TWMP-01. RESECTION OF SUPPLEMENTARY MOTOR AREA GLIOMAS: REVISITING SUPPLEMENTARY MOTOR SYNDROME AND THE ROLE OF THE FRONTAL ASLANT TRACT

INTRODUCTION The supplemental motor area (SMA) is an eloquent region that is frequently a site for gliomas or the region is included in the resection trajectory to deeper lesions. METHODS Patient, tumor and outcome data were collected retrospectively from the UCSF tumor registry for patients who underwent surgical resection for newly diagnosed supratentorial diffuse glioma (WHO Grade II - IV) between 2010 and 2019 in the SMA region and the extent of SMA resection was determined by volumetric assessment. Tumors were registered to a standard brain atlas to create a frequency heat map of tumor volumes and resection cavities. RESULTS Although the volume of tumor within the SMA region did not correlate with the development of SMA syndrome, patients with SMA syndrome had larger resection cavities in the SMA region (25.4% SMA resection 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 SMA syndrome had cavities that were located more posteriorly in the SMA region and in the cingulate. When the frontal aslant tract (FAT) was preserved, 50% of patients developed SMA syndrome post-operatively; whereas 100% of patients who had disruption of the FAT during surgery developed SMA syndrome (p = 0.06). There was no difference in the overall survival for newly diagnosed glioblastoma patients with SMA syndrome compared to those without SMA syndrome (1.6 years vs. 3.0 years, p = 0.33). CONCLUSION For patients with SMA gliomas, larger resections and resections involving the posterior SMA region and posterior cingulate gyrus increased the likelihood of a post-operative SMA syndrome. Although SMA syndrome occurred in all cases where the FAT was resected, FAT preservation does not reliably avoid SMA syndrome post-operatively.

Resection of supplementary motor area gliomas: revisiting supplementary motor syndrome and the role of the frontal aslant tract

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.

Assessment of Standardization Circumferential Resection Margin Status Influence Survival following Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma

Background: Not only to assess the prognostic influence on standardization circumferential resection margin R0 and R1 Status but also to research the prognostic influence on adjuvant chemotherapy to PV/SMV, SMA resection margins﹤1mm. The SMV and SMA resection margins had an important prognostic influence to PDAC patients, and the survival prognosis of R1 status(resection margin﹤1mm) was poor. Methods: A total of 228 patients performed PD between 2015 and 2019 were included, which was assessment of standardization circumferential resection margin status and survival prognosis. There were cancer cells within 1mm clearance of PV/SMV and SMA resection margins named R1 PV/SMV, SMA, and no cancer cells named R0 PV/SMV, SMA.Results: The resection margin 1mm clearance of PV/SMV, SMA (P=0.010) and postoperative adjuvant chemotherapy (P=0.001) were prognostic independent predictors. The median survival time was 22 months of 166 R0 PV/SMV, SMA patients (73%) compared to 15 months of 62 R1 PV/SMV, SMA patients (27%) (P=0.005). There was the statistical significance of survival time between the adjuvant chemotherapy group and the none-adjuvant chemotherapy group (P=0.000). In the R1 PV/SMV, SMA group, there was no statistical significance of survival time between the adjuvant chemotherapy patients and the none-adjuvant chemotherapy patients (P=0.208).Conclusions: Patients undergoing PD for PDAC, postoperative adjuvant chemotherapy could not improve the poor survival prognosis of R1 PV/SMV, SMA resection patients. The resection margins of PV/SMV, SMA had a greater prognostic influence on survival than postoperative adjuvant chemotherapy.Trial registration: Clinicaltrials.gov/ct2/show/NCT02928081

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

OBJECTIVESupplementary 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.METHODSData 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.RESULTSIn 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).CONCLUSIONSRecovery 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.

Risk factor analysis of the development of new neurological deficits following supplementary motor area resection

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.

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.

Somatotopy of the Supplementary Motor Area: Evidence from Correlation of the Extent of Surgical Resection with the Clinical Patterns of Deficit

ABSTRACT 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.

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.