Altered cortical morphology in patients with chronic shoulder pain.

Shoulder pain is a common condition associated with slow recovery and high recurrence rates. Persistent pain may lead to structural brain changes that may further promote pain chronification. The present study addressed whether abnormal changes in cortical surface structure exist in patients with chronic shoulder pain of myofascial origin and whether such changes would be related to pain measures. Brain structural MRIs were obtained in 22 patients with chronic pain in the bilateral upper trapezius muscles and in 22 healthy controls. Cortical thickness, gyrification index and sulcal depth were assessed together with pain measures. Shallower sulcal depth was found in patients in the right central sulcus, posterior insula, inferior frontal and dorsomedial prefrontal cortices, precuneus, and the middle temporal cortex, and in the left medial orbitofrontal cortex. Negative correlations were found between the right central sulcus and pain intensity and between the left medial orbitofrontal cortex and pain affect. Cortical thickness or gyrification index did not differ significantly between the two groups. The afflicted cortical regions constitute interacting networks responsible for sensory, affective and cognitive dimensions of the pain experience.

The Efficacy of a Haptic-Enhanced Virtual Reality System for Precision Grasp Acquisition in Stroke Rehabilitation.

Stroke is a leading cause of long-term disability, and virtual reality- (VR-) based stroke rehabilitation is effective in increasing motivation and the functional performance. Although much of the functional reach and grasp capabilities of the upper extremities were regained, the pinch movement remains impaired following stroke. In this study, we developed a haptic-enhanced VR system to simulate haptic pinch tasks to assist the recovery of upper-extremity fine motor function. We recruited 16 adults with stroke to verify the efficacy of this new VR system. Each patient received 30 min VR training sessions 3 times per week for 8 weeks. Outcome measures, Fugl-Meyer assessment (FMA), Test Evaluant les Membres superieurs des Personnes Agees (TEMPA), Wolf motor function test (WMFT), Box and Block test (BBT), and Jamar grip dynamometer, showed statistically significant progress from pretest to posttest and follow-up, indicating that the proposed system effectively promoted fine motor recovery of function. Additionally, our evidence suggests that this system was also effective under certain challenging conditions such as being in the chronic stroke phase or a coside of lesion and dominant hand (nondominant hand impaired). System usability assessment indicated that the participants strongly intended to continue using this VR-based system in rehabilitation.

Short-term effect of ultrasound-guided low-molecular-weight hyaluronic acid injection on clinical outcomes and imaging changes in patients with rheumatoid arthritis of the ankle and foot joints. A randomized controlled pilot trial.

To determine whether hyaluronic acid (HA) injection into rheumatoid arthritis ankles and feet can achieve improvement in foot function and reduce synovial hyper-vascularization. Forty-four patients with RA having unilateral or bilateral painful ankle and foot involvement (N = 75) were studied. All the patients were randomized to receive HA (N = 40) or lidocaine (LI) (N = 35) injection at 2-week intervals; Clinical assessments were performed using a visual analog scale (VAS) and foot function index (FFItotal) including subscales of pain (FFIpain) before injection at baseline, 4 weeks (first evaluation) and 12 weeks (secondary evaluation). Imaging evaluation based on color Doppler ultrasound (CDUS) and synovitis scores was performed simultaneously. HA injection improved the VAS score (p = .009), FFIpain (p = .041), and FFItotal (p = .032) considerably more than LI injections did at the first evaluation. The CDUS values at first evaluation (p = .005) and secondary evaluation (p < .001) decreased significantly compared with the base line values. HA injections reduced the CDUS values of more than half of the joints (54%, p = .042) while the control group exhibited no change (20%, p = .56). However, HA injection did not reduce the CDUS values more than LI injection did. Regarding the evaluation of synovial hypertrophy, no significant difference was observed between or within the groups in the synovitis scores. HA injection improved short-term foot function and pain reduction. HA injection may have a modest effect in reducing synovial hyper-vascularization. Further large-scale study is warranted to confirm this result.

Sonographic diagnosis of a glomus tumor of the thigh.

Extradigital glomus tumors are a very rare entity. Here, we report a rare case of a glomus tumor in an atypical anatomic site: the thigh. The clinical features together with the results of MRI, and sonography and Doppler sonographic imaging helped to distinguish glomus tumor of the thigh from other soft tissue neoplasms. The tumor arising from the thigh was excised, and following surgery, the patient was symptom free without evidence of complications or recurrence. There have only been a few previously reported cases describing the use of Doppler sonography in the evaluation of extradigital glomus tumors. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:50-52, 2017.

Motor Ingredients Derived from a Wearable Sensor-Based Virtual Reality System for Frozen Shoulder Rehabilitation.

Objective. This study aims to extract motor ingredients through data mining from wearable sensors in a virtual reality goal-directed shoulder rehabilitation (GDSR) system and to examine their effects toward clinical assessment. Design. A single-group before/after comparison. Setting. Outpatient research hospital. Subjects. 16 patients with frozen shoulder. Interventions. The rehabilitation treatment involved GDSR exercises, hot pack, and interferential therapy. All patients first received hot pack and interferential therapy on the shoulder joints before engaging in the exercises. The GDSR exercise sessions were 40 minutes twice a week for 4 weeks. Main Measures. Clinical assessments included Constant and Murley score, range of motion of the shoulder, and muscle strength of upper arm as main measures. Motor indices from sensor data and task performance were measured as secondary measures. Results. The pre- and posttest results for task performance, motor indices, and the clinical assessments indicated significant improvement for the majority of the assessed items. Correlation analysis between the task performance and clinical assessments revealed significant correlations among a number of items. Stepwise regression analysis showed that task performance effectively predicted the results of several clinical assessment items. Conclusions. The motor ingredients derived from the wearable sensor and task performance are applicable and adequate to examine and predict clinical improvement after GDSR training.

Profuse unilateral hyperhidrosis induced by urinary retention in a stroke patient.

INTRODUCTION: The diagnosis of urinary retention in stroke patients is challenging because their symptoms may be subtle, or go unnoticed. Furthermore, patients suffering from aphasia or impaired cognition often have difficulties communicating urination problems, leading to their urinary retention being overlooked. CASE REPORT: We report a 53-year-old man with bilateral pontine hemorrhage resulting in incomplete locked-in syndrome. During the patient's hospital course, he developed 3 episodes of rapid onset of profuse unilateral hyperhidrosis. All 3 episodes were found to be induced by an overly distended bladder and each time the unilateral hyperhidrosis resolved promptly after bladder drainage. CONCLUSIONS: This case provides the first description of unilateral hyperhidrosis as a manifestation of urinary retention in a stroke patient. It is important for clinicians to recognize this condition so that appropriate management can be implemented in time to prevent potential detrusor injury and renal impairment caused by bladder overdistension.

Localization of the cricothyroid muscle under ultrasound guidance for vagal nerve mapping.

During surgical removal of tumors of the skull base or cerebellopontine angle with brainstem compression, the vagus nerve is at a high risk for injury that can result in permanent or transient swallowing and speech dysfunction. Intramuscular recording of cricothyroid muscle can be used for vagal nerve mapping during intraoperative neurophysiologic monitoring so as to prevent the above complications. However, it is a small muscle that lies beneath the strap muscles over the anterior neck and is not easily accessible by a blind approach. Here, we present a case in which cricothyroid muscle was identified for precise electrode placement under ultrasound guidance during preparation for intraoperative monitoring. We concluded that localization of the cricothyroid muscle by ultrasonography proved to be a feasible and easy technique, and the compound muscle action potential recorded by this approach is clearly recognizable during intraoperative vagal nerve mapping.

The influence of shoulder pain on functional limitation, perceived health, and depressive mood in patients with traumatic paraplegia.

OBJECTIVE: To assess whether functional activity, perceived health, and depressive symptoms differ between individuals with traumatic paraplegia with and without shoulder pain. DESIGN: Cross sectional and comparative investigation using the unified questionnaire. SETTING: Neural Regeneration and Repair Division unit of Taipei Veterans General Hospital in Taiwan. PARTICIPANTS: Seventy-six patients with paraplegia (23 with and 53 without shoulder pain) who had experienced spinal cord injury at American Spinal Injury Association Impairment Scale T2 to T12 neurologic level (at least 6 months previously). OUTCOME MEASURES: Spinal Cord Independence Measure (SCIM), a single item from the Medical Outcomes Study 36-Item Short-Form Health Survey, and Patient Health Questionnaire-9 (PHQ-9) depression scale. RESULTS: Shoulder pain was prevalent in 30% patients. Patients with shoulder pain had significantly worse perceived health and greater depressive symptoms than those without. No significant difference was found in functional ability between groups. Greater shoulder pain intensity was related to higher depressive scores (r=0.278, P=0.017) and lower self-perceived health scores (r=-0.433, P<0.001) but not SCIM scores (P=0.342). CONCLUSION: Although shoulder pain was unrelated to functional limitation, it was associated with lower perceived health and higher depressive mood levels.

Corticospinal integrity and motor impairment predict outcomes after excitatory repetitive transcranial magnetic stimulation: a preliminary study.

OBJECTIVE: To identify the effective predictors for therapeutic outcomes based on intermittent theta-burst stimulation (iTBS). DESIGN: A sham-controlled, double-blind parallel study design. SETTING: A tertiary hospital. PARTICIPANTS: People with stroke (N=72) who presented with unilateral hemiplegia. INTERVENTIONS: Ten consecutive sessions of real or sham iTBS were implemented with the aim of enhancing hand function. Patients were categorized into 4 groups according to the presence (MEP+) or absence (MEP-) of motor-evoked potentials (MEPs) and grip strength according to the Medical Research Council (MRC) scale. MAIN OUTCOME MEASURES: Cortical excitability, Wolf Motor Function Test (WMFT), finger-tapping task (FT), and simple reaction time were performed before and after the sessions. RESULTS: MEPs and the MRC scale were predictive of iTBS therapeutic outcomes. Group A (MEP+, MRC>1) exhibited the greatest WMFT change (7.6±2.3, P<.001), followed by group B (MEP-, MRC>1; 5.2±2.2 score change) and group C (MEP-, MRC=0; 2.3±1.5 score change). These improvements were correlated significantly with baseline motor function and ipsilesional maximum MEP amplitude. CONCLUSIONS: The effectiveness of iTBS modulation for poststroke motor enhancement depends on baseline hand grip strength and the presence of MEPs. Our findings indicate that establishing neurostimulation strategies based on the proposed electrophysiological and clinical criteria can allow iTBS to be executed with substantial precision. Effective neuromodulatory strategies can be formulated by using electrophysiological features and clinical presentation information as guidelines.

Massage-induced brachial plexus injury.

BACKGROUND AND PURPOSE: There are few reports in the literature of adverse effects resulting from massage therapy (MT) and no reports of brachial plexus injury (BPI) associated with MT. This case report describes an uncommon case of BPI that developed after a session of MT and reviews previously published reports of peripheral nerve injury following MT. CASE DESCRIPTION: A 58-year-old Asian woman developed sudden unilateral paralysis of her left shoulder girdle after a session of MT. A diagnosis of acute BPI was suspected due to her recent history and the results of several examinations. The results of electrodiagnostic studies indicated a possible location for the lesion and ultimately led to a different diagnosis. OUTCOMES: The patient regularly participated in a twice-weekly rehabilitation program targeting the left shoulder. The rehabilitation program included supervised passive range of motion, strengthening, and stretching exercises as well as a home exercise program. A 12-month follow-up showed the patient had achieved gradual recovery of shoulder strength, resolution of limitations of range of motion, and relief of shoulder pain. DISCUSSION: This is believed to be the first report of BPI associated with MT. This case report serves as a reminder to massage therapists and physical therapists that MT of the neck should be carefully performed to avoid injury. Further studies will help design safer and more effective MT for the future.

Effects of interactive visual feedback training on post-stroke pusher syndrome: a pilot randomized controlled study.

OBJECTIVE: We investigated the effects of a computer-generated interactive visual feedback training program on the recovery from pusher syndrome in stroke patients. DESIGN: Assessor-blinded, pilot randomized controlled study. PARTICIPANTS: A total of 12 stroke patients with pusher syndrome were randomly assigned to either the experimental group (N = 7, computer-generated interactive visual feedback training) or control group (N = 5, mirror visual feedback training). MAIN OUTCOME MEASURES: The scale for contraversive pushing for severity of pusher syndrome, the Berg Balance Scale for balance performance, and the Fugl-Meyer assessment scale for motor control were the outcome measures. Patients were assessed pre- and posttraining. RESULTS: A comparison of pre- and posttraining assessment results revealed that both training programs led to the following significant changes: decreased severity of pusher syndrome scores (decreases of 4.0 ± 1.1 and 1.4 ± 1.0 in the experimental and control groups, respectively); improved balance scores (increases of 14.7 ± 4.3 and 7.2 ± 1.6 in the experimental and control groups, respectively); and higher scores for lower extremity motor control (increases of 8.4 ± 2.2 and 5.6 ± 3.3 in the experimental and control groups, respectively). Furthermore, the computer-generated interactive visual feedback training program produced significantly better outcomes in the improvement of pusher syndrome (p < 0.01) and balance (p < 0.05) compared with the mirror visual feedback training program. CONCLUSIONS: Although both training programs were beneficial, the computer-generated interactive visual feedback training program more effectively aided recovery from pusher syndrome compared with mirror visual feedback training.

Effect of pillow size preference on extensor digitorum communis muscle strength and electromyographic activity during maximal contraction in healthy individuals: a pilot study.

BACKGROUND: Cervical pillow height is an important factor that affects the perception of pillow comfort. However, few studies have addressed methods for predicting a patient's preferred cervical pillow size. We studied the effect of pillow size preference on the strength and electromyographic (EMG) signals of the upper extremity muscle. If the response of the upper extremity muscle is affected by pillow size preference, this would aid in devising an alternate strategy for selecting the optimal pillow size. METHODS: Twenty-nine healthy individuals (mean age: 28.6 years, range: 24-55 years) participated in this study. The participants performed isometric maximal finger extension in the supine position with their heads supported on four different size preferences of cervical pillow (the most comfortable, next most comfortable, worst, and next worst). Maximal contraction force and peak-to-peak EMG amplitude of the extensor digitorum communis (EDC) during contraction were measured. One-way repeated-measures analysis of variance was used to evaluate the effect of pillow size preference. We also explored the relationship between anthropometric parameters and the individual's cervical pillow height preference. RESULTS: The two most comfortable pillows were associated with significantly larger maximal EDC force than the two worst pillows. However, no significant differences in EMG were observed between pillows. No statistically significant correlation was found between anthropometric parameters and pillow height preference. CONCLUSION: The results suggest that anatomical body measurements are not good predictors of optimal pillow height. As EDC muscle strength is affected by pillow height preference, maximal EDC muscle strength may be a useful complement for selecting the optimal pillow size.

Pediatric aquatic therapy on motor function and enjoyment in children diagnosed with cerebral palsy of various motor severities.

This study investigates the effects of pediatric aquatic therapy on motor function, enjoyment, activities of daily living, and health-related quality of life for children with spastic cerebral palsy of various motor severities. Children with spastic cerebral palsy were assigned to a pediatric aquatic therapy group (n = 11; mean age = 85.0 ± 33.1 months; male : female = 4 : 7) or a control group (n = 13; mean age = 87.6 ± 34.0 months; male : female = 9 : 4). The statistic results indicate that the pediatric aquatic therapy group had greater average 66-item Gross Motor Function Measure following intervention than the control group (η(2) = 0.308, P = .007), even for children with Gross Motor Function Classification System level IV (5.0 vs 1.3). The pediatric aquatic therapy group had higher Physical Activity Enjoyment Scale scores than the control group at post-treatment (P = .015). These findings demonstrate that pediatric aquatic therapy can be an effective and alternative therapy for children with cerebral palsy even with poor Gross Motor Function Classification System level.

The therapeutic effect of collateral meridian therapy is comparable to acupoint pressure therapy in treating myofascial pain syndrome.

PURPOSE: This study compared the therapeutic effects of collateral meridian therapy (CMT) with traditional acupoint pressure therapy (APT) in patients with unilateral upper back pain. MATERIAL AND METHODS: Forty-nine patients with active myofascial trigger points in upper trapezius muscle were randomly allocated to the control (CTL), APT, or CMT group. Each subject in the CMT and APT groups received 2 sessions of treatment per week over 1 month. RESULTS: Patients in the APT and CMT groups showed significant improvements 1 month after treatment in visual analogue scale, range of motion, pain pressure threshold, regional superficial blood flow, and physical health, as compared to the CTL group. No significant differences in outcome measures were found between APT and CMT groups 1 month after treatment. CONCLUSION: Both APT and CMT have comparable therapeutic efficacy in the treatment of unilateral upper back pain with active myofascial trigger points in the upper trapezius muscle.

Efficacy of synchronous verbal training during repetitive transcranial magnetic stimulation in patients with chronic aphasia.

BACKGROUND AND PURPOSE: Although multiple studies have suggested that repetitive transcranial magnetic stimulation (rTMS) may facilitate recovery after stroke, the efficacy of synchronous speech therapy integrated with an rTMS protocol has yet to be determined. We investigated language responses to this strategy and determined the longevity of the resulting therapeutic outcomes. METHODS: Forty-five patients with stroke who presented with nonfluent aphasia were randomly assigned to the TMSsyn group and underwent synchronous picture-naming training together with contralesional 1 Hz-rTMS for 10 daily sessions. The TMSsub group underwent subsequent picture-naming activity after the primed 1 Hz-rTMS, and the TMSsham group received concurrent naming task along with the sham 1 Hz-rTMS. The Concise Chinese Aphasia test and the picture-naming test were performed before, immediately, and after 3 months of the intervention. RESULTS: TMSsyn showed significantly superior results in Concise Chinese Aphasia test score (P<0.001), expression and description subtests (P<0.001), and action (P=0.02) and object naming activity (P=0.008); the superior results lasted for 3 months (P=0.005), in comparison with the TMSsub and TMSsham groups. CONCLUSIONS: We established a real-time model that involved implementing verbal tasks together with the rTMS protocol. Our results confirmed that the strategy yielded favorable outcomes that were of considerable longevity. The results also indicated that the rTMS protocol and language training can be combined to achieve outcomes superior to those obtained when used separately. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02120508.

A virtual reality system integrated with robot-assisted haptics to simulate pinch-grip task: Motor ingredients for the assessment in chronic stroke.

BACKGROUND: Among numerous studies on virtual reality (VR) technology for motor rehabilitation, the majorities have only used it as a motor training system and did not use the kinematic or kinetic information obtained as the basis for therapeutic effect assessment. OBJECTIVE: Incorporating the kinematic and kinetic information acquired through a robot-assisted VR system on pinch-grip training, this study intends to propose novel motor ingredients represented as indices for the interpretation of motor behaviors and verify the efficacy of them for the assessment in chronic stroke. METHODS: Clinical trials were conducted on eight stroke patients and clinical assessments were made as the objective standard. Non-parametric test and correlation analysis were performed on results of motor indices and clinical assessments. RESULTS: Non-parametric test indicated that 50% of the motor indices significantly improved while the others showed a trend of improvement, consisting with the findings in clinical assessments. Correlation analysis showed that the three clinical assessment items were correlated to items in the motor ingredients. CONCLUSIONS: The proposed motor ingredients gathered from the robot-assisted VR training system were able to contribute to the assessment of therapeutic effect in chronic stroke and were capable for the interpretation of behavior phases.

Inhibitory repetitive transcranial magnetic stimulation of the contralesional premotor and primary motor cortices facilitate poststroke motor recovery.

PURPOSE: The premotor cortex plays a major role in motor planning and control, exhibiting hierarchical importance comparable to that of the primary motor cortex (M1). In this study, we compared the effects of cPMd modulation, which was achieved using inhibitory repetitive transcranial magnetic stimulation (rTMS), with those of contralesional M1 (cM1) modulation, to elucidate the roles of both regions on longitudinal motor recovery following a stroke. METHODS: Forty-four patients who had sustained hemiplegia for 3 to 12 months were randomly allocated to a cPMd group, cM1 group, or sham group and received 10 sessions of 1-Hz rTMS. The Medical Research Council (MRC) Scale, Fugl-Meyer Assessment (FMA), Wolf Motor Function Test (WMFT), and a cortical excitability test were administered pre- and post- rTMS intervention. RESULTS: cPMd modulation yielded significant improvements in MRC, FMA, and WMFT scores compared with sham stimulation and a significant effect on cortical excitability suppression equivalent to that of cM1 modulation, but engendered effects on motor improvement inferior to those of cM1 modulation. CONCLUSIONS: In patients with chronic stroke, the cPMd can fulfill a role similar to that of the cM1 in interhemispheric imbalance, which can be ameliorated by applying inhibitory rTMS to achieve substantial motor restoration.

Impact of Phase II cardiac rehabilitation on abnormal heart rate recovery.

BACKGROUND: A delayed decrease in heart rate recovery (HRR) following a maximal exercise test is a predictor of mortality in healthy adults and in those referred for diagnostic testing evaluation. Cardiac rehabilitation (CR) has been proven to be beneficial in the treatment of numerous diseases. The purpose of this retrospective study was to explore the relationship between CR and improvement of HRR and to determine which factors can be predictive for the improvement of abnormal HRR after Phase II CR. METHODS: We reviewed the medical histories of patients referred for symptom-limited cardiopulmonary treadmill testing with abnormal HRR. Each patient underwent exercise testing before and after Phase II CR, and parameters including functional aerobic impairment, metabolic equivalent, anaerobic threshold (AT), and %AT were recorded and compared. RESULTS: Of the 25 patients recruited, 13 patients showed no abnormal HRR after Phase II CR. The functional capacity of these patients was improved after Phase II CR, to a statistically significant extent; the aerobic capacity (as expressed with AT and %AT) showed improvement, but without statistical significance. CONCLUSION: There are multiple factors of cardiopulmonary exercise tests that cannot be used to predict the effect of Phase II CR on the improvement of abnormal HRR. Forty-one percent of patients with abnormal HRR could improve after Phase II CR, but all of the patients could have improved exercise capacity regardless of whether or not HRR improved. We can conclude that HRR and exercise capacity change independently. However, it is important to closely follow-up during Phase III CR for patients with persistently abnormal HRR after Phase II CR has been completed.

Increased risk of ischemic stroke in patients with benign paroxysmal positional vertigo: a 9-year follow-up nationwide population study in taiwan.

Benign paroxysmal positional vertigo (BPPV) is a common form of vertigo and is characterized by episodic dizziness related to changes in head position relative to gravity. BPPV symptoms can be similar to those of central nervous system vascular diseases. The association between BPPV and ischemic stroke has not yet been investigated. The study cohort consisted of patients who were diagnosed with BPPV at least twice in the previous year as an outpatient or for whom BPPV was the primary diagnosis as an inpatient (n = 4104). An age- and gender-matched sample that excluded patients with a diagnosis of any form of vertigo was selected as the comparison cohort (n = 8397). All cases were followed up from January 1, 2000, to December 31, 2008. The demographic characteristics, medical comorbidities, and use of medications in both groups were investigated using chi-square tests. A stratified analysis of stroke risk factors was performed to determine the hazard ratios of BPPV. During the 9-year follow-up period, 185 of the 4104 (4.5%) subjects with BPPV and 240 of the 8379 (2.9%) subjects without BPPV developed ischemic strokes. The crude hazard ratio of BPPV for developing ischemic strokes was 1.708. After adjusting for stroke risk factors, the risk of developing ischemic strokes in BPPV subjects was 1.415-fold higher than the risk among those without BPPV (confidence interval: 1.162-1.732, p = 0.001). After a subgroup analysis stratified according to stroke risk factors, BPPV remained independently associated with a higher risk of developing future ischemic stroke. We conclude that BPPV is independently associated with a risk of subsequent ischemic stroke. More aggressive control of modifiable risk factors for ischemic strokes should be conducted in patients with BPPV.

Intraoperative brain mapping to identify corticospinal projections during resective epilepsy surgery in children with congenital hemiparesis.

PURPOSE: The purpose of the study is to determine corticospinal organization using intraoperative neurophysiologic monitoring (IONM) during resective epilepsy surgery for patients with congenital hemiparesis and intractable epilepsy. METHODS: Ten patients, aged 3-17, with intractable epilepsy underwent resective surgery. Transcranial stimulation (TCS) was achieved using a pair of cork screws at Cz and C3/C4, respectively. A 1 × 4 stimulating electrode strip was placed on the presumed motor cortex of the affected hemisphere for direct cortical stimulation (DCS) after craniotomy. Multipulse TCS and DCS train stimulation was delivered, with simultaneous recordings from bilateral abductor pollicis brevis and abductor halluces, to determine the corticospinal projection pattern of the paretic limbs. RESULTS: The above mapping techniques revealed ipsilateral corticospinal projections from the contralesional hemisphere to target muscles in the paretic limbs in three patients, projections from both hemispheres to target muscles in three, and preserved crossed projections from the affected hemisphere in four. Nine patients were seizure free after surgery. Five had unchanged postoperative functional status, and three showed minimally improved use of the paretic hand. Two developed new motor deficits after surgery, which may have been due to a premotor syndrome in one patient, since it completely resolved within 2 weeks. The other experienced increased weakness of the paretic lower limb because a small part of the eloquent cortex was removed for better seizure control. CONCLUSIONS: Using IONM to define the corticospinal projection pattern is a valuable technique that can potentially replace preoperative fMRI and transcranial magnetic stimulation in resective epilepsy surgery, particularly for younger patients.