Functional results after resective procedures involving the supplementary motor area.

In this article, the authors report their experience with surgically induced supplementary motor area (SMA) deficiency syndrome in a prospective clinical trial of 28 patients who underwent surgery for tumorous (19 patients) or nontumorous (nine patients) lesions. The dominant side was affected in 17 patients and the nondominant side in 11 patients. The primary presenting symptoms included seizure activity (23 patients), hemiparesis (four patients), and aphasia (one patient). Functional topographic mapping, achieved by phase reversal of somatosensory evoked potentials, allowed precise localization of the central sulcus in 25 of the 28 patients. Motor evoked potential (MEP) monitoring, which was performed successfully in 13 of 15 cases during the resective procedure, showed no significant changes in the potentials in any patient. Immediately after surgery, 25 (89%) of the 28 patients displayed additional neurological deficits (aphasia and/or hemiparesis) that depended on the extent of the SMA resection. In 12 patients the SMA was resected completely: nine of these patients demonstrated a complete and three an incomplete deficit. In 16 patients the SMA resection was incomplete: 13 of these patients displayed an incomplete deficit, whereas three had no deficit. Neurological disorders resolved completely within 3 to 42 days (mean 11 days), except for a minimal disturbance of fine motor and/or speech function in complex tasks or at high speed. Electromagnetically elicited MEPs, examined postoperatively in five patients, were initially absent but recovered with improvement of motor function. In conclusion, although the SMA is known to control important functions such as initiation of motor activity or speech, our findings show that unilateral SMA removal can be accomplished without resulting in significant permanent deficits. Functional topographic mapping and monitoring facilitate the exact delineation of the adequate resection plane along the precentral sulcus, and postoperative magnetic resonance imaging allows precise correlation of clinical and anatomical data.

[1]  J. Talairach,et al.  Clinical consequences of corticectomies involving the supplementary motor area in man , 1977, Journal of the Neurological Sciences.

[2]  H. J. Gelmers,et al.  Cortical organization of voluntary motor activity as revealed by measurement of regional cerebral blood flow , 1981, Journal of the Neurological Sciences.

[3]  M Wiesendanger,et al.  Recent developments in studies of the supplementary motor area of primates. , 1986, Reviews of physiology, biochemistry and pharmacology.

[4]  Jerome Engel,et al.  Outcome with respect to epileptic seizures. , 1993 .

[5]  J C Rothwell,et al.  Simple and complex movements in a patient with infarction of the right supplementary motor area , 1986, Movement disorders : official journal of the Movement Disorder Society.

[6]  P. Bucy.  ELECTRICAL EXCITABILITY AND CYTO-ARCHITECTURE OF THE PREMOTOR CORTEX IN MONKEYS , 1933 .

[7]  G A Ojemann,et al.  Correlation of motor cortex brain mapping data with magnetic resonance imaging. , 1990, Journal of neurosurgery.

[8]  R. Passingham,et al.  Premotor cortex and the conditions for movement in monkeys (Macaca fascicularis) , 1985, Behavioural Brain Research.

[9]  S Jonas,et al.  The supplementary motor region and speech emission. , 1981, Journal of communication disorders.

[10]  R P Lesser,et al.  Cortical somatosensory evoked potentials in response to hand stimulation. , 1983, Journal of neurosurgery.

[11]  G A Ojemann,et al.  Postoperative deficits and functional recovery following removal of tumors involving the dominant hemisphere supplementary motor area. , 1991, Journal of neurosurgery.

[12]  E. Ross,et al.  The aprosodias. Functional-anatomic organization of the affective components of language in the right hemisphere. , 1981, Archives of neurology.

[13]  M. Wiesendanger,et al.  The Supplementary Motor Area in the Light of Recent Investigations , 1984 .

[14]  P. Roland,et al.  Regional cerebral blood flow changes in cortex and basal ganglia during voluntary movements in normal human volunteers. , 1982, Journal of neurophysiology.

[15]  J. Tanji,et al.  Neuronal activity in cortical motor areas related to ipsilateral, contralateral, and bilateral digit movements of the monkey. , 1988, Journal of neurophysiology.

[16]  E Wyllie,et al.  Supplementary motor seizures , 1988, Neurology.

[17]  C. Woolsey,et al.  Localization in somatic sensory and motor areas of human cerebral cortex as determined by direct recording of evoked potentials and electrical stimulation. , 1979, Journal of neurosurgery.

[18]  M. Wiesendanger,et al.  Structural and functional definition of the motor cortex in the monkey (Macaca fascicularis) , 1982, The Journal of physiology.

[19]  H. Funkenstein,et al.  Aphasia following infarction of the left supplementary motor area , 1978, Neurology.

[20]  M. Inase,et al.  Neuronal activity in the primate premotor, supplementary, and precentral motor cortex during visually guided and internally determined sequential movements. , 1991, Journal of neurophysiology.

[21]  C. Arseni,et al.  SPEECH DISTURBANCES CAUSED BY TUMOURS OF THE SUPPLEMENTARY MOTOR AREA , 1961, Acta psychiatrica Scandinavica.

[22]  H. Lüders,et al.  Neurophysiological techniques as an aid to surgical treatment of primary brain tumors , 1986, Annals of neurology.

[23]  H. Braak,et al.  A primitive gigantopyramidal field buried in the depth of the cingulate sulcus of the human brain , 1976, Brain Research.

[24]  U. Jürgens,et al.  The efferent and afferent connections of the supplementary motor area , 1984, Brain Research.

[25]  E Wyllie,et al.  Functional anatomy of the human supplementary sensorimotor area: results of extraoperative electrical stimulation. , 1994, Electroencephalography and clinical neurophysiology.

[26]  G. Goldberg.  Supplementary motor area structure and function: Review and hypotheses , 1985, Behavioral and Brain Sciences.

[27]  H. Kornhuber,et al.  Chapter 6 Will, Volitional Action, Attention and Cerebral Potentials in Man: Bereitschaftspotential, Performance-Related Potentials, Directed Attention Potential, Eeg Spectrum Changes , 1989 .

[28]  W. Penfield,et al.  The Cerebral Cortex of Man: A Clinical Study of Localization of Function , 1968 .

[29]  S. Goldring,et al.  Localization of function in the excision of lesions from the sensorimotor region. , 1984, Journal of neurosurgery.

[30]  H. Freund.  Premotor areas in man , 1984, Trends in Neurosciences.

[31]  P. Roland,et al.  Supplementary motor area and other cortical areas in organization of voluntary movements in man. , 1980, Journal of neurophysiology.

[32]  M. Raichle,et al.  The role of cerebral cortex in the generation of voluntary saccades: a positron emission tomographic study. , 1985, Journal of neurophysiology.

[33]  H. Freund,et al.  Premotor area and preparation of movement. , 1990, Revue neurologique.

[34]  J Talairach,et al.  The supplementary motor area in man (anatomo-functional findings by stereoencephalography in epilepsy) , 1966 .

[35]  J. White,et al.  Significance of the supplementary motor area in partial seizures and in cerebral localization. , 1980, Neurosurgery.

[36]  Makoto Taniguchi,et al.  Modification of cortical stimulation for motor evoked potentials under general anesthesia: technical description. , 1993, Neurosurgery.

[37]  C. Elger,et al.  Surgical Treatment of Extratemporal Epilepsy: Clinical, Radiologic, and Histopathologic Findings in 60 Patients , 1996, Epilepsia.

[38]  J. V. Van Buren,et al.  Functional representation on the medial aspect of the frontal lobes in man. , 1976, Journal of neurosurgery.

[39]  K. Heilman,et al.  Response preparation and response inhibition after lesions of the medial frontal lobe. , 1987, Archives of neurology.

[40]  H. Freund,et al.  Lesions of premotor cortex in man. , 1985, Brain : a journal of neurology.

[41]  H. J. Gelmers,et al.  Non-paralytic motor disturbances and speech disorders: the role of the supplementary motor area. , 1983, Journal of neurology, neurosurgery, and psychiatry.

[42]  J. Tanji,et al.  The role of premotor cortex and the supplementary motor area in the temporal control of movement in man. , 1993, Brain : a journal of neurology.

[43]  B. Larsen,et al.  Activation of the supplementary motor area during voluntary movement in man suggests it works as a supramotor area. , 1979, Science.

[44]  F. Sanides.  THE CYTO-MYELOARCHITECTURE OF THE HUMAN FRONTAL LOBE AND ITS RELATION TO PHYLOGENETIC DIFFERENTIATION OF THE CEREBRAL CORTEX. , 1964, Journal fur Hirnforschung.

[45]  K M Heilman,et al.  Apraxia and the supplementary motor area. , 1986, Archives of neurology.

[46]  H. Jasper,et al.  Epilepsy and the functional anatomy of the human brain , 1985 .

[47]  E. Skinhøj,et al.  Variations in regional cortical blood flow in the right and left hemispheres during automatic speech. , 1978, Brain : a journal of neurology.

[48]  A. Rubens.  Aphasia With Infarction in the Territory of the Anterior Cerebral Artery , 1975, Cortex.

[49]  P. Strick,et al.  The origin of thalamic inputs to the arcuate premotor and supplementary motor areas , 1984, The Journal of neuroscience : the official journal of the Society for Neuroscience.

[50]  W PENFIELD,et al.  The supplementary motor area of the cerebral cortex; a clinical and experimental study. , 1951, A.M.A. archives of neurology and psychiatry.