J.Jpn. Surg. Soc.. 62(11): 1137-1169, 1961
ON THE MOTOR AND SENSORY FUNCTIONS AFTER HENISPHERECTOMY OF HUMAN CERERUM
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Department of Neurological Surgery, Niigata University School of Meclicune (Director: Prof. Komei UEKI) Takeshi SAKURAI |
1) Motor functions after hemispherectomy :
In the group with poor result, only a stereotype associated movement consisted of flexion and extension was observed in the arm proxymal to the elbow joint. The hand and fingers could be placed in the grasping position with difficulty, being accompanied with the associated movement proximal to the wrist. The grasped hand could be opened in the condition of relaxation but this voluntary movement was not effective.
In Case 6 which belonged to the group with good result, the grasping movement or other movements of hand distal to the wrist were only possible with th associated movement in the forearm. However, considerably isolated voluntary movements were maintained in the elbow and shoulder joints. The hairdressing posture or sash-tieing posture could be taken in this case.
In Case 5 which belonged to the group with best result, isolated voluntary movement in all upper extremity joints were possible. All fingers moved together usually, but the thumb and index finger could be moved emphatically. Consequently, hair-dressing, sash-tieing, water-drinking or smoking movement was possible in this case. Only in this case a symmetrical associated movement in the bilateral hands and fingers was observed.
In all cases, the legs proximal to the ankle joint showed an associated movement consisted of flexion and extension. The movements in the ankle joint and toes were difficult due to pes equinus. However, spottiness or circumduction was mild and running was laboriously possible.
The earlier the cerebral damage developed, the milder the motor disturbances.
These remaining movements are considered to be mainly performed by the impulses from four motor areas with somatic representation, that is, the precentral and postcentral motor areas with marked contralateral representation and weak ipsilateral representation, and second motor area and supplementary motor area with marked bilateral representation, which are conducted through the extrapyramidal and ipsilateral pyramidal tracts. When the extrapyramidal element is great the stereotype associated movement is resulted, and when the ipsilateral pyramidal element is more intense the voluntary movements with marked variety as in the Case 5 is provoked.
The athetoid movement which had been observed in 3 cases preoperatively disappeared in 2 cases and remarkably diminished in one case after hemispherectomy.
2) Spasticity :
Spasticity decreased significantly but transiently after hemispherectomy, followed with gradual reappearance and increase after one year postoperatively. The temporary weakenning of spsticity might be explained by diaschisis due to resection of the cortex and corpus striatum which had been acting inhibitorily on the development of spasticity still in some degree before hemispherectorny. With the recovery from the diaschisis, the spasticity reappears and becomes more intense than the preoperative degree.
4) Reflexes :
No remarkable difference was observed in the reflexes before and after operation. Slight acceleration of tendon reflex, appearance of ankle clonus, and weakening of abdominal reflex were found postoperatively. The pathological reflexes which had been present preoperatively were not altered by hemispherectomy, that is Babinski phenomenon and Chacock's sign.
4) The sensory function :
Three out of 9 cases were examined very closely and the author would say, general speeking, the disturbance could be more insignificant than imagination. The solycalled protopathic sensation was slightly disturbed. In general the epicritic sensations, especially those which require complicated collective interpretation such as two-point discrimination or stereognosis, were rather markedly disturbed. There was, however, an exceptional case in which stereognosis and others were well preserved. These sensory disturbances were the mildest on the facial area and comparatively more remarkable in the distal portions of the body, especially in the periphery of the limbs. A gradual prolonged improvement was observed in the sensory disturbances with the elapse of postoperative time. The postoperative well preserved condition may be caused partially by learning due to improved emotional functions in the postoperative period, though the compensation in the remaining cerebral structure will play an impotant role.
It is surmised that the remained sensory functions may be maintained by the followwing condition :
The sensory impulses might be conducted through the spinothalamic tract which ascends crossing twice and reach to the ipsilateral thalamus (the posteroventral nucleus and possibly centre median partially) .
From the thalamus the impulses may be transmitted to the postcentral sensory area and precentral sensory area in which the facial representations are markedly bilateral while the other are chiefly contralateral, and to the second sensory area with marked bilateral representation. It might be also possible the superior and inferior parietal lobules would receive the impulses from the relay nuclei of the thalamus through the association nuclei. The each area in the thalamus and the cortex is closely related each other with a definite localization. Thus the sensory functions on the hemispherectomized patients are carried out.
5) Hyperpathia was observed in 3 out of 9 hemispherectomized cases. All these cases had presented marked inter-brain autonomic nervous symptoms immediately after operation. It is considered to be due to extension of the damage to the thalamus and inter- or/and mid-brain directly or indirectly simultaneously.
(Author's abstract)
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