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Restorative neurosurgery of the cortex: resections of pathologies of the central area can improve preexisting motor deficits

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Abstract

Different pathologies such as tumors or focal dysplasias can be removed from eloquent areas without subsequent functional deficits. What has not yet been established is the removal of structural abnormalities in sensorimotor area associated with substantial neurological deficits performed in order to accomplish functional improvement. Neurosurgical resections in highly eloquent areas thus hold promise to open a new field—achievement of functional restitution even in cases with long-standing deficits. We present four exemplary cases where the removal of different structural abnormalities led to an impressive improvement of motor deficits. One patient had bilateral ischemic lesion resulting from perinatal hypoxia, one cavernoma, and two focal cortical dysplasias. All presented with motor or sensorimotor deficits and three had long-standing therapy refractory focal seizures. The extent of safe lesionectomy was determined using fMRI, fiber tracking, and PET studies and performed with intraoperative functional neuronavigation guidance and cortical stimulation. The achievement of the planned amount of resection was verified with an intraoperative MR examination. New persisting neurological deficits after surgery were not registered. One patient had temporary worsening of the right hand weakness that rapidly resolved. One patient was completely seizure free, and in two patients, the seizures’ frequency, duration, and severity were significantly reduced. The preoperatively disturbed motor function improved in all four cases in the course of days or weeks. In summary, pathological processes affecting the sensorimotor area may cause focal seizures and/or compromise sensorimotor functions. Lesionectomy may accomplish not only the amelioration of focal seizures but also substantial functional improvement.

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Authors and Affiliations

  1. International Neuroscience Institute, Rudolf Pichlmayr Str. 4, 30625, Hannover, Germany

    Madjid Samii, Venelin M. Gerganov & Hans-Joachim Freund

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  1. Madjid Samii
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  2. Venelin M. Gerganov
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  3. Hans-Joachim Freund
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Correspondence to Venelin M. Gerganov.

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Comments

George Ojemann, Seattle, USA

This interesting case series highlights the deleterious effects on motor function of various nontumor lesions of sensory-motor cortex, effects that can be reversed by lesion excision. What are the mechanisms for that improvement? That control of seizures can be associated with improvement of function, perhaps especially motor function with control of complex partial sensory-motor seizures, is well known and likely accounts for the improvement in Cases 1, 2 and 4. Moreover, there is some evidence that even eliminating interictal discharges may be associated with functional improvement. We have found intraoperative electrocorticography a useful tool in such cases to maximize the probability of becoming seizure-free, in addition to the techniques used by the authors. It is unfortunate that more detail on the status of the motor system in Case 3 was not available, particularly whether the excision decreased spasticity, which might account for the improvement. There is also evidence that remaining normal tissue may actively inhibit motor function, an effect that has been extensively studied by Pascual-Leon and his associates [1], combining fMRI and transcranial magnetic stimulation to show that suppressing active areas in ipsilateral “normal” motor cortex may enhance motor performance in patients with stable motor deficits after strokes, presumably by reducing transcallosal inhibition. This effect may also contribute to the improved function in Case 3, and suggests further avenues to develop “restorative neurosurgery of the cortex”

Reference

1. Pascual-Leon A, Amedi A, Fregni F, Merabet L (2005) The Plastic Human Brain Cortex. Annu Rev Neurosci 28:377-401

Hugues Duffau, Montpellier, France

The authors report a series of four patients with motor or sensorimotor deficits and intractable epilepsy that underwent surgery for a central lesion (ischemic lesion with scar tissue in one case, one cavernoma and two focal cortical dysplasias). In addition to the favourable impact on seizures in 3 patients, surgery also allowed an improvement of the neurological status in the four patients. The authors concluded that lesionectomy in the central region could accomplish functional improvement.

This is a very interesting article. The rationale of this study is original. The methodology is robust and well exposed by a team with a large experience in this field. The results are well presented and well discussed. Currently, very few data are available in the field of "restorative neurosurgery of the cortex". The plastic potential of the brain has likely been underestimated by neurosurgeons in the past. Thus, this paper may have both clinical and fundamental implications.

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Samii, M., Gerganov, V.M. & Freund, HJ. Restorative neurosurgery of the cortex: resections of pathologies of the central area can improve preexisting motor deficits. Neurosurg Rev 35, 277–286 (2012). https://doi.org/10.1007/s10143-011-0361-2

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  • DOI: https://doi.org/10.1007/s10143-011-0361-2

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