� No Epileptic Activity: 58 Patients (40%)
MEG Results:� Localizable dipoles: 38 Patients (65.5%)
� MEG-Unique Information: 12 Pt (31.6%)
( Ito et al. American Epilepsy Society Meeting, 2012 )
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MEG in Non-Focal VEEG Patients
Routine MEG 358 Patients, 375 Studies
Previous EMU Evaluation 336 Patients (93.4%)
� Only generalized, no regional Activity:
83 Patients (24.7%)83 Patients (24.7%)
MEG Results:
� Localizable dipoles: 48 Patients (57.8%)
� MEG-Unique Information: 5 Pt (10.4%)
( Ito et al. American Epilepsy Society Meeting, 2012 )
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History:
42 yo right handed male
Patient #3: MEG prompts re-review of a
previously negative PET, identifying a
subtle hypometabolism
Sz triggered by music with lyrics (or just thinking
about the lyrics) that he knows
Sz Classification: Auditory aura � Dialeptic �
Right versive � GTC
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PET: Nonspecific
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Simultaneous Multi-Modality Review:
PET and MEG
MEG highlights a subtle hypometabolism on a previously negative PET
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Simultaneous MEG and Subdural Grid
Recording
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Multi-
modality
integrationintegration
(Wang et al 2012, J of Neurology)
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Some Myths and Realities about MEG
Myth #1: MEG is too sensitive to artifacts and noise
Myth #2: MEG only records interictal activity
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Myth #1: MEG is too sensitive
to noise and artifact.
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Relative Field StrengthBrain sources:
Evoked cortical fields: 10 fT
Alpha rhythm: 1000 fT
Noise sources:Noise sources:
Earth’s magnetic field: ~50 µT
Field from home appliances and wiring: <10 µT
Urban environmental noise: 108 fT
(fT = femto Tesla or 10-15 Tesla)
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MEG’s Immunity to EMG ArtifactEEG
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MEGSame Time Epoch as EEG on Previous Slide
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Patient with multiple implants
20 y.o. RH female with seizure onset age 13
Three seizure types:� Dialeptic � right version � right arm tonic � GTC
� Bilateral limb myoclonus
� Generalized myoclonic with eye blinking and shoulder shrugging
S / P VNS implantation 2 yrs ago with no benefit
Scalp VEEG: Interictal and ictal discharges generalized
Multiple body piercings, three of which were unremoveable (one in left ear)
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EEG:Run I: Double banana bipolar EEG
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Left temporal sensors
MEG without tSSS (temporal signal space separation)
Right temporal sensors
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Left temporal sensors
MEG with tSSS (same time segment with same amplitude scale)
Right temporal sensors
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Effect of tSSS Noise Cancellation in a Patient
with a Left Temporal Spike and a VNS
no SSS SSS tSSS(Taulu and Simola 2006: Jin, Burgess et al 2012)
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Myth #2: MEG only records
interictal epileptic activity
While MEG has been found most suitable for evaluation of interictal activity, as noted above, ictal MEG recordings have been made --- frequently serendipitously.
Despite the obliteration of the MEG signal by movement artifact during an ictus, a sizable proportion of focal seizures artifact during an ictus, a sizable proportion of focal seizures are manifest by EEG/MEG activity for many seconds (typically 5-20) prior to any clinical movements, or even without any movements (patients with frequent auras).
These recordings of ictal onset by MEG can yield precise localization of the epileptogenic zone.
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Ictal MEG RecordingLeft temporal gradiometers
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Ictal MEG studies at Cleveland Clinic
All epilepsy patients-� Between February 2008 – January 2012
� Who underwent VEEG and
� Who also had MEG studies within 6 months
309 total MEGs, 139 inpatients (45%), 170 outpatients
228 positive interictal MEGs� 106/139 (76%) inpatients, 122/170 (72%) outpatients� 106/139 (76%) inpatients, 122/170 (72%) outpatients
� I.e. Similar proportion (p = n.s.)
39 ictal MEGs (12.6%)� 26 (67%) inpatients and (33%) in outpatients
� Significantly higher in inpatients 26/139 (19%) than in outpatients 13/170 (8%) p <0.01
Of the 39 ictal MEGs, 25 (64%) localized using SECD� Approximately half of which (14 or 56%) were not localizable by VEEG.
( Ito et al. 30th International Epilepsy Congress, 2013 )
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What should the referring physician
expect from a MEG study?
The publication of Clinical Practice Guidelines*
has helped to establish referring physicians’
expectations for a high level of quality in the
interpretation and for practical utility from the interpretation and for practical utility from the
results.
Centers with MEGs are striving to practice
according to these guidelines.
*Bagic, Knowlton, Rose, Ebersole. CPG #1. J Clin Neurophysiol, 2011.
Burgess, Funke, Bowyer, Lewine, Kirsch, Bagic. CPG #2. J Clin Neurophysiol, 2011.
Bagic, Knowlton, Rose, Ebersole. CPG #3. J Clin Neurophysiol, 2011.
Bagic, Barkley, Rose, Ebersole. CPG #4. J Clin Neurophysiol, 2011.
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A routine and standardized procedure.
ACMEGS Clinical Practice Guidelines CPG # 1:
Recording and Analysis of Spontaneous Cerebral Activity
What Can Epileptologists Expect From MEG?
Recording and Analysis of Spontaneous Cerebral Activity
ACMEGS Clinical Practice Guidelines CPG # 2:
Presurgical Functional Brain Mapping Using Magnetic Evoked Fields
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A clear and helpful report.
An answer to the clinical question posed.
What Can Epileptologists Expect From MEG?
ACMEGS Clinical Practice Guidelines CPG # 3:
MEG-EEG Reporting
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MEG is a “complementary” technique with different
sensitivity, i.e. it adds new and unique information.
MEG prompts focused re-review of other structural
and functional tests.
How does MEG help to fill in the
gaps in our clinical understanding?
and functional tests.
MEG’s whole-head coverage fills in the gaps left by
other techniques.
MEG helps to explain results of other tests when they
are surprising and to understand discordant results.
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Beyond the basics:
What might we expect in the future?
Noise cancellation
Movement compensation
Streamlined software
Multimodality integration and neuronavigation
Analysis of connectivity and other quantitative
assessments
Replacement for intracranial VEEG monitoring
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Dipole Sources Coregistered
with Surface-Reconstructed MRI
MEG dipole sources (blue)
Subdural grids (green)
Stereotactic EEG electrodes (green)
Previous Resection (orange)
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For Further Information
Regarding:
MEG Clinical Practice Guidelines
Conferences, Courses & Symposia
Scientific Information
Regarding:
Evaluation of Epilepsy
Clinical Consultation
MEG Testing
American Clinical MEG Society
Phone: 414 918-9804
Email: [email protected]
Web: http://[email protected]
Cleveland Clinic Epilepsy Center
Phone: 216 444-0601
Email: [email protected]@ccf.org
Web: http://my.clevelandclinic.org/
neurological_institute/epilepsy
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Additional slides
for Q & A periodfor Q & A period
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First identify important waveforms (e.g.
spikes)
� By time correlation with EEG ?
How is MEG analyzed and
interpreted (1)
� By time correlation with EEG ?
� Blindly ?
� From spike detector ?
Spike !
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Analysis of MEG Signals (2)Field determination requires computerized calculation
200fT/step
Iso-magnetic field map
Rt lateral viewLt lateral view
Top view
200fT/step
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Analysis of MEG Signals (3)Source localization – dipole modeling
� Single or multiple dipole modeling – most common
� Iteratively search dipole parameters (location, orientation,
current strength) for best fit to the actual field distribution
� Requires a starting point (initial guess) for search
= +
Measurement Model Residual
(x,y,z)=45.2, 31.7, 8.8 mm
(Q)= 373 nAm
Goodness of fit = 84.5%Modeled dipole parameters
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Spike Source Estimation (4) ---
Solving the Inverse ProblemRecording spontaneous MEG activity --- trace mode
Typical MEG waveforms from sensors overlying the right central region; an epileptiform spike is outlined.
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Spike Source Estimation (4) ---
Solving the Inverse ProblemTopographic view of MEG activity during the bracketed epoch
Expanded view of MEG activity
at maximally active sensorat maximally active sensor
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Analysis of MEG Signals (5)
Co-registration to Anatomy
� Requires 3-dimensional coordinate digitization of
surface landmarks
� Import 3-D MRI� Import 3-D MRI
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Ictal MEG Analysis
MEG’s strength: Time dimension !
Example case:
Six seizures during MEG recording,
1 clinical seizure and
5 with no clinical signs (NCS).
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Left temporal
NCS Seizure. MEG: Spike and wave complex,
Right parietal sensors
Right
temporal
Onset, #5
(MR#70084422)
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Dipole of #5 (Onset): Right posterior middle frontal gyrus (stable)
L
CS
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Run I EEG
Clinical Seizure. EEG: Onset, Right centro-parietal,
Somatosensory Aura
EEG Onset #2 #3 #4#1
(MR#70084422)
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Left temporal
Clinical Seizure. MEG: Attenuation -> beta, polyspikes,
Right parietal sensors
Right EEG Onset #2 #3 #4#1
(MR#70084422)
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Dipole of #1-1 (early component): Right posterior middle frontal gyrus
L
CS
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Dipole of #1-2 (late component): Right precentral gyrus
L
CS
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Dipole of #2 (3.3 sec after onset): Right precentral & parietal (unstable)
L
CS
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Dipole of #3 (3.9 sec after): Right postcentral (hand and face) (stable)
L
CS
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Dipole of #4 (5.2 sec after): Right postcentral (hand and face) (stable)
L
CS
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All ICTAL dipoles
RIGHT
CS
Clinical Sz
1 recorded
NCS Sz
AwakeAwake
10-50 sec
5 recorded
(2 dipoles each)
The likely reason that one out of the six seizures had clinical
manifestations is because of propagation of that seizure from
the posterior middle frontal gyrus to the post central gyrus.
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Subdural Grids and Depth Electrodes
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Dipoles of NCS Seizures
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Dipoles of Clinical Seizures
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Does MEG See It All?Study of MEG ability to detect and localize spikes recorded on SEEG
• 3 simultaneous MEG / SEEG recordings
• Both TLE and ETLE
• 30 MEG patients who underwent intracranial recordings after MEG
• All extratemporal
• To assess factors which determine concordance between MEG and ICEEG• To assess factors which determine concordance between MEG and ICEEG
• Depth of contacts / sources
• Amplitude of spikes on intracranial electrodes
• “Tightness of clusters” on MEG
• Dipole orientation
Jin, Burgess et al., JES 2010
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Simultaneous MEG and SEEG (Case 1)
SEEG
S1
S2
S3
S4
S5
S6
S7
S5
S1Depth of contact:Approx. 39 mm
Max. Amplitude:
304.5 ± 137.0 uV (202.6 – 878.6)
Number of Contacts >200 uV:
1 contact (30 SPKs)
2 contacts (7 SPKs)
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Simultaneous MEG and SEEG (Case 1)Magnetometer Gradiometer
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Simultaneous MEG and SEEG (Case 3)
M1
M2
M3
M4
M5
M6
M7
SEEG
M8
Q1
Q2
Q3
Q4
Q6
M9
Q5
M9
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Simultaneous MEG and SEEG (Case 3)
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Simultaneous MEG and SEEG (Case 3)
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Summary of 3 Cases
CASE 1 2 3
Depth of
Contact (mm)39 21 20
Average of Max. 304.5 250.6 468.0
Average of Max.
Amplitude (uV)304.5 250.6 468.0
Number of Contacts
>200 uV1-2 1-2 1-4
Detectability (%) 0 0 66.0
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