Challenges in Identifying the Foot Motor Region in Patients with Brain Tumor on Routine MRI: Advantages of fMRI

Fellows’ Journal Club

Editor’s Comment

Thirty-five attending-level raters evaluated 14 brain tumors involving the frontoparietal convexity. Raters identified the location of the foot motor homunculus and determined whether the tumor involved the foot motor area and/or motor cortex by using anatomic MR imaging. Seventy-seven percent of the time raters correctly identified whether the tumor was in the foot motor cortex. Raters with fMRI experience were significantly better than raters without experience at foot motor fMRI centroid predictions.

Abstract

Axial T1-weighted without (A) or with (B) coregistered functional MR images obtained during a bilateral finger-tapping and foot motor paradigm. The raters were asked to identify the foot motor homunculus solely on the basis of the anatomic images (A) without the benefit of fMRI (B). fMRI places the extra-axial lesion just posterior to the primary motor gyrus, including the foot motor portion of the motor homunculus. Edema extends to involve both the precentral and postcentral gyri. The average arrow placement from the foot motor center was 16 mm in those with fMRI experience and 23 mm in those without it. A higher percentage of raters with fMRI experience than those without it placed the arrow in the motor gyrus (65% versus 50%). Eighteen percent of raters with fMRI experience correctly identified the tumor as not being located in the foot motor cortex, while 33% of raters without fMRI experience did so. Last, 35% and 39% of raters with and without fMRI experience, respectively, correctly identified the tumor as not being located in the motor gyrus. Most of the incorrect arrow placements were due to the arrow being placed in a gyrus posterior to the motor gyrus.
Axial T1-weighted without (A) or with (B) coregistered functional MR images obtained during a bilateral finger-tapping and foot motor paradigm. The raters were asked to identify the foot motor homunculus solely on the basis of the anatomic images (A) without the benefit of fMRI (B). fMRI places the extra-axial lesion just posterior to the primary motor gyrus, including the foot motor portion of the motor homunculus. Edema extends to involve both the precentral and postcentral gyri. The average arrow placement from the foot motor center was 16 mm in those with fMRI experience and 23 mm in those without it. A higher percentage of raters with fMRI experience than those without it placed the arrow in the motor gyrus (65% versus 50%). Eighteen percent of raters with fMRI experience correctly identified the tumor as not being located in the foot motor cortex, while 33% of raters without fMRI experience did so. Last, 35% and 39% of raters with and without fMRI experience, respectively, correctly identified the tumor as not being located in the motor gyrus. Most of the incorrect arrow placements were due to the arrow being placed in a gyrus posterior to the motor gyrus.

Background and Purpose

Accurate localization of the foot/leg motor homunculus is essential because iatrogenic damage can render a patient wheelchair- or bed-bound. We hypothesized the following: 1) Readers would identify the foot motor homunculus <100% of the time on routine MR imaging, 2) neuroradiologists would perform better than nonradiologists, and 3) those with fMRI experience would perform better than those without it.

Materials and Methods

Thirty-five attending-level raters (24 neuroradiologists, 11 nonradiologists) evaluated 14 brain tumors involving the frontoparietal convexity. Raters were asked to identify the location of the foot motor homunculus and determine whether the tumor involved the foot motor area and/or motor cortex by using anatomic MR imaging. Results were compared on the basis of prior fMRI experience and medical specialty by using Mann-Whitney U test statistics.

Results

No rater was 100% correct. Raters correctly identified whether the tumor was in the foot motor cortex 77% of the time. Raters with fMRI experience were significantly better than raters without experience at foot motor fMRI centroid predictions (13 ± 6 mm versus 20 ± 13 mm from the foot motor cortex center, P = 2 × 10−6) and arrow placement in the motor gyrus (67% versus 47%, P = 7 × 10−5). Neuroradiologists were significantly better than nonradiologists at foot motor fMRI centroid predictions (15 ± 8 mm versus 20 ± 14 mm, P = .005) and arrow placement in the motor gyrus (61% versus 46%, P = .008).

Conclusions

The inability of experienced readers to consistently identify the location of the foot motor homunculus on routine MR imaging argues for using fMRI in the preoperative setting. Experience with fMRI leads to improved accuracy in identifying anatomic structures, even on routine MR imaging.

Read this article: http://www.ajnr.org/content/36/8/1488.full

Challenges in Identifying the Foot Motor Region in Patients with Brain Tumor on Routine MRI: Advantages of fMRI
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jross
Jeffrey Ross • Mayo Clinic, Phoenix

Dr. Jeffrey S. Ross is a Professor of Radiology at the Mayo Clinic College of Medicine, and practices neuroradiology at the Mayo Clinic in Phoenix, Arizona. His publications include over 100 peer-reviewed articles, nearly 60 non-refereed articles, 33 book chapters, and 10 books. He was an AJNR Senior Editor from 2006-2015, is a member of the editorial board for 3 other journals, and a manuscript reviewer for 10 journals. He became Editor-in-Chief of the AJNR in July 2015. He received the Gold Medal Award from the ASSR in 2013.