Neurological Surgery 脳神経外科33巻4号

2005年04月発行

解剖を中心とした脳神経手術手技

補足運動野近傍の腫瘍に対する外科治療

著者： 山根文孝¹ 加藤宏一² 落合卓² 丸山隆志² 村垣善浩² 池田昭夫³ 堀智勝²

所属機関： ¹埼玉医科大学脳神経外科 ²東京女子医科大学脳神経センター脳神経外科 ³京都大学神経内科

ページ範囲：P.327 - P.336

Ⅰ．はじめに

　補足運動野（supplementary motor area：以下SMA）に存在する腫瘍の摘出術について述べる．この部位の摘出においては従来より永続的神経脱落症状を残さない，あるいは残存してもごく軽微な症状であるとされている^14,20,21)．ただし，運動野に接して存在していること，また術後においてはしばしば難治なてんかん発作を合併することもあり，機能的によりよい予後を得るためには機能マッピングのみならず発作起始領域についても正確に同定しておく．SMA摘出によって生じる機能障害を補足運動野症候群（SMA症候群）と総称するが，SMA症候群の回復については，回復の期間や程度についての個人差が多く，症例によって差異を認める^1,12,13)．

　SMA近傍の腫瘍において，その摘出を前提とした脳機能マッピングにおいて問題となるのは，1）腫瘍周辺の詳細な位置関係，すなわち一次運動野およびSMAの正確な同定，2）皮質下線維の走行と腫瘍の位置関係，3）術中ナビゲーションの利用と摘出範囲の確認（根治性を高めるための術中MRIの応用），などである．以下，SMA野周辺の腫瘍に対する外科治療についてその現状と問題点について述べる．

参考文献

1）Bleasel A, Comair Y, Luders H：Surgical ablation of the medial frontal lobe in human. In：Luders H, ed. Supplementary motor area. Philadelphia, Lippincott-Raven, pp217-235, 1996

2）Brodmann K：Verleichende Lokalisationslehre der Groshirnrinde. Leipzig Barth, 1909 [Reprinted 1925]

3）Deeke L, Kornhuber HH：An electrical sign of participation of the mesial “supplementary” motor cortex in human voluntary finger movement. Brain Res 159：473-476, 1978

4）Dinner DS, Luders H, Morris HH, Wyllie E, Kramer R. Human supplementary motor area (SMA) electrical stimulation study. Epilepsia 28：619, 1987

5）Freund HJ：Hitorical overview, In Advances in Neurology 70, Supplementary motor area, Luders HO ed, p17, 1996

6）Ikeda A, Luders HO, Burgess RC, Shibasaki H：Movement-related potentials recorded from supplementary motor area and primary motor area：role of supplementary motor area in voluntary movement. Brain 115：1017-1043, 1992

7）Ikeda A, Luders HO, Shibasaki H, Collura TF, Burgess RC, Morris III HH, Hamano T：Movement-related potentials associated with bilateral simultaneous and unilateral movements recorded from human supplementary motor area. Electroenceph Clin Neurophysiol 95：323-334, 1994

8）Ikeda A, Miyamoto S, Shibasaki H：Cortical motor mapping in epilepsy patients. Information from subdural electrodes in presurgical evaluation. Epilepsia 43 (suppl9)：56-60, 2002

9）Ikeda A, Ohara S, Matsumoto R, Kunieda T, Nagamine T, Miyamoto S, Kohara N, Taki W, Hashimoto N, Shibasaki H：Role of primary sensorimotor cortices in generating inhibitory motor response in humans. Brain 123：1710-1721, 2000

10）Ingvar DH, Philipson L：Distribution of cerebral blood flow in the dominant hemisphere during motor ideation and moto performance. Ann Neurol 2：230-237, 1977

11）Krainik A, Duffau H, Capelle L, Cornu P, Boch AL, Mangin JF, Bihan Le, Marsault C, Chiras J, Lehericy S：Role of the healthy hemisphere in recovery after resection of the supplementary motor area. Neurology 62：1323-1332, 2004

12）Krainik A, Lehericy S, Duffau H, Vlaicu M, Poupon F, Capelle L, Cornu P, Clemenceau S, Sahel M, Valery CA, Boch AL, Mangin JF, Bihan DL, Marsault C：Role of the supplementary motor area in motor deficits following medial frontal lobe surgery. Neurology 57：871-878, 2001

13）Kurata K：Somatotopy in the human supplementary motor area. TINS 15：159-160, 1992

14）Laplane D, Talairach J, Meininger V, Bancaud J, Boucharine A：Motor consequences of motor area ablations in man. J Neurol Sci 31：29-49, 1977

15）Lim SH, Dinner DS, Pillary PK, Luders H, Morris HH, Klem G, Wyllie E, Awad IA：Functional anatomy of the human supplementary sensorimotor area：results of extraoperative electrical stimulation. Electroencephalogr Clin Neurophysiol 91：179-193, 1994

16）Luders HO, Dinner DS, Morris HH, Hahn JF, Friedman L, Skipper G, Wyllie E, Comair YG：Cortical electric stimulation in human. The negative motor areas . In Fahn S, Hallett M, Luders HO(,eds) Negative motor phenomena. Advances in Neurology, 67. New York, Lippincott-Raven, pp115-119,1995

17）LudersH, Lesser RP, Dinner DS, Morris HH, Wyllie E, Godoy J, Hahn JH：A negatve motor response elicited by electrical stimulation of the human frontal cortex. Adv Neurol 57：149-157,1992

18）Morris III HH, Dinner DS, Luders H, Wyllie E, Kramer R：Suplementary motor seizure：clinical and electroencephalographic findings. Neurology 38：1075-1082, 1988

19）村垣善浩，丸山隆志，伊関　洋，堀　智勝，高倉公朋：Intraoperative MRI and update navigation．日本臨牀62：697-706, 2004

20）Penfield W, Jasper H：Epilepsy and the functional anatomy of the human brain. Boston, Little Brown, 1954

21）Rostomily R, Berger M, Ojemann G, Lettich E：Postoperative deficits and functional recovery following removal of tumors involving the dominant hemisphere supplementary mortor area. J Neurosurg 75：62-68, 1991

22）Shibasaki H, Sadato N, Lyshkow H, Yonekura Y, Honda M, Nagamine T, Suwazono S, Magata Y, Ikeda A, Miyazati M, et al：Both primary motor cortex and supplementary motor area play an important role in complex finger movement. Brain 116：1387-1398, 1993

23）Suzuki K,Kodama N, Sasaki T, Matsumoto M, Konno Y, Sakuma J, Oinuma M, Murakawa M：Intraoperative monitoring of blood flow insufficiency in the anterior choridal artery during aneurysm surgery J Neurosurg 98：507-13, 2003

24）Talairach J, Bancaud J：The supplementary motor area in man (anatomofunctional findings on SEEG in epilepsy). Int J Neurol 5：330-347, 1966

25）Talairach J, Tournoux P：Co-planar Stereotactic Atlas of the human brain. 3-Dimensional proportional system.：an approach to cerebral imaging. New York, NY; Thieme, 1987

26）Tanji J：The supplementary motor area in the cerebral cortex. Neurosci Res 19：251-268, 1994

27）Yamane F, Muragaki Y, Maruyama T, Okada Y, Iseki H, Ikeda A, Homma I, Hori T：Preoperative mapping for patients with supplementary motor area epilepsy：Multimodality brain mapping. Psychiatry Clin Neurosci 58：S16-S21, 2004

28）Wakana S, Jiang H, Nagae-Poetscher LM, van Ziji PCM, Mori S：Fiber tract-based atlas of human white matter anatomy. Radiology 230：77-87, 2004

29）柳澤信夫，柴崎　浩：神経生理を学ぶ人のために， 東京，医学書院, pp276-300, 1997

30）Yoursry TA, Schmid UD, Jassoy AG, Schmidt D, Eisner WE, Reulen HJ, Reiser MF, Lissner J：Topography of the cortical motor hand area：prospective study with functional MR imaging and direct motor mapping at surgery. Radiology 195：23-29, 1995