Somatotopy of the supplementary motor area: evidence from correlation of the extent of surgical resection with the clinical patterns of deficit

OBJECTIVE: This study, which aimed to confirm or invalidate the somatotopic organization of the supplementary motor area (SMA), correlates the pattern of clinical symptoms observed after SMA removal with the extent of resection. METHODS: Eleven patients with medial precentral glioma underwent partial or complete tumoral resection of the SMA. Seven patients underwent preoperative functional magnetic resonance imaging that incorporated speech and motor tasks. During the operation, the primary motor and speech areas and pathways (in the dominant side) were identified by use of intraoperative direct cortical or subcortical stimulation, and these areas were respected. RESULTS: SMA resection resulted in motor deficits, language deficits, or both; the deficits were always regressive, and they corresponded to the SMA syndrome. The topography and severity of these deficits were correlated to the extent of the SMA resection. The location of the deficit corresponded to SMA somatotopy: the representations of the lower limb, the upper limb, the face, and language (in the left-dominant SMA) were located from posterior to anterior. This somatotopy was also observed with functional magnetic resonance imaging. CONCLUSION: Correlation between clinical patterns of deficit and the extent of SMA resection, guided by means of pre- and intraoperative functional methods, provides strong arguments in favor of somatotopy in this area. This knowledge should allow clinicians to base preoperative predictions of the pattern of postsurgical deficit and recovery on the planned resection, thus allowing them to inform patients accurately before the procedure.     

Incidence and clinical evolution of postoperative deficits after volumetric stereotactic resection of glial neoplasms involving the supplementary motor area

OBJECTIVE: We report the incidence and clinical evolution of postoperative deficits and supplementary motor area (SMA) syndrome after volumetric stereotactic resection of glial neoplasms involving the posterior one-third of the superior frontal convolution. We investigated variables that may be associated with the occurrence of SMA syndrome. METHODS: The postoperative clinical status of 27 consecutive patients who underwent resection of SMA gliomas was retrospectively reviewed. Neurological examination results were recorded 1 day, 1 week, 1 month, and 6 months postoperatively. The extent of tumor resection, the percentage of SMA resection, violation of the cingulate gyrus, and operative complications were tabulated. RESULTS: The overall incidence of SMA-related deficits was 26% (7 of 27 patients), with 3 patients having complete SMA syndrome and 4 patients having partial SMA syndrome. Two additional patients (7.5%) had other postoperative deficits, including one with mild facial weakness and one with transient aphasia. The resection of low-grade gliomas was associated with a higher incidence of SMA syndrome, an outcome that likely reflects more complete removal of functional SMA cortex in this subset of patients. Intraoperative monitoring localized the precentral sulcus within the preoperatively defined tumor volume in 6 (22%) of 27 patients, thereby precluding gross total resection. All 27 patients had excellent outcomes at the 6-month follow-up examination. CONCLUSION: When the resection of SMA gliomas is limited to the radiographic tumor boundaries, the incidence and severity of SMA syndrome may be minimized. With the use of these resection parameters, patients with high-grade SMA gliomas are unlikely to experience SMA syndrome. These findings are helpful in the preoperative counseling of patients who are to undergo cytoreductive resection of SMA gliomas.     

The supplementary motor area syndrome: a neurosurgical review

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

     

Surgical resection of grade II astrocytomas in the superior frontal gyrus

OBJECTIVE: Surgery in the superior frontal gyrus partially involving the supplementary motor area (SMA) may be followed by contralateral transient weakness and aphasia initially indistinguishable from damage to the primary motor cortex. However, recovery is different, and SMA deficits may resolve completely within days to weeks. No study has assessed the distinct postoperative deficits after tumor resection in the SMA on a homogeneous patient group. METHODS: Twenty-four patients with World Health Organization Grade II astrocytomas in the superior frontal gyrus consecutively treated by surgery were studied. Degree and duration of postoperative deficits were evaluated according to tumor location and boundaries via magnetic resonance imaging scans, intraoperative neuromonitoring results, and extent of tumor resection. RESULTS: Postoperatively, motor deficits were evident in 21 of 24 and speech deficits in 9 of 12 patients. Motor function quickly recovered in 11 and speech function in 3 patients. None of the 12 patients in whom the posterior tumor resection line was at a distance of more than 0.5 cm from the precentral sulcus experienced persistent motor deficits. Eight of these patients developed typical SMA syndrome with transient initiation difficulties. Seven of 12 patients in whom the tumor extended to the precentral sulcus still had motor deficits at the 12-month follow-up assessment. CONCLUSION: Surgery for Grade II gliomas in the superior frontal gyrus is more likely to result in permanent morbidity when the resection is performed at a distance of less than 0.5 cm from the precentral gyrus or positive stimulation points. Therefore, cortical mapping of motor and speech function, in critical cases under local anesthesia with the patient as his or her own monitor, is recommended; resection should be tailored to obtain good functional outcome and maintain quality of life.     

Intraoperative Motor Symptoms during Brain Tumor Resection in the Supplementary Motor Area (SMA) without Positive Mapping during Awake Surgery

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.     

Preoperative mapping of the supplementary motor area in patients harboring tumors in the medial frontal lobe

OBJECT: Injury to the supplementary motor area (SMA) is thought to be responsible for transient motor and speech deficits following resection of tumors involving the medial frontal lobe. Because direct intraoperative localization of SMA is difficult, the authors hypothesized that functional magnetic resonance (fMR) imaging might be useful in predicting the risk of postoperative deficits in patients who undergo resection of tumors in this region. METHODS: Twelve patients who had undergone fMR imaging mapping while performing speech and motor tasks prior to excision of their tumor, that is, based on anatomical landmarks involving the SMA, were included in this study. The distance between the edge of the tumor and the center of SMA activation was measured and was correlated with the risk of incurring postoperative neurological deficits. In every patient, SMA activation was noted in the superior frontal gyrus on preoperative fMR imaging. Two speech and two motor deficits typical of SMA injury were observed in three of the 12 patients. The two speech deficits occurred in patients with tumors involving the dominant hemisphere, whereas one of the motor deficits occurred in a patient with a tumor in the nondominant hemisphere. The risk of developing a postoperative speech or motor deficit was 100% when the distance between the SMA and the tumor was 5 mm or less. When the distance between SMA activation and the lesion was greater than 5 mm, the risk of developing a motor or a speech deficit was 0% (p = 0.0007). CONCLUSIONS: Early data from this study indicated that fMR imaging might be useful in localizing the SMA and in determining the risk of postoperative deficits in patients who undergo resection of tumors located in the medial frontal lobe.     

大脑半球切除术后患者上肢运动功能定位及神经功能重塑性研究

目的 对改良式大脑半球切除术后患者进行肢体运动在同侧大脑半球的功能定位及其神经功能重塑的研究.方法 2007年7月至12月以改良式解剖性大脑半球切除术后患者为研究对象,使用3.0 T磁共振仪行大脑运动功能磁共振(fMRI)检测.受检者分别行双侧上肢屈肘运动,使用BOLD序列,检测双侧上肢运动在健侧大脑半球的皮质投射区.结果 6例行改良式解剖性大脑半球切除术后患者有5例检测出对侧肢体运动fMRI代表区,其中3例得到双侧上肢在健侧大腑皮质的运动代表区.同侧上肢运动定位区出现在第一运动区、辅助运动区和顶后小叶皮质.结论 在人类一侧大脑半球切除后,健侧大脑半球存在支配同侧肢体运动的功能区,有神经运动功能的重塑发生.神经运动重塑的结果可能与手术术式有一定的关系.     

Surgical resection of gliomas WHO grade II and III located in the opercular region

Summary Background. Surgery in the opercular region especially in the dominant hemisphere impose a major challenge for the neurosurgeon due to the close vicinity to functional important motor and speech areas. The purpose of the present study is to analyse on a homogenous patient group pre- and postoperative functional deficits with regard to different speech qualities (e.g. aphasia, apraxia), and to correlate these data with MR and intraoperative monitoring results. Method. Fourteen patients with suspected low grade astrocytomas in the opercular region consecutively treated by surgery were eligible for this study (histology revealed 3 WHO grade III tumours). Degree and duration of postoperative deficits were retrospectively evaluated according to tumour location and boundaries on MR, intraoperative neuromonitoring results and extent of tumour resection. Findings. Postoperatively, 8 patients showed speech or language disturbances, in 4 patients combined with motor deficits mainly of the contralateral upper extremity. Fifty percent of the neuropsychologically tested patients exhibited speech apraxia while the other 50% had a true aphasic syndrome. Recovery of the latter deficits was in general faster and more complete. The severity and duration of postoperative deficits was in good correlation with the distance of the resection margin to the next positive stimulation point(s), and a distance of more than 0.5cm proved to avoid major impairments. The distribution of functional important stimulation points in relation to the tumour extension was not predictable, and – unexpectedly – up to 50% of these sites were found overlaying the tumour. Interpretation. Surgery for WHO grade II and III gliomas in the opercular region can result in speech apraxia or an aphasic syndrome with or without concomitant motor deficits. Intraoperative cortical electrical stimulation is essential in resecting tumours in the opercular region to avoid permanent morbidity.     

Resection of parietal lobe gliomas: incidence and evolution of neurological deficits in 28 consecutive patients correlated to the location and morphological characteristics of the tumor

OBJECT: The goal of this study is to report the incidence and clinical evolution of neurological deficits in patients who underwent resection of gliomas confined to the parietal lobe. METHODS: Patient demographics, findings of serial neurological examinations, tumor location and neuroimaging characteristics, extent of resection, and surgical outcomes were tabulated by reviewing inpatient and office records, as well as all pre- and postoperative magnetic resonance (MR) images obtained in 28 consecutive patients who underwent resection of a glial neoplasm found on imaging studies to be confined to the parietal lobe. Neurological deficits were correlated with hemispheric dominance, location of the lesion within the superior or inferior parietal lobules, subcortical extension, and involvement of the postcentral gyrus. The tumors were located in the dominant hemisphere in 18 patients (64%); had a mean diameter of 39 mm (range 14-69 mm); were isolated to the superior parietal lobule in six patients (21%) and to the inferior parietal lobule in eight patients (29%); and involved both lobules in 14 patients (50%). Gross-total resection, documented by MR imaging, was achieved in 24 patients (86%). Postoperatively, nine patients (32%) experienced new neurological deficits, whereas seven (25%) had an improvement in their preoperative deficit. A correlation was noted between larger tumors and the presence of neurological deficits both before and after resection. Postoperatively higher-level (association) parietal deficits were noted only in patients with tumors involving both the superior and inferior parietal lobules in the dominant hemisphere. At the 3-month follow-up examination, five of nine new postoperative deficits had resolved. CONCLUSIONS: Neurological deterioration and improvement occur after resection of parietal lobe gliomas. Parietal lobe association deficits, specifically the components of Gerstmann syndrome, are mostly associated with large tumors that involve both the superior and inferior parietal lobules of the dominant hemisphere. New hemineglect or sensory extinction was not noted in any patient following resection of lesions located in the nondominant hemisphere. Nevertheless, primary parietal lobe deficits (for example, a visual field loss or cortical sensory syndrome) occurred in patients regardless of hemispheric dominance.     

Differential effect of spinal cord injury and functional impairment on human brain activation

Reorganization of human brain function after spinal cord injury (SCI) has been shown in electrophysiological studies. However, it is less clear how far changes of brain activation in SCI patients are influenced by the extent of SCI (neuronal lesion) or the consequent functional impairment. Positron emission tomography ([15O]-H2O-PET) was performed during an unilateral hand movement in SCI patients and healthy subjects. SCI patients with paraplegia and normal hand function were compared to tetraplegic patients with impaired hand movements. Intergroup comparison between paraplegic patients and healthy subjects showed an increased activation of contralateral sensorimotor cortex (SMC), contralateral thalamus, ipsilateral superior parietal lobe, and bilateral cerebellum. In contrast to this, tetraplegic patients with impaired upper limb function revealed only a significant activation of supplementary motor area (SMA). Correlational analysis in the tetraplegic patients showed that the strength of hand movement was related to the activation of contralateral SMC. However, the severity of upper limb sensorimotor deficit was related to a reduced activation of contralateral SMA and ipsilateral cerebellum. The findings suggest that in paraplegic patients with normal hand function the spinal neuronal lesion itself induces a reorganization of brain activation unrelated to upper limb function. Compared to this, in tetraplegic patients changes of brain activation are related to the impaired upper limb function. Therefore, in patients with SCI a differential impact of spinal lesion and functional impairment on brain activation can be shown. The effect of impaired afferent feedback and/or increased compensatory use of non-impaired limbs in SCI patients needs further evaluation.     

Surgical Treatment of Intraspinal Angiomatous Meningiomas from a Single Center

Intraspinal angiomatous meningiomas (AMs) are rare lesions, and no case series have been reported. We retrospectively reviewed the data of 12 patients with intraspinal AMs. All patients underwent magnetic resonance imaging (MRI) of the spine. Computed tomography angiography was performed for three cases with cervical lesion. The series included six females and six males with a mean age of 49.6 years. Five tumors were located in the cervical, one in the cervicothoracic, five in the thoracic, and one in the thoracolumbar spine. The most common symptom was motor deficits and the mean duration of symptoms was 18 months. All patients were treated surgically with gross total resection (GTR) (Simpson grade I and II resection). No patients underwent embolization. After surgery immediately, the neurological function was improved in five patients, remained stable in six patients, and was deteriorated in one patient. During an average follow up of 78.6 months, 11 patients experienced an improvement in the neurological function and one patient maintained preoperative status. No tumor recurrence was observed on MRI. Compared to conventional meningiomas, AMs have no special clinical and radiological features. The accurate diagnosis depends on pathology. Timely GTR (en bloc resection) is the best treatment and embolization is not necessary for most patients. Radiotherapy is not recommended after GTR (Simpson grade I and II resection), and the risk of tumor recurrence is low.     

Postoperative transient hemiplegia after resection of the medial frontal tumor involving the supplementary motor area: report of two cases

The supplementary motor cortex (SMA) is located anterior to the primary motor cortex, and is considered to play an important role in planning, initiating and maintaining sequential motor actions. Disturbance of this area sometimes causes severe contralateral hemiplegia. If the disturbance doesn't affect the primary motor cortex, motor function will recover in relatively early postoperative time. We encountered two cases in which the patients developed postoperative severe hemiplegia after resection of a medial frontal lobe glioma, although there was no apparent change shown in the monitoring of intraoperative motor evoked potential (MEP). Both cases recovered from hemiplegia in the early postoperative period. In our cases, the disturbances of SMA were considered to be the causes of the development of transient hemiplegia. Intraoperative MEP monitoring is useful to distinguish the damage of the primary motor area from that of the SMA.     

Extraoperative functional mapping of motor areas in epileptic patients by high-frequency cortical stimulation

OBJECT: The aim of this study was to investigate the usefulness of a short train of high-frequency (500 Hz) cortical stimulation to delineate the primary motor cortex (MI), supplementary motor area (SMA), primary somatosensory cortex (SI), supplementary sensory area (SSA), negative motor area (NMA), and supplementary negative motor area (SNMA) in patients with epilepsy who were undergoing functional mapping. METHODS: Seventeen patients were studied, all of whom underwent functional mapping using 50-Hz electrical stimulation. After these clinical evaluations, cortical stimulations with a short train of electrical pulses at 500 Hz were performed through subdural electrodes placed at the MI, SMA, SI, SSA, NMA, and SNMA, which had been identified by 50-Hz stimulation, and surrounding cortical areas, while surface electromyography readings were recorded. RESULTS: Stimulation of the MI elicited motor evoked potentials (MEPs) in contralateral muscles. Stimulation of the SMA also induced MEPs in contralateral muscles but with longer latencies compared with the MI stimulation. Stimulation of the SMA did not elicit MEPs in ipsilateral muscles. Stimulation of the SI, SSA, NMA, and SNMA did not induce MEPs in any muscle. In one patient, MEPs were elicited without seizure induction by 500-Hz stimulation of the electrodes, whereas a 50-Hz stimulation of the same electrodes induced his habitual seizures. CONCLUSIONS: Extraoperative high-frequency stimulation with MEP monitoring is a useful complementary method for cortical mapping without inducing seizure. Stimulation of SMA induces MEPs in contralateral muscles, with longer latencies compared with the stimulation of MI. This finding may be useful for the differentiation between MI and SMA, especially in the foot motor areas.     

Resection of intrinsic tumors from nondominant face motor cortex using stimulation mapping: report of two cases

We report two right-handed patients who underwent resection of intrinsic glial tumors from the nondominant hemisphere, face motor cortex. Both patients underwent preoperative assessment with computed tomography and magnetic resonance imaging localizing the tumor in the inferior region of the Rolandic cortex. With the patients under general anesthesia and without muscular paralysis, the tumor volume was determined by intraoperative ultrasound and resective surgery accomplished with the aid of cortical and subcortical stimulation mapping techniques. Radical resection of the tumor from the face motor cortex was achieved in both patients. A transient contralateral facial weakness and apraxia were noted in each patient, and this resolved within 6 to 8 weeks following surgery. Removal of intrinsic tumors involving the nondominant face motor cortex may be safely achieved using brain mapping techniques to localize inferior Rolandic cortex and avoid resection of the hand motor cortex and descending subcortical motor pathways. Permanent disability will be prevented due to the bilateral representation of face motor function at the neocortical level. However, due to language localization in cortical zones contiguous with the dominant hemisphere, face motor cortex, we do not recommend resection of this region.     

Superior Mesenteric Artery Syndrome after Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Gastrointestinal obstructive complications after laparoscopic Roux-en-Y gastric bypass (LRYGBP) are not uncommon. Their usual causes are strictures, internal hernias and adhesions. Superior mesenteric artery (SMA) syndrome is a rare disorder caused by compression of the third portion of the duodenum by the SMA that can occur after rapid weight loss. This has been reported in patients with scoliosis, burns, immobilization in body casts, and idiopathic weight loss. SMA syndrome following bariatric surgery has not been reported. We present 3 cases of SMA syndrome after LRYGBP and extensive weight loss. Two patients underwent laparoscopic duodenojejunostomy and the third patient was treated with intravenous hyperalimentation. All three are symptom free at 4-18 months follow-up. The diagnosis of SMA syndrome should be considered in bariatric surgery patients with rapid weight loss who develop atypical, recurrent obstructive symptoms not attributable to other common causes.     

Surgical treatment of insular gliomas

Summary Surgical treatment of glial tumours arising in the insula is specially challenging due to the proximity of the internal capsule. Although small insular gliomas have been removed safely by a transylvian approach, in large dominant insular tumours only biopsy has been recommended to avoid postoperative deficits. Unfortunately that is a suboptimal form of treatment as low grade supratentorial gliomas should be removed radically to prevent tumour progression, malignization and to increase the recurrence-free-interval. Addition of radiotherapy to partial removal is associated with a much higher incidence of recurrences and early malignizations compared to radical removal and no radiotherapy.Between 1st October 1989 and 1st September 1996 we treated twenty-three patients harbouring insular gliomas. To increase the radicality of the resection the surgical procedure was performed under local anaesthesia whenever possible, as general anaesthesia usually leads to more conservative resections. In 20/23 (86.9%) patients complete resection was accomplished, and subtotal in three (13.1%). The removed tumours were: two oligodendrogliomas, five grade I astrocytomas, nine grade II, four grade III and three grade IV.Postoperative neurological deficits occurred in five patients. Four suffered a hemiparesis (that recovered in an average of 6 months) and one a motor dysphasia which took a week to recover. Two of the seventeen patients operated on for low grade insular gliomas underwent malignant change.We conclude that complete surgical removal of insular gliomas should be considered and at least attempted in all cases.     

Ischemic complications associated with resection of opercular glioma

OBJECT: Opercular glioma inferolateral to the hand/digit sensorimotor area can be resected safely using a neuronavigation system and functional brain mapping techniques. However, the surgery can still sometimes cause postoperative ischemic complications, the character of which remains unclear. The authors of this study investigated the occurrence of infarction associated with resection of opercular glioma and the arterial supply to this region. METHODS: The study involved 11 consecutive patients with gliomas located in the opercular region around the orofacial primary motor and somatosensory cortices but not involving either the hand/digit area or the insula, who had been treated in their department after 1997. Both pre- and postoperative diffusion-weighted magnetic resonance (MR) imaging was performed in the nine consecutive patients after 1998 to detect ischemic complications. All patients underwent open surgery for maximum tumor resection. Postoperative MR imaging identified infarction beneath the resection cavity in all patients. Permanent motor deficits associated with infarction involving the descending motor pathway developed in two patients. Cadaveric angiography showed that the distributing arteries to the corona radiata were the long insular arteries and/or medullary arteries from the opercular and cortical segments of the middle cerebral artery. CONCLUSIONS: Subcortical resection around the upper limiting sulcus of the posterior region of the insula and wide resection in the anteroposterior and cephalocaudal directions of the opercular region were considered to be risk factors of the critical infarction. Surgeons should be aware that resection of opercular glioma can disrupt the blood supply of the corona radiata, and carries the risk of permanent motor deficits.     

Single-neuron activity in the human supplementary motor area underlying preparation for action

OBJECT: The supplementary motor area (SMA) is considered critical in the planning, initiation, and execution of motor acts. Despite decades of research, including electrical stimulation mapping in patients undergoing neurosurgery, the contribution of this region to the generation of motor behavior has remained enigmatic. This is a study of single-neuron responses at various stages of a motor task during depth electrode recording in the SMA, pre-SMA, and medial temporal lobe of humans, with the goal of elucidating the disparate roles of neurons in these regions during movements. METHODS: The patients were undergoing evaluation for epilepsy surgery requiring implantation of intracranial depth electrodes. Single-unit recordings were made during both the execution and mental imagery of finger apposition sequences. Only medial frontal neurons responded selectively to specific features of the motor plan, such as which hand performed the motor activity or the complexity of the sequence. Neuron activity progressively increased before the patient was given a "go" cue for the execution of movements; this activity peaked earlier in the pre-SMA than in the SMA proper. We observed similar patterns of activation during motor imagery and actual movement, but only neurons in the SMA differentiated between imagined and real movements. CONCLUSIONS: These results provide support at the single-neuron level for the role of the medial frontal cortex in the temporal organization and planning of movements in humans.     

累及补充运动区额上回胶质瘤的外科治疗

目的　探讨累及补充运动区额上回胶质瘤的外科治疗。方法　对 16例累及补充运动区的低级别星形细胞瘤患者的临床资料及随访结果进行分析。结果　手术切除范围距中央前沟 >1cm的病变 8例 ,其中 6例表现为补充运动区综合征 ,虽出现暂时的运动和语言功能障碍 ,但随访 12个月 ,均得到恢复 ;而手术切除范围距中央前沟 <1cm的 8例病变 ,术后均立即出现对侧肢体偏瘫 ,随访 12个月 ,仍有 5例遗留运动障碍。结论　对于累及补充运动区的额上回胶质瘤 ,当手术切除范围距中央前沟 <1cm时 ,很可能造成永久性的功能障碍     

Isolated inferior mesenteric artery revascularization for chronic visceral ischemia.

PURPOSE: Complete visceral artery revascularization is recommended for the treatment of chronic visceral ischemia. However, in rare cases, it may not be possible to revascularize either the celiac or superior mesenteric (SMA) arteries. We have managed a series of patients with isolated revascularization of the inferior mesenteric artery (IMA) and now report our experience gained over a period of three decades. METHODS: Records were reviewed from 11 patients with chronic visceral ischemia who underwent isolated IMA revascularization (n = 8) or who, because of failure of concomitant celiac or SMA repairs, were functionally left with an isolated IMA revascularization (n = 3). All the patients had symptomatic chronic visceral ischemia documented with arteriography. Five patients had recurrent visceral ischemia after failed visceral revascularization, and two patients had undergone resection of ischemic bowel. The celiac or the SMA was unsuitable for revascularization in five cases, and extensive adhesions precluded safe exposure of the celiac or the SMA in five cases. IMA revascularization techniques included: bypass grafting (n = 4), transaortic endarterectomy (n = 4), reimplantation (n = 2), and patch angioplasty (n = 1). RESULTS: There was one perioperative death, and the remaining 10 patients had cured or improved conditions at discharge. One IMA repair thrombosed acutely but was successfully revascularized at reoperation. The median follow-up period was 6 years (range, 1 month to 13 years). Two patients had recurrent symptoms develop despite patent IMA repairs and required subsequent visceral revascularization; interruption of collateral circulation by prior bowel resection may have contributed to recurrence in both patients. Objective follow-up examination with arteriography or duplex scanning was available for eight patients at least 1 year after IMA revascularization, and all underwent patent IMA repairs. There were no late deaths as a result of bowel infarction. CONCLUSION: Isolated IMA revascularization may be useful when revascularization of other major visceral arteries cannot be performed and a well-developed, intact IMA collateral circulation is present. In this select subset of patients with chronic visceral ischemia, isolated IMA revascularization can achieve relief of symptoms and may be a lifesaving procedure.