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Wangapakul T, Kayssi AR, Riley AEM. Akinetic mutism following bilateral parasagittal meningioma occupied supplementary motor area removal and the spontaneous recovery of symptoms. Surg Neurol Int 2024; 15:150. [PMID: 38742016 PMCID: PMC11090544 DOI: 10.25259/sni_130_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/08/2024] [Indexed: 05/16/2024] Open
Abstract
Background Resection of bilateral parasagittal meningiomas of the dominant cortex is challenging. Some postoperative consequences are difficult to predict due to their low incidence. However, it is essential to recognize reversible symptoms. Akinetic mutism is a devastating but reversible symptom that occurs after supplementary motor area (SMA) injury. This report aims to provide more information to support the clinical progression of this syndrome. Case Description A 47-year-old woman presented with psychomotor retardation and subtle weakness, particularly on the left side. A palpable mass was identified at the head vertex. Magnetic resonance imaging revealed bilateral parasagittal meningiomas with bone and sinus invasion of the SMA. A craniotomy was performed to remove the intracapsular tumor. Two days after the operation, the patient developed gradual deterioration in her motor function until it became a lock-in-like syndrome. Then, 1.5 months after treatment in the hospital and rehabilitation unit, she gradually improved her motor, cognitive, and psychomotor skills. Total recovery was achieved after 1 year. Conclusion Surgery for lesions involving bilateral SMA can cause akinetic mutism. The typical manifestation of this syndrome may be devastating. However, it is reversible, and patients can regain full motor and cognitive functions over time without specific treatments. It is crucial to persevere and continue to provide the best care to the patient until recovery.
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Affiliation(s)
| | - Abdel Raouf Kayssi
- Department of Neurosurgery, Arkansas Neuroscience Institute, Arkansas, United States
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Maurer S, Butenschoen VM, Kelm A, Schramm S, Schröder A, Meyer B, Krieg SM. Permanent deterioration of fine motor skills after the resection of tumors in the supplementary motor area. Neurosurg Rev 2024; 47:114. [PMID: 38480549 PMCID: PMC10937754 DOI: 10.1007/s10143-024-02330-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 02/15/2024] [Accepted: 02/21/2024] [Indexed: 03/17/2024]
Abstract
Supplementary motor area syndrome (SMAS) represents a common neurosurgical sequela. The incidence and time frame of its occurrence have yet to be characterized after surgery for brain tumors. We examined patients suffering from a brain tumor preoperatively, postoperatively, and during follow-up examinations after three months, including fine motor skills testing and transcranial magnetic stimulation (TMS). 13 patients suffering from a tumor in the dorsal part of the superior frontal gyrus underwent preoperative, early postoperative, and 3-month follow-up testing of fine motor skills using the Jebsen-Taylor Hand Function Test (JHFT) and the Nine-Hole Peg Test (NHPT) consisting of 8 subtests for both upper extremities. They completed TMS for cortical motor function mapping. Test completion times (TCTs) were recorded and compared. No patient suffered from neurological deficits before surgery. On postoperative day one, we detected motor deficits in two patients, which remained clinically stable at a 3-month follow-up. Except for page-turning, every subtest indicated a significant worsening of function, reflected by longer TCTs (p < 0.05) in the postoperative examinations for the contralateral upper extremity (contralateral to the tumor manifestation). At 3-month follow-up examinations for the contralateral upper extremity, each subtest indicated significant worsening compared to the preoperative status despite improvement to the immediate postoperative level. We also detected significantly longer TCTs (p < 0.05) postoperatively in the ipsilateral upper extremity. This study suggests a long-term worsening of fine motor skills even three months after SMA tumor resection, indicating the necessity of targeted physical therapy for these patients.
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Affiliation(s)
- Stefanie Maurer
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| | - Vicki M Butenschoen
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Anna Kelm
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Severin Schramm
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Axel Schröder
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany.
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Maiuri F, Corvino S. Meningiomas of the rolandic region: risk factors for motor deficit and role of intra-operative monitoring. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05630-6. [PMID: 37277557 DOI: 10.1007/s00701-023-05630-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/12/2023] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Meningiomas of the rolandic region are associated to high risk of postoperative motor deficits. This study discusses the factors affecting motor outcome and recurrences from the analysis of a monoinstitutional case series and eight studies from a literature review. METHODS Data of 75 patients who underwent surgery for meningioma of the rolandic region were retrospectively reviewed. The analyzed factors included tumor location and size, clinical presentation, magnetic resonance imaging (MRI) and surgical findings, brain-tumor interface, extent of resection, postoperative outcome and recurrence. Eight studies from literature on rolandic meningiomas treated with or without intraoperative monitoring (IOM) were reviewed with the aim to define the impact of IOM on the extent of resection and motor outcome. RESULTS Among the 75 patients of the personal series, the meningioma was on the brain convexity in 34 (46%), at the parasagittal region in 28 (37%) and at the falx in 13 (17%). The brain-tumor interface was preserved in 53 cases (71%) at MRI and in 56 (75%) at surgical exploration. Simpson grade I resection was obtained in 43% of patients, grade II in 33%, grade III in 15% and grade IV in 9%. The motor function worsened postoperatively in 9 among 32 cases with preoperative deficit (28%) and in 5 among 43 with no preoperative deficit (11.5%); definitive motor deficit was evidenced in overall series at follow-up in 7 (9.3%). Patients with meningioma with lost arachnoid interface had significant higher rates of worsened postoperative motor deficit (p = 0.01) and seizures (p = 0.033). Recurrence occurred in 8 patients (11%). The analysis of the 8 reviewed studies (4 with and 4 without IOM) shows in the group without IOM higher rates of Simpson grades I and II resection (p = 0.02) and lower rates of grades IV resection (p = 0.002); no significant differences in postoperative immediate and long-term motor deficits were evidenced between the two groups. CONCLUSIONS Data from literature review show that the use of IOM does not affect the postoperative motor deficit Therefore, its role in rolandic meningiomas resection remains to be determined and will be defined in further studies.
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Affiliation(s)
- Francesco Maiuri
- Department of Neuroscience and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, University of Naples "Federico II", School of Medicine, Via Pansini, 5, 80131, Naples, Italy.
| | - Sergio Corvino
- Department of Neuroscience and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, University of Naples "Federico II", School of Medicine, Via Pansini, 5, 80131, Naples, Italy
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Tsai CC, Su YF, Tsai FJ, Su HY, Ko HJ, Cheng YH, Chen YL, Tsai CY. Supplementary Motor Area Syndrome after Removal of an Unusual Extensive Parasagittal Meningioma: Analysis of Twelve Reported Cases. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58081126. [PMID: 36013593 PMCID: PMC9414816 DOI: 10.3390/medicina58081126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/15/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Supplementary motor area (SMA) syndrome is a common post-operation complication in intra-axial brain tumors, such as glioma. Direct damage to parenchyma or scarification of the major vessels during an operation are the main causes. However, it is rarely reported as a postoperative complication in extra-axial tumors. Materials and Methods: We reviewed 11 reported cases of supplementary motor area syndrome after removal of extra-axial meningiomas in the English literature from the PubMed database. We also added our case, which presented as an unusual huge meningioma, to analyze the clinical parameters and outcomes of these 12 reported cases. Results: Recovery time of supplementary motor area syndrome in extra-axial tumors could be within 1-7 weeks, shorter than intra-axial tumors (2-9 weeks). Epilepsy and progressive limb weakness are the most common presentations in 50% of cases. Different degrees of postoperative muscle power deterioration were noted in the first 48 h (from 0-4). Lower limbs (66.6%, 8/12) were slightly predominant compared to upper limbs (58.3%, 7/12). Mutism aphasia was also observed in 41.6% (5/12, including our case), and occurred in tumors which were involved in the dominant side; this recovered faster than limb weakness. Discussion and Conclusions: Our work indicated that SMA syndrome could occur in extra-axial brain tumors presenting as mutism aphasia and limb weakness without any direct brain parenchyma damage. In our analysis, we found that recovery time of postoperative motor function deficit could be within 1-7 weeks. Our study also provides a further insight of SMA syndrome in extra-axial brain tumors.
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Affiliation(s)
- Chia-Chih Tsai
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80708, Taiwan
| | - Yu-Feng Su
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80708, Taiwan
- Post Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Feng-Ji Tsai
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80708, Taiwan
- Department of Public Health, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Hui-Yuan Su
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80708, Taiwan
| | - Huey-Jiun Ko
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Yung-Han Cheng
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80708, Taiwan
| | - Yu-Li Chen
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80708, Taiwan
| | - Cheng-Yu Tsai
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80708, Taiwan
- Post Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Correspondence: ; Tel.: +886-7321-5049
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Palmisciano P, Haider AS, Balasubramanian K, Dadario NB, Robertson FC, Silverstein JW, D'Amico RS. Supplementary Motor Area Syndrome after Brain Tumor Surgery: A Systematic Review. World Neurosurg 2022; 165:160-171.e2. [PMID: 35752423 DOI: 10.1016/j.wneu.2022.06.080] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Supplementary motor area syndrome (SMAS) may occur after frontal tumor surgery, with variable presentation and outcomes. We reviewed the literature on postoperative SMAS following brain tumor resection. METHODS PubMed, Web-of-Science, Scopus, and Cochrane were searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to include studies reporting SMAS after brain tumor resection. RESULTS We included 31 studies encompassing 236 patients. Most tumors were gliomas (94.5%), frequently of low-grade (61.4%). Most lesions were located on the left hemisphere (64.4%), involving the supplementary motor area (61.4%) and the cingulate gyrus (20.8%). Tractography and functional MRI evaluation were completed in 45 (19.1%) and 26 (11%) patients. Gross total resection was achieved in 46.3% cases and complete SMA resection in 69.4%. 215 procedures (91.1%) utilized intraoperative neuromonitoring mostly consisting of direct cortical/subcortical stimulation (56.4%), motor (33.9%), and somatosensory (25.4%) evoked potentials. Postoperative SMAS symptoms occurred within 24 hours after surgery, characterized by motor deficits (97%) including paresis (68.6%) and hemiplegia (16.1%), and speech disorders (53%) including hesitancy (24.2%) and mutism (22%). Average SMAS duration was 45 days (range, 1-365), with total resolution occurring in 188 patients (79.7%) and partial improvement in 46 (19.5%). 48 patients (20.3%) had persisting symptoms, mostly speech hesitancy (60.4%) and fine motor disorders (45.8%). CONCLUSION Postoperative SMAS may occur within the first 24 hours after mesial frontal tumor surgery. Preoperative mapping and intraoperative neuromonitoring may assist resection and predict outcomes. Neuroplasticity and interhemispheric connectivity play a major role in resolution.
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Affiliation(s)
- Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Ali S Haider
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center
| | | | - Nicholas B Dadario
- Department of Neurological Surgery, Northwell Health, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, NY, USA
| | - Faith C Robertson
- Department of Neurological Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Justin W Silverstein
- Department of Neurology, Northwell Health, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, NY, USA; Neuro Protective Solutions, New York, NY, USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Northwell Health, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, NY, USA
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Salvati M, Armocida D, Pesce A, Palmieri M, Venditti E, D'Andrea G, Frati A, Santoro A. No prognostic differences between GBM-patients presenting with postoperative SMA-syndrome and GBM-patients involving cortico-spinal tract and primary motor cortex. J Neurol Sci 2020; 419:117188. [PMID: 33075591 DOI: 10.1016/j.jns.2020.117188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/23/2020] [Accepted: 10/12/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The supplementary motor area (SMA) is involved in several aspects of motor control and its can be associated to a contralateral motor deficit and speech disorders. After the resection of low-grade gliomas, this syndrome is diffusely reported but it is rarely investigated in high-grade gliomas. SMA deficits may resolve completely or with minor sequelae within weeks. Whether this condition of transient deficit affects survival, was not previously investigated, and is not currently understood. OBJECTIVE The study aimed to perform an accurate investigation concerning the real clinical and prognostic impact of the postoperative SMA syndrome in order to shed light over its relationship to survival parameters and postoperative functional status of the patients. METHODS We performed a retrospective review of a series of 176 surgically treated patients suffering from Glioblastomas. Tumors classified as Group A: Involving the SMA and Group B: Lesion located outside and distal to the SMA but in anatomical relationship to primary motor cortices (PM1) or corticospinal tract (CST), in order to investigate differences concerning immunohistochemical and molecular profiles in regard to the survival parameters. RESULTS Although lesions involving SMA demonstrated a significantly higher volume in respect to their general counterparts they did not significantly differ in concerns to the molecular patterns, pre and postoperative KPS scores and in PFS and OS findings. CONCLUSIONS In our cohort SMA-syndrome is reversible and therefore guarantees a satisfactory functional status at follow-up, apparently not compromising survival when compared to other lesions affecting the primary or cortical motor area -spinal tract.
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Affiliation(s)
- Maurizio Salvati
- Human Neurosciences Department Neurosurgery Division "Sapienza" University, Italy; IRCCS "Neuromed", Pozzilli (IS), Italy
| | - Daniele Armocida
- Human Neurosciences Department Neurosurgery Division "Sapienza" University, Italy.
| | - Alessandro Pesce
- Human Neurosciences Department Neurosurgery Division "Sapienza" University, Italy; IRCCS "Neuromed", Pozzilli (IS), Italy
| | - Mauro Palmieri
- Human Neurosciences Department Neurosurgery Division "Sapienza" University, Italy
| | - Emiliano Venditti
- Human Neurosciences Department Neurosurgery Division "Sapienza" University, Italy
| | | | | | - Antonio Santoro
- Human Neurosciences Department Neurosurgery Division "Sapienza" University, Italy
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Recurrent supplementary motor area syndrome in relapsed parasagittal meningiomas: from the onset to the origin. NEUROLOGÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.nrleng.2019.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Martínez-Pérez R, Vergara C, Rayo N, Mura J. Recurrent supplementary motor area syndrome in relapsed parasagittal meningiomas: from the onset to the origin. Neurologia 2020; 35:606-608. [PMID: 31780324 DOI: 10.1016/j.nrl.2019.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/13/2019] [Accepted: 07/31/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- R Martínez-Pérez
- Departamento de Neurocirugía, Instituto de Neurociencias Clínicas, Universidad Austral de Chile, Valdivia, Chile.
| | - C Vergara
- Departamento de Neurocirugía, Instituto de Neurociencias Clínicas, Universidad Austral de Chile, Valdivia, Chile
| | - N Rayo
- University of Western Ontario, London, Ontario, Canadá
| | - J Mura
- Instituto de Neurocirugía Dr. Asenjo, Universidad de Chile, Santiago, Chile; Departamento de Neurocirugía, Clínica las Condes, Santiago, Chile
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Nakajima R, Kinoshita M, Yahata T, Nakada M. Recovery time from supplementary motor area syndrome: relationship to postoperative day 7 paralysis and damage of the cingulum. J Neurosurg 2020; 132:865-874. [PMID: 30738403 DOI: 10.3171/2018.10.jns182391] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 10/04/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Supplementary motor area (SMA) syndrome is defined as temporary paralysis after the resection of brain tumor localized in the SMA. Although in most cases paralysis induced by SMA resection resolves within a short period, the time until complete recovery varies and has not been precisely analyzed to date. In this study, the authors investigated factors for predicting the time required for recovery from paralysis after SMA resection. METHODS Data from 20 cases were analyzed. All 20 patients (mean age 54.9 ± 12.6 years) had undergone resection of frontal lobe glioma involving the SMA. The severity of postoperative paralysis was recorded until complete recovery using the Brunnstrom recovery stage index. To investigate factors associated with recovery time, the authors performed multivariate analysis with the following potentially explanatory variables: age, severity of paralysis after the surgery, resected volume of the SMA, and probability of disconnection of fibers running through or near the SMA. Moreover, voxel-based lesion symptom analysis was performed to clarify the resected regions related to prolonged recovery. RESULTS In most cases of severe to moderate paralysis, there was substantial improvement within the 1st postoperative week, but 2-9 weeks were required for complete recovery. Significantly delayed recovery from paralysis was associated with resection of the cingulate cortex and its deep regions. The factors found to influence recovery time from paralysis were stage of paralysis at postoperative day 7 and disconnection probability of the cingulum (adjusted R2 = 0.63, p < 0.0001). CONCLUSIONS Recovery time from paralysis due to SMA syndrome can be predicted by the severity of paralysis at postoperative day 7 and degree of damage to the cingulum.
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Affiliation(s)
- Riho Nakajima
- 1Department of Occupational therapy, Faculty of Health Sciences
| | - Masashi Kinoshita
- 2Department of Neurosurgery, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University; and
| | - Tetsutaro Yahata
- 3Department of Physical Medicine and Rehabilitation, Kanazawa University Hospital, Kanazawa, Japan
| | - Mitsutoshi Nakada
- 2Department of Neurosurgery, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University; and
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Abstract
Parasagittal meningiomas are defined as meningiomas that grow into at least one wall of the superior sagittal sinus. Long- and short-term morbidity is, in addition to cortical function, related to management of venous structures and flow. Clinical management needs to address the extent of removal in the sinus wall and to address relations to the adjacent cortex, which is highly eloquent in the Rolandic and calcarine areas.
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Affiliation(s)
- Tiit Mathiesen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.
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Nigro L, Delfini R. Considerations regarding supplementary motor area syndrome after surgery for parasagittal meningiomas. Acta Neurochir (Wien) 2018; 160:1555-1556. [PMID: 29934839 DOI: 10.1007/s00701-018-3604-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 06/18/2018] [Indexed: 10/28/2022]
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