Postoperative speech disorder after medial frontal surgery: role of the supplementary motor area

Role of Neural Plasticity of Motor Cortex in Gliomas Evaluated by Brain Imaging and Mapping Techniques in Pre- and Postoperative Period: A Systematic Review

BACKGROUND

 Resection of infiltrative neuroepithelial primary brain tumors, such as low-grade gliomas (LGGs) remains a neurosurgical challenge. Usual lack of clinical deficit despite LGGs growing in eloquent brain areas may be explained by reshaping and reorganization of functional networks. The development of modern diagnostic imaging techniques could disclose better understanding of the rearrangement of the brain cortex; however, mechanisms underlying such compensation and how it occurs in the motor cortex remain unclear. This systematic review aims to analyze the neuroplasticity of motor cortex in patients with LGGs, as determined by neuroimaging and functional techniques.

METHODS

 Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, medical subject headings (MeSH) and the following terms related to neuroimaging, LGGs and neuroplasticity were used with the Boolean operators AND and OR to synonymous terms in the PubMed database. Among the 118 results, 19 studies were included in the systematic review.

RESULTS

 Motor function in patients with LGG was characterized by a compensation in the contralateral and supplementary motor areas and premotor functional networks. Furthermore, ipsilateral activation in these types of gliomas was rarely described. Moreover, some studies did not reveal statistical significance in association between functional reorganization and the postoperative period, which can be explained by the low number of patients.

CONCLUSION

 Our findings suggest a high pattern of reorganization per different eloquent motor areas and gliomas diagnosis. Understanding this process is useful to guide safe surgical resection and to develop protocols that assess the plasticity, even though functional network rearrangement needs to be better characterized by more studies.

Functional MRI applications for intra-axial brain tumours: uses and nuances in surgical practise

PURPOSE

Functional MRI (fMRI) has well-established uses to inform risks and plan maximally safe approaches in neurosurgery. In the field of brain tumour surgery, however, fMRI is currently in a state of clinical equipoise due to debate around both its sensitivity and specificity.

MATERIALS AND METHODS

In this review, we summarise the role and our experience of fMRI in neurosurgery for gliomas and metastases. We discuss nuances in the conduct and interpretation of fMRI that, based on our practise, most directly impact fMRI's usefulness in the neurosurgical setting.

RESULTS

Illustrated examples in which fMRI in our hands directly influences the neurosurgical treatment of brain tumours include evaluating the probability and nature of functional risks, especially for language functions. These presurgical risk assessments, in turn, help to predict the resectability of tumours, select or deselect patients for awake surgery, indicate the need for neurophysiological monitoring and guide the optimal use of intra-operative stimulation mapping. A further emerging application of fMRI is in measuring functional adaptation of functional networks after (partial) surgery, of potential use in the timing of further surgery.

CONCLUSIONS

In appropriately selected patients with a clearly defined surgical question, fMRI offers a valuable complementary tool in the pre-surgical evaluation of brain tumours. However, there is a great need for standards in the administration and analysis of fMRI as much as in the techniques that it is commonly evaluated against. Surprisingly little data exists that evaluates the accuracy of fMRI not just against complementary methods, but in terms of its ultimate clinical aim of minimising post-surgical morbidity.

Current State of Functional MRI in the Presurgical Planning of Brain Tumors

Surgical resection of brain tumors is challenging because of the delicate balance between maximizing tumor removal and preserving vital brain functions. Functional MRI (fMRI) offers noninvasive preoperative mapping of widely distributed brain areas and is increasingly used in presurgical functional mapping. However, its impact on survival and functional outcomes is still not well-supported by evidence. Task-based fMRI (tb-fMRI) maps blood oxygen level-dependent (BOLD) signal changes during specific tasks, while resting-state fMRI (rs-fMRI) examines spontaneous brain activity. rs-fMRI may be useful for patients who cannot perform tasks, but its reliability is affected by tumor-induced changes, challenges in data processing, and noise. Validation studies comparing fMRI with direct cortical stimulation (DCS) show variable concordance, particularly for cognitive functions such as language; however, concordance for tb-fMRI is generally greater than that for rs-fMRI. Preoperative fMRI, in combination with MRI tractography and intraoperative DCS, may result in improved survival and extent of resection and reduced functional deficits. fMRI has the potential to guide surgical planning and help identify targets for intraoperative mapping, but there is currently limited prospective evidence of its impact on patient outcomes. This review describes the current state of fMRI for preoperative assessment in patients undergoing brain tumor resection. Keywords: MR-Functional Imaging, CNS, Brain/Brain Stem, Anatomy, Oncology, Functional MRI, Functional Anatomy, Task-based, Resting State, Surgical Planning, Brain Tumor © RSNA, 2023.

Beyond Broca's and Wernicke's: Functional Mapping of Ancillary Language Centers Prior to Brain Tumor Surgery

Functional MRI is a well-established tool used for pre-surgical planning to help the neurosurgeon have a roadmap of critical functional areas that should be avoided, if possible, during surgery to minimize morbidity for patients with brain tumors (though this also has applications for surgical resection of epileptogenic tissue and vascular lesions). This article reviews the locations of secondary language centers within the brain along with imaging findings to help improve our confidence in our knowledge on language lateralization. Brief overviews of these language centers and their contributions to the language networks will be discussed. These language centers include primary language centers of "Broca's Area" and "Wernicke's Area". However, there are multiple secondary language centers such as the dorsal lateral prefrontal cortex (DLPFC), frontal eye fields, pre- supplemental motor area (pre-SMA), Basal Temporal Language Area (BTLA), along with other areas of activation. Knowing these foci helps to increase self-assurance when discussing the nature of laterality with the neurosurgeon. By knowing secondary language centers for language lateralization, via fMRI, one can feel confident on providing neurosurgeon colleagues with appropriate information on the laterality of language in preparation for surgery.

Beyond Avoiding Hemiplegia after Glioma Surgery: The Need to Map Complex Movement in Awake Patient to Preserve Conation

Improving the onco-functional balance has always been a challenge in glioma surgery, especially regarding motor function. Given the importance of conation (i.e., the willingness which leads to action) in patient's quality of life, we propose here to review the evolution of its intraoperative assessment through a reminder of the increasing knowledge of its neural foundations-based upon a meta-networking organization at three levels. Historical preservation of the primary motor cortex and pyramidal pathway (first level), which was mostly dedicated to avoid hemiplegia, has nonetheless shown its limits to prevent the occurrence of long-term deficits regarding complex movement. Then, preservation of the movement control network (second level) has permitted to prevent such more subtle (but possibly disabling) deficits thanks to intraoperative mapping with direct electrostimulations in awake conditions. Finally, integrating movement control in a multitasking evaluation during awake surgery (third level) enabled to preserve movement volition in its highest and finest level according to patients' specific demands (e.g., to play instrument or to perform sports). Understanding these three levels of conation and its underlying cortico-subcortical neural basis is therefore critical to propose an individualized surgical strategy centered on patient's choice: this implies an increasingly use of awake mapping and cognitive monitoring regardless of the involved hemisphere. Moreover, this also pleads for a finer and systematic assessment of conation before, during and after glioma surgery as well as for a stronger integration of fundamental neurosciences into clinical practice.

The impact of etiology in lesion-symptom mapping - A direct comparison between tumor and stroke

INTRODUCTION

Lesion-symptom mapping is a key tool in understanding the relationship between brain structures and behavior. However, the behavioral consequences of lesions from different etiologies may vary because of how they affect brain tissue and how they are distributed. The inclusion of different etiologies would increase the statistical power but has been critically debated. Meanwhile, findings from lesion studies are a valuable resource for clinicians and used across different etiologies. Therefore, the main objective of the present study was to directly compare lesion-symptom maps for memory and language functions from two populations, a tumor versus a stroke population.

METHODS

Data from two different studies were combined. Both the brain tumor (N = 196) and stroke (N = 147) patient populations underwent neuropsychological testing and an MRI, pre-operatively for the tumor population and within three months after stroke. For this study, we selected two internationally widely used standardized cognitive tasks, the Rey Auditory Verbal Learning Test and the Verbal Fluency Test. We used a state-of-the-art machine learning-based, multivariate voxel-wise approach to produce lesion-symptom maps for these cognitive tasks for both populations separately and combined.

RESULTS

Our lesion-symptom mapping results for the separate patient populations largely followed the expected neuroanatomical pattern based on previous literature. Substantial differences in lesion distribution hindered direct comparison. Still, in brain areas with adequate coverage in both groups, considerable LSM differences between the two populations were present for both memory and fluency tasks. Post-hoc analyses of these locations confirmed that the cognitive consequences of focal brain damage varied between etiologies.

CONCLUSION

The differences in the lesion-symptom maps between the stroke and tumor population could partly be explained by differences in lesion volume and topography. Despite these methodological limitations, both the lesion-symptom mapping results and the post-hoc analyses confirmed that etiology matters when investigating the cognitive consequences of lesions with lesion-symptom mapping. Therefore, caution is advised with generalizing lesion-symptom results across etiologies.

Electrical stimulation-induced speech-related negative motor responses in the lateral frontal cortex

OBJECTIVE

Speech arrest is a common but crucial negative motor response (NMR) recorded during intraoperative brain mapping. However, recent studies have reported nonspeech-specific NMR sites in the ventral precentral gyrus (vPrCG), where stimulation halts both speech and ongoing hand movement. The aim of this study was to investigate the spatial relationship between speech-specific NMR sites and nonspeech-specific NMR sites in the lateral frontal cortex.

METHODS

In this prospective cohort study, an intraoperative mapping strategy was designed to identify positive motor response (PMR) sites and NMR sites in 33 consecutive patients undergoing awake craniotomy for the treatment of left-sided gliomas. Patients were asked to count, flex their hands, and simultaneously perform these two tasks to map NMRs. Each site was plotted onto a standard atlas and further analyzed. The speech and hand motor arrest sites in the supplementary motor area of 2 patients were resected. The 1- and 3-month postoperative language and motor functions of all patients were assessed.

RESULTS

A total of 91 PMR sites and 72 NMR sites were identified. NMR and PMR sites were anteroinferiorly and posterosuperiorly distributed in the precentral gyrus, respectively. Three distinct NMR sites were identified: 24 pure speech arrest (speech-specific NMR) sites (33.33%), 7 pure hand motor arrest sites (9.72%), and 41 speech and hand motor arrest (nonspeech-specific NMR) sites (56.94%). Nonspeech-specific NMR sites and speech-specific NMR sites were dorsoventrally distributed in the vPrCG. For language function, 1 of 2 patients in the NMA resection group had language dysfunction at the 1-month follow-up but had recovered by the 3-month follow-up. All patients in the NMA resection group had fine motor dysfunction at the 1- and 3-month follow-ups.

CONCLUSIONS

The study results demonstrated a functional segmentation of speech-related NMRs in the lateral frontal cortex and that most of the stimulation-induced speech arrest sites are not specific to speech. A better understanding of the spatial distribution of speech-related NMR sites will be helpful in surgical planning and intraoperative mapping and provide in-depth insight into the motor control of speech production.

Brain Functional Imaging Anatomy

Human brain function is an increasingly complex framework that has important implications in clinical medicine. In this review, the anatomy of the most commonly assessed brain functions in clinical neuroradiology, including motor, language, and vision, is discussed. The anatomy and function of the primary and secondary sensorimotor areas are discussed with clinical case examples. Next, the dual stream of language processing is reviewed, as well as its implications in clinical medicine and surgical planning. Last, the authors discuss the striate and extrastriate visual cortex and review the dual stream model of visual processing.

Neuroplasticity Mechanisms in Frontal Brain Gliomas: A Preliminary Study

Background

Pathological brain processes may induce adaptive cortical reorganization, however, the mechanisms underlying neuroplasticity that occurs in the presence of lesions in eloquent areas are not fully explained. The aim of this study was to evaluate functional compensatory cortical activations in patients with frontal brain gliomas during a phonemic fluency task and to explore correlations with cognitive performance, white matter tracts microstructural alterations, and tumor histopathological and molecular characterization.

Methods

Fifteen patients with frontal glioma were preoperatively investigated with an MRI study on a 3T scanner and a subgroup underwent an extensive neuropsychological assessment. The hemispheric laterality index (LI) was calculated through phonemic fluency task functional MRI (fMRI) activations in the frontal, parietal, and temporal lobe parcellations. Diffusion-weighted images were acquired for all patients and for a group of 24 matched healthy volunteers. Arcuate Fasciculus (AF) and Frontal Aslant Tract (FAT) tractography was performed using constrained spherical deconvolution diffusivity modeling and probabilistic fiber tracking. All patients were operated on with a resective aim and underwent adjuvant therapies, depending on the final diagnosis.

Results

All patients during the phonemic fluency task fMRI showed left hemispheric dominance in temporal and parietal regions. Regarding frontal regions (i.e., frontal operculum) we found right hemispheric dominance that increases when considering only those patients with tumors located on the left side. These latter activations positively correlate with verbal and visuo-spatial short-term memory, and executive functions. No correlations were found between the left frontal operculum and cognitive performance. Furthermore, patients with IDH-1 mutation and without TERT mutation, showed higher rightward frontal operculum fMRI activations and better cognitive performance in tests measuring general cognitive abilities, semantic fluency, verbal short-term memory, and executive functions. As for white matter tracts, we found left and right AF and FAT microstructural alterations in patients with, respectively, left-sided and right-side glioma compared to controls.

Conclusions

Compensatory cortical activation of the corresponding region in the non-dominant hemisphere and its association with better cognitive performance and more favorable histopathological and molecular tumor characteristics shed light on the neuroplasticity mechanisms that occur in the presence of a tumor, helping to predict the rate of post-operative deficit, with the final goal of improving patients'quality of life.

Cerebrovascular Dysregulation in Patients with Glioma Assessed with Time-shifted BOLD fMRI

Background Microscopic vascular events, such as neovascularization and neurovascular uncoupling, are common in cerebral glioma. Mapping the cerebrovascular network remodeling at the macroscopic level may provide an alternative approach to assess hemodynamic dysregulation in patients with glioma. Purpose To investigate cerebrovascular dynamics and their relevance to tumor aggressiveness by using time-shift analysis (TSA) of the systemic low-frequency oscillation (sLFO) of the resting-state blood oxygenation level-dependent signal and a decision tree model. Materials and Methods In this retrospective study, 96 patients with histologically confirmed cerebral glioma were consecutively included (March 2012 to February 2017). TSA was performed to quantify the temporal properties of sLFO signals. Alteration in the time-shift properties was assessed in the tumor region and the contralesional hemisphere relative to the brains of healthy controls by using the Mann-Whitney U test. A decision tree model based on time-shift features was developed to predict the World Health Organization (WHO) glioma grade. Results A total of 88 patients with glioma (WHO grade II, 45; grade III, 21; grade IV, 22; mean age, 42 years; age range, 20-73 years; 51 men) and 40 healthy individuals from the 1000 Functional Connectomes Project (mean age, 32 years; age range, 24-49 years; 19 men) were included. The sLFO of the brain tissues was characterized by increased time shift in the tumor region and enhanced correlation with the global reference signal in the contralesional hemisphere compared with healthy brains. The proportion of tumor voxels with negative correlation to the reference signal significantly increased with the glioma malignancy grade. The decision tree model achieved an accuracy of 91% (80 of 88 patients) in predicting the glioma malignancy grade at the individual level (P = .004) based on the time-shift features. Conclusion Gliomas induced grade-specific cerebrovascular dysregulation in the entire brain, with altered time-shift features of systemic low-frequency oscillation signals. © RSNA, 2022 Online supplemental material is available for this article.

The Effect of Right Temporal Lobe Gliomas on Left and Right Hemisphere Neural Processing During Speech Perception and Production Tasks

Using fMRI, we investigated how right temporal lobe gliomas affecting the posterior superior temporal sulcus alter neural processing observed during speech perception and production tasks. Behavioural language testing showed that three pre-operative neurosurgical patients with grade 2, grade 3 or grade 4 tumours had the same pattern of mild language impairment in the domains of object naming and written word comprehension. When matching heard words for semantic relatedness (a speech perception task), these patients showed under-activation in the tumour infiltrated right superior temporal lobe compared to 61 neurotypical participants and 16 patients with tumours that preserved the right postero-superior temporal lobe, with enhanced activation within the (tumour-free) contralateral left superior temporal lobe. In contrast, when correctly naming objects (a speech production task), the patients with right postero-superior temporal lobe tumours showed higher activation than both control groups in the same right postero-superior temporal lobe region that was under-activated during auditory semantic matching. The task dependent pattern of under-activation during the auditory speech task and over-activation during object naming was also observed in eight stroke patients with right hemisphere infarcts that affected the right postero-superior temporal lobe compared to eight stroke patients with right hemisphere infarcts that spared it. These task-specific and site-specific cross-pathology effects highlight the importance of the right temporal lobe for language processing and motivate further study of how right temporal lobe tumours affect language performance and neural reorganisation. These findings may have important implications for surgical management of these patients, as knowledge of the regions showing functional reorganisation may help to avoid their inadvertent damage during neurosurgery.

Memory enhancement with stimulants: Differential neural effects of methylphenidate, modafinil, and caffeine. A pilot study

Human memory is susceptible to manipulation in many respects. While consolidation is well known to be prone to disruption, there is also growing evidence for the enhancement of memory function. Beside cognitive strategies and mnemonic training, the use of stimulants may improve memory processing in healthy adults. In this single-dose, double-blind, within-subject, randomized, placebo-controlled pilot study, 20 mg methylphenidate (N = 13) or 200 mg modafinil (N = 12) or 200 mg caffeine (N = 14) were administrated to in total 39 healthy participants while performing a declarative memory task. Each participant received only one substance and functional magnetic resonance imaging (fMRI) was used to assess drug-dependent memory effects of the substance for encoding and recognition compared to task-related activation under placebo. While methylphenidate showed some behavioral effect regarding memory recall performance, on the neural level, methylphenidate-dependent deactivations were found in fronto-parietal and temporal regions during recognition of previously learned words. No BOLD alterations were seen during encoding. Caffeine led to deactivations in the precentral gyrus during encoding whereas modafinil did not show any BOLD signal alterations at all. These results should be interpreted with caution since this a pilot study with several limitations, most importantly the small number of participants per group. However, our main finding of task-related deactivations may point to a drug-dependent increase of efficiency in physiological response to memory processing.

Language supplementary motor area syndrome correlated with dynamic changes in perioperative task-based functional MRI activations: case report

Supplementary motor area (SMA) syndrome is well known; however, the mechanism underlying recovery from language SMA syndrome is unclear. Herein the authors report the case of a right-handed woman with speech aphasia following resection of an oligodendroglioma located in the anterior aspect of the left superior frontal gyrus. The patient exhibited language SMA syndrome, and functional MRI (fMRI) findings 12 days postoperatively demonstrated a complete shift of blood oxygen level–dependent (BOLD) activation to the contralateral right language SMA/pre-SMA as well as coequal activation and an increased volume of activation in the left Broca’s area and the right Broca’s homolog. The authors provide, to the best of their knowledge, the first description of dynamic changes in task-based hemispheric language BOLD fMRI activations across the preoperative, immediate postoperative, and more distant postoperative settings associated with the development and subsequent complete resolution of the clinical language SMA syndrome.

Can Preoperative Mapping with Functional MRI Reduce Morbidity in Brain Tumor Resection? A Systematic Review and Meta-Analysis of 68 Observational Studies

Background Preoperative functional MRI (fMRI) is one of several techniques developed to localize critical brain structures and brain tumors. However, the usefulness of fMRI for preoperative surgical planning and its potential effect on neurologic outcomes remain unclear. Purpose To assess the overall postoperative morbidity among patients with brain tumors by using preoperative fMRI versus surgery without this tool or with use of standard (nonfunctional) neuronavigation. Materials and Methods A systematic review and meta-analysis of studies across major databases from 1946 to June 20, 2020, were conducted. Inclusion criteria were original studies that (a) included patients with brain tumors, (b) performed preoperative neuroimaging workup with fMRI, (c) investigated the usefulness of a preoperative or intraoperative functional neuroimaging technique and used that technique to resect cerebral tumors, and (d) reported postoperative clinical measures. Pooled estimates for adverse event rate (ER) effect size (log ER, log odds ratio, or Hedges g) with 95% CIs were computed by using a random-effects model. Results Sixty-eight studies met eligibility criteria (3280 participants; 58.9% men [1555 of 2641]; mean age, 46 years ± 8 [standard deviation]). Functional deterioration after surgical procedure was less likely to occur when fMRI mapping was performed before the operation (odds ratio, 0.25; 95% CI: 0.12, 0.53; P < .001]), and postsurgical Karnofsky performance status scores were higher in patients who underwent fMRI mapping (Hedges g, 0.66; 95% CI: 0.21, 1.11; P = .004]). Craniotomies for tumor resection performed with preoperative fMRI were associated with a pooled adverse ER of 11% (95% CI: 8.4, 13.1), compared with a 21.0% ER (95% CI: 12.2, 33.5) in patients who did not undergo fMRI mapping. Conclusion From the currently available data, the benefit of preoperative functional MRI planning for the resection of brain tumors appears to reduce postsurgical morbidity, especially when used with other advanced imaging techniques, such as diffusion-tensor imaging, intraoperative MRI, or cortical stimulation. © RSNA, 2021 Online supplemental material is available for this article.

The supplementary motor area syndrome: a neurosurgical review

The supplementary motor area (SMA) syndrome is a frequently encountered clinical phenomenon associated with surgery of the dorsomedial prefrontal lobe. The region has a known motor sequencing function and the dominant pre-SMA specifically is associated with more complex language functions; the SMA is furthermore incorporated in the negative motor network. The SMA has a rich interconnectivity with other cortical regions and subcortical structures using the frontal aslant tract (FAT) and the frontostriatal tract (FST). The development of the SMA syndrome is positively correlated with the extent of resection of the SMA region, especially its medial side. This may be due to interruption of the nearby callosal association fibres as the contralateral SMA has a particular important function in brain plasticity after SMA surgery. The syndrome is characterized by a profound decrease in interhemispheric connectivity of the motor network hubs. Clinical improvement is related to increasing connectivity between the contralateral SMA region and the ipsilateral motor hubs. Overall, most patients know a full recovery of the SMA syndrome, however a minority of patients might continue to suffer from mild motor and speech dysfunction. Rarely, no recovery of neurological function after SMA region resection is reported.

Functional anatomy of the frontal aslant tract and surgical perspectives

The frontal aslant tract (FAT) is an intralobar white matter fasciculus providing dense connections between the medial part of the superior frontal gyrus, in particular the pre-supplementary motor area (SMA) and the SMA proper, and the lateral part of the frontal lobe, especially the inferior frontal gyrus. Although this tract has been characterized belatedly, it has received important attention in recent years due notably to its increasingly evidenced role in the speech and language networks. As cerebral tumors frequently affect the frontal lobe, an improved knowledge of the functional anatomy of the FAT is mandatory to refine the way neurosurgeries are performed and to give the patients the best opportunities to recover after surgery. In this work, we first describe the spatial arrangement of the FAT and detail its cortical projections. We then provide a comprehensive review of the functions supposedly mediated by this transverse frontal connectivity. It is structured following a tripartite organization where the linguistic (i.e. speech and language), supralinguistic (i.e. functions that interact with speech and language: executive functions, working memory, and social communication) and extralinguistic implications (i.e. functions outside the linguistic domain: visuospatial processing, praxis and motor skills) are successively addressed. We lastly discussed this knowledge in the context of wide-awake neurosurgeries for brain tumors. We emphasize the need to evaluate thoroughly the functions conveyed by FAT by means of longitudinally-designed studies to first estimate its plasticity potential and then to determine which tasks should be selected to avoid lasting impairments due to its disconnective breakdown.

Motor speech disorders in the nonfluent, semantic and logopenic variants of primary progressive aphasia

OBJECTIVE

Motor speech disorders (MSDs) are characteristic for nonfluent primary progressive aphasia (nfvPPA). In primary progressive aphasia (PPA) of the semantic (svPPA) and of the logopenic type (lvPPA), speech motor function is considered typically intact. However, knowledge on the prevalence of MSDs in svPPA and lvPPA is mainly based on studies with a priori knowledge of PPA syndrome diagnosis. This fully blinded retrospective study aims to provide data on the prevalence of all types of MSDs in a large sample of German-speaking patients with different subtypes of PPA.

METHOD

Two raters, blinded for PPA subtype, independently evaluated connected speech samples for MSD syndrome and severity from 161 patients diagnosed with nfvPPA, svPPA or lvPPA in the database of the German Consortium of Frontotemporal Lobar Degeneration (FTLDc). In case of disagreement, a third experienced rater re-evaluated the speech samples, followed by a consensus procedure. Consensus was reached for 160 patients (74 nfvPPA, 49 svPPA, 37 lvPPA).

MAIN RESULTS

Across all PPA syndromes, 43.8% of the patients showed MSDs. Patients with nfvPPA demonstrated the highest proportion of MSDs (62.2%), but MSDs were also identified in svPPA (26.5%) and lvPPA (29.7%), respectively. Overall, dysarthria was the most common class of MSDs, followed by apraxia of speech. In addition, we identified speech abnormalities presenting as "syllabic speech", "dysfluent speech", and "adynamic speech".

DISCUSSION

Our study confirmed MSDs as frequently occurring in PPA. The study also confirmed MSDs to be most common in patients with nfvPPA. However, MSDs were also found in substantial proportions of patients with svPPA and lvPPA. Furthermore, our study identified speech motor deficits that have not received attention in previous studies on PPA. The results are discussed against the background of the existing literature on MSDs in PPA, including theoretical considerations of the neuroanatomical conditions described for each of the different subtypes of PPA.

No prognostic differences between GBM-patients presenting with postoperative SMA-syndrome and GBM-patients involving cortico-spinal tract and primary motor cortex

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.

What do we know about pre- and postoperative plasticity in patients with glioma? A review of neuroimaging and intraoperative mapping studies

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Brain reorganization can take place before and after surgery of low- and high-grade gliomas.

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Plasticity is observed for low-grade but also for high-grade gliomas.

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The contralesional hemisphere can be vital for successful compensation.

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There is evidence of plasticity for both the language system and the sensorimotor system.

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Partial compensation can also occur at the white-matter level.

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Subcortical connectivity is crucial for brain reorganization.

Brain plasticity potential is a central theme in neuro-oncology and is currently receiving increased attention. Advances in treatment have prolonged life expectancy in neuro-oncological patients and the long-term preservation of their quality of life is, therefore, a new challenge. To this end, a better understanding of brain plasticity mechanisms is vital as it can help prevent permanent deficits following neurosurgery.

Indeed, reorganization processes can be fundamental to prevent or recover neurological and cognitive deficits by reallocating brain functions outside the lesioned areas. According to more recent studies in the literature, brain reorganization taking place following neurosurgery is associated with good neurofunctioning at follow-up. Interestingly, in the last few years, the number of reports on plasticity has notably increased.

Aim of the current review was to provide a comprehensive overview of pre- and postoperative neuroplasticity patterns. Within this framework, we aimed to shed light on some tricky issues, including i) involvement of the contralateral healthy hemisphere, ii) role and potential changes of white matter and connectivity patterns, and iii) reorganization in low- versus high-grade gliomas.

We finally discussed the practical implications of these aspects and role of additional potentially relevant factors to be explored. Final purpose was to provide a guideline helpful in promoting increase in the extent of tumor resection while preserving the patients’ neurological and cognitive functioning.

Microsurgical anatomy of language

The localizationist model, which focused on classical cortical areas such as Broca's and Wernicke's, can no longer explain how language processing works. Over recent years, several studies have revealed new language-related cortical and subcortical areas, resulting in a transition from localizationist concepts to a hodotopical model. These studies have described language processing as an extensive and complex network of multiple interconnected cortical areas and subcortical pathways, differing from the classical circuit described by the localizationist perspective. The hodotopical model was made possible by a paradigm shift in the treatment of cerebral tumors, especially low-grade gliomas: total or subtotal tumor resections with cortical and subcortical mapping on awake patients have become the gold standard treatment for lesions located in the dominant hemisphere. In this article, we review current understating of the microsurgical anatomy of language.

Functional Mapping before and after Low-Grade Glioma Surgery: A New Way to Decipher Various Spatiotemporal Patterns of Individual Neuroplastic Potential in Brain Tumor Patients

Intraoperative direct electrostimulation mapping (DEM) is currently the gold-standard for glioma surgery, since functional-based resection allows an optimization of the onco-functional balance (increased resection with preserved quality of life). Besides intrasurgical awake mapping of conation, cognition, and behavior, preoperative mapping by means of functional neuroimaging (FNI) and transcranial magnetic stimulation (TMS) has increasingly been utilized for surgical selection and planning. However, because these techniques suffer from several limitations, particularly for direct functional mapping of subcortical white matter pathways, DEM remains crucial to map neural connectivity. On the other hand, non-invasive FNI and TMS can be repeated before and after surgical resection(s), enabling longitudinal investigation of brain reorganization, especially in slow-growing tumors like low-grade gliomas. Indeed, these neoplasms generate neuroplastic phenomena in patients with usually no or only slight neurological deficits at diagnosis, despite gliomas involving the so-called "eloquent" structures. Here, data gained from perioperative FNI/TMS mapping methods are reviewed, in order to decipher mechanisms underpinning functional cerebral reshaping induced by the tumor and its possible relapse, (re)operation(s), and postoperative rehabilitation. Heterogeneous spatiotemporal patterns of rearrangement across patients and in a single patient over time have been evidenced, with structural changes as well as modifications of intra-hemispheric (in the ipsi-lesional and/or contra-lesional hemisphere) and inter-hemispheric functional connectivity. Such various fingerprints of neural reconfiguration were correlated to different levels of cognitive compensation. Serial multimodal studies exploring neuroplasticity might lead to new management strategies based upon multistage therapeutic approaches adapted to the individual profile of functional reallocation.

Functional linguistic specificity of the left frontal aslant tract for spontaneous speech fluency: Evidence from intraoperative language mapping

The left frontal aslant tract (FAT) has been proposed to be relevant for language, and specifically for spontaneous speech fluency. However, there is missing causal evidence that stimulation of the FAT affects spontaneous speech, and not language production in general. We present a series of 12 neurosurgical cases with awake language mapping of the cortex near the left FAT. Tasks for language mapping included the commonly used action picture naming, and sentence completion, tapping more specifically into spontaneous speech. A task dissociation was found in 10 participants: while being stimulated on specific sites, they were able to name a picture but could not complete a sentence. Overlaying of these sites on preoperative white-matter tract reconstructions revealed that in each individual case they were located on cortical terminations of the FAT. This corroborates the language functional specificity of the left FAT as a tract underlying fluent spontaneous speech.

Task-Induced Functional Connectivity of the Syntax-Related Networks for Patients with a Cortical Glioma

Analysis of the functional connectivity has enabled understanding of the cortical networks. In the present study, we used a picture-sentence matching task to introduce syntactically harder conditions, and clarified 3 major points. First, patients with a glioma in the lateral premotor cortex/inferior frontal gyrus or in other cortical regions showed much weaker activations than controls, especially in the left inferior frontal gyrus. Moreover, the error rates under the harder conditions were much higher for these patients. Secondly, syntactic loads induced selective connectivity with enhancement and suppression, consistently for both patients and controls. More specifically, the local connectivity was enhanced among the 3 syntax-related networks within the left frontal cortex, while the global connectivity of both dorsal and ventral pathways was suppressed. In addition, the exact reproducibility of r-values across the control and patient groups was remarkable, since under easier conditions alone, connectivity patterns for the patients were completely unmatched with those for the controls. Thirdly, we found an additional syntax-related network, further confirming the intergroup similarity of task-induced functional connectivity. These results indicate that functional connectivity of agrammatic patients is mostly preserved regardless of a glioma, and that the connectivity can change dynamically and systematically according to syntactic loads.

Left frontal aslant tract and lexical selection: Evidence from frontal lobe lesions

The frontal aslant tract (FAT) is a white-matter tract connecting the inferior frontal gyrus (IFG) and the supplementary motor complex (SMC). Damage to either component of the network causes spontaneous speech dysfluency, indicating its critical role in language production. However, spontaneous speech dysfluency may stem from various lower-level linguistic deficits, precluding inferences about the nature of linguistic processing subserved by the IFG-SMC network. Since the IFG and the SMC are attributed a role in conceptual and lexical selection during language production, we hypothesized that these processes rely on the IFG-SMC connectivity via the FAT. We analysed the effects of FAT volume on conceptual and lexical selection measures following frontal lobe stroke. The measures were obtained from the sentence completion task, tapping into conceptual and lexical selection, and the picture-word interference task, providing a more specific measure of lexical selection. Lower FAT volume was not associated with lower conceptual or lexical selection abilities in our patient cohort. Current findings stand in marked discrepancy with previous lesion and neuroimaging evidence for the joint contribution of the IFG and the SMC to lexical and conceptual selection. A plausible explanation reconciling this discrepancy is that the IFG-SMC connectivity via the FAT does contribute to conceptual and/or lexical selection but its disrupted function undergoes reorganisation over the course of post-stroke recovery. Thus, our negative findings stress the importance of testing the causal role of the FAT in lexical and conceptual selection in patients with more acute frontal lobe lesions.

Exploring the anatomy of negative motor areas (NMAs): Findings in awake surgery

Positive motor responses have been used in neurosurgery for the identification of motor structures. With the term "negative motor responses" (NMRs) a complete inhibition of movement without loss of muscle tone or consciousness is meant. Papers already exist in the literature regarding cortical areas in which such NMRs are evoked, the so-called "negative motor areas" (NMAs), but their location and functional meaning are still poorly understood. This paper discusses the anatomy of the NMAs of the human brain, in light of our brain mapping experience. 21 patients underwent awake surgery and direct electrical stimulation (DES) was performed using bipolar electrodes. Excision was interrupted when functional responses were intraoperatively identified through DES. The labeled mapping sites were recorded by photography prior to and following tumor resection. Results depicting a probabilistic map of negative motor network anatomy were retrospectively analyzed. Our findings strongly support the fact that the precentral gyrus, classical site of the of the Primary Motor Areas, is also strongly involved in generating NMRs. The distribution of NMAs was noted not to be as rigid as previously described, ranging in different brain areas with a somatotopic arrangement. Presented anatomical results are consistent with the literature, but the exact functional meaning of NMAs and their subcortical connectivity is still far from being completely understood.

Sex Effect on Presurgical Language Mapping in Patients With a Brain Tumor

Differences between males and females in brain development and in the organization and hemispheric lateralization of brain functions have been described, including in language. Sex differences in language organization may have important implications for language mapping performed to assess, and minimize neurosurgical risk to, language function. This study examined the effect of sex on the activation and functional connectivity of the brain, measured with presurgical functional magnetic resonance imaging (fMRI) language mapping in patients with a brain tumor. We carried out a retrospective analysis of data from neurosurgical patients treated at our institution who met the criteria of pathological diagnosis (malignant brain tumor), tumor location (left hemisphere), and fMRI paradigms [sentence completion (SC); antonym generation (AG); and resting-state fMRI (rs-fMRI)]. Forty-seven patients (22 females, mean age = 56.0 years) were included in the study. Across the SC and AG tasks, females relative to males showed greater activation in limited areas, including the left inferior frontal gyrus classically associated with language. In contrast, males relative to females showed greater activation in extended areas beyond the classic language network, including the supplementary motor area (SMA) and precentral gyrus. The rs-fMRI functional connectivity of the left SMA in the females was stronger with inferior temporal pole (TP) areas, and in the males with several midline areas. The findings are overall consistent with theories of greater reliance on specialized language areas in females relative to males, and generalized brain areas in males relative to females, for language function. Importantly, the findings suggest that sex could affect fMRI language mapping. Thus, considering sex as a variable in presurgical language mapping merits further investigation.

Cortical Dynamics of Semantic Priming and Interference during Word Production: An Intracerebral Study

Language production requires that semantic representations are mapped to lexical representations on the basis of the ongoing context to select the appropriate words. This mapping is thought to generate two opposing phenomena, “semantic priming,” where multiple word candidates are activated, and “interference,” where these word activities are differentiated to make a goal-relevant selection. In previous neuroimaging and neurophysiological research, priming and interference have been associated to activity in regions of a left frontotemporal network. Most of such studies relied on recordings that either have high temporal or high spatial resolution, but not both. Here, we employed intracerebral EEG techniques to explore with both high resolutions, the neural activity associated with these phenomena. The data came from nine epileptic patients who were stereotactically implanted for presurgical diagnostics. They performed a cyclic picture-naming task contrasting semantically homogeneous and heterogeneous contexts. Of the 84 brain regions sampled, 39 showed task-evoked activity that was significant and consistent across two patients or more. In nine of these regions, activity was significantly modulated by the semantic manipulation. It was reduced for semantically homogeneous contexts (i.e., priming) in eight of these regions, located in the temporal ventral pathway as well as frontal areas. Conversely, it was increased only in the pre-SMA, notably at an early poststimulus temporal window (200–300 msec) and a preresponse temporal window (700–800 msec). These temporal effects respectively suggest the pre-SMA's role in initial conflict detection (e.g., increased response caution) and in preresponse control. Such roles of the pre-SMA are traditional from a history of neural evidence in simple perceptual tasks, yet are also consistent with recent cognitive lexicosemantic theories that highlight top–down processes in language production. Finally, although no significant semantic modulation was found in the ACC, future intracerebral EEG work should continue to inspect ACC with the pre-SMA.

Recovery time from supplementary motor area syndrome: relationship to postoperative day 7 paralysis and damage of the cingulum

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.

The frontal aslant tract (FAT) and its role in speech, language and executive function

In this review, we examine the structural connectivity of a recently-identified fiber pathway, the frontal aslant tract (FAT), and explore its function. We first review structural connectivity studies using tract-tracing methods in non-human primates, and diffusion-weighted imaging and electrostimulation in humans. These studies suggest a monosynaptic connection exists between the lateral inferior frontal gyrus and the pre-supplementary and supplementary motor areas of the medial superior frontal gyrus. This connection is termed the FAT. We then review research on the left FAT's putative role in supporting speech and language function, with particular focus on speech initiation, stuttering and verbal fluency. Next, we review research on the right FAT's putative role supporting executive function, namely inhibitory control and conflict monitoring for action. We summarize the extant body of empirical work by suggesting that the FAT plays a domain general role in the planning, timing, and coordination of sequential motor movements through the resolution of competition among potential motor plans. However, we also propose some domain specialization across the hemispheres. On the left hemisphere, the circuit is proposed to be specialized for speech actions. On the right hemisphere, the circuit is proposed to be specialized for general action control of the organism, especially in the visuo-spatial domain. We close the review with a discussion of the clinical significance of the FAT, and suggestions for further research on the pathway.

Quantitative MRI in post-operative paediatric cerebellar mutism syndrome

Post-operative paediatric cerebellar mutism syndrome (pCMS) occurs in around 25% of children undergoing surgery for cerebellar and fourth ventricular tumours. Reversible mutism is the hallmark of a syndrome which comprises severe motor, cognitive and linguistic deficits. Recent evidence from advanced neuroimaging studies has led to the current theoretical understanding of the condition as a form of diaschisis contingent on damage to efferent cerebellar circuitry. Tractography data derived from diffusion MRI studies have shown disruption of the dentato-rubro-thalamo-cortical tract in patients with pCMS, and perfusion studies have indicated widespread supratentorial regions which may give rise to the florid signs and symptoms of pCMS. Given the difficulties in predicting pCMS from standard structural MRI, this review discusses findings from quantitative MRI modalities which have contributed to our understanding of this debilitating syndrome, and considers the goals and challenges which lie ahead in the field.

Contralateral functional reorganization of the speech supplementary motor area following neurosurgical tumor resection

We evaluated plasticity in speech supplemental motor area (SMA) tissue in two patients using functional magnetic resonance imaging (fMRI), following resection of tumors in or associated with the dominant hemisphere speech SMA. Patient A underwent resection of a anaplastic astrocytoma NOS associated with the left speech SMA, experienced SMA syndrome related mutism postoperatively, but experienced full recovery 14 months later. FMRI performed 32 months after surgery demonstrated a migration of speech SMA to homologous contralateral hemispheric regional tissue. Patient B underwent resection of a oligodendroglioma NOS in the left speech SMA, and postoperatively experienced speech hesitancy, latency and poor fluency, which gradually resolved over 18 months. FMRI performed at 64 months after surgery showed a reorganization of speech SMA to the contralateral hemisphere. These data support the hypothesis of dynamic, time based plasticity in speech SMA tissue, and may represent a noninvasive neural marker for SMA syndrome recovery.

Working Memory Deficits After Lesions Involving the Supplementary Motor Area

The Supplementary Motor Area (SMA)—located in the superior and medial aspects of the superior frontal gyrus—is a preferential site of certain brain tumors and arteriovenous malformations, which often provoke the so-called SMA syndrome. The bulk of the literature studying this syndrome has focused on two of its most apparent symptoms: contralateral motor and speech deficits. Surprisingly, little attention has been given to working memory (WM) even though neuroimaging studies have implicated the SMA in this cognitive process. Given its relevance for higher-order functions, our main goal was to examine whether WM is compromised in SMA lesions. We also asked whether WM deficits might be reducible to processing speed (PS) difficulties. Given the connectivity of the SMA with prefrontal regions related to executive control (EC), as a secondary goal we examined whether SMA lesions also hampered EC. To this end, we tested 12 patients with lesions involving the left (i.e., the dominant) SMA. We also tested 12 healthy controls matched with patients for socio-demographic variables. To ensure that the results of this study can be easily transferred and implemented in clinical practice, we used widely-known clinical neuropsychological tests: WM and PS were measured with their respective Wechsler Adult Intelligence Scale indexes, and EC was tested with phonemic and semantic verbal fluency tasks. Non-parametric statistical methods revealed that patients showed deficits in the executive component of WM: they were able to sustain information temporarily but not to mentally manipulate this information. Such WM deficits were not subject to patients' marginal PS impairment. Patients also showed reduced phonemic fluency, which disappeared after controlling for the influence of WM. This observation suggests that SMA damage does not seem to affect cognitive processes engaged by verbal fluency other than WM. In conclusion, WM impairment needs to be considered as part of the SMA syndrome. These findings represent the first evidence about the cognitive consequences (other than language) of damage to the SMA. Further research is needed to establish a more specific profile of WM impairment in SMA patients and determine the consequences of SMA damage for other cognitive functions.

A Role for the Frontal Aslant Tract in Speech Planning: A Neurosurgical Case Study

Frontal and temporal white matter pathways play key roles in language processing, but the specific computations supported by different tracts remain a matter of study. A role in speech planning has been proposed for a recently described pathway, the frontal aslant tract (FAT), which connects the posterior inferior frontal gyrus to the pre-SMA. Here, we use longitudinal functional and structural MRI and behavioral testing to evaluate the behavioral consequences of a lesion to the left FAT that was incurred during surgical resection of a frontal glioma in a 60-year-old woman, Patient AF. The pattern of performance in AF is compared, using the same measures, with that in a 37-year-old individual who underwent a left anterior temporal resection and hippocampectomy (Patient AG). AF and AG were both cognitively intact preoperatively but exhibited specific and doubly dissociable behavioral deficits postoperatively: AF had dysfluent speech but no word finding difficulty, whereas AG had word finding difficulty but otherwise fluent speech. Probabilistic tractography showed that the left FAT was lesioned postoperatively in AF (but not AG) whereas the inferior longitudinal fasciculus was lesioned in AG (but not AF). Those structural changes were supported by corresponding changes in functional connectivity to the posterior inferior frontal gyrus: decreased functional connectivity postoperatively between the posterior inferior frontal gyrus and pre-SMA in AF (but not AG) and decreased functional connectivity between the posterior inferior frontal gyrus and the middle temporal gyrus in AG (but not AF). We suggest from these findings that the left FAT serves as a key communicative link between sentence planning and lexical access processes.

Presurgical language fMRI: Clinical practices and patient outcomes in epilepsy surgical planning

The goal of this study was to document current clinical practice and report patient outcomes in presurgical language functional MRI (fMRI) for epilepsy surgery. Epilepsy surgical programs worldwide were surveyed as to the utility, implementation, and efficacy of language fMRI in the clinic; 82 programs responded. Respondents were predominantly US (61%) academic programs (85%), and evaluated adults (44%), adults and children (40%), or children only (16%). Nearly all (96%) reported using language fMRI. Surprisingly, fMRI is used to guide surgical margins (44% of programs) as well as lateralize language (100%). Sites using fMRI for localization most often use a distance margin around activation of 10mm. While considered useful, 56% of programs reported at least one instance of disagreement with other measures. Direct brain stimulation typically confirmed fMRI findings (74%) when guiding margins, but instances of unpredicted decline were reported by 17% of programs and 54% reported unexpected preservation of function. Programs reporting unexpected decline did not clearly differ from those which did not. Clinicians using fMRI to guide surgical margins do not typically map known language‐critical areas beyond Broca's and Wernicke's. This initial data shows many clinical teams are confident using fMRI not only for language lateralization but also to guide surgical margins. Reported cases of unexpected language preservation when fMRI activation is resected, and cases of language decline when it is not, emphasize a critical need for further validation. Comprehensive studies comparing commonly‐used fMRI paradigms to predict stimulation mapping and post‐surgical language decline remain of high importance.

Supplementary motor area syndrome after surgery for parasagittal meningiomas

BACKGROUND

Resection within the supplementary motor area (SMA) may be accompanied by dramatic motor deficits and speech arrest when the dominant hemisphere is involved, termed the SMA syndrome. Typically, the muscle tone of the paralyzed extremities is preserved, and in most cases, a complete or near complete recovery is seen within a few months. The SMA syndrome has not been recognized for extra-axial tumor surgery in approximation of the SMA.

METHODS

We observed the SMA syndrome in a patient operated for a parasagittal meningioma in the posterior frontal region, and this observation intrigued us to prospectively collect similar cases.

RESULTS

In the period from January 2010 to December 2015, we observed five patients who developed a partial SMA syndrome after surgery for frontal parasagittal meningiomas. The muscle tone was preserved in the affected extremities. All patients experienced improvement in motor function within a few days, and on follow-up, three out of five patients had recovered completely. Three of the patients had meningioma WHO grade II.

CONCLUSIONS

Surgically induced SMA syndrome can easily be confused with pyramidal weakness. This series of cases demonstrate that the syndrome may also develop after removal of extra-axial tumors and is probably underdiagnosed and underreported. The good functional prognosis is helpful in the preoperative counseling and follow-up of these patients.

Spontaneous speech in patients with gliomas in eloquent areas: Evaluation until 1 year after surgery

OBJECTIVE

Glioma patients often complain about problems in daily conversation with a negative impact on quality of life. Disorders in standardized language tests (e.g. naming and fluency), are frequently observed. Most studies claim recovery of language functions within 3 months. However, long-term effects of surgery on spontaneous speech remain unknown.

PATIENTS AND METHODS

Eighteen glioma patients were compared to healthy controls in spontaneous speech variables: Type Token Ratio (TTR), Mean Length of Utterance words (MLUw), Incomplete Sentences, Self-corrections and Repetitions. Boston Naming Test (BNT) and Category Fluency (CF) were also assessed. We compared: pre- and 3 months postoperatively (T1-T2), 3 months and 1 year postoperatively (T2-T3), pre- and 1 year postoperatively (T1-T3). Correlations were computed between deviating variables and BNT/CF, tumor localization, and tumor grade.

RESULTS

Patients had deficits in Incomplete sentences (T1, T2, T3), TTR (T2,T3), MLUw (T3) and Self-corrections (T2). Between T1-T2 no decline was present. Between T2-T3 and T1-T3, there was a decrease of MLUw, Self-corrections and Repetitions and an increase of Incomplete Sentences, BNT and CF were impaired (T1, T2, T3) without differences between test-moments. Most spontaneous speech variables did not correlate with standardized tests. Tumor localization and grade had no influence on spontaneous speech.

CONCLUSION

Glioma patients showed impaired spontaneous speech combined with naming and fluency deficits. Surgery appeared to have deteriorated the quality of spontaneous speech until long-term but not the performance at test-level. Hence, spontaneous speech has an added value to standardized tests for diagnosis of language impairments.

Presurgical language fMRI: Mapping of six critical regions

Language mapping is a key goal in neurosurgical planning. fMRI mapping typically proceeds with a focus on Broca's and Wernicke's areas, although multiple other language‐critical areas are now well‐known. We evaluated whether clinicians could use a novel approach, including clinician‐driven individualized thresholding, to reliably identify six language regions, including Broca's Area, Wernicke's Area (inferior, superior), Exner's Area, Supplementary Speech Area, Angular Gyrus, and Basal Temporal Language Area. We studied 22 epilepsy and tumor patients who received Wada and fMRI (age 36.4[12.5]; Wada language left/right/mixed in 18/3/1). fMRI tasks (two × three tasks) were analyzed by two clinical neuropsychologists who flexibly thresholded and combined these to identify the six regions. The resulting maps were compared to fixed threshold maps. Clinicians generated maps that overlapped significantly, and were highly consistent, when at least one task came from the same set. Cases diverged when clinicians prioritized different language regions or addressed noise differently. Language laterality closely mirrored Wada data (85% accuracy). Activation consistent with all six language regions was consistently identified. In blind review, three external, independent clinicians rated the individualized fMRI language maps as superior to fixed threshold maps; identified the majority of regions significantly more frequently; and judged language laterality to mirror Wada lateralization more often. These data provide initial validation of a novel, clinician‐based approach to localizing language cortex. They also demonstrate clinical fMRI is superior when analyzed by an experienced clinician and that when fMRI data is of low quality judgments of laterality are unreliable and should be withheld. Hum Brain Mapp 38:4239–4255, 2017. © 2017 Wiley Periodicals, Inc.

The etiopathogenesis of diffuse low-grade gliomas

The origins of diffuse low-grade gliomas (DLGG) are unknown. Beyond some limited data on their temporal and cellular origins, the mechanisms and risk factors involved are poorly known. First, based on strong relationships between DLGG development and the eloquence of brain regions frequently invaded by these tumors, we propose a "functional theory" to explain the origin of DLGG. Second, the biological pathways involved in DLGG genesis may differ according to tumor location (anatomo-molecular correlations). The cellular and molecular mechanisms of such "molecular theory" will be reviewed. Third, the geographical distribution of diffuse WHO grade II-III gliomas within populations is heterogeneous, suggesting possible environmental risk factors. We will discuss this "environmental theory". Finally, we will summarize the current knowledge on genetic susceptibility in gliomas ("genetic predisposition theory"). These crucial issues illustrate the close relationships between the pathophysiology of gliomagenesis, the anatomo-functional organization of the brain, and personalized management of DLGG patients.

Language Mapping Using fMRI and Direct Cortical Stimulation for Brain Tumor Surgery: The Good, the Bad, and the Questionable

Language functional magnetic resonance imaging for neurosurgical planning is a useful but nuanced technique. Consideration of primary and secondary language anatomy, task selection, and data analysis choices all impact interpretation. In the following chapter, we consider practical considerations and nuances alike for language functional magnetic resonance imaging in the support of and comparison with the neurosurgical gold standard, direct cortical stimulation. Pitfalls and limitations are discussed.

The Posterior Transcallosal Approach to the Pineal Region and Posterior Third Ventricle: Intervenous and Paravenous Variants

BACKGROUND: There are a number of surgical approaches to the posterior third ventricle and pineal region, each with its associated advantages and disadvantages.

OBJECTIVE: To present our experience with the posterior interhemispheric transcallosal approach and to analyze the indications, technique, and outcomes.

METHODS: A retrospective study was conducted to identify and analyze all children and young adults who underwent the posterior transcallosal approach from July 2010 to March 2015. Perioperative data included patient demographics, signs and symptoms on presentation, tumor characteristics (type, origin, and size), complications, and clinical and radiographic outcome at final follow-up.

RESULTS: Twenty-two patients (9 female, 13 male) were identified in 24 cases with a mean age of 10.5 years (range, 3-32 years). The most common tumor type was pineoblastoma (n = 6). Eleven patients underwent gross total resections; 11 underwent subtotal resections; and 2 tumors were biopsied. The intervenous operative corridor was used in 15 cases; the paravenous was used in 9. Of the 22 patients, 19 experienced 31 total postoperative events. There were 12 instances of contralateral weakness. Retraction-related hemiparesis was usually temporary; resection-related hemiparesis lasted longer. There were no complications related to occlusion of one or more bridging cortical veins or from thrombosis of 1 internal cerebral vein. Eight patients have died of tumor progression, and of the remaining 14 patients, only 1 patient to date has developed local progression.

CONCLUSION: The posterior interhemispheric transcallosal approach allows resection of tumors located within the pineal region, posterior third ventricle, and thalamus. New postoperative neurological deficits can occur; however, many will improve significantly or resolve completely over time.

The role of the supplementary motor area for speech and language processing

Apart from its function in speech motor control, the supplementary motor area (SMA) has largely been neglected in models of speech and language processing in the brain. The aim of this review paper is to summarize more recent work, suggesting that the SMA has various superordinate control functions during speech communication and language reception, which is particularly relevant in case of increased task demands. The SMA is subdivided into a posterior region serving predominantly motor-related functions (SMA proper) whereas the anterior part (pre-SMA) is involved in higher-order cognitive control mechanisms. In analogy to motor triggering functions of the SMA proper, the pre-SMA seems to manage procedural aspects of cognitive processing. These latter functions, among others, comprise attentional switching, ambiguity resolution, context integration, and coordination between procedural and declarative memory structures. Regarding language processing, this refers, for example, to the use of inner speech mechanisms during language encoding, but also to lexical disambiguation, syntax and prosody integration, and context-tracking.

Recovery of functional connectivity of the sensorimotor network after surgery for diffuse low-grade gliomas involving the supplementary motor area

OBJECTIVE The supplementary motor area (SMA) syndrome is a well-studied lesional model of brain plasticity involving the sensorimotor network. Patients with diffuse low-grade gliomas in the SMA may exhibit this syndrome after resective surgery. They experience a temporary loss of motor function, which completely resolves within 3 months. The authors used functional MRI (fMRI) resting state analysis of the sensorimotor network to investigate large-scale brain plasticity between the immediate postoperative period and 3 months' follow-up. METHODS Resting state fMRI was performed preoperatively, during the immediate postoperative period, and 3 months postoperatively in 6 patients with diffuse low-grade gliomas who underwent partial surgical excision of the SMA. Correlation analysis within the sensorimotor network was carried out on those 3 time points to study modifications of its functional connectivity. RESULTS The results showed a large-scale reorganization of the sensorimotor network. Interhemispheric connectivity was decreased in the postoperative period, and increased again during the recovery process. Connectivity between the lesion side motor area and the contralateral SMA rose to higher values than in the preoperative period. Intrahemispheric connectivity was decreased during the immediate postoperative period and had returned to preoperative values at 3 months after surgery. CONCLUSIONS These results confirm the findings reported in the existing literature on the plasticity of the SMA, showing large-scale modifications of the sensorimotor network, at both inter- and intrahemispheric levels. They suggest that interhemispheric connectivity might be a correlate of SMA syndrome recovery.

Infiltration of the basal ganglia by brain tumors is associated with the development of co-dominant language function on fMRI

Studies have shown that some patients with left-hemispheric brain tumors have an increased propensity for developing right-sided language support. However, the precise trigger for establishing co-dominant language function in brain tumor patients remains unknown. We analyzed the MR scans of patients with left-hemispheric tumors and either co-dominant (n=35) or left-hemisphere dominant (n=35) language function on fMRI to investigate anatomical factors influencing hemispheric language dominance. Of eleven neuroanatomical areas evaluated for tumor involvement, the basal ganglia was significantly correlated with co-dominant language function (p<0.001). Moreover, among patients whose tumors invaded the basal ganglia, those with language co-dominance performed significantly better on the Boston Naming Test, a clinical measure of aphasia, compared to their left-lateralized counterparts (56.5 versus 36.5, p=0.025). While further studies are needed to elucidate the role of the basal ganglia in establishing co-dominance, our results suggest that reactive co-dominance may afford a behavioral advantage to patients with left-hemispheric tumors.

Functional MRI evidence for the decline of word retrieval and generation during normal aging

This fMRI study aimed to explore the effect of normal aging on word retrieval and generation. The question addressed is whether lexical production decline is determined by a direct mechanism, which concerns the language operations or is rather indirectly induced by a decline of executive functions. Indeed, the main hypothesis was that normal aging does not induce loss of lexical knowledge, but there is only a general slowdown in retrieval mechanisms involved in lexical processing, due to possible decline of the executive functions. We used three tasks (verbal fluency, object naming, and semantic categorization). Two groups of participants were tested (Young, Y and Aged, A), without cognitive and psychiatric impairment and showing similar levels of vocabulary. Neuropsychological testing revealed that older participants had lower executive function scores, longer processing speeds, and tended to have lower verbal fluency scores. Additionally, older participants showed higher scores for verbal automatisms and overlearned information. In terms of behavioral data, older participants performed as accurate as younger adults, but they were significantly slower for the semantic categorization and were less fluent for verbal fluency task. Functional MRI analyses suggested that older adults did not simply activate fewer brain regions involved in word production, but they actually showed an atypical pattern of activation. Significant correlations between the BOLD (Blood Oxygen Level Dependent) signal of aging-related (A > Y) regions and cognitive scores suggested that this atypical pattern of the activation may reveal several compensatory mechanisms (a) to overcome the slowdown in retrieval, due to the decline of executive functions and processing speed and (b) to inhibit verbal automatic processes. The BOLD signal measured in some other aging-dependent regions did not correlate with the behavioral and neuropsychological scores, and the overactivation of these uncorrelated regions would simply reveal dedifferentiation that occurs with aging. Altogether, our results suggest that normal aging is associated with a more difficult access to lexico-semantic operations and representations by a slowdown in executive functions, without any conceptual loss.

Functional magnetic resonance imaging

Functional magnetic resonance imaging (fMRI) maps the spatiotemporal distribution of neural activity in the brain under varying cognitive conditions. Since its inception in 1991, blood oxygen level-dependent (BOLD) fMRI has rapidly become a vital methodology in basic and applied neuroscience research. In the clinical realm, it has become an established tool for presurgical functional brain mapping. This chapter has three principal aims. First, we review key physiologic, biophysical, and methodologic principles that underlie BOLD fMRI, regardless of its particular area of application. These principles inform a nuanced interpretation of the BOLD fMRI signal, along with its neurophysiologic significance and pitfalls. Second, we illustrate the clinical application of task-based fMRI to presurgical motor, language, and memory mapping in patients with lesions near eloquent brain areas. Integration of BOLD fMRI and diffusion tensor white-matter tractography provides a road map for presurgical planning and intraoperative navigation that helps to maximize the extent of lesion resection while minimizing the risk of postoperative neurologic deficits. Finally, we highlight several basic principles of resting-state fMRI and its emerging translational clinical applications. Resting-state fMRI represents an important paradigm shift, focusing attention on functional connectivity within intrinsic cognitive networks.