Case Reports Motor Organization After Early Middle Cerebral Artery Stroke: A PET Study Ralph-Axel Mu ¨ ller, PhD*, Craig E. Watson, MD † , Otto Muzik, PhD*, Pulak K. Chakraborty, PhD ‡ , and Harry T. Chugani, MD* †‡ The brain organization for movement in a 20-year-old man with a history of intrauterine or perinatal right middle cerebral artery stroke was studied. [ 15 O]-water positron emission tomography demonstrated a normal pattern of activation during finger movement in the right hand. Movement of the hemiparetic left hand was associated with activation in the supplementary motor area bilaterally and in the left premotor cortex. Blood flow increase was observed in the right temporal lobe adjacent to an extensive area of encephalomalacia, suggesting atypical motor function in the temporal lobe. © 1998 by Elsevier Science Inc. All rights reserved. Mu ¨ller R-A, Watson CE, Muzik O, Chakraboty PK, Chugani HT. Motor organization after early middle cere- bral artery stroke: A PET study. Pediatr Neurol 1998;19: 294 -298. Introduction Functional imaging studies on postlesional reorganiza- tion in the motor domain in the past have focused mostly on adult stroke patients. Motor recovery has been reported to be associated with activations in the precentral and postcentral sulci [1], as well as the insula and the inferior parietal lobe [2]. A study including pediatric patients suggested an enhanced potential for interhemispheric mo- tor reorganization after lesion in the first few years of life (as compared with late lesion onset) [3]. Although some studies have reported homotopic interhemispheric re- organization into primary sensorimotor cortex of the undamaged hemisphere [2,4,5], the authors’ data suggest predominantly nonhomotopic reorganization (i.e., reallo- cation of motor functions into secondary motor regions and regions that are not primarily dedicated to motor function in the normal brain) [3,6,7]. In the present study, motor organization in a patient with early intrauterine or perinatal stroke involving the motor cortex of the right hemisphere was evaluated. Patient and Methods The patient is a 20-year-old right-handed man with chronic intractable epilepsy. There were no indications of perinatal complications, but slow achievement of early milestones and left hemiparesis were noted soon after birth. The first seizure occurred at approximately 8 years of age. Cognitive delays were evident throughout childhood. Current seizure frequency is variable (about one daily with seizure-free periods). Sei- zures are complex partial and typically characterized by a blank stare with impaired awareness and responsiveness, lip smacking, and automa- tisms, especially in the right upper limb. Postictally, the patient is confused and occasionally demonstrates language deficits. Current anti- epileptic medications are valproic acid and phenytoin. On neurologic examination, mild mental retardation was noted. Mus- cle tone was increased on the left side of the body, and hemiparesis was mild to moderate on the left with greater involvement of the upper rather than the lower limb. Tendon reflexes were brisker on the left (3/4) compared with the right (2/4), and plantar reflexes were flexor on the right and equivocal on the left. Sensory examination (including tactile localization and stereognosis, pain, vibration, and joint position) and cerebellar examination were within normal limits. Gait and stance were mildly hemiparetic. Neuropsychologic testing demonstrated borderline intellectual functioning (FSIQ: 72, VIQ: 75, and PIQ: 70), with moder- ate-to-marked impairment of language and verbal memory and mild-to- moderate visuospatial deficits. The patient underwent video electroencephalogram monitoring for 5 days during which time he had five clinical and electrographic complex partial seizures, one of them with secondary generalization. No subclin- ical seizures were recorded during the entire period of monitoring, which was carried out with automated seizure and spike detection software and 24-hour technician surveillance. Magnetic resonance imaging demonstrated a porencephalic cyst and encephalomalacia in the right frontotemporal region (in the distribution of the middle cerebral artery) characteristic of an intrauterine or perinatal vascular event (Figs 1, 2). Evaluation failed to uncover the cause of the stroke. Family history for stroke and myocardial infarction is positive. A 2-deoxy-2[ 18 F]fluoro-D-glucose positron emission tomography (PET) scan demonstrated absent glucose metabolism in the distribution of the right middle cerebral artery and hypometabolism in the remaining neocortex, lentiform nucleus, and thalamus of the right hemisphere. Normal glucose metabolism was seen in the left cerebral hemisphere and both cerebellar hemispheres. From the Departments of *Pediatrics; † Neurology; and ‡ Radiology; Wayne State University Medical School; Detroit, Michigan. Communications should be addressed to: Dr. Chugani; Children’s Hospital of Michigan; 3901 Beaubien Boulevard; Detroit, MI 48201. Received January 26, 1998; accepted April 13, 1998. 294 PEDIATRIC NEUROLOGY Vol. 19 No. 4 © 1998 by Elsevier Science Inc. All rights reserved. PII S0887-8994(98)00049-6 ● 0887-8994/98/$19.00