Search

Background: Supplementary motor area (SMA) syndrome commonly occurs after glioma resection and requires weeks to months of recovery. Methods: Thirty‐four glioma patients with SMA syndrome were reviewed and assigned to recovered and non‐recovered groups based on whether their motor function recovered on postoperative day 7. To validate the association between variations in nodal properties and recovery time, neuro‐navigated repetitive transcranial magnetic stimulation (nrTMS) was applied to stimulate potential nodes. Nine other patients (five nrTMS therapy and four sham‐nrTMS treatments) with SMA syndrome with unrecovered motor functions on postoperation day 7 were prospectively enrolled. Results: The potential nodes of the sensorimotor network related to recovery time were investigated using preoperative and postoperative resting‐state functional magnetic resonance imaging, graph theoretical analysis, and dynamic functional connectome analysis. Nodal efficiency of the lesional‐hemispheric upper limb region of BA 4 (A4ul_L) increased in the recovered group (preoperative, 0.472 ± 0.027; postoperative, 0.535 ± 0.020; p = 0.0006). The patients in the nrTMS therapy group quickly recovered (12.0 ± 1.6 days) compared to the sham‐nrTMS group (29.5 ± 3.8 days, p = 0.0024). Variations in A4ul_L nodal efficiency was negatively correlated with recovery time (r = −0.841; p = 0.0046). Conclusion: A4ul_L demonstrates enhanced postoperative nodal efficiency and shows therapeutic potential in SMA syndrome recovery, suggesting its viability as a therapeutic target. [ABSTRACT FROM AUTHOR]

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). 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. 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%. 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background and Objectives: Supplementary motor area (SMA) syndrome is a common post-operation complication in intra-axial brain tumors, such as glioma. Direct damage to parenchyma or scarification of the major vessels during an operation are the main causes. However, it is rarely reported as a postoperative complication in extra-axial tumors. Materials and Methods: We reviewed 11 reported cases of supplementary motor area syndrome after removal of extra-axial meningiomas in the English literature from the PubMed database. We also added our case, which presented as an unusual huge meningioma, to analyze the clinical parameters and outcomes of these 12 reported cases. Results: Recovery time of supplementary motor area syndrome in extra-axial tumors could be within 1–7 weeks, shorter than intra-axial tumors (2–9 weeks). Epilepsy and progressive limb weakness are the most common presentations in 50% of cases. Different degrees of postoperative muscle power deterioration were noted in the first 48 h (from 0–4). Lower limbs (66.6%, 8/12) were slightly predominant compared to upper limbs (58.3%, 7/12). Mutism aphasia was also observed in 41.6% (5/12, including our case), and occurred in tumors which were involved in the dominant side; this recovered faster than limb weakness. Discussion and Conclusions: Our work indicated that SMA syndrome could occur in extra-axial brain tumors presenting as mutism aphasia and limb weakness without any direct brain parenchyma damage. In our analysis, we found that recovery time of postoperative motor function deficit could be within 1–7 weeks. Our study also provides a further insight of SMA syndrome in extra-axial brain tumors. [ABSTRACT FROM AUTHOR]

Introduction Collision tumors present as histologically different juxtaposed neoplasms within the same anatomical region, independent of the adjacent cell population. De novo intracranial collision tumors involving metachronous primary brain neoplasms alongside dural meningiomatosis are not well documented in the literature. Clinical Presentation We present staged surgical management of a 72-year-old female with known left hemispheric stable dural-based convexity mass lesions over 10 years and new-onset expressive aphasia and headaches. MRI had revealed left supratentorial dural-based enhanced masses consistent with en plaque meningiomatosis. Embolization angiography showed an unusual tumor blush from an aberrant branch of anterior cerebral artery suggesting a deeper focal intra-axial nature; a stage 1 craniotomy for dural-based tumor resection was completed with diagnosis of a meningioma (WHO grade 1). Intraoperatively, a distinct intra-axial deep discrete lesion was verified stereotactically, concordant with the location of tumor blush. The patient made a complete neurological recovery from a transient postoperative supplemental motor area syndrome in a week. Subsequent postoperative follow-up showed worsening of right hemiparesis and MRI showed an increase in residual lesion size and perilesional edema, which prompted a stage 2 radical resection of a glioblastoma, WHO grade 4. She improved neurologically after surgery with steroids and physical therapy. At 15 months following adjuvant therapy, she remains neurologically intact throughout the postoperative course, with no recurrent tumor on MRI. Conclusion A de novo glioblastoma presented as a masquerading lesion within hemispheric convexity meningiomatosis in an elderly patient with no prior radiation/phakomatosis, inciting a non-causal juxtapositional coexistence. The authors highlight rare pathognomonic angiographic findings and the rationale for two-staged resections of these collision lesions that led to excellent clinicoradiological outcome.

Background and Objectives: Supplementary motor area (SMA) syndrome is a common post-operation complication in intra-axial brain tumors, such as glioma. Direct damage to parenchyma or scarification of the major vessels during an operation are the main causes. However, it is rarely reported as a postoperative complication in extra-axial tumors. Materials and Methods: We reviewed 11 reported cases of supplementary motor area syndrome after removal of extra-axial meningiomas in the English literature from the PubMed database. We also added our case, which presented as an unusual huge meningioma, to analyze the clinical parameters and outcomes of these 12 reported cases. Results: Recovery time of supplementary motor area syndrome in extra-axial tumors could be within 1–7 weeks, shorter than intra-axial tumors (2–9 weeks). Epilepsy and progressive limb weakness are the most common presentations in 50% of cases. Different degrees of postoperative muscle power deterioration were noted in the first 48 h (from 0–4). Lower limbs (66.6%, 8/12) were slightly predominant compared to upper limbs (58.3%, 7/12). Mutism aphasia was also observed in 41.6% (5/12, including our case), and occurred in tumors which were involved in the dominant side; this recovered faster than limb weakness. Discussion and Conclusions: Our work indicated that SMA syndrome could occur in extra-axial brain tumors presenting as mutism aphasia and limb weakness without any direct brain parenchyma damage. In our analysis, we found that recovery time of postoperative motor function deficit could be within 1–7 weeks. Our study also provides a further insight of SMA syndrome in extra-axial brain tumors.

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. [ABSTRACT FROM AUTHOR]

Background: The postoperative supplementary motor area (SMA) syndrome may complicate unilateral surgery involving the SMA cortex and manifests as contralateral or global akinesia, mutism, or speech deficit, with complete or major recovery in weeks to months. Case series: We observed retrospectively nine patients (median age 47 years, range 27-60, five female) who underwent surgery for left premotor area tumors (six intra-axial and three extra-axial). Volumetric microsurgical resection was performed with neuro-navigational assistance (Vector Vision-BrainLab™ or SonoWand Invite™). We achieved gross or near gross total resection in all cases. The patients were followed clinically for one year, with control computed tomography scan within 24-48 hours from the operation and control magnetic resonance imaging three months and one year postoperatively. Five patients had only akinesia of the contralateral limbs, two had akinesia and mutism, and the remaining two had mutism only. All recovered within three months. The severity and duration were related to the location of resection rather than the volume removed. Cortical excision closer to the premotor area was related to more prominent SMA syndrome, while the cingular gyrus' involvement related to mutism. Conclusion: Prevention of SMA syndrome is not always possible in resective surgery. Given its favorable prognosis, it should be well known to the health professionals of different specialties engaged in such patients' postoperative care. The possibility of SMA should be preoperatively discussed with the patients and caregivers. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Supplementary motor area (SMA) syndrome is a constellation of temporary symptoms that may occur following tumors of the frontal lobe. Affected patients develop akinesia and mutism but often recover within weeks to months. With our own case examples and with correlations to fiber tracking validated by gross anatomical dissection as ground truth, we describe a white matter pathway through which recovery may occur. Methods: Diffusion spectrum imaging from the Human Connectome Project was used for tractography analysis. SMA outflow tracts were mapped in both hemispheres using a predefined seeding region. Postmortem dissections of 10 cadaveric brains were performed using a modified Klingler technique to verify the tractography results. Results: Two cases were identified in our clinical records in which patients sustained permanent SMA syndrome after complete disconnection of the SMA and corpus callosum (CC). After investigating the postoperative anatomy of these resections, we identified a pattern of nonhomologous connections through the CC connecting the premotor area to the contralateral premotor and SMAs. The transcallosal fibers have projections from the previously described frontal aslant tract (FAT) and thus, we have termed this path the “crossed FAT.” Conclusions: We hypothesize that this newly described tract may facilitate recovery from SMA syndrome by maintaining interhemispheric connectivity through the supplementary motor and premotor areas. [ABSTRACT FROM AUTHOR]

This report describes a case of a 62-year-old man who developed Foix-Chavany-Marie syndrome subsequent to traumatic brain injury. The initial presentation of the syndrome was profound loss of voluntary control of orofacial muscles, causing a loss of speech and impairment of swallow. Over subsequent months, a remarkable recovery of these functions was observed. The natural history of FCMS in this case was favourable, with good improvement in function over months. Furthermore, the pattern of bilateral opercular injury was more readily recognised on MRI than on CT, supporting the role of MRI in cases of traumatic brain injury. [ABSTRACT FROM AUTHOR]

The supplementary motor area syndrome is a characteristic neurosurgical syndrome that can occur after unilateral resection of the supplementary motor area. 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 supplementary motor area syndrome and extrapolate these findings to seemingly unrelated diseases and symptoms such as Parkinson’s disease and tics. Furthermore, we integrate findings from lesion, stimulation and functional imaging studies to provide insight in the motor function of the supplementary motor area.

Background and Objective: Supplementarymotor area (SMA) syndrome, an executive disorder with motor and speech dysfunctions, is rather unpredictable with typically a complete or almost complete functional recovery within weeks or months. Compensatory mechanisms are associated with contralateral cortical recruitment of the lateral premotor circuitry. We sought to investigate the role of healthy SMA formotor recovery following surgery in the medial frontal lobe. Methods: A 48-year-old right-handed man presented with focal motor seizures. The diagnostic work-up revealed a low-grade glioma at the superior frontal gyrus. The patient was operated on with intraoperative monitoring of motor pathways, and resection was taken to the functional boundaries. Results: Postoperatively, the patient experienced a typical SMA syndrome that almost completely resolved in the long term. Motor recovery occurred concurrently with a shift of SMA activation to the healthy hemisphere together with an increased lateral premotor circuitry, especially for the hand map. Conclusion: Our results confirm brain remodeling of the lateral premotor cortex, as previously described, and indicate that functional improvement is also paralleled with a shift of SMA activation toward the healthy hemisphere. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Supplementary motor area syndrome (SMAS) may occur after frontal tumor surgery, with variable presentation and outcomes. We reviewed the literature on postoperative SMAS after brain tumor resection. PubMed, Web of Science, Scopus, and Cochrane were searched following the PRISMA guidelines to include studies reporting SMAS after brain tumor resection. 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 magnetic resonance imaging evaluation were completed in 45 (19.1%) and 26 (11%) patients. Gross total resection was achieved in 46.3% patients and complete SMA resection in 69.4%. A total of 215 procedures (91.1%) used 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 days), with total resolution occurring in 188 patients (79.7%) and partial improvement in 46 (19.5%). Forty-eight patients (20.3%) had persisting symptoms, mostly speech hesitancy (60.4%) and fine motor disorders (45.8%). 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. [ABSTRACT FROM AUTHOR]

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.

Background: The postoperative supplementary motor area (SMA) syndrome may complicate unilateral surgery involving the SMA cortex and manifests as contralateral or global akinesia, mutism, or speech deficit, with complete or major recovery in weeks to months., Case Series: We observed retrospectively nine patients (median age 47 years, range 27-60, five female) who underwent surgery for left premotor area tumors (six intra-axial and three extra-axial). Volumetric microsurgical resection was performed with neuro-navigational assistance (Vector Vision-BrainLab™ or SonoWand Invite™). We achieved gross or near gross total resection in all cases. The patients were followed clinically for one year, with control computed tomography scan within 24-48 hours from the operation and control magnetic resonance imaging three months and one year postoperatively. Five patients had only akinesia of the contralateral limbs, two had akinesia and mutism, and the remaining two had mutism only. All recovered within three months. The severity and duration were related to the location of resection rather than the volume removed. Cortical excision closer to the premotor area was related to more prominent SMA syndrome, while the cingular gyrus' involvement related to mutism., Conclusion: Prevention of SMA syndrome is not always possible in resective surgery. Given its favorable prognosis, it should be well known to the health professionals of different specialties engaged in such patients' postoperative care. The possibility of SMA should be preoperatively discussed with the patients and caregivers. HIPPOKRATIA 2020, 24(1): 38-42., Competing Interests: The authors declare no conflict of interest., (Copyright 2020, Hippokratio General Hospital of Thessaloniki.)

OBJECTIVE Previous studies have suggested a correlation between interhemispheric sensorimotor networks and recovery from supplementary motor area (SMA) syndrome. In the present study, the authors examined the hypothesis that interhemispheric connectivity of the primary motor cortex in one hemisphere with the contralateral SMA may be important in the recovery from SMA syndrome. Further, they posited that motor cortical fiber connectivity with the SMA is related to the severity of SMA syndrome. METHODS Patients referred to the authors' neurological surgery department were retrospectively analyzed for this study. All patients with tumors involving the unilateral SMA region, without involvement of the primary motor area, and diagnosed with SMA syndrome in the postoperative period were eligible for inclusion. Preoperative diffusion tensor imaging tractography (DTT) was used to examine the number of fiber tracts (NFidx) connecting the contralateral SMA to the ipsilateral primary motor area via the corpus callosum. Complete neurological examination had been performed in all patients in the pre- and postoperative periods. All patients were divided into two groups: those who recovered from SMA syndrome in ≤ 7 days (early recovery group) and those who recovered in ≥ 8 days (late recovery group). Differences between the two groups were assessed using the Student t-test and the chi-square test. RESULTS Eleven patients (10 men, 1 woman) were included in the study. All patients showed transient postoperative motor deficits because of SMA syndrome. Tractography data revealed NFidx from the contralateral SMA to the ipsilateral primary motor area via the corpus callosum. The mean tumor volume (early 27.87 vs late 50.91 cm 3 , p = 0.028) and mean NFidx (early 8923.16 vs late 4726.4, p = 0.002) were significantly different between the two groups. Fisher exact test showed a significant difference in the days of recovery from SMA syndrome between patients with an NFidx > 8000 and those with an NFidx < 8000. CONCLUSIONS Diffusion tensor imaging tractography may be useful for predicting the speed of recovery from SMA syndrome. To the authors' knowledge, this is the first DTT study to identify interhemispheric connectivity of the SMA in patients with brain tumors.

A correction to the article "Insights from the supplementary motor area syndrome in balancing movement initiation and inhibition" published in the November 2014 issue is presented.