Space-Occupying Lesions of the Sensori-Motor Region

  • U. Ebeling
  • H.-J. Reulen
Part of the Advances and Technical Standards in Neurosurgery book series (NEUROSURGERY, volume 22)


Successful surgery of the sensori-motor region requires precise pre- and intraoperative localization of the sensori-motor region and pyramidal tract. Important aids are the landmarks of cranio-cerebral topography, coronal suture and bregma and the sulcal anatomy of the sensori-motor region, which can be identified in CT or MR images. Due to considerable displacement and distortion of the anatomical structures, elicited by mass lesions, these aids often fail to render reliable support. In this situation, identification of the motor area can be achieved by electrical stimulation of the precentral gyrus in association with the recording of somatosensory evoked potentials of the pre- and postcentral gyrus. The localisation of the “motor mosaics” in relation to the lesion, enable determination of the direction of displacement of the motor strip and the fan of the pyramidal tract. Based on this information the most appropriate route of access to the lesion is selected, either transcortical or transsulcal. Lesion-specific operative techniques as well as locationspecific approaches are discussed. With consequent application of these principles the risk of a new persistent motor deficit was as low as 4% . Thus, the indication for surgery in this area can now be set with greater confidence and far more generously than in the past.


Sensori-motor region motor strip precentral gyrus surgical anatomy motor cortex stimulation motor cortex mapping somato-sensory evoked potentials 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Ahmadi J, Jong SH, Teal SH, Tsai FY, Zee C, Segall HP (1982) Localization of intracranial lesions utilizing the coronal suture as a landmark on axial computed tomography. Surg Neurol 17: 209–212PubMedCrossRefGoogle Scholar
  2. 2.
    Allison T (1987) Localization of sensori-motor cortex in neurosurgery by recording of somato-sensory evoked potentials. Yale J Biol Med 60: 143–150PubMedGoogle Scholar
  3. 3.
    Allison T, Mc Carthy G, Wood CC, Darcey TM, Spencer DD, Williamson PD (1989) Human cortical potentials evoked by stimulation of the median nerve. I. Cytoarchitectonic areas generating short-latency activity. J Neurophysiol 62: 694–710PubMedGoogle Scholar
  4. 4.
    Allison T, Mc Carthy G, Wood CC, Williamson PD, Spencer DD (1989) Human cortical potentials evoked by stimulation of the median nerve. II. Cytoarchitectonic areas generating long-latency activity. J Neurophysiol 62: 711–722PubMedGoogle Scholar
  5. 5.
    Apuzzo MLJ (1993) Brain surgery. Complication avoidance and management, vol 1. Churchill Livingstone, New York, pp 379–390Google Scholar
  6. 6.
    Barr LM (1972) The human nervous system. An anatomical viewpoint. Harper, pp 316–330Google Scholar
  7. 7.
    Beevor CE (1890) An experimental investigation into the arrangement of the excitable fibers in the internal capsule of the bonnet monkey. Phil Trans Roy Soc (London) 181 B: 49–88Google Scholar
  8. 8.
    Bennett AH (1885) Case of brachial monoplegia due to lesions of the internal capsule. Brain 8: 78–84CrossRefGoogle Scholar
  9. 9.
    Berger MS, Kincaid J, Ojemann GA, Lettich BA (1989) Brain mapping techniques to maximize resection, safety and seizure control in children with brain tumors. Neurosurgery 25: 786–992PubMedCrossRefGoogle Scholar
  10. 10.
    Berger MS, Wendy A, Ojemann GA (1990) Correlation of motor cortex mapping data with magnetic-resonance imaging. J Neurosurg 72: 383–387PubMedCrossRefGoogle Scholar
  11. 11.
    Berger MS, Ojemann GA, Lettich E (1990) Neurophysiologieal monitoring during astrocytoma surgery. Neurosurg Clin North Am 1: 65–80Google Scholar
  12. 12.
    Berger MS, Ghation BS, Haglund MM, Dobbius J, Ojemann GA (1993) Low grade gliomas associated with intractable epilepsy: seizure outcome utilizing electrocorticography during tumor resection. J Neurosurg 79: 62–69PubMedCrossRefGoogle Scholar
  13. 13.
    Black P, Ronner SF (1987) Cortical mapping for defining the limits of tumor resection. Neurosurg 20: 914–920CrossRefGoogle Scholar
  14. 14.
    Brodal A (1969) Neurological anatomy — in relation to clinical medicine, 2nd ed. University Press, New YorkGoogle Scholar
  15. 15.
    Bucy PC (ed) (1944) The precentral motor cortex. University of Illinois Press, UrbanaGoogle Scholar
  16. 16.
    Creutzfeld OD (1983) Cortex cerebri. Leistung, strukturelle und funktionelle Organisation der Hirnrinde. Springer, Berlin Heidelberg New York TokyoGoogle Scholar
  17. 17.
    Crosby EC, Humphrey T, Lauer EW (1962) Correlative anatomy of the nervous system. McMillan, New YorkGoogle Scholar
  18. 18.
    Cunningham DJ (1892) Contribution to the surface anatomy of the cerebral hemispheres. Royal Irish Academy, DublinGoogle Scholar
  19. 19.
    Curran EJ (1909) A new association fiber tract in the cerebrum: with remarks on the fiber tract dissection method of studying the brain. J Comp Neurol 19: 645–657CrossRefGoogle Scholar
  20. 20.
    Cushing H (1909) A note upon the faradic stimulation of the precentral gyrus in conscious patients. Brain 32: 44–54CrossRefGoogle Scholar
  21. 21.
    Denny-Brown D (1965) The cerebral control of movement. University Press, LiverpoolGoogle Scholar
  22. 22.
    Ebeling U, Huber P, Reulen HJ (1986) Localization of the precentral gyrus in the CT and its clinical application. J Neurol 233: 73–76PubMedCrossRefGoogle Scholar
  23. 23.
    Ebeling U, Rikli D, Huber P, Reulen HJ (1987) The coronal suture. A useful landmark in neurosurgery? Craniocerebral topography between bony landmarks on the skull and the brain. Acta Neurochir (Wien) 89: 130–134CrossRefGoogle Scholar
  24. 24.
    Ebeling U, Reulen HJ (1989) Neurosurgical topography of the pyramidal tract. In: Klingler M, Brock M, Frowein RA (eds) Advances in neurosurgery, vol 17. Springer, Berlin Heidelberg New York TokyoGoogle Scholar
  25. 25.
    Ebeling U, Steinmetz H, Huang Y, Khan T (1989) Topography and identification of the precentral sulcus in MR-imaging. AJNR 10: 937–942PubMedGoogle Scholar
  26. 26.
    Ebeling U, Schmid UD, Reulen HJ (1990) Tumor surgery within the central motor strip: surgical results with aid of electrical cortical motor cortex stimulation. Acta Neurochir (Wien) 101: 110–117Google Scholar
  27. 27.
    Ebeling U, Schmid UD, Ying Z (1991) Mapping bei Tumorpatienten in der Zentralregion. Schweiz Rundschau Med Prax 47: 1318–1323Google Scholar
  28. 28.
    Ebeling U, Reulen HJ (1992) Subcortical topography and proportions of the pyramidal tract. Acta Neurochir (Wien) 118: 164–171CrossRefGoogle Scholar
  29. 29.
    Ebeling U, Seiler RW, Hasdemir MG (1992) Les astrocytomes différenciés (grade IIOMS) de la region centrale: portée et limites de la chirurgie. Med Hyg 50: 2488–2493Google Scholar
  30. 30.
    Ebeling U, Schmid UD, Ying Z, Reulen HJ (1992) Safe surgery of lesions near the motor cortex using intraoperative mapping techniques. A report on 50 patients. Acta Neurochir (Wien) 119: 23–28CrossRefGoogle Scholar
  31. 31.
    Ebeling U, Huber P (1992) Localization of central lesions by correlation of CT-findings and neurological deficits. Acta Neurochir (Wien) 119: 17–22CrossRefGoogle Scholar
  32. 32.
    Ebeling U, Hasdemir MG, Barth A (1993) Stereotaktisch geleitete Mikrochirurgie zerebraler Prozesse. Schweiz Med Wschr 123: 1585–1590PubMedGoogle Scholar
  33. 33.
    Eberstaller O (1890) Das Stirnhirn. Ein Beitrag zur Oberfläche des Gehirnes. Urban und Schwarzenberg, WienGoogle Scholar
  34. 34.
    Englander RN (1975) Location of the pyramidal tract in the internal capsule. Anatomic evidence. Neurology (NY) 25: 823–826PubMedGoogle Scholar
  35. 35.
    Firsching R, King N, Börner U, Sanker P (1992) Lesions of the sensorimotor region: somatosensory evoked potentials and ultrasound guided surgery. Acta Neurochir (Wien) 118: 87–90CrossRefGoogle Scholar
  36. 36.
    Flechsig P (1881) Zur Anatomie und Entwicklungsgeschichte der Leitungsbahnen im Großhirn. Arch Anat Physiol: 12–75Google Scholar
  37. 37.
    Flechsig P (1887) Ueber Systemerkrankungen im Rückenmark. Arch Heilk 18: 101, 298 ffGoogle Scholar
  38. 38.
    Foerster O, Bumke O (1936) Handbuch der Neurologie, Bd 6. Springer, Berlin, pp 1–357Google Scholar
  39. 39.
    Freund HJ, Hummelsheim H (1984) Premotor cortex in man: evidence for innervation of proximal limb muscles. Exp Brain Res 53: 479–82CrossRefGoogle Scholar
  40. 40.
    Freund HJ, Hummelsheim H (1985) Lesions of premotor cortex in man. Brain 108: 697–734PubMedCrossRefGoogle Scholar
  41. 41.
    Freund HJ (1988) Abnormalities of motor behavior after cortical lesions in humans. In: Handbook of physiology — the nervous system, vol V, pp 763–810Google Scholar
  42. 42.
    Goldring S (1978) A method of surgical management of focal epilepsy, especially as it relates to children. J Neurosurg 49: 344–356PubMedCrossRefGoogle Scholar
  43. 43.
    Goldring S, Gregorie E (1984) Surgical management of epilepsy using recordings to localize the seizure focus. J Neurosurg 60: 457–466PubMedCrossRefGoogle Scholar
  44. 44.
    Gregorie S, Goldring S (1984) Localization of function in the excision of lesions from the sensorimotor region. J Neurosurg 61: 1047–1054PubMedCrossRefGoogle Scholar
  45. 45.
    Hanaway J, Young RR (1977) Localization of the pyramidal tract in the internal capsule of man. J Neurol Sci 34: 63–70PubMedCrossRefGoogle Scholar
  46. 46.
    Harky HL, Al-Mefty O, Haines DE, Smith RR (1989) The surgical anatomy of the sulci. Neurosurgery 24: 651–654CrossRefGoogle Scholar
  47. 47.
    Hasdemir MG, Ebeling U (1993) Stereotactic guided puncture of cerebral abcesses. Acta Neurochir (Wien) 125: 58–63CrossRefGoogle Scholar
  48. 48.
    Holmes G, Horrax G (1981) Disturbance of visual orientation. Br J Ophthalmol 2: 440–468, 506–516Google Scholar
  49. 49.
    Holmes G, Horrax G (1919) Disturbance of spatial orientation and visual attention with loss of stereoscopic vision. Arch Neurol Psychiatry 1: 385–407Google Scholar
  50. 50.
    Horsely V (1892) On the topographical relations of the cranium and the surface of the cerebrum. In: Cunningham CJ (ed) Contribution to the surface anatomy of the cerebral hemispheres. Academy House, Dublin, pp 306–355Google Scholar
  51. 51.
    Jane JA, Yashon D, De Myer D, Bucy PC (1967) The contribution of the precentral gyrus to the pyramidal tract in man. J Neurosurg 26: 244–248PubMedCrossRefGoogle Scholar
  52. 52.
    Kido DK, LeMay M, Levanswon AW, Benson WE (1980) Computed tomographic localization of the precentral sulcus. Radiology 135: 373–377PubMedGoogle Scholar
  53. 53.
    King RB, Schell GR (1987) Cortical localization and monitoring during cerebral operations. J Neurosurg 67: 210–219PubMedCrossRefGoogle Scholar
  54. 54.
    Klingler J, Gloor P (1960) The connections of the amygdala and of the anterior temporal cortex in the human brain. J Comp Neurol 115: 333–369PubMedCrossRefGoogle Scholar
  55. 55.
    Kròenlein RV (1889) Zur craniocerebralen Topographie. Beiträge zur klinischen Chirurgie XXII: 364–370Google Scholar
  56. 56.
    Kwan HC, McKay WA, Murphy BT (1978) Spatial organization of the precentral cortex in awake primates, II. Motor outputs. J Neurophysiol 41:1120–1121PubMedGoogle Scholar
  57. 57.
    Lang J (1981) Klinische Anatomie des Kopfes. Neurokranium, Orbita, kraniozervikaler Übergang. Springer, Berlin Heidelberg New YorkGoogle Scholar
  58. 58.
    Lang J, Belz J (1981) Form und Masse der Gyri und Sulci an der Facies superolateralis und Facies inferior hemispherii. J Hirnforsch 22: 517–533PubMedGoogle Scholar
  59. 59.
    Lang J (1985) Mikroanatomischer Kurs für junge Neurochirurgen. Anatomisches Institut, Universität WürzburgGoogle Scholar
  60. 60.
    Lassek AM (1954) The pyramidal tract. Its status in medicine. Thomas, SpringfieldGoogle Scholar
  61. 61.
    Le Blanc FE, Rasmussen T (1974) Cerebral seizures and brain tumor. In: Vinken PM, Bruyn GW (eds) Handbook of neurology, vol 15. North Holland, Amsterdam, pp 295–301Google Scholar
  62. 62.
    Le Roux PD, Berger MS, Haglund MM, Pilcher WH, Ojemann GA (1991) Resection of intrinsic tumors from nondominant face motor cortex using stimulation mapping: report of two cases. Surg Neurol 36: 44–48CrossRefGoogle Scholar
  63. 63.
    Ludwig E, Klingler J (1956) Atlas cerebri humani. Karger, BaselGoogle Scholar
  64. 64.
    Lüders H, Lesser RP, Hahn J (1983) Cortical somatosensory evoked potentials in response to hand stimulation. J Neurosurg 58: 885–894CrossRefGoogle Scholar
  65. 65.
    Luria AR (1966) Higher cortical functions in man. Basic, New YorkGoogle Scholar
  66. 66.
    Matsui T, Hirano A (1978) An atlas of the human brain for computerized tomography. Fischer, Stuttgart, Igaku-Shoin, TokyoGoogle Scholar
  67. 67.
    Missir O, Dutheil-Desclercs C, Meder JC, Musolino A, Fredy D (1989) Aspect du sillon central en IRM. Central sulcus patterns at MRI. J Neuroradiol 16: 133–144PubMedGoogle Scholar
  68. 68.
    von Monakow C (1915) Zur Anatomie und Physiologie der Pyramidenbahn und der Armregion, nebst Bemerkungen liber die sekundäre Degeneration des Fasciculus centroparietalis. Neurol Zbl 34: 217–224Google Scholar
  69. 69.
    Nathan PW, Smith MC (1955) Long descending tract in man. 1st review of present knowledge. Brain 78: 248–303PubMedCrossRefGoogle Scholar
  70. 70.
    Nathan PW, Smith MC, Deacon P (1990) The corticospinal tracts in man. Course and location of fibers at different segmental levels. Brain 113: 303–324PubMedCrossRefGoogle Scholar
  71. 71.
    Nuwer MR (1991) Localization of motor cortex with median nerve somatosensory evoked potentials. In: Schramm J, Moller AR (eds) Intraoperative neurophysiologic monitoring in neurosurgery. Springer, Berlin Heidelberg New York Tokyo, pp 63–71Google Scholar
  72. 72.
    Obana WG, Laxer KD, Cogan PH, Walker JA, Davis RL, Barbara NM (1992) Resection of dominant opercular gliosis in refractory partial epilepsy. Report of two cases. J Neurosurg. 77: 632–639PubMedCrossRefGoogle Scholar
  73. 73.
    Ojemann GA (1978) Individual variability in cortical localization of language. J Neurosurg 50: 164–169Google Scholar
  74. 74.
    Ojemann GA (1979) Organization for language from perspective of electrical stimulation mapping. Behav Brain Sci 6: 189–220CrossRefGoogle Scholar
  75. 75.
    Ojemann GA, Ojemann J, Lettich E, Berger M (1989) Cortical language localization in left, dominant hemisphere. J Neurosurg 71: 316–326PubMedCrossRefGoogle Scholar
  76. 76.
    Ono M, Kubik S, Abernathy CD (1990) Atlas of the cerebral sulci. Thieme, Stuttgart, pp 36–62Google Scholar
  77. 77.
    Passet J (1882) Über einige Unterschiede des Großhims nach dem Geschlecht. Archiv für Antropologie (Braunschweig), Bd 14, pp 89–141Google Scholar
  78. 78.
    Penfield W, Boldrey E (1937) Somatic and sensory representation in the cerebral cortex of man as studied by electrical stimulation. Brain 60: 389–443CrossRefGoogle Scholar
  79. 79.
    Penfield W, Welch K (1949) The supplementary motor area in the cerebral cortex of man. Trans Am Neurol Assoc 74: 179–184Google Scholar
  80. 80.
    Penfield W, Rasmussen T (1950) The cerebral cortex of man. McMillan, New YorkGoogle Scholar
  81. 81.
    Penfield W (1954) Mechanisms of voluntary movements. Brain 77: 1–17PubMedCrossRefGoogle Scholar
  82. 82.
    Pfeiffer RA (1934) Myelogenetisch-anatomische Untersuchungen über den zentralen Abschnitt der Taststrahlung, Pyramidenbahn, der Hirnnerven und zusätzlicher motorischer Bahnen. Nov Acta Leop Carol 1: 341–473Google Scholar
  83. 83.
    Pia HW (1986) Microsurgery of glioms. Acta Neurochir 80: 1–11CrossRefGoogle Scholar
  84. 84.
    Quensel R (1910) Über den Stabkranz des menschlichen Stirnhirnes. Folia Neurobiol 4: 319–334Google Scholar
  85. 85.
    Ross ED (1980) Localization of the pyramidal tract in the internal capsule by whole brain dissection. Neurology 30: 59–64PubMedGoogle Scholar
  86. 86.
    Rostomily RC, Berger MS, Ojemann GA, Lettich E (1991) Postoperative deficits and functional recovery following removal of tumors involving the dominant hemisphere supplementary motor area. J Neurosurg 75: 62–68PubMedCrossRefGoogle Scholar
  87. 87.
    Rowland LP, Mettler FA (1948) Relation between the coronal suture and the cerebrum. J Comp Neurol 89: 21–40PubMedCrossRefGoogle Scholar
  88. 88.
    Schmid U, Sturzenegger M, Ludin HP, Seiler RW, Reulen HJ (1988) Orthodromic (intra/extracranial) neurography of monitor facial nerve function intraoperatively. Technical note. Neurosurgery 22: 945–950PubMedCrossRefGoogle Scholar
  89. 89.
    Schmid U, Ebeling U, Reulen HJ (1989) Electrophysiological localization of the human sensori-motor cortex. Neurosurgical forum. J Neurosurg 70: 817–818PubMedGoogle Scholar
  90. 90.
    Seeger W (1978) Atlas of topographical anatomy of the brain and the surrounding structures for neurosurgeons, neuroradiologists and neuropathologists. Springer, Wien New YorkGoogle Scholar
  91. 91.
    Seeger W (1980) Microsurgery of the brain. Anatomical and technical principles, vol 1. Springer, Wien New YorkGoogle Scholar
  92. 92.
    Stöhr M, Dichgans S, Diener HC, Büttner UW (1989) Evozierte Potentiale SEP, VEP, AEP, EKP, MEP, 2nd ed. Springer, Berlin Heidelberg New York TokyoGoogle Scholar
  93. 93.
    Suzuki A, Yasmi N (1992) Intraoperative localization of the central sulcus by cortical somato-sensory evoked potentials in brain tumor. Case report. J Neurosurg 76: 867–870PubMedCrossRefGoogle Scholar
  94. 94.
    Talairach J, Bancaud J(1966) The supplementary motor area in man. Int J Neurol 5: 330–347Google Scholar
  95. 95.
    Talairach J, Szikla G (1967) Atlas of stereotactic anatomy of the telencephalon. Masson and Cie, ParisGoogle Scholar
  96. 96.
    Taylor EH, Haughton WS (1900) Some recent researches on the topography and convolutions and fissures of the brain. Transactions of the Royal Academy of Medicine in Ireland 18: 511–522CrossRefGoogle Scholar
  97. 97.
    Taylor E, Haughton VM, Syverston A, Ho K (1980) Taylor Haughton line revisited. Am J Neuroradiol (Baltimore) 1: 55–56PubMedGoogle Scholar
  98. 98.
    Tredici G, Pizzini G, Bogliun G, Tagliabue M (1982) The site of motor corticospinal fibers in the internal capsule of man. A computerised tomographic study of restricted lesions. J Anat 134: 199–208PubMedGoogle Scholar
  99. 99.
    Uematsu S, Lesser RP, Gordon B (1992) Localization of sensorimotor cortex: the influence of Sherington and Cushing on the modern concept. Neurosurgery 30: 904–913PubMedCrossRefGoogle Scholar
  100. 100.
    Uematsu S, Lesser RP, Fisher RS, Gordon B, Hara K, Krauss GL, Vining EP, Webber RW (1992) Motor and sensor cortex in humans. Topography studied with chronic subdural stimulation. Neurosurgery 31: 59–72PubMedCrossRefGoogle Scholar
  101. 101.
    Weiller C, Choller F, Friston KJ, Wise RJS, Frackowiak RSJ (1992) Functional reorganization of the brain in recovery from striatocapsular infarction in man. Ann Neurol 31: 463–472PubMedCrossRefGoogle Scholar
  102. 102.
    Weiller C, Ramsay SC, Wise RJS, Friston KJ, Frachowiak RJS (1993) Individual patterns on functional reorganization in the human cerebral after capsular infarction. Ann Neurol 33: 181–189PubMedCrossRefGoogle Scholar
  103. 103.
    Wood CC, Spencer DD, Allison T, McCarthy G, Williams PD, Groff WR (1988) Localization of human sensori-motor cortex during surgery by cortical surface recordings of somatosensory evoked potentials. J Neurosurg 68: 99–111PubMedCrossRefGoogle Scholar
  104. 104.
    Woolsey CN, Erikson TC, Gibson WE (1979) Localization in somatic sensory and motor areas of human cerebral cortex as determined by direct recording of evoked potentials and electrical stimulation. J Neurosurg 51: 476–506PubMedCrossRefGoogle Scholar
  105. 105.
    Yasargil MG, Cravens GC, Roth P (1988) Surgical approaches to “inaccessible” brain tumors. Clin Neurosurg 34: 42–110PubMedGoogle Scholar
  106. 106.
    Yasargil MG, von Ammon K, Cavazos E, Doczi T, Reeves JD, Roth P (1992) Tumors of the limbic and paralimbic systems. Acta Neurochir (Wien) 118:40–52CrossRefGoogle Scholar

Copyright information

© Springer-Verlag/Wien 1995

Authors and Affiliations

  • U. Ebeling
    • 1
  • H.-J. Reulen
    • 2
  1. 1.Department of NeurosurgeryUniversity of BerneBerneSwitzerland
  2. 2.Department of NeurosurgeryLudwig Maximilians UniversityMunichFederal Republic of Germany

Personalised recommendations