title: Prediction of neurological deficits and recovery after surgery in the supplementary motor area: a prospective study in 26 patients.
abstract: OBJECTIVE
  Resection of lesions involving the supplementary motor area (SMA) may result in immediate postoperative motor and speech deficits that are reversible in most cases. In the present study the authors aimed to determine the critical involvement of SMA in the lesioned and healthy hemispheres in this functional recovery. They hypothesized that compensatory mechanisms take place following surgery in the SMA, and that these mechanisms can involve either the lesioned or the non-lesioned hemisphere. In addition, they hypothesized that a correlation will be present between the functional MR imaging (fMR) imaging-related activation in the SMA and the occurrence of a functional deficit during intraoperative cortical stimulation.
  
  
  METHODS
  Twenty-six patients scheduled for resection of space-occupying lesions involving, or in the vicinity of, the SMA were recruited. Patients underwent an fMR imaging examination that included finger-tapping and verb-generation tests to assess for motor and language functions. Intraoperatively direct cortical stimulation (DCS) of the SMA region was performed while patients were monitored for language and motor functions using tests similar to those used for the fMR imaging. Task dysfunction during DCS assessed the critical involvement of the SMA in the tested functions. Neurological evaluations were performed prior to surgery and at 3 time points within a month following surgery. A region of interest-based approach was used to evaluate fMR imaging blood oxygen level-dependent activation level and asymmetry in the SMA. These measurements were later compared with the intraoperative DCS and neurological findings.
  
  
  RESULTS
  Functional MR imaging showed greater activation and dominance of the SMA in the lesioned hemisphere in patients who exhibited no motor or language dysfunction during DCS. In addition, patients with the highest activation of the SMA in the lesioned hemisphere for language and motor tests showed stronger coupling of this region with ipsilateral motor and language networks. In contrast, activation in the nonlesioned hemisphere did not correspond with DCS results.
  
  
  CONCLUSIONS
  The authors' findings demonstrate the necessity of activation in the vicinity of the lesioned SMA for functional compensation in motor and language tasks. It is possible that more effective functional coupling of the SMA with motor and language areas in the same hemisphere prevents dysfunctions following surgical intervention. Importantly, fMR imaging activation in the unaffected SMA was not sufficient for development of functional compensation and, if anything, indicated decompensation.
authors.affiliation: Whole Institute for Advanced Imaging, Department of Neurosurgery, Epilepsy and Functional Neurosurgery Unit, Tel Aviv Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
authors.forename: Keren
authors.initials: K
authors.lastname: Rosenberg
authors.forename: Erez
authors.initials: E
authors.lastname: Nossek
authors.forename: Ronit
authors.initials: R
authors.lastname: Liebling
authors.forename: Itzhak
authors.initials: I
authors.lastname: Fried
authors.forename: Irit
authors.initials: I
authors.lastname: Shapira-Lichter
authors.forename: Talma
authors.initials: T
authors.lastname: Hendler
authors.forename: Zvi
authors.initials: Z
authors.lastname: Ram
mesh_terms: D000222:Adaptation, Physiological; D000328:Adult; D000368:Aged; D001921:Brain / Q000601:surgery; D001927:Brain Diseases / Q000209:etiology / Q000601:surgery*; D002540:Cerebral Cortex; D004558:Electric Stimulation; D005260:Female; D005625:Frontal Lobe / Q000601:surgery; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009044:Motor Cortex / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000009:adverse effects*; D011237:Predictive Value of Tests; D020127:Recovery of Function; D013064:Speech Disorders / Q000209:etiology; D013647:Task Performance and Analysis; D055815:Young Adult