Unusual cortical stimulation findings: connectivity between primary motor and supplementary motor areas

We describe a 42-year old patient with right hand sensorimotor seizures who underwent extraoperative cortical stimulation mapping (CSM) of the left primary motor cortex (M1). Cortical stimulation of the region where primary motor cortex was expected evoked exclusively complex motor responses with proximal right arm and proximal left leg asymmetric tonic movements that are usually observed on stimulation of the supplementary motor area (SMA). Right hand function could not be isolated during either extraoperative or intraoperative cortical stimulation of the anatomical M1 representation. Ictal and interictal activity was contained within the region with the abnormal motor response, and MEG of interictal activity showed spike propagation from the left mesial to lateral frontal cortex. This propagation pathway may have facilitated M1-to-SMA connectivity and therefore explain the unusual motor response after stimulation of M1. This case highlights the potential impact of interictal activity on plasticity of the motor cortex.