Penfield’s Motor Homunculus Revisited:

New Data from cortical and subcortical intraoperative

motor mapping

Mr Prajwal Ghimire
MBBS MRCSEd. MSc
Clinical Fellow and Registrar Neurosurgery

King’s College Hospital, London, UK

 Conflict of Interest: None; No disclosures

Cortical mapping Literature Subcortical

review mapping
Introduction: Standing on the Shoulder of the Giants!

Penfield W, Boldrey E. Brain 60:389–443 (1937)

 Materials and Methods
• Single center retrospective study Jan 2015-
Jan 2020 (n=180)

• Intraoperative data on consecutive patients

who underwent craniotomy for eloquent
brain lesions with intraoperative cortical and
sub- cortical motor neuromonitoring

• 1mA = 1mm (Distance to CST/MT)

• Pre-op: Neuro-oncology MDT, MRI tumour

protocol, fMRI, DTI, nTMS

• Intra-op: Cortical and subcortical

stimulation/mapping, IONM (MEPs), ioUS
(brain shift)

• Post op: T1 post GAD MRI Ghimire P et al. Brain Struct Funct 226, 1601–1611 (2021)
 Cortical Motor Mapping

• cMEPs: recorded with direct electrical monopolar

stimulations of primary motor cortex
• Muscles monitored

• orbicularis oris, masseter, tongue,

• Parameters for stimulation:
cricothyroid,
• Train of five pulses,
• UL:
• positive pulse form,
• deltoid, brachioradialis/flexor carpi
• inter-stimuli interval of 4.0 ms,
ulnaris (BR/FCU), abductor pollicis
• pulse width of 0.5 ms, 1 Hz and anodal pole
brevis/abductor digiti minimi
(APB/ADM), first dorsal interosseous
(FDI), intercostals
• Continuous cMEPs were monitored using a four-
contact strip electrode positioned over the motor
• LL:
• quadriceps femoris, tibialis anterior,
cortex recording stable MEPs at the motor
abductor hallucis.
threshold.

Ghimire P et al. Brain Struct Funct 226, 1601–1611 (2021)

 Results: Patient Demographics

Demographics Data
Mean Age (years) (with Range) 50 (16-79)
Laterality of the lesion N (%)
Right 97 (53.8%)
Left 83 (46.2%)
Gender N (%)
Male 105 (58.4%)
Female 75 (41.6%)
Pathology of the lesion
Glioma
-High Grade (III,IV) 104 (57.7%)
-Low Grade (I,II) 41 (23%)
Meningioma 8 (4.4%)
Metastasis 25 (13.8%)
Vascular malformations 2 (1.1%)

Ghimire P et al. Brain Struct Funct 226, 1601–1611 (2021)

Cortical Motor Mapping

a 1,2,3: hand and forearm 4,5: foot and leg

b 6,7,8,9,10,11,13,14- hand knob (ADM, FDI, APB,

forearm, deltoid) 1,2,5- post central gyrus

c 1,2: intercostal muscles 3,4: deltoid 5: foot

d 1,2: arm, forearm, hand 3,4,5: hand, face 6,7: face

Ghimire P et al. Brain Struct Funct 226, 1601–1611 (2021)

 Cortical Motor Mapping
Cortical MT Intraoperative Representation (Tag Numbers)
Stimulation
Leg 12mA 1,2,3: hand and forearm

4, 5: foot and leg

Intercostal 12mA 1,2-intercostals

Muscles
3,4-deltoid

5 -Foot

Arm 10mA 1,2 – arm, forearm, hand

3,4,5 – hand and face

6,7 – face

Hand 6mA 6,7,8,9,10,11,13,14- hand knob

(ADM, FDI, APB, forearm, deltoid)

1,2,5- post central gyrus

Face 10mA 5,6,7- Face

Ghimire P et al. Brain Struct Funct 226, 1601–1611 (2021)

 Cortical and subcortical intercostal muscles Stimulation (MEP)
SN Age Location of lesion Histopathology Cortical Subcortical nTMS
stimulation stimulation pre-op
1 53y Right SMA Anaplastic Oligodendroglioma Grade III N Y; 4mA Yes
(IDH -, ATRX preserved)
2 64y Right parietal Metastatic malignant melanoma N Y; 4mA Yes
3 35y Right SMA Oligodendroglioma Grade III (IDH1 mutant, ATRX N Y; 5mA Yes
preserved)
4 69y Left Precentral Radiation induced Vascular malformation Y; 14 mA Y; 6mA No
5 31y Right parietal Glioblastoma Grade IV (IDH wild; ATRX preserved; N Y; 6mA No
MGMT unmethylated)
6 62y Left Precental Metastatic Carcinoma Lung Y;12mA N Yes
7 41y Left Central lobule Metastatic Breast Carcinoma Y; 10mA N Yes
8 56y Left precentral Metastatic lung Carcinoma Y; 6mA Y; 12mA Yes
9 57y Right frontal Anaplastic oligodendroglioma (IDH-mutant, grade III Y; 10mA Y Yes
IDH1 R132H clone positive (IHC) ATRX retained)
10 36y Right frontal Anaplastic gemistocytic astrocytoma (IDH mutant, Y N Yes
WHO grade III ATRX lost)
11 36y Left precentral Glioblastoma, IDH-wildtype, grade IV (WHO) N Y; 5mA Yes
(IDH wildtype ATRX expression retained
Unmethylated MGMT promoter)

Ghimire P et al. Brain Struct Funct 226, 1601–1611 (2021)

Proposal of supplemental map of cortical motor region
(clinical cortical motor homunculus)

Ghimire P et al. Brain Struct Funct 226, 1601–1611 (2021)

 Sub-cortical mapping

• Subcortical motor evoked potentials (scMEPs) were recorded using modified monopolar
suction probe and monopolar probe

• Parameters were same as cMEP recording with cathodal pole

(Seidel et al. 2013; Schucht et al. 2017; Lavrador et al. 2020)

Ghimire P et al. Brain Struct Funct 226, 1601–1611 (2021)

 Literature Review
Subcortical intraoperative mapping demonstrating each mapped area
SN Articles N Technique Pathology Mapped Areas MT (mA)

Leg Trunk Arm Hand Face

1. Duffau et al, 39 Bipolar Glioma + - + + + -
2003
2. Mikuni et al, 21 Monopolar Glioma + - + + - 5-15
2007 Train of 4 Cavernoma
(cortical) Ependymoma
Bipolar train of 4
(subcortical)
3. Bello et al., 57 Monopolar Glioma + - + + - 3.5-16
2008

4. Vassal et al., 10 Monopolar Glioma + - + + + -

2013
5. Bello et al., 591 High frequency Glioma + - + + + HF: 5-13
2014 (monopolar) vs LF: 2-6
Low frequency
(bipolar)
6. Ghimire et al., 1 Monopolar Glioma - + - - - 5
2019 (Train of 5) Intercostal
muscle
Ghimire P et al. Brain Struct Funct 226, 1601–1611 (2021)
 scMEP DCS Subcortical stimulation scMEP DCS Subcortical stimulation

Sub-cortical mapping b

1 2

3 4

a. Subcortical stimulation in the resection cavity

demonstrating subcortical mapping of the corticospinal 5 6

tract with contact numbers (b.1–15)

7 8

13 14

9 10

Ghimire P et al. Brain Struct Funct 226, 1601–1611 (2021)

15 11 12
 Sub-cortical mapping
Subcortical Stimulation MT Representative Demonstration

Leg 4mA 1,2,3- hand

5- face
6- foot
7,8,9- UL, LL

6,7,8- 5-7mA
9- 4mA

Intercostal muscles 4mA

1,2,3,10- hand, forearm (10 mA)
4,5- foot, leg (12 mA)
6- Intercostal Muscles
7,8- foot, leg
9- hand, forearm (5 mA)

Arm 1,2,3- Intercostal muscles (cortical)

4- Deltoids (arm)
5- foot
6,8- Hand
7- UL, LL, Face, Intercostal muscles
Hand 9- Intercostal muscles (subcortical) 12mA
10- Hand (subcortical)

20mA

Face
Green- Superimposed CST model with operating
microscope

Ghimire P et al. Brain Struct Funct 226, 1601–1611 (2021)

Proposal of map of intraoperative subcortical corticospinal tract (isCST)
(clinical subcortical motor homunculus)

Ghimire P et al. Brain Struct Funct 226, 1601–1611 (2021)

Conclusion

Penfield’s motor homunculus represented a landmark in understating the functional

anatomy of the motor cortex with real implications for surgery in motor eloquent
brain.

• Data from a large cohort of patients

• Modern intra-operative stimulation of motor pathways,
• widely accepted standard methodology for brain mapping based on accuracy
and clinical relevance,
• Generated a supplementary updated motor homunculus and a novel
subcortical motor map.

• will aid surgical planning for lesions in or around the motor pathways
• to reduce the risks
• increase the extent of resection.

Ghimire P et al. Brain Struct Funct 226, 1601–1611 (2021)

Future Directions

Probabilistic Atlas/Maps

Large Scale Prospective studies with normalization of stimulation sites into a

template space

IO Mapping with Enhanced Correlation with DTI/non-invasive Tracing of CST

Ghimire P et al. Brain Struct Funct 226, 1601–1611 (2021)

 The Team
Neuro-Oncology Neurosurgeons
Ranjeev Bhangoo
Neuropathology Department
Keyoumars Ashkan
Richard Gullan
Neuroradiology Department
Francesco Vergani
José Pedro Lavrador
Neurology Department
Gerald Finnerty
Neurosurgery Fellows and Trainees
Katia Cikurel
Physician Associates
Research Team
Sabina Patel
Gerald Finnerty
Alastair Kirby
CNS Nurses
Natalie Long
Vicky Hurwitz
Josephine Jung
Liz Ford
Sashika Selvackadunco
Laura Mullens
Charlote Robinson
Speech and Language Therapist
Jessica La
Hilary Wren
Maria McEwan
Neuro-Physiotherapy Team Questions?
Neurophysiology
Guy’s Cancer Centre Neuro-Oncology
INOMED Neurocare Ltd
Noémia Pereira
Kent Cancer Centre Neuro-Oncology
Hannah Keeble

King’s College Hospital

Dipendra Yadav
And all other Neuro-Oncology Collaborators
Argel Lajarde
Fábio Martins
Ana Milharve