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Di L, Tiefenbach J, McCarthy DJ, Sedighim S, Dagal A, Blandino CF, Luther EM, Lu VM, Ivan ME, Komotar RJ, Eichberg DG, Shah AH. The Utility of Transcranial Electrical Stimulation Motor Evoked Potential Monitoring in Predicting Postoperative Supplementary Motor Area Syndrome and Motor Function Recovery. World Neurosurg 2024; 183:e892-e899. [PMID: 38237803 DOI: 10.1016/j.wneu.2024.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/09/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Postoperative hemiparesis following frontal lobe lesion resection is alarming, and predicting motor function recovery is challenging. Supplementary motor area (SMA) syndrome following resection of frontal lobe lesions is often indistinguishable from postoperative motor deficit due to surgical injury of motor tracts. We aimed to describe the use of intraoperative transcranial electrical stimulation (TES) with motor evoked potential monitoring data as a diagnostic tool to distinguish between SMA syndrome and permanent motor deficit (PMD). METHODS A retrospective analysis of 235 patients undergoing craniotomy and resection with TES-MEP monitoring for a frontal lobe lesion was performed. Patients who developed immediate postoperative motor deficit were included. Motor deficit and TES-MEP findings were categorized by muscle group as left upper extremity, left lower extremity, right upper extremity, or right lower extremity. Statistical analysis was performed to determine the predictive value of stable TES-MEP for SMA syndrome versus PMD. RESULTS This study included 20 patients comprising 29 cases of immediate postoperative motor deficit by muscle group. Of these, 27 cases resolved and were diagnosed as SMA syndrome, and 2 cases progressed to PMD. TES-MEP stability was significantly associated with diagnosis of SMA syndrome (P = 0.015). TES-MEP showed excellent diagnostic utility with a sensitivity and positive predictive value of 100% and 92.6%, respectively. Negative predictive value was 100%. CONCLUSIONS Temporary SMA syndrome is difficult to distinguish from PMD immediately postoperatively. TES-MEP may be a useful intraoperative adjunct that may aid in distinguishing SMA syndrome from PMD secondary to surgical injury.
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Affiliation(s)
- Long Di
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jakov Tiefenbach
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
| | - David J McCarthy
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Shaina Sedighim
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Arman Dagal
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA; Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Carlos F Blandino
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Evan M Luther
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Victor M Lu
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA; Sylvester Comprehensive Cancer, University of Miami, Miami, Florida, USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA; Sylvester Comprehensive Cancer, University of Miami, Miami, Florida, USA
| | - Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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2
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Stipa G, Muti M, Ciampini A, Frondizi D, Rossi V, Fanelli C, Conti C. Persistent hemiplegia with normal intraoperative neurophysiological monitoring in supratentorial neurosurgery: a case report and review of literature. Neurol Sci 2024; 45:119-127. [PMID: 37615875 DOI: 10.1007/s10072-023-07022-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023]
Abstract
Intraoperative neurophysiological monitoring (IONM) is needed for evaluating and demonstrating the integrity of the central and peripheral nervous system during surgical manoeuvres that take place in proximity to eloquent motor and somatosensory nervous structures. The integrity of the monitored motor pathways is not always followed by consistent clinical normality, particularly in the first hours/days following surgery, when surgical resection involves brain structures such as the supplementary motor areas (SMA). We report the case of a patient who underwent surgical excision of a right frontal glioblastoma with normal preoperative, intraoperative (IONM), and postoperative central motor conduction, but with persistent postoperative hemiplegia (> 6 months). The literature regarding SMA syndrome and its diagnosis and prognosis is reviewed.
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Affiliation(s)
- Giuseppe Stipa
- Neurophysiopathology Unit, Neuroscience Department, S. Maria University Hospital, Via Tristano Di Joannuccio 05100, Terni, Italy.
| | - Marco Muti
- Health Physic Unit, S. Maria University Hospital, Terni, Italy
| | - Alessandro Ciampini
- Neurosurgery Unit, Neuroscience Department, Santa Maria University Hospital, Terni, Italy
| | - Domenico Frondizi
- Neurophysiopathology Unit, Neuroscience Department, S. Maria University Hospital, Via Tristano Di Joannuccio 05100, Terni, Italy
| | - Vera Rossi
- Neurophysiopathology Unit, Neuroscience Department, S. Maria University Hospital, Via Tristano Di Joannuccio 05100, Terni, Italy
| | - Cinzia Fanelli
- Neurophysiopathology Unit, Neuroscience Department, S. Maria University Hospital, Via Tristano Di Joannuccio 05100, Terni, Italy
| | - Carlo Conti
- Neurosurgery Unit, Neuroscience Department, Santa Maria University Hospital, Terni, Italy
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3
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Rech F, Duffau H. Beyond Avoiding Hemiplegia after Glioma Surgery: The Need to Map Complex Movement in Awake Patient to Preserve Conation. Cancers (Basel) 2023; 15:cancers15051528. [PMID: 36900318 PMCID: PMC10001205 DOI: 10.3390/cancers15051528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
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.
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Affiliation(s)
- Fabien Rech
- Department of Neurosurgery, CHRU de Nancy, Université de Lorraine, F-54000 Nancy, France
- Le Centre de Recherche en Automatique de Nancy, Le Centre National de la Recherche Scientifique, Université de Lorraine, F-54000 Nancy, France
| | - Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, F-34295 Montpellier, France
- Team ‘Plasticity of Central Nervous System, Stem Cells and Glial Tumours’, INSERM U1191, Institute of Genomics of Montpellier, University of Montpellier, F-34295 Montpellier, France
- Correspondence:
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4
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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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5
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Fang S, Li L, Weng S, Zhang Z, Fan X, Jiang T, Wang Y. Increasing nodal vulnerability and nodal efficiency implied recovery time prolonging in patients with supplementary motor area syndrome. Hum Brain Mapp 2022; 43:3958-3969. [PMID: 35507429 PMCID: PMC9374886 DOI: 10.1002/hbm.25896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 04/21/2022] [Indexed: 11/30/2022] Open
Abstract
Supplementary motor area (SMA) syndrome is a surgery‐related complication that commonly occurs after removing SMA glioma, and needs weeks to recover. However, susceptible factors of patients suffering from SMA syndrome remain unknown. Graphic theory was applied to reveal topological properties of sensorimotor network (SMN) by processing resting‐state functional magnetic resonance images in 66 patients with SMA gliomas. Patients were classified into SMA and non‐SMA groups based on whether they suffered from SMA syndrome. We collected recovery time and used causal mediation analysis to find association between topological properties and recovery time. Compared with the non‐SMA group, higher vulnerability (left: p = .0018; right: p = .0033) and lower fault tolerance (left: p = .0022; right: p = .0248) of the whole SMN were found in the SMA group. Moreover, higher nodal properties of lesional‐hemispheric cingulate cortex (nodal efficiency: left, p = .0389; right, p = .0169; nodal vulnerability: left, p = .0185; right, p = .0085) and upper limb region of primary motor cortex (PMC; nodal efficiency: left, p = .0132; right, p = .0001; nodal vulnerability: left, p = .0091; right, p = .0209) were found in the SMA group. Nodal efficiency and nodal vulnerability of cingulate cortex and upper limb region of PMC were important predictors for SMA syndrome occurring and recovery time prolonging. Neurosurgeons should carefully deal with upper limb region of PMC and cingulate cortex, and protect them if these two region were unnecessary to damage during SMA glioma resection.
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Affiliation(s)
- Shengyu Fang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Lianwang Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Shimeng Weng
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Zhong Zhang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Xing Fan
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Tao Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Research Unit of Accurate Diagnosis, Treatment, and Translational Medicine of Brain Tumors, Chinese Academy of Medical Sciences, Beijing, China
| | - Yinyan Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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6
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Young JS, Gogos AJ, Aabedi AA, Morshed RA, Pereira MP, Lashof-Regas S, Mansoori Z, Luks T, Hervey-Jumper SL, Villanueva-Meyer JE, Berger MS. Resection of supplementary motor area gliomas: revisiting supplementary motor syndrome and the role of the frontal aslant tract. J Neurosurg 2022; 136:1278-1284. [PMID: 34598138 DOI: 10.3171/2021.4.jns21187] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/14/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The supplementary motor area (SMA) is an eloquent region that is frequently a site for glioma, or the region is included in the resection trajectory to deeper lesions. Although the clinical relevance of SMA syndrome has been well described, it is still difficult to predict who will become symptomatic. The object of this study was to define which patients with SMA gliomas would go on to develop a postoperative SMA syndrome. METHODS The University of California, San Francisco, tumor registry was searched for patients who, between 2010 and 2019, had undergone resection for newly diagnosed supratentorial diffuse glioma (WHO grades II-IV) performed by the senior author and who had at least 3 months of follow-up. Pre- and postoperative MRI studies were reviewed to confirm the tumor was located in the SMA region, and the extent of SMA resection was determined by volumetric assessment. Patient, tumor, and outcome data were collected retrospectively from documents available in the electronic medical record. Tumors were registered to a standard brain atlas to create a frequency heatmap of tumor volumes and resection cavities. RESULTS During the study period, 56 patients (64.3% male, 35.7% female) underwent resection of a newly diagnosed glioma in the SMA region. Postoperatively, 60.7% developed an SMA syndrome. Although the volume of tumor within the SMA region did not correlate with the development of SMA syndrome, patients with the syndrome had larger resection cavities in the SMA region (25.4% vs 14.2% SMA resection, p = 0.039). The size of the resection cavity in the SMA region did not correlate with the severity of the SMA syndrome. Patients who developed the syndrome had cavities that were located more posteriorly in the SMA region and in the cingulate gyrus. When the frontal aslant tract (FAT) was preserved, 50% of patients developed the SMA syndrome postoperatively, whereas 100% of the patients with disruption of the FAT during surgery developed the SMA syndrome (p = 0.06). Patients with SMA syndrome had longer lengths of stay (5.6 vs 4.1 days, p = 0.027) and were more likely to be discharged to a rehabilitation facility (41.9% vs 0%, p < 0.001). There was no difference in overall survival for newly diagnosed glioblastoma patients with SMA syndrome compared to those without SMA syndrome (1.6 vs 3.0 years, p = 0.33). CONCLUSIONS For patients with SMA glioma, more extensive resections and resections involving the posterior SMA region and posterior cingulate gyrus increased the likelihood of a postoperative SMA syndrome. Although SMA syndrome occurred in all cases in which the FAT was resected, FAT preservation does not reliably avoid SMA syndrome postoperatively.
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Affiliation(s)
- Jacob S Young
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Andrew J Gogos
- 1Department of Neurological Surgery, University of California, San Francisco
| | | | - Ramin A Morshed
- 1Department of Neurological Surgery, University of California, San Francisco
| | | | | | - Ziba Mansoori
- 3Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Tracy Luks
- 3Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | | | - Javier E Villanueva-Meyer
- 3Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Mitchel S Berger
- 1Department of Neurological Surgery, University of California, San Francisco
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7
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Pasquini L, Di Napoli A, Rossi-Espagnet MC, Visconti E, Napolitano A, Romano A, Bozzao A, Peck KK, Holodny AI. Understanding Language Reorganization With Neuroimaging: How Language Adapts to Different Focal Lesions and Insights Into Clinical Applications. Front Hum Neurosci 2022; 16:747215. [PMID: 35250510 PMCID: PMC8895248 DOI: 10.3389/fnhum.2022.747215] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 01/18/2022] [Indexed: 12/13/2022] Open
Abstract
When the language-dominant hemisphere is damaged by a focal lesion, the brain may reorganize the language network through functional and structural changes known as adaptive plasticity. Adaptive plasticity is documented for triggers including ischemic, tumoral, and epileptic focal lesions, with effects in clinical practice. Many questions remain regarding language plasticity. Different lesions may induce different patterns of reorganization depending on pathologic features, location in the brain, and timing of onset. Neuroimaging provides insights into language plasticity due to its non-invasiveness, ability to image the whole brain, and large-scale implementation. This review provides an overview of language plasticity on MRI with insights for patient care. First, we describe the structural and functional language network as depicted by neuroimaging. Second, we explore language reorganization triggered by stroke, brain tumors, and epileptic lesions and analyze applications in clinical diagnosis and treatment planning. By comparing different focal lesions, we investigate determinants of language plasticity including lesion location and timing of onset, longitudinal evolution of reorganization, and the relationship between structural and functional changes.
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Affiliation(s)
- Luca Pasquini
- Neuroradiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Neuroradiology Unit, NESMOS Department, Sant’Andrea Hospital, La Sapienza University, Rome, Italy
| | - Alberto Di Napoli
- Neuroradiology Unit, NESMOS Department, Sant’Andrea Hospital, La Sapienza University, Rome, Italy
- Radiology Department, Castelli Hospital, Rome, Italy
- IRCCS Fondazione Santa Lucia, Rome, Italy
| | | | - Emiliano Visconti
- Neuroradiology Unit, Cesena Surgery and Trauma Department, M. Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Antonio Napolitano
- Medical Physics Department, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Andrea Romano
- Neuroradiology Unit, NESMOS Department, Sant’Andrea Hospital, La Sapienza University, Rome, Italy
| | - Alessandro Bozzao
- Neuroradiology Unit, NESMOS Department, Sant’Andrea Hospital, La Sapienza University, Rome, Italy
| | - Kyung K. Peck
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Andrei I. Holodny
- Neuroradiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Radiology, Weill Medical College of Cornell University, New York, NY, United States
- Department of Neuroscience, Weill-Cornell Graduate School of the Medical Sciences, New York, NY, United States
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8
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Pinson H, Van Lerbeirghe J, Vanhauwaert D, Van Damme O, Hallaert G, Kalala JP. The supplementary motor area syndrome: a neurosurgical review. Neurosurg Rev 2021; 45:81-90. [PMID: 33993354 DOI: 10.1007/s10143-021-01566-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/19/2021] [Accepted: 05/06/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Harry Pinson
- Department of Neurosurgery, AZ Delta, Roeselare, Belgium. .,Department of Neurosurgery, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
| | | | | | | | - Giorgio Hallaert
- Department of Neurosurgery, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Jean-Pierre Kalala
- Department of Neurosurgery, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
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9
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Krishna S, Kakaizada S, Almeida N, Brang D, Hervey-Jumper S. Central Nervous System Plasticity Influences Language and Cognitive Recovery in Adult Glioma. Neurosurgery 2021; 89:539-548. [PMID: 33476391 DOI: 10.1093/neuros/nyaa456] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 08/05/2020] [Indexed: 01/01/2023] Open
Abstract
Gliomas exist within the framework of complex neuronal circuitry in which network dynamics influence both tumor biology and cognition. The generalized impairment of cognition or loss of language function is a common occurrence for glioma patients. The interface between intrinsic brain tumors such as gliomas and functional cognitive networks are poorly understood. The ability to communicate effectively is critically important for receiving oncological therapies and maintaining a high quality of life. Although the propensity of gliomas to infiltrate cortical and subcortical structures and disrupt key anatomic language pathways is well documented, there is new evidence offering insight into the network and cellular mechanisms underpinning glioma-related aphasia and aphasia recovery. In this review, we will outline the current understanding of the mechanisms of cognitive dysfunction and recovery, using aphasia as an illustrative model.
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Affiliation(s)
- Saritha Krishna
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Sofia Kakaizada
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Nyle Almeida
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - David Brang
- Department of Psychology, University of Michigan, Ann Arbor, Michigan
| | - Shawn Hervey-Jumper
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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10
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de la Peña MJ, Gil-Robles S, de Vega VM, Aracil C, Acevedo A, Rodríguez MR. A Practical Approach to Imaging of the Supplementary Motor Area and Its Subcortical Connections. Curr Neurol Neurosci Rep 2020; 20:50. [PMID: 32930895 DOI: 10.1007/s11910-020-01070-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW First, an anatomical and functional review of these cortical areas and subcortical connections with T-fMRI and tractography techniques; second, to demonstrate the value of this approach in neurosurgical planning in a series of patients with tumors close to the SMA. RECENT FINDINGS Implications in language and cognitive networks with a clear hemispheric lateralization of these SMA/pre-SMA. The recommendation of the use of the advanced neuroimaging studies for surgical planning and preservation of these areas. The SMA/pre-SMA and their subcortical connections are functional areas to be taken into consideration in neurosurgical planning. These areas would be involved in the control/inhibition of movement, in verbal expression and fluency and in tasks of cognitive control capacity. Its preservation is key to the patient's postsurgical cognitive and functional evolution.
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Affiliation(s)
- Mar Jiménez de la Peña
- Department of Radiology, Hospital Universitario QuironSalud Madrid, C/ Diego de Velázquez 1, Pozuelo de Alarcón, 28223, Madrid, Spain.
| | - Santiago Gil-Robles
- Department of Neurosurgery, Hospital Universitario QuironSalud Madrid, Pozuelo de Alarcón, Madrid, Spain
| | - Vicente Martínez de Vega
- Department of Radiology, Hospital Universitario QuironSalud Madrid, C/ Diego de Velázquez 1, Pozuelo de Alarcón, 28223, Madrid, Spain
| | - Cristina Aracil
- Department of Neurosurgery, Hospital Universitario QuironSalud Madrid, Pozuelo de Alarcón, Madrid, Spain
| | - Agustín Acevedo
- Department of Pathology, Hospital Universitario QuironSalud Madrid, Pozuelo de Alarcón, Madrid, Spain
| | - Manuel Recio Rodríguez
- Department of Radiology, Hospital Universitario QuironSalud Madrid, C/ Diego de Velázquez 1, Pozuelo de Alarcón, 28223, Madrid, Spain
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11
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Grønbæk J, Molinari E, Avula S, Wibroe M, Oettingen G, Juhler M. The supplementary motor area syndrome and the cerebellar mutism syndrome: a pathoanatomical relationship? Childs Nerv Syst 2020; 36:1197-1204. [PMID: 31127340 DOI: 10.1007/s00381-019-04202-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/09/2019] [Indexed: 01/25/2023]
Abstract
PURPOSE The supplementary motor area (SMA) syndrome affects adults after tumour resection in SMA neighbouring motor cortex. Cerebellar mutism syndrome (CMS) affects children after tumour resection in the posterior fossa. Both syndromes include disturbances in speech and motor function. The causes of the syndromes are unknown; however, surgical damage to the dentato-thalamo-cortical pathway (DTCP) has been associated with CMS. Thus, an anatomical link between the areas associated with the syndromes is possible. We discuss the syndromes and their possible relationship through the DTCP. METHODS We identified 61 articles (cohort studies, case reports and reviews) in MEDLINE and Embase searching for CMS, SMA syndrome or DTCP or synonyms and reviewed for evidence linking CMS and SMA. RESULTS We found that SMA syndrome and CMS are similar regarding (1) surgical causation; (2) symptoms including speech impairment, disturbance in motor function and facial dysfunction; (3) delayed onset; (4) the courses of the syndromes are transient; and (5) long-term sequelae are seen in both. Relevant differences include age predominance of adults in SMA syndrome versus children in CMS. CONCLUSIONS The similarities of the two syndromes could be traced back to their mutual connection through the DTCP and their membership to a cerebro-cerebellar circuit. The connectivity network could explain the emotional changes and speech reduction in CMS. The difference in time of post-surgical onset may be related to the anatomical distance between the surgical damage to the cerebellum and the SMA, respectively, and the effector neural loop underpinning symptoms.
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Affiliation(s)
- Jonathan Grønbæk
- Department of Neurosurgery, The University Hospital Rigshospitalet, Copenhagen, Denmark.
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark.
| | - Emanuela Molinari
- Department of Neurology, The Queen Elizabeth University Hospital, University of Glasgow, Glasgow, UK
| | - Shivaram Avula
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Morten Wibroe
- Department of Neurosurgery, The University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Gorm Oettingen
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, The University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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12
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Intraoperative Electrophysiologic Mapping of Medial Frontal Motor Areas and Functional Outcomes. World Neurosurg 2020; 138:e389-e404. [DOI: 10.1016/j.wneu.2020.02.129] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/20/2020] [Accepted: 02/21/2020] [Indexed: 11/19/2022]
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13
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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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14
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Monticelli M, Zeppa P, Altieri R, Veneziani Santonio F, Cofano F, Melcarne A, Junemann CV, Zenga F, Sabatino G, La Rocca G, Della Pepa GM, Ducati A, Garbossa D. Exploring the anatomy of negative motor areas (NMAs): Findings in awake surgery. J Clin Neurosci 2020; 73:219-223. [PMID: 32001111 DOI: 10.1016/j.jocn.2020.01.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/05/2020] [Accepted: 01/11/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Matteo Monticelli
- Department of Neuroscience "Rita Levi Montalcini"; Neurosurgery Unit, University of Turin, Turin, Italy.
| | - Pietro Zeppa
- Department of Neuroscience "Rita Levi Montalcini"; Neurosurgery Unit, University of Turin, Turin, Italy
| | - Roberto Altieri
- Department of Neuroscience "Rita Levi Montalcini"; Neurosurgery Unit, University of Turin, Turin, Italy; Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy; PhD program at Department of Neuroscience "Rita Levi Montalcini"; University of Turin, Turin, Italy
| | | | - Fabio Cofano
- Department of Neuroscience "Rita Levi Montalcini"; Neurosurgery Unit, University of Turin, Turin, Italy
| | - Antonio Melcarne
- Department of Neuroscience "Rita Levi Montalcini"; Neurosurgery Unit, University of Turin, Turin, Italy
| | - Carola Vera Junemann
- Department of Neuroscience "Rita Levi Montalcini"; Neurosurgery Unit, University of Turin, Turin, Italy
| | - Francesco Zenga
- Department of Neuroscience "Rita Levi Montalcini"; Neurosurgery Unit, University of Turin, Turin, Italy
| | | | - Giuseppe La Rocca
- Mater Olbia Hospital, Neurosurgery Unit, Italy; "Agostino Gemelli" Policlinic Hospital, Neurosurgery Unit, Italy
| | | | - Alessandro Ducati
- Department of Neuroscience "Rita Levi Montalcini"; Neurosurgery Unit, University of Turin, Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience "Rita Levi Montalcini"; Neurosurgery Unit, University of Turin, Turin, Italy
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15
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Postoperative isolated lower extremity supplementary motor area syndrome: case report and review of the literature. Childs Nerv Syst 2020; 36:189-195. [PMID: 31705188 DOI: 10.1007/s00381-019-04362-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/30/2019] [Indexed: 10/25/2022]
Abstract
The supplementary motor area (SMA) syndrome is characterized by transient weakness and akinesia contralateral to the side of the affected hemisphere. The underlying pathology of the syndrome is not fully understood but is thought to be related to lesions in the SMA, residing principally in the mesial superior frontal gyrus (Broadmann's area 6c). Although the SMA syndrome a well-characterized clinical entity, we report herein, to our knowledge, the first case of isolated lower extremity SMA syndrome in the literature. This case highlights the importance of considering this rare clinical entity in the context of new or worsening postoperative neurologic deficits. Moreover, early studies did not support somatotopic organization of the SMA as in the primary motor cortex; emerging evidence suggests that delicate somatotopic representation may underlie distinct presentations like that reported in the present case.
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16
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Postoperative navigated transcranial magnetic stimulation to predict motor recovery after surgery of tumors in motor eloquent areas. Clin Neurophysiol 2019; 130:952-959. [PMID: 30981901 DOI: 10.1016/j.clinph.2019.03.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 03/23/2019] [Accepted: 03/25/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To know whether motor deficits after tumor surgery are transient is reassuring for the patient and crucial for planning rehabilitation and adjuvant treatment. We analyze the value of postoperative MRI navigated transcranial magnetic stimulation (nTMS) compared to intraoperative MEP monitoring in predicting recovery of motor function. METHODS Retrospective series of nTMS mappings within 14 days after surgery for supratentorial tumors (09/2014-05/2018). All patients with motor deficits of Medical-Research-Council-Grade (MRCS) 0-4- were included. RESULTS We performed nTMS mapping on average 3.8 days after surgery and recorded nTMS MEP in 11 of 13 patients. Motor strength recovered to at least MRCS 4 within one month if postoperative nTMS elicited MEPs (positive predictive value 90.9%). If nTMS did not elicit MEPs, the patient did not recover (negative predictive value 100%). Intraoperative MEP and postoperative nTMS were equally predictive for long-term motor recovery. In cases of intraoperative MEP alteration/signal loss, but a positive postoperative nTMS mapping, 2/3 patients demonstrated a good motor recovery. CONCLUSION nTMS may predict long-term motor recovery of patients suffering from severe motor deficits directly after resection of tumors located in motor eloquent areas. SIGNIFICANCE In cases of intraoperative MEP alterations, postoperative nTMS may clarify the potential for motor recovery.
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17
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Dick AS, Garic D, Graziano P, Tremblay P. The frontal aslant tract (FAT) and its role in speech, language and executive function. Cortex 2018; 111:148-163. [PMID: 30481666 DOI: 10.1016/j.cortex.2018.10.015] [Citation(s) in RCA: 151] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 08/27/2018] [Accepted: 10/18/2018] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
| | - Dea Garic
- Department of Psychology, Florida International University, Miami, FL, USA
| | - Paulo Graziano
- Department of Psychology, Florida International University, Miami, FL, USA
| | - Pascale Tremblay
- Departement de Readaptation, Université Laval, Quebec City, Quebec, Canada; CERVO Brain Research Center, Quebec City, Canada
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18
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Wongsripuemtet J, Tyan AE, Carass A, Agarwal S, Gujar SK, Pillai JJ, Sair HI. Preoperative Mapping of the Supplementary Motor Area in Patients with Brain Tumor Using Resting-State fMRI with Seed-Based Analysis. AJNR Am J Neuroradiol 2018; 39:1493-1498. [PMID: 30002054 DOI: 10.3174/ajnr.a5709] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/08/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The supplementary motor area can be a critical region in the preoperative planning of patients undergoing brain tumor resection because it plays a role in both language and motor function. While primary motor regions have been successfully identified using resting-state fMRI, there is variability in the literature regarding the identification of the supplementary motor area for preoperative planning. The purpose of our study was to compare resting-state fMRI to task-based fMRI for localization of the supplementary motor area in a large cohort of patients with brain tumors presenting for preoperative brain mapping. MATERIALS AND METHODS Sixty-six patients with brain tumors were evaluated with resting-state fMRI using seed-based analysis of hand and orofacial motor regions. Rates of supplementary motor area localization were compared with those in healthy controls and with localization results by task-based fMRI. RESULTS Localization of the supplementary motor area using hand motor seed regions was more effective than seeding using orofacial motor regions for both patients with brain tumor (95.5% versus 34.8%, P < .001) and controls (95.2% versus 45.2%, P < .001). Bilateral hand motor seeding was superior to unilateral hand motor seeding in patients with brain tumor for either side (95.5% versus 75.8%/75.8% for right/left, P < .001). No difference was found in the ability to identify the supplementary motor area between patients with brain tumors and controls. CONCLUSIONS In addition to task-based fMRI, seed-based analysis of resting-state fMRI represents an equally effective method for supplementary motor area localization in patients with brain tumors, with the best results obtained with bilateral hand motor region seeding.
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Affiliation(s)
- J Wongsripuemtet
- From the Russell H. Morgan Department of Radiology and Radiological Sciences (J.W., A.E.T., S.A., S.K.G., J.J.P., H.I.S.).,Department of Radiology (J.W.), Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - A E Tyan
- From the Russell H. Morgan Department of Radiology and Radiological Sciences (J.W., A.E.T., S.A., S.K.G., J.J.P., H.I.S.)
| | - A Carass
- Department of Computer Science and Department of Electrical and Computer Engineering (A.C.), Johns Hopkins University, Baltimore, Maryland
| | - S Agarwal
- From the Russell H. Morgan Department of Radiology and Radiological Sciences (J.W., A.E.T., S.A., S.K.G., J.J.P., H.I.S.)
| | - S K Gujar
- From the Russell H. Morgan Department of Radiology and Radiological Sciences (J.W., A.E.T., S.A., S.K.G., J.J.P., H.I.S.)
| | - J J Pillai
- From the Russell H. Morgan Department of Radiology and Radiological Sciences (J.W., A.E.T., S.A., S.K.G., J.J.P., H.I.S.).,Department of Neurosurgery (J.J.P.), Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - H I Sair
- From the Russell H. Morgan Department of Radiology and Radiological Sciences (J.W., A.E.T., S.A., S.K.G., J.J.P., H.I.S.)
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19
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Cañas A, Juncadella M, Lau R, Gabarrós A, Hernández M. Working Memory Deficits After Lesions Involving the Supplementary Motor Area. Front Psychol 2018; 9:765. [PMID: 29875717 PMCID: PMC5974158 DOI: 10.3389/fpsyg.2018.00765] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 04/30/2018] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Alba Cañas
- Department of Neurology, Hospital Universitari de Bellvitge L'Hospitalet de Llobregat, Spain
| | - Montserrat Juncadella
- Department of Neurology, Hospital Universitari de Bellvitge L'Hospitalet de Llobregat, Spain
| | - Ruth Lau
- Department of Neurosurgery, Hospital Universitari de Bellvitge L'Hospitalet de Llobregat, Spain
| | - Andreu Gabarrós
- Department of Neurosurgery, Hospital Universitari de Bellvitge L'Hospitalet de Llobregat, Spain.,Cognition and Brain Plasticity Group, Bellvitge Biomedical Research Institute (IDIBELL) L'Hospitalet de Llobregat, Spain
| | - Mireia Hernández
- Cognition and Brain Plasticity Group, Bellvitge Biomedical Research Institute (IDIBELL) L'Hospitalet de Llobregat, Spain.,Section of Cognitive Processes, Department of Cognition, Development and Educational Psychology, University of Barcelona, Barcelona, Spain.,Basque Center on Cognition, Brain and Language, Donostia, Spain
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20
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Berg-Johnsen J, Høgestøl EA. Supplementary motor area syndrome after surgery for parasagittal meningiomas. Acta Neurochir (Wien) 2018; 160:583-587. [PMID: 29362933 DOI: 10.1007/s00701-018-3474-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 01/16/2018] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Jon Berg-Johnsen
- Department of Neurosurgery, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Einar August Høgestøl
- Department of Neurology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
- Department of Neurology, Neuroscience Research Unit, Oslo University Hospital, Domus Medica 4, room L-268, Gaustadalleén 34, 0372, Oslo, Norway.
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21
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Nucera A, Azarpazhooh MR, Cardinali L, Alsubaie R, Chiang TC, Weishaupt N, Hachinski V. Inhibition of the primary motor cortex and the upgoing thumb sign. eNeurologicalSci 2017; 8:31-33. [PMID: 29260033 PMCID: PMC5730890 DOI: 10.1016/j.ensci.2017.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 07/18/2017] [Indexed: 11/29/2022] Open
Abstract
Background The upgoing thumb sign has been frequently observed in patients with minor strokes and transient ischemic attacks as an indicator of brain involvement. We assessed the effect of primary motor cortex (M1) inhibition in the development of the upgoing thumb sign. Methods Used repetitive Transcranial Magnetic Stimulation (rTMS, 1 Hz frequency for 15 min, 1s ISI, 900 pulses) at 60% of resting motor threshold to inhibit the right or left primary motor cortex of 10 healthy individuals. Participants were examined before and after rTMS by a neurologist who was blind to the site of motor cortex inhibition. Results 10 neurological intact participants (5 women/5 men) were recruited for this study. 2 cases were excluded due to pre-existing possible thumb signs. After the inhibition of the primary motor cortex, in 6 subjects out of 8, we observed a thumb sign contralateral to the site of primary motor cortex inhibition. In one subject an ipsilateral thumbs sign was noted. In another case, we did not find an upgoing thumb sign. Conclusion The upgoing thumb sign is a subtle neurological finding that may be related to the primary motor cortex or corticospinal pathways involvements. After the inhibition of the primary motor cortex, using repetitive Transcranial Magnetic Stimulation 9 (rTMS), in 7 subjects out of 8, the upgoing thumb sign was observed. The upgoing thumb sign is a subtle neurological finding related to the upper motor neuron involvements. The upgoing thumb sign may be seen in the primary motor cortex or corticospinal pathways lesions.
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Affiliation(s)
- Antonia Nucera
- Department of Clinical Neurological Science, University Hospital, University of Western Ontario, Ontario, Canada.,Department of Neurology, Saint Andrea Hospital, Stroke Unit, La Spezia, Italy
| | - Mahmoud Reza Azarpazhooh
- Department of Clinical Neurological Science, University Hospital, University of Western Ontario, Ontario, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, Ontario, Canada.,Department of Neurology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Lucilla Cardinali
- Department of Neurology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Rasha Alsubaie
- Department of Clinical Neurological Science, University Hospital, University of Western Ontario, Ontario, Canada
| | - Tzu-Ching Chiang
- The Brain and Mind Institute, University of Western Ontario, Ontario, Canada
| | - Nina Weishaupt
- Department of Anatomy and Cell Biology, University of Western Ontario, Ontario, Canada
| | - Vladimir Hachinski
- Department of Clinical Neurological Science, University Hospital, University of Western Ontario, Ontario, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, Ontario, Canada
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22
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Xu J, Elazab A, Liang J, Jia F, Zheng H, Wang W, Wang L, Hu Q. Cortical and Subcortical Structural Plasticity Associated with the Glioma Volumes in Patients with Cerebral Gliomas Revealed by Surface-Based Morphometry. Front Neurol 2017. [PMID: 28649229 PMCID: PMC5465275 DOI: 10.3389/fneur.2017.00266] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Postlesional plasticity has been identified in patients with cerebral gliomas by inducing a large functional reshaping of brain networks. Although numerous non-invasive functional neuroimaging methods have extensively investigated the mechanisms of this functional redistribution in patients with cerebral gliomas, little effort has been made to investigate the structural plasticity of cortical and subcortical structures associated with the glioma volume. In this study, we aimed to investigate whether the contralateral cortical and subcortical structures are able to actively reorganize by themselves in these patients. The compensation mechanism following contralateral cortical and subcortical structural plasticity is considered. We adopted the surface-based morphometry to investigate the difference of cortical and subcortical gray matter (GM) volumes in a cohort of 14 healthy controls and 13 patients with left-hemisphere cerebral gliomas [including 1 patients with World Health Organization (WHO I), 8 WHO II, and 4 WHO III]. The glioma volume ranges from 5.1633 to 208.165 cm2. Compared to healthy controls, we found significantly increased GM volume of the right cuneus and the left thalamus, as well as a trend toward enlargement in the right globus pallidus in patients with cerebral gliomas. Moreover, the GM volumes of these regions were positively correlated with the glioma volumes of the patients. These results provide evidence of cortical and subcortical enlargement, suggesting the usefulness of surface-based morphometry to investigate the structural plasticity. Moreover, the structural plasticity might be acted as the compensation mechanism to better fulfill its functions in patients with cerebral gliomas as the gliomas get larger.
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Affiliation(s)
- Jinping Xu
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Ahmed Elazab
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China.,Misr Higher Institute for Commerce and Computers, Mansoura, Egypt
| | - Jinhua Liang
- Neurosurgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China
| | - Fucang Jia
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Huimin Zheng
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Weimin Wang
- Neurosurgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China
| | - Limin Wang
- Psychological Department, Guangzhou First People's Hospital, Guangzhou, China
| | - Qingmao Hu
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
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Rech F, Duffau H, Pinelli C, Masson A, Roublot P, Billy-Jacques A, Brissart H, Civit T. Intraoperative identification of the negative motor network during awake surgery to prevent deficit following brain resection in premotor regions. Neurochirurgie 2017; 63:235-242. [DOI: 10.1016/j.neuchi.2016.08.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 08/17/2016] [Accepted: 08/30/2016] [Indexed: 12/01/2022]
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Vassal M, Charroud C, Deverdun J, Le Bars E, Molino F, Bonnetblanc F, Boyer A, Dutta A, Herbet G, Moritz-Gasser S, Bonafé A, Duffau H, de Champfleur NM. Recovery of functional connectivity of the sensorimotor network after surgery for diffuse low-grade gliomas involving the supplementary motor area. J Neurosurg 2016; 126:1181-1190. [PMID: 27315027 DOI: 10.3171/2016.4.jns152484] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Matthieu Vassal
- Departments of 1 Neurosurgery and.,Neuroradiology.,Institut d'Imagerie Fonctionnelle Humaine, and.,Institut des Neurosciences de Montpellier, INSERM U1051, Centre Hospitalier Régional Universitaire de Montpellier; and
| | - Céline Charroud
- Neuroradiology.,Institut d'Imagerie Fonctionnelle Humaine, and
| | - Jérémy Deverdun
- Neuroradiology.,Institut d'Imagerie Fonctionnelle Humaine, and.,Institut des Neurosciences de Montpellier, INSERM U1051, Centre Hospitalier Régional Universitaire de Montpellier; and.,Institut de Génomique Fonctionnelle, UMR 5203-INSERM U661.,Laboratoire Charles Coulomb, CNRS UMR 5221, and
| | - Emmanuelle Le Bars
- Neuroradiology.,Institut d'Imagerie Fonctionnelle Humaine, and.,Laboratoire Charles Coulomb, CNRS UMR 5221, and
| | - François Molino
- Institut de Génomique Fonctionnelle, UMR 5203-INSERM U661.,Laboratoire Charles Coulomb, CNRS UMR 5221, and
| | - Francois Bonnetblanc
- Laboratoire d'Informatique, de Robotique et de Microélectronique de Montpellier, CNRS UMR5506, Université de Montpellier, Montpellier, France
| | - Anthony Boyer
- Laboratoire d'Informatique, de Robotique et de Microélectronique de Montpellier, CNRS UMR5506, Université de Montpellier, Montpellier, France
| | - Anirban Dutta
- Laboratoire d'Informatique, de Robotique et de Microélectronique de Montpellier, CNRS UMR5506, Université de Montpellier, Montpellier, France
| | - Guillaume Herbet
- Departments of 1 Neurosurgery and.,Institut des Neurosciences de Montpellier, INSERM U1051, Centre Hospitalier Régional Universitaire de Montpellier; and
| | - Sylvie Moritz-Gasser
- Departments of 1 Neurosurgery and.,Institut des Neurosciences de Montpellier, INSERM U1051, Centre Hospitalier Régional Universitaire de Montpellier; and
| | - Alain Bonafé
- Neuroradiology.,Institut d'Imagerie Fonctionnelle Humaine, and.,Institut des Neurosciences de Montpellier, INSERM U1051, Centre Hospitalier Régional Universitaire de Montpellier; and
| | - Hugues Duffau
- Departments of 1 Neurosurgery and.,Institut des Neurosciences de Montpellier, INSERM U1051, Centre Hospitalier Régional Universitaire de Montpellier; and
| | - Nicolas Menjot de Champfleur
- Neuroradiology.,Institut d'Imagerie Fonctionnelle Humaine, and.,Institut des Neurosciences de Montpellier, INSERM U1051, Centre Hospitalier Régional Universitaire de Montpellier; and.,Laboratoire Charles Coulomb, CNRS UMR 5221, and
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Padwal JA, Dong X, Hirshman BR, Hoi-Sang U, Carter BS, Chen CC. Superior Efficacy of Gross Total Resection in Anaplastic Astrocytoma Patients Relative to Glioblastoma Patients. World Neurosurg 2016; 90:186-193. [DOI: 10.1016/j.wneu.2016.02.078] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 10/22/2022]
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Abel TJ, Buckley RT, Morton RP, Gabikian P, Silbergeld DL. Recurrent Supplementary Motor Area Syndrome Following Repeat Brain Tumor Resection Involving Supplementary Motor Cortex. Neurosurgery 2016; 11 Suppl 3:447-55; discussion 456. [PMID: 26087004 DOI: 10.1227/neu.0000000000000847] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Supplementary motor area (SMA) syndrome occurs after surgery involving the SMA and is characterized by contralateral hemiparesis with or without speech impairment (dependent on involvement of the dominant SMA), which is transient and characteristically resolves over the course of weeks to months. Recurrent SMA syndrome after repeat craniotomy has not been previously described. OBJECTIVE To describe the presentation and clinical course of patients who developed recurrent SMA syndrome after redo resection of tumors involving the SMA. METHODS We performed a retrospective review of 15 patients who underwent repeated resection of low-grade glioma from the superior and middle frontal gyrus. Of these patients, we identified 6 cases of recurrent SMA syndrome. RESULTS Six patients had a documented SMA syndrome occurring after initial and subsequent resection of tumor in proximity to the SMA. Intraoperative localization of eloquent motor and language cortex was achieved in each patient by using a combination of somatosensory evoked potentials and electrocortical stimulation mapping. Location of tumor and extent of resection was examined with magnetic resonance imaging. CONCLUSION This series demonstrates that recurrent SMA syndrome occurs in patients undergoing repeat resection of tumors involving the SMA. The presence of recurrent SMA syndrome provides support for reorganization of SMA function to adjacent ipsilateral cortex after resection. Patients with recurrent neoplasms of the SMA should be counseled on the possibility of recurrent SMA syndrome.
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Affiliation(s)
- Taylor J Abel
- Department of Neurological Surgery, University of Washington, Seattle, Washington
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Ibe Y, Tosaka M, Horiguchi K, Sugawara K, Miyagishima T, Hirato M, Yoshimoto Y. Resection extent of the supplementary motor area and post-operative neurological deficits in glioma surgery. Br J Neurosurg 2016; 30:323-9. [PMID: 26760482 DOI: 10.3109/02688697.2015.1133803] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective The supplementary motor area (SMA) is important for the prediction of post-operative symptoms after surgical resection of gliomas. We investigated the relationships between clinical factors and the resection range of SMA gliomas, and the post-operative neurological symptoms. Methods We retrospectively studied 18 consecutive surgeries for gliomas involving the SMA proper performed in 13 patients. Seven cases were recurrence of the tumour. Clinical factors and details of specific resection of the SMA proper (resection of posterior part, medial wall) and cingulate motor area (CMA) were examined. Results Eight cases suffered new post-operative neurological deficits. Six of these eight cases had transient deficits. Permanent deficits persisted in two cases with partial weakness or paresis, after rapid improvement of post-operative global weakness or hemiplegia, respectively. The risk of post-operative neurological deficits was not associated with the resection of the posterior part of the SMA proper or the CMA, but was associated with resection of the medial wall of the SMA proper. Surgery for recurrent tumour was associated with post-operative neurological deficits. The medial wall was frequently resected in recurrent cases. Discussion The frequency of post-operative neurological symptoms, including SMA syndrome, may be higher after resection of the medial wall of the SMA proper compared with the resection of only the lateral surface of the SMA proper.
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Affiliation(s)
- Yoko Ibe
- a Department of Neurosurgery , Gunma University Graduate School of Medicine , Maebashi , Japan
| | - Masahiko Tosaka
- a Department of Neurosurgery , Gunma University Graduate School of Medicine , Maebashi , Japan
| | - Keishi Horiguchi
- a Department of Neurosurgery , Gunma University Graduate School of Medicine , Maebashi , Japan
| | - Kenichi Sugawara
- a Department of Neurosurgery , Gunma University Graduate School of Medicine , Maebashi , Japan
| | - Takaaki Miyagishima
- a Department of Neurosurgery , Gunma University Graduate School of Medicine , Maebashi , Japan
| | - Masafumi Hirato
- a Department of Neurosurgery , Gunma University Graduate School of Medicine , Maebashi , Japan
| | - Yuhei Yoshimoto
- a Department of Neurosurgery , Gunma University Graduate School of Medicine , Maebashi , Japan
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Incidence of local in-brain progression after supramarginal resection of cerebral metastases. Acta Neurochir (Wien) 2015; 157:905-10; discussion 910-1. [PMID: 25845550 DOI: 10.1007/s00701-015-2405-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 03/17/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Microsurgical circumferential stripping of intracerebral metastases is often insufficient in achieving local tumor control. Supramarginal resection may improve local tumor control. METHODS A retrospective analysis was performed for patients who underwent supramarginal resection of a cerebral metastasis by awake surgery with intraoperative cortical and subcortical stimulation, MEPs, and SSEPs. Supramarginal resection was achieved by circumferential stripping of the metastasis and additional removal of approximately 3 mm of the surrounding tissue. Pre- and postsurgical neurological status was assessed by the NIH Stroke Scale. Permanent deficits were defined by persistence after 3-month observation time. RESULTS Supramarginal resection of cerebral metastases in eloquent brain areas was performed in 34 patients with a mean age of 60 years (range, 33-83 years). Five out of 34 patients (14.7%) had a new transient postoperative neurological deficit, which improved within a few days due to supplementary motor area (SMA) syndrome. Five out of 34 patients (14.7%) developed a local in-brain progression and nine patients (26.4%) a distant in-brain progression. CONCLUSIONS Supramarginal resection of cerebral metastases in eloquent locations is feasible and safe. Safety might be increased by intraoperative neuromonitoring. The better outcome in the present series may be entirely based on other predictors than extend of surgical resection and not necessarily on the surgical technique applied. However, supramarginal resection was safe and apparently did not lead to worse results than regular surgical techniques. Prospective, controlled, and randomized studies are mandatory to determine the possible benefit of supramarginal resection on local tumor control and overall outcome.
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Nakajima R, Nakada M, Miyashita K, Kinoshita M, Okita H, Yahata T, Hayashi Y. Intraoperative Motor Symptoms during Brain Tumor Resection in the Supplementary Motor Area (SMA) without Positive Mapping during Awake Surgery. Neurol Med Chir (Tokyo) 2015; 55:442-50. [PMID: 25925753 PMCID: PMC4628172 DOI: 10.2176/nmc.oa.2014-0343] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Awake surgery could be a useful modality for lesions locating in close proximity to the eloquent areas including primary motor cortex and pyramidal tract. In case with supplementary motor area (SMA) lesion, we often encounter with intraoperative motor symptoms during awake surgery even in area without positive mapping. Although the usual recovery of the SMA syndrome has been well documented, rare cases with permanent deficits could be encountered in the clinical setting. It has been difficult to evaluate during surgery whether the intraoperative motor symptoms lead to postoperative permanent deficits. The purpose of this study was to demonstrate the intraoperative motor symptoms could be reversible, further to provide useful information for making decision to continue surgical procedure of tumor resection. Eight consecutive patients (from July 2012 to June 2014, six men and two women, aged 33–63 years) with neoplastic lesions around the SMA underwent an awake surgery. Using a retrospective analysis of intraoperative video records, intraoperative motor symptoms during tumor resection were investigated. In continuous functional monitoring during resection of SMA tumor under awake conditions, the following motor symptoms were observed during resection of the region without positive mapping: delayed motor weakness, delay of movement initiation, slowness of movement, difficulty in dual task response, and coordination disturbance. In seven patients hemiparesis observed immediately after surgery recovered to preoperative level within 6 weeks. During awake surgery for SMA tumors, the above-mentioned motor symptoms could occur in area without positive mapping and might be predictors for reversible SMA syndrome.
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Affiliation(s)
- Riho Nakajima
- Pharmaceutical and Health Sciences, Kanazawa University
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Potgieser ARE, de Jong BM, Wagemakers M, Hoving EW, Groen RJM. Insights from the supplementary motor area syndrome in balancing movement initiation and inhibition. Front Hum Neurosci 2014; 8:960. [PMID: 25506324 PMCID: PMC4246659 DOI: 10.3389/fnhum.2014.00960] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 11/11/2014] [Indexed: 11/24/2022] Open
Abstract
The supplementary motor area (SMA) syndrome is a characteristic neurosurgical syndrome that can occur after unilateral resection of the SMA. Clinical symptoms may vary from none to a global akinesia, predominantly on the contralateral side, with preserved muscle strength and mutism. A remarkable feature is that these symptoms completely resolve within weeks to months, leaving only a disturbance in alternating bimanual movements. In this review we give an overview of the old and new insights from the SMA syndrome and extrapolate these findings to seemingly unrelated diseases and symptoms such as Parkinson's disease (PD) and tics. Furthermore, we integrate findings from lesion, stimulation and functional imaging studies to provide insight in the motor function of the SMA.
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Affiliation(s)
- A. R. E. Potgieser
- Department of Neurosurgery, University Medical Center Groningen, University of GroningenGroningen, Netherlands
| | - B. M. de Jong
- Department of Neurology, University Medical Center Groningen, University of GroningenGroningen, Netherlands
| | - M. Wagemakers
- Department of Neurosurgery, University Medical Center Groningen, University of GroningenGroningen, Netherlands
| | - E. W. Hoving
- Department of Neurosurgery, University Medical Center Groningen, University of GroningenGroningen, Netherlands
| | - R. J. M. Groen
- Department of Neurosurgery, University Medical Center Groningen, University of GroningenGroningen, Netherlands
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Ter Minassian A, Ricalens E, Nguyen The Tich S, Dinomais M, Aubé C, Beydon L. The presupplementary area within the language network: a resting state functional magnetic resonance imaging functional connectivity analysis. Brain Connect 2014; 4:440-53. [PMID: 24939724 DOI: 10.1089/brain.2014.0263] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The presupplementary motor area (pre-SMA) is involved in volitional selection. Despite the lateralization of the language network and different functions for both pre-SMA, few studies have reported the lateralization of pre-SMA activity and very little is known about the possible lateralization of pre-SMA connectivity. Via functional connectivity analysis, we sought to understand how the language network may be connected to other intrinsic connectivity networks (ICNs) through the pre-SMA. We performed a spatial independent component analysis of resting state functional magnetic resonance imaging in 30 volunteers to identify the language network. Subsequently, we applied seed-to-voxel functional connectivity analyses centered on peaks detected in the pre-SMA. Three signal peaks were detected in the pre-SMA. The left rostral pre-SMA intrinsic connectivity network (LR ICN) was left lateralized in contrast to bilateral ICNs associated to right pre-SMA peaks. The LR ICN was anticorrelated with the dorsal attention network and the right caudal pre-SMA ICN (RC ICN) anticorrelated with the default mode network. These two ICNs overlapped minimally. In contrast, the right rostral ICN overlapped the LR ICN. Both right ICNs overlapped in the ventral attention network (vATT). The bilateral connectivity of the right rostral pre-SMA may allow right hemispheric recruitment to process semantic ambiguities. Overlap between the right pre-SMA ICNs in vATT may contribute to internal thought to external environment reorientation. Distinct ICNs connected to areas involved in lexico-syntactic selection and phonology converge in the pre-SMA, which may constitute the resolution space of competing condition-action associations for speech production.
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Affiliation(s)
- Aram Ter Minassian
- 1 Laboratoire Angevin de Recherche en Ingénierie des Systèmes (LARIS) , Équipe Information, Signal, Image et Sciences du Vivant (ISISV), Université d'Angers, Angers, France
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Satoer D, Kloet A, Vincent A, Dirven C, Visch-Brink E. Dynamic aphasia following low-grade glioma surgery near the supplementary motor area: a selective spontaneous speech deficit. Neurocase 2014; 20:704-16. [PMID: 24098945 DOI: 10.1080/13554794.2013.841954] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We describe a patient (KO) with reduced spontaneous speech, resembling dynamic aphasia, after awake glioma surgery in the proximity of the supplementary motor area. Naming, repetition, and comprehension were intact. He was tested with an extensive neuropsychological test-battery and a protocol for dynamic aphasia at 1 year. He presented with postoperative reduced spontaneous speech and selective executive function deficits. Most language recovery took place at 3 months postoperatively, whereas the executive functions improved between 3 months and 1 year. Results suggest that resection near the supplementary motor area could increase the risk of cognitive disturbances at long term, especially language.
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Affiliation(s)
- Djaina Satoer
- a Department of Neurosurgery , Erasmus MC- University Medical Center , Rotterdam , the Netherlands
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33
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Endo Y, Saito Y, Otsuki T, Takahashi A, Nakata Y, Okada K, Hirozane M, Kaido T, Kaneko Y, Takada E, Okazaki T, Enokizno T, Saito T, Komaki H, Nakagawa E, Sugai K, Sasaki M. Persistent verbal and behavioral deficits after resection of the left supplementary motor area in epilepsy surgery. Brain Dev 2014; 36:74-9. [PMID: 24370003 DOI: 10.1016/j.braindev.2013.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 12/14/2012] [Accepted: 01/05/2013] [Indexed: 11/25/2022]
Abstract
An 8-year-old boy underwent a resection for focal cortical dysplasia at the left supplementary motor area (SMA) for the treatment of intractable epilepsy. The manifestations of SMA syndrome, such as transient mutism and right hemiparesis, resolved within a few weeks. Verbal disfluency and impaired executive function, accompanied by impulsivity and distractibility, persisted for more than 12months. The verbal and behavioral problems caused serious difficulties in the school life of the patient, until they became less evident at 18months after surgery. Tractography performed 18months after surgery revealed a defect in the subportion of fronto-parietal association fibers within the left superior longitudinal fascicles. Verbal influency can persist with unusually long duration after resection of SMA during childhood. Although not discernible on the routine neuroimaging, white matter damage beneath the SMA region could result in serious disabilities in executive function. These complications should be recognized for the prediction and assessment of deficits in children after surgical intervention involving this region.
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Affiliation(s)
- Yukari Endo
- Department of Child Neurology, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigachi-cho, Kodaira, Tokyo 187-8551, Japan
| | - Yoshiaki Saito
- Department of Child Neurology, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigachi-cho, Kodaira, Tokyo 187-8551, Japan.
| | - Taisuke Otsuki
- Department of Neurosurgery, National Center of Neurology and Psychiatry, Japan
| | - Akio Takahashi
- Department of Neurosurgery, National Center of Neurology and Psychiatry, Japan
| | - Yasuhiro Nakata
- Department of Radiology, National Center of Neurology and Psychiatry, Japan
| | - Kazue Okada
- Department of Clinical Psychology, National Center of Neurology and Psychiatry, Japan
| | - Mayumi Hirozane
- Department of Rehabilitation, National Center of Neurology and Psychiatry, Japan
| | - Takanobu Kaido
- Department of Neurosurgery, National Center of Neurology and Psychiatry, Japan
| | - Yuu Kaneko
- Department of Neurosurgery, National Center of Neurology and Psychiatry, Japan
| | - Eiko Takada
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe-shi, Saitama 350-8550, Japan
| | - Tetsuya Okazaki
- Department of Child Neurology, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigachi-cho, Kodaira, Tokyo 187-8551, Japan
| | - Takashi Enokizno
- Department of Child Neurology, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigachi-cho, Kodaira, Tokyo 187-8551, Japan
| | - Takashi Saito
- Department of Child Neurology, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigachi-cho, Kodaira, Tokyo 187-8551, Japan
| | - Hirofumi Komaki
- Department of Child Neurology, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigachi-cho, Kodaira, Tokyo 187-8551, Japan
| | - Eiji Nakagawa
- Department of Child Neurology, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigachi-cho, Kodaira, Tokyo 187-8551, Japan
| | - Kenji Sugai
- Department of Child Neurology, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigachi-cho, Kodaira, Tokyo 187-8551, Japan
| | - Masayuki Sasaki
- Department of Child Neurology, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigachi-cho, Kodaira, Tokyo 187-8551, Japan
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Heiferman DM, Ackerman PD, Hayward DM, Primeau MJ, Anderson DE, Prabhu VC. Bilateral supplementary motor area syndrome causing akinetic mutism following parasagittal meningioma resection. ACTA ACUST UNITED AC 2014. [DOI: 10.7243/2052-6946-2-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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35
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Jenabi M, Peck KK, Young RJ, Brennan N, Holodny AI. Probabilistic fiber tracking of the language and motor white matter pathways of the supplementary motor area (SMA) in patients with brain tumors. J Neuroradiol 2013; 41:342-9. [PMID: 24380641 DOI: 10.1016/j.neurad.2013.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 12/02/2013] [Accepted: 12/04/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Accurate localization of anatomically and functionally separate SMA tracts is important to improve planning prior to neurosurgery. Using fMRI and probabilistic DTI techniques, we assessed the connectivity between the frontal language area (Broca's area) and the rostral pre-SMA (language SMA) and caudal SMA proper (motor SMA). MATERIALS AND METHODS Twenty brain tumor patients completed motor and language fMRI paradigms and DTI. Peaks of functional activity in the language SMA, motor SMA and Broca's area were used to define seed regions for probabilistic tractography. RESULTS fMRI and probabilistic tractography identified separate and unique pathways connecting the SMA to Broca's area - the language SMA pathway and the motor SMA pathway. For all subjects, the language SMA pathway had a larger number of voxels (P<0.0001) and higher connectivity (P<0.0001) to Broca's area than did the motor SMA pathway. In each patient, the number of voxels was greater in the language and motor SMA pathways than in background pathways (P<0.0001). No differences were found between patients with ipsilateral and those with contralateral tumors for either the language SMA pathway (degree of connectivity: P<0.36; number of voxels: 0.35) or the motor SMA pathway (degree of connectivity, P<0.28; number of voxels, P<0.74). CONCLUSION Probabilistic tractography can identify unique white matter tracts that connect language SMA and motor SMA to Broca's area. The language SMA is more significantly connected to Broca's area than is the motor subdivision of the SMA proper.
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Affiliation(s)
- Mehrnaz Jenabi
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275, York avenue, New York, 10065 NY, USA
| | - Kyung K Peck
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275, York avenue, New York, 10065 NY, USA; Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, 1275, York avenue, New York, 10065 NY, USA
| | - Robert J Young
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275, York avenue, New York, 10065 NY, USA; Brain Tumor Center, Memorial Sloan-Kettering Cancer Center, 1275, York avenue, New York, 10065 NY, USA; Department of Radiology, Weill Medical College of Cornell University, New York, 10065 NY, USA
| | - Nicole Brennan
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275, York avenue, New York, 10065 NY, USA
| | - Andrei I Holodny
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275, York avenue, New York, 10065 NY, USA; Brain Tumor Center, Memorial Sloan-Kettering Cancer Center, 1275, York avenue, New York, 10065 NY, USA; Department of Radiology, Weill Medical College of Cornell University, New York, 10065 NY, USA.
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36
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Suzuki K, Mikami T, Sugino T, Wanibuchi M, Miyamoto S, Hashimoto N, Mikuni N. Discrepancy between voluntary movement and motor-evoked potentials in evaluation of motor function during clipping of anterior circulation aneurysms. World Neurosurg 2013; 82:e739-45. [PMID: 24036339 DOI: 10.1016/j.wneu.2013.08.034] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 04/10/2013] [Accepted: 08/28/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Various modalities have been used to confirm the blood flow through parent arteries or surrounding perforating arteries during surgical aneurysm clipping, including motor-evoked potentials (MEPs), Doppler ultrasound, and indocyanine green videoangiography. Nonetheless, contralateral hemiparesis due to arterial blood flow insufficiency may arise because of false-positive or false-negative errors. By performing controlled intraoperative awakening during aneurysm clipping, we compared patients' voluntary movements with simultaneous MEP. METHODS Four patients with anterior choroidal artery aneurysms and one patient with a dorsal internal carotid artery aneurysm were included in this study. MEP and intraoperative voluntary movements under awake craniotomy were assessed simultaneously during and after the clipping procedure. RESULTS Aneurysms were safely and successfully clipped in all patients, with no evidence of postoperative neurological deficits. Voluntary movements and MEP findings did not differ from the control state in three patients. In the other two patients, we observed a discrepancy between MEP amplitudes and voluntary movements. In one patient, deterioration and subsequent improvement in voluntary movements were preceded by MEP amplitude reduction during clipping. In the other patient, MEP amplitude did not change although voluntary movement deteriorated during temporary occlusion of the internal carotid artery. CONCLUSIONS Intraoperative neurological assessment during aneurysmal clipping under awake craniotomy is feasible and safe, and should be valuable for the assessment of ischemia, especially in the anterior choroidal artery. From a neurophysiologic viewpoint, MEP may be insufficiently sensitive for evaluating voluntary movement under ischemia.
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Affiliation(s)
- Kengo Suzuki
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Takeshi Mikami
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Toshiya Sugino
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | | | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan.
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Barbaro NM. Supplementary motor resections. J Neurosurg 2013; 119:4. [PMID: 23641827 DOI: 10.3171/2013.1.jns121986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Kim YH, Kim CH, Kim JS, Lee SK, Han JH, Kim CY, Chung CK. Risk factor analysis of the development of new neurological deficits following supplementary motor area resection. J Neurosurg 2013; 119:7-14. [PMID: 23641824 DOI: 10.3171/2013.3.jns121492] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Supplementary motor area (SMA) resection often induces postoperative contralateral hemiparesis or speech disturbance. This study was performed to assess the neurological impairments that often follow SMA resection and to assess the risk factors associated with these postoperative deficits. METHODS The records for patients who had undergone SMA resection for pharmacologically intractable epilepsy between 1994 and 2010 were gleaned from an epilepsy surgery database and retrospectively reviewed in this study. RESULTS Forty-three patients with pharmacologically intractable epilepsy underwent SMA resection with intraoperative cortical stimulation and mapping while under awake anesthesia. The mean patient age was 31.7 years (range 15-63 years), and the mean duration and frequency of seizures were 10.4 years (range 0.1-30 years) and 14.6 per month (range 0.1-150 per month), respectively. Pathological examination of the brain revealed cortical dysplasia in 18 patients (41.9%), tumors in 16 patients (37.2%), and other lesions in 9 patients (20.9%). The mean duration of the follow-up period was 84.0 months (range 24-169 months). After SMA resection, 23 patients (53.5%) experienced neurological deficits. Three patients (7.0%) experienced permanent deficits, and 20 (46.5%) experienced symptoms that were transient. All permanent deficits involved contralateral weakness, whereas the transient symptoms patients experienced were varied, including contralateral weaknesses in 15, apraxia in 1, sensory disturbances in 1, and dysphasia in 6. Thirteen patients recovered completely within 1 month. Univariate analysis revealed that resection of the SMA proper, a shorter lifetime seizure history (<10 years), and resection of the cingulate gyrus in addition to the SMA were associated with the development of neurological deficits (p=0.078, 0.069, and 0.023, respectively). Cingulate gyrus resection was the only risk factor identified on multivariate analysis (p=0.027, OR 6.530, 95% CI 1.234-34.562). CONCLUSIONS Resection of the cingulate gyrus in addition to the SMA was significantly associated with the development of postoperative neurological impairment.
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Affiliation(s)
- Young-Hoon Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
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Kamp MA, Dibué M, Niemann L, Reichelt DC, Felsberg J, Steiger HJ, Szelényi A, Rapp M, Sabel M. Proof of principle: supramarginal resection of cerebral metastases in eloquent brain areas. Acta Neurochir (Wien) 2012; 154:1981-6. [PMID: 22875595 DOI: 10.1007/s00701-012-1463-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 07/23/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cerebral metastases are not sharply delimitatable; therefore, microsurgical circumferential stripping of intracerebral metastases is often insufficient for preventing local tumor recurrence. Supramarginal resection significantly improves local tumor control but was suggested not to be suitable for metastases in eloquent brain areas. Therefore, we retrospectively analyzed a series of patients with cerebral metastases situated in eloquent areas for newly occurring neurologic deficits after supramarginal resection performed as awake surgery. METHODS A retrospective analysis was performed for all patients who underwent supramarginal resection for a cerebral metastasis performed as awake surgery between June 2011 and April 2012. All metastases were localized in eloquent brain areas. Pre- and postsurgical neurologic status was documented as well as data regarding the primary cancer and histopathologic data. Postoperative MRI within 72 h was scheduled routinely to verify complete resection. RESULTS A total of 19 patients underwent awake surgery for a cerebral metastasis in eloquent brain areas. Surgery was well tolerated in all patients. Neurologic symptoms improved in five patients after surgery. In three patients, neurologic deficits existing before surgery worsened. The postoperative median National Institute of Health Stroke Scale (NIHSS) score did not differ from the preoperative value. CONCLUSIONS Awake surgery is a feasible tool for metastases in eloquent areas, minimizing postoperative neurologic deficits and morbidity. Therefore, eloquently situated metastases may also be eligible for supramarginal resection. Further studies are needed in order to analyze the benefit of this method in achieving better tumor control.
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Affiliation(s)
- Marcel A Kamp
- Department for Neurosurgery, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225 Düsseldorf, Germany.
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Kasasbeh AS, Yarbrough CK, Limbrick DD, Steger-May K, Leach JL, Mangano FT, Smyth MD. Characterization of the supplementary motor area syndrome and seizure outcome after medial frontal lobe resections in pediatric epilepsy surgery. Neurosurgery 2012; 70:1152-68; discussion 1168. [PMID: 22067422 DOI: 10.1227/neu.0b013e31823f6001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In adults, resection of the medial frontal lobe has been shown to result in supplementary motor area (SMA) syndrome, a disorder characterized by transient motor impairment. Studies examining the development of SMA syndrome in children, however, are wanting. OBJECTIVE To characterize the development of SMA syndrome and to analyze seizure outcomes after surgery in the medial frontal lobe for medically intractable epilepsy. METHODS Thirty-nine patients with medically intractable epilepsy who underwent surgery in the medial frontal lobe were reviewed retrospectively. The progression of neurological impairment and seizure outcome after surgery was recorded, and the extent of cortex resected was analyzed. RESULTS After resection in the region of the SMA, 23 patients (59%) developed postoperative neurological impairment; 17 (74%) were identified as SMA syndrome. No neurological impairment was found after surgery in 16 patients (41%). Six patients (15%) experienced permanent neurological impairment. The majority of patients (82%) who developed SMA syndrome had resolution of their symptoms by 1 month postoperatively. Preoperative magnetic resonance imaging finding of lesional cases was associated with a significantly decreased likelihood of developing SMA syndrome (P = .02). Seizure outcome was favorable after surgery in most patients. CONCLUSION Surgery for medically intractable epilepsy in the region of the medial frontal cortex is effective and associated with reversible neurological impairment in children. All patients had resolution of their SMA syndrome by 6 months postoperatively.
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Affiliation(s)
- Aimen S Kasasbeh
- Department of Neuroscience, University of Arizona, Tucson, Arizona 85719, USA.
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Kim YH, Kim CH, Kim JS, Lee SK, Chung CK. Resection frequency map after awake resective surgery for non-lesional neocortical epilepsy involving eloquent areas. Acta Neurochir (Wien) 2011; 153:1739-49. [PMID: 21732127 PMCID: PMC3232069 DOI: 10.1007/s00701-011-1074-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 06/15/2011] [Indexed: 11/29/2022]
Abstract
Background The resection of eloquent areas is challenging due to postoperative neurological deficits. The purpose of this study was to assess the efficacy and risk of awake brain surgery for non-lesional epilepsy involving the eloquent areas or their adjacent areas and to advocate the generation of a resection frequency map. Methods We enrolled 55 patients who underwent awake surgery between 1994 and 2007 for non-lesional epilepsy involving the primary sensori-motor or language areas. All patients underwent two-staged operations including subdural electrode monitoring and awake resective surgery. For each case, the preoperative and postoperative images were spatially normalized and compared on a standard atlas, and the resection map was then computed by summing up each resected area on the atlas. Results The postoperative seizure outcome was Engel class I in 27 patients (49.1%), II in nine (16.4%), III in 14 (25.5%) and IV in five (9.1%). Ten patients (18.2%) experienced postoperative neurological deficits including seven transient (12.7%) and three permanent, but mild ones (5.5%). The neurological complication rate of purely eloquent area resection was 36.8% (7/19). The resection frequency map computed in this study showed that the resection of eloquent areas was tolerable, with the exception of the Broca’s area. Conclusions Awake resective surgery with intraoperative brain mapping is an effective and safe treatment option for non-lesional epilepsy involving eloquent areas. The resection frequency map can show the resected area of a group as well as individuals and provide an objective measure of neurological risk. Electronic supplementary material The online version of this article (doi:10.1007/s00701-011-1074-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Young-Hoon Kim
- Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul, Korea 110–744
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul, Korea 110–744
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - June Sic Kim
- Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul, Korea 110–744
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Sang Kun Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul, Korea 110–744
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
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Prabhu VC, Khaldi A, Barton KP, Melian E, Schneck MJ, Primeau MJ, Lee JM. Management of Diffuse Low-Grade Cerebral Gliomas. Neurol Clin 2010; 28:1037-59. [DOI: 10.1016/j.ncl.2010.03.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Tate MC, Kim CY, Chang EF, Polley MY, Berger MS. Assessment of morbidity following resection of cingulate gyrus gliomas. Clinical article. J Neurosurg 2010; 114:640-7. [PMID: 20932098 DOI: 10.3171/2010.9.jns10709] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The morbidity associated with resection of tumors in the cingulate gyrus (CG) is not well established. The goal of the present study is to define the short- and long-term morbidity profile associated with resection of gliomas within this region. METHODS Ninety consecutive patients with gliomas involving the CG were analyzed. Resections were classified by zones corresponding to functionally defined regions of the CG as follows: Zone I (perigenual, anterior), Zone II (midcingulate), Zone III (posterior), and Zone IV (retrosplenial). Basic demographic, imaging, operative details, and pre- and postoperative neurological examinations were recorded for each patient. Patients in whom neurological morbidity was documented during their initial postoperative examination who did not completely improve by the 6-month follow-up examination were considered to have a permanent deficit. For each patient with surgery-related morbidity, postoperative MR imaging and operative notes were reviewed, and the cortical regions incorporated in the surgical trajectory were recorded. The analysis was carried out for tumors confined to the CG (> 90% of tumor contained within the CG) as well as those involving the CG but extending into adjacent cortical structures. RESULTS Analysis of the entire patient cohort demonstrated that 29% of patients experienced a new or worsened neurological deficit immediately after surgery. The most common deficits were supplementary motor area (SMA) syndrome (20%), weakness (6%), and sensory changes (2%). All patients with an SMA syndrome in our series had intentional resection of SMA as part of the surgical approach. Patients with resections including Zone II or III had a higher rate of total morbidity and SMA syndrome than patients with Zone I resections (p < 0.05). Only 4% of patients had a persistent neurological deficit at 6 months postoperatively. A similar morbidity profile was observed in the subset analysis of patients with tumors confined to the CG, with no additional morbidity related to known cingulate-specific functions. CONCLUSIONS Resection of gliomas involving the CG can be performed with minimal, predictable long-term morbidity (< 5%). Surgical morbidity is primarily a function of surgical trajectory rather than the particular cingulate region resected.
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Affiliation(s)
- Matthew C Tate
- Department of Neurological Surgery, University of California, San Francisco, California, USA
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Rosenberg K, Nossek E, Liebling R, Fried I, Shapira-Lichter I, Hendler T, Ram Z. Prediction of neurological deficits and recovery after surgery in the supplementary motor area: a prospective study in 26 patients. J Neurosurg 2010; 113:1152-63. [PMID: 20635854 DOI: 10.3171/2010.6.jns1090] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Resection of lesions involving the supplementary motor area (SMA) may result in immediate postoperative motor and speech deficits that are reversible in most cases. In the present study the authors aimed to determine the critical involvement of SMA in the lesioned and healthy hemispheres in this functional recovery. They hypothesized that compensatory mechanisms take place following surgery in the SMA, and that these mechanisms can involve either the lesioned or the non-lesioned hemisphere. In addition, they hypothesized that a correlation will be present between the functional MR imaging (fMR) imaging-related activation in the SMA and the occurrence of a functional deficit during intraoperative cortical stimulation. METHODS Twenty-six patients scheduled for resection of space-occupying lesions involving, or in the vicinity of, the SMA were recruited. Patients underwent an fMR imaging examination that included finger-tapping and verb-generation tests to assess for motor and language functions. Intraoperatively direct cortical stimulation (DCS) of the SMA region was performed while patients were monitored for language and motor functions using tests similar to those used for the fMR imaging. Task dysfunction during DCS assessed the critical involvement of the SMA in the tested functions. Neurological evaluations were performed prior to surgery and at 3 time points within a month following surgery. A region of interest-based approach was used to evaluate fMR imaging blood oxygen level-dependent activation level and asymmetry in the SMA. These measurements were later compared with the intraoperative DCS and neurological findings. RESULTS Functional MR imaging showed greater activation and dominance of the SMA in the lesioned hemisphere in patients who exhibited no motor or language dysfunction during DCS. In addition, patients with the highest activation of the SMA in the lesioned hemisphere for language and motor tests showed stronger coupling of this region with ipsilateral motor and language networks. In contrast, activation in the nonlesioned hemisphere did not correspond with DCS results. CONCLUSIONS The authors' findings demonstrate the necessity of activation in the vicinity of the lesioned SMA for functional compensation in motor and language tasks. It is possible that more effective functional coupling of the SMA with motor and language areas in the same hemisphere prevents dysfunctions following surgical intervention. Importantly, fMR imaging activation in the unaffected SMA was not sufficient for development of functional compensation and, if anything, indicated decompensation.
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Affiliation(s)
- Keren Rosenberg
- Whole Institute for Advanced Imaging, Department of Neurosurgery, Epilepsy and Functional Neurosurgery Unit, Tel Aviv Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Tremblay P, Gracco VL. Contribution of the pre-SMA to the production of words and non-speech oral motor gestures, as revealed by repetitive transcranial magnetic stimulation (rTMS). Brain Res 2009; 1268:112-124. [PMID: 19285972 DOI: 10.1016/j.brainres.2009.02.076] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2008] [Revised: 02/08/2009] [Accepted: 02/27/2009] [Indexed: 11/30/2022]
Abstract
An emerging theoretical perspective, largely based on neuroimaging studies, suggests that the pre-SMA is involved in planning cognitive aspects of motor behavior and language, such as linguistic and non-linguistic response selection. Neuroimaging studies, however, cannot indicate whether a brain region is equally important to all tasks in which it is activated. In the present study, we tested the hypothesis that the pre-SMA is an important component of response selection, using an interference technique. High frequency repetitive TMS (10 Hz) was used to interfere with the functioning of the pre-SMA during tasks requiring selection of words and oral gestures under different selection modes (forced, volitional) and attention levels (high attention, low attention). Results show that TMS applied to the pre-SMA interferes selectively with the volitional selection condition, resulting in longer RTs. The low- and high-attention forced selection conditions were unaffected by TMS, demonstrating that the pre-SMA is sensitive to selection mode but not attentional demands. TMS similarly affected the volitional selection of words and oral gestures, reflecting the response-independent nature of the pre-SMA contribution to response selection. The implications of these results are discussed.
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Affiliation(s)
- Pascale Tremblay
- McGill University, Faculty of Medicine, School of Communication Sciences and Disorders, 1266 Avenue des Pins, Montreal, Canada; Centre for Research on Language, Mind and Brain, Canada.
| | - Vincent L Gracco
- McGill University, Faculty of Medicine, School of Communication Sciences and Disorders, 1266 Avenue des Pins, Montreal, Canada; Centre for Research on Language, Mind and Brain, Canada; Haskins Laboratories, New Haven, Connecticut, USA
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Abstract
Surgery is indicated in almost all glioma patients at some point during the course of their disease. The surgical intervention aims at obtaining a tissue diagnosis, providing symptom relief, improving patient survival by reducing the tumor burden, and in rare cases even effecting a cure.A resection will reduce symptoms related to the mass effect of the tumor, and offers a good chance for seizure control. An increasing body of data suggests that glioma patients will benefit from a maximal safe surgical cytoreduction. However, the size of the effect may vary for the different glioma entities. Modern adjuvant neuro-oncological treatment strategies rely heavily on the histological diagnosis. A (stereotactic) biopsy should therefore be offered to patients with nonresectable gliomas to allow for histology-guided adjuvant therapy. Some gliomas can be managed successfully with stereotactic interstitial radiosurgery (brachytherapy). Intra- and extraoperative electrophysiological mapping and/or monitoring, functional MRI, intraoperative imaging, and neuronavigation are increasingly used in many neurosurgical centers in order to reduce surgical morbidity. A definite effect on long-term outcome needs yet to be proven.Advances in computers, imaging, and other technologies will continue to play a large role in the evolution of neurosurgical treatment for gliomas. This may well lead to further centralization of care. There will be an increasing pressure on neurosurgeons to justify the costs involved by showing that patients will actually benefit from complex treatments in highly specialized centers.
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Affiliation(s)
- Matthias Simon
- Department of Neurosurgery, University Hospital Bonn, Sigmund-Freud-Strasse 25, Bonn 53105, Germany.
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Hall WA, Kim P, Truwit CL. Functional magnetic resonance imaging-guided brain tumor resection. Top Magn Reson Imaging 2009; 19:205-212. [PMID: 19148037 DOI: 10.1097/rmr.0b013e3181934a09] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES We evaluated the safety and efficacy of using functional magnetic resonance imaging (fMRI) brain activation data obtained at both 1.5 and 3 T to guide brain tumor resections using 1.5-T intraoperative MRI (ioMRI) guidance. MATERIALS AND METHODS From January 1997 to March 2006, fMRI was performed on 29 patients before attempted brain tumor resection. Functional MRI was used to identify and coregister areas of brain activation for motor (n = 18), speech (n = 6), motor and speech (n = 4), and short-term memory and speech (n = 1) with respect to the tumor using a 1.5-T and two 3-T MRI scanners. Surgical resection was accomplished using 2 different 1.5-T ioMRI systems. The appropriate MRI scan sequences were obtained during surgery to determine and maximize the extent of the surgical resection depending on the tumor type. RESULTS Of 29 patients, 20 (69%) had radiographically complete fMRI-guided tumor resections and 2 (7%) had successful MRI-guided brain biopsy because of the proximity of their astrocytomas to the eloquent cortex. The tumors were oligodendrogliomas (n = 16), astrocytomas (n = 4), meningiomas (n = 3), glioblastomas multiforme (n = 2), a pleomorphic astrocytoma (n = 1), and a dysembryoplastic neuroepithelial tumor (n = 1). The preoperative fMRI data were accurate in all cases. After tumor resection, 7 patients (26%) had transient neurologic deficits that resolved completely within 1 month of the surgical procedure in all cases. No adverse events associated with ferromagnetic instrumentation occurred. CONCLUSIONS Functional MRI was accurate for localizing areas of eloquent neurologic function before ioMRI-guided brain tumor resection.
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Affiliation(s)
- Walter A Hall
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, NY 13210, USA.
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Chainay H, Francois-Xaxier A, Alexandre K, Hugues D, Laurent C, Emmanuelle V, Laurent C, Stephane L. Motor and language deficits before and after surgical resection of mesial frontal tumour. Clin Neurol Neurosurg 2008; 111:39-46. [PMID: 18845388 DOI: 10.1016/j.clineuro.2008.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 06/30/2008] [Accepted: 07/15/2008] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The goal of the present study was to better characterize pre- and immediately post-surgical motor and language deficits resulting from the surgery of tumours located in the medial part of the frontal lobe. PATIENTS AND METHODS Seven patients treated by surgical resection of low-grade gliomas affecting the medial part of the frontal lobe were studied with neuropsychological tasks investigating motor and language abilities before surgery and at three time points after surgery (first, third and seventh day after surgery). The tasks were constructed in a way that allowed the structured comparison between language and motor functions, and controlled the level of external constraint of the production. RESULTS The main results of this study are: (1) globally the patients were impaired in both language and motor production the day after surgery; (2) the performance improved faster for tasks with strongly constrained production; (3) the verbal and semantic fluency were very sensitive and appropriate tasks for examination of the deficits resulting from the resection; and (4) performances were back to normal seven days after the surgery for most of the tasks. CONCLUSION These results confirm that surgery of low-grade gliomas affecting the prefrontal midline areas affects only transiently motor and language functions as tested in this study. They also suggest that verbal and semantic fluency were the most severely affected tests postoperatively. On the basis of these results, the surgical resection of the low-grade gliomas of the prefrontal midline seems a valuable treatment alternative.
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Affiliation(s)
- Hanna Chainay
- Laboratoire d'Etude des Mécanismes Cognitifs, Institut de Psychologie, Université Lyon 2, Lyon, France.
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Abstract
Functional brain mapping may be useful for both preoperative planning and intraoperative neurosurgical decision making. "Gold standard" functional studies such as direct electrical stimulation and recording are complemented by newer, less invasive techniques such as functional magnetic resonance imaging. Less invasive techniques allow more areas of the brain to be mapped in more subjects (including healthy subjects) more often (including pre- and postoperatively). Expansion of the armamentarium of tools allows convergent evidence from multiple brain mapping techniques to bear on pre- and intraoperative decision making. Functional imaging techniques are used to map motor, sensory, language, and memory areas in neurosurgical patients with conditions as diverse as brain tumors, vascular lesions, and epilepsy. In the future, coregistration of high resolution anatomic and physiological data from multiple complementary sources will be used to plan more neurosurgical procedures, including minimally invasive procedures. Along the way, new insights on fundamental processes such as the biology of tumors and brain plasticity are likely to be revealed.
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Affiliation(s)
- Suzanne Tharin
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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