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Vol. 22. Issue 2.
Pages 123-132 (January 2011)
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Vol. 22. Issue 2.
Pages 123-132 (January 2011)
Identificación intraoperatoria del área motora suplementaria en cirugía neurooncológica
Intraoperative identification of the supplementary motor area in neurooncological surgery
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A. Gabarrós
Corresponding author
agabarros@ub.edu

Correspondencia: Hospital Universitari de Bellvitge. Feixa Llarga s/n. 08907 L’Hospitalet de Llobregat (Barcelona).
, J. Martino, G. Plans, O. Godino, A. Torres, A. Aparicio, J.J. Acebes
Servicios de Neurocirugía, Hospital Universitari de Bellvitge (Barcelona)
M. Juncadella*, R. Pujol**, J. Deus**, G. Conesa***
* Servicios de Neuropsicología, Hospital Universitari de Bellvitge (Barcelona)
** Servicios de Neurorradiología, Hospital del Mar (Barcelona)
*** Servicios de Neurocirugía, Hospital del Mar (Barcelona)
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Resumen
Objetivos

El objetivo principal del estudio es conseguir la identificación intraoperatoria de la función del área motora suplementaria (AMS) implicada en tareas motoras complejas. El objetivo secundario es valorar el pronóstico funcional tras la preservación quirúrgica de este área.

Método

Se han seleccionado 15 pacientes con tumores cerebrales localizados en área premotora. Todos los pacientes fueron intervenidos despiertos. El córtex motor primario fue identificado mediante estimulación cerebral directa. Para identificar el AMS, el paciente realizó una tarea motora de oposición de dedos con la mano contralateral a la lesión que se bloqueaba mediante la estimulación eléctrica del córtex cerebral premotor.

Resultados

El AMS pudo ser identificada en todos los pacientes mediante este método.

La resección fue macroscópicamente completa en 13 pacientes (86.6%) y subtotal en 2 (13.3%). La función encontrada en el AMS se ha podido preservar en 14 pacientes (93,3%). Sólo en una paciente se resecó parcialmente el AMS funcional junto a la lesión por infiltración de la misma (6.6%). En el postoperatorio inmediato 8 pacientes (53.3%) presentaron empeoramiento de los déficits, cinco pacientes (33.3%) no mostraron cambios respecto a su exploración preoperatoria y 2 pacientes mejoraron. A los 6 meses de la intervención 5 pacientes (33.3%) se encuentran asintomáticos y 10 pacientes presentan déficits permanentes. En este último grupo, 5 pacientes (33.3%) muestran un déficit muy leve que no interfiere en su vida normal. En los otros 5 pacientes (33.3%) los déficits permanentes interfieren con la vida del paciente: dos pacientes presentan hemiparesia severa 3/5 (igual estado preoperatorio que no mejora), uno afasia de expresión y otros dos (13.3%) presentan un síndrome del AMS izquierda permanente. En los 2 pacientes con hemiparesia severa postoperatoria se objetivó intraoperatoriamente una infiltración tumoral del córtex motor primario y de la vía motora; el déficit motor severo preoperatorio (KPS<70) se asoció con mal pronóstico funcional postoperatorio.

Conclusiones

La estimulación cortical intraoperatoria resulta útil para la identificación del AMS. La preservación del AMS, una vez identificada, disminuye la aparición de síntomas postquirúrgicos y la persistencia del síndrome del AMS. Cuando el AMS se encuentra infiltrada por tumor, su resección quirúrgica puede causar déficits permanentes, especialmente en el hemisferio dominante. El déficit motor severo preoperatorio se asocia con mal pronóstico funcional.

Palabras clave:
Área motora suplementaria
Mapping
Tarea intraoperatoria
Paciente despierto
Tumor cerebral
Abreviaturas:
AMS
IES
RMf
SMA
Summary
Objectives

The main objective of the present work was to identify, by means of intraoperative electrical stimulation, the supplementary motor area (SMA) region which is implicated in complex motor function. The functional prognostic relevance of the surgical preservation of this area was also analyzed.

Method

Fifteen patients with tumors infiltrating the premotor cortex were selected. All patients were operated under awake conditions. Primary motor cortex was identified with intraoperative electrical stimulation (IES). To identify the SMA, patients were asked to do a finger opposition motor task with their hand contralateral to the lesion, that was blocked by electrically stimulating the premotor cerebral cortex.

Results

SMA was identified in all patients with IES. Complete surgical resection was achieved in 13 patients (86.6%) and subtotal in 2 patients (13.3%). SMA function was preserved in 14 patients (93.3%). In only one patient the SMA was partially resected because of tumor infiltration (6.6%). In the immediate postoperative period, 8 patients (53.3%) did not show changes in comparison to their preoperative clinical status, and 2 patients improved. At 6 months follow up, 5 patients (33.3%) were asymptomatic and 10 patients showed permanent deficits. In this last group, five patients (33.3%) showed mild deficits that did not interfere with a normal life. In the other 5 patients (33.3%), permanent deficits interfered with daily life activities: two patients presented severe hemiparesis 3/5 (same similar to their preoperative status with no improvement), one patient had motor aphasia, and two other patients (13.3%) showed permanent left SMA syndrome.

In two patients with severe postoperative hemiparesis, tumor infiltration of primary motor cortex and piramidal pathway was observed; severe preoperative motor deficit (KPS <70) was associated with poor functional outcome.

Conclusions

Intraoperative electrical cortical stimulation is useful to identify the SMA. Once identified, SMA preservation decreases the risk of postoperative symptoms and permanent SMA syndrome. When SMA is infiltrated by the tumor, radical resection may cause permanent neurological deficits, specially in the dominant hemisphere. Severe preoperative motor deficit was associated with poor outcome.

Key words:
Supplementary motor area
Mapping
Intraoperative task
Awake patient Brain tumor

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