CASE REPORT

Ipsilateral Motor Innervation Discovered

Incidentally on Intraoperative Monitoring:
A Case Report
Jerry Ku, MD∗
Daniel Mendelsohn, MD∗
Jason Chew, MB, ChB‡
Jason Shewchuk, MD‡
Charles Dong, PhD∗
Ryojo Akagami, MD∗
∗
Division of Neurosurgery, Department
of Surgery, Faculty of Medicine, Univer-
sity of British Columbia, Vancouver,
British Columbia, Canada; ‡ Division of
Neuroradiology, Department of Radi-
ology, Faculty of Medicine, University
of British Columbia, Vancouver, British
Columbia, Canada
Correspondence:
Ryojo Akagami, MD.
Gordon and Leslie Diamond Health
Care Centre,
8109 – 2775 Laurel Street,
Vancouver, BC V5Z 1M9, Canada.
E-mail: ryojo.akagami@vch.ca
Received, November 18, 2015.
Accepted, November 11, 2016.
Published Online, January 10, 2017.
BACKGROUND AND IMPORTANCE: Lesions in the corticospinal tract above the decus-
sation at the medullary pyramids almost universally produce contralateral deficits. Rare
cases of supratentorial lesions causing ipsilateral motor deficits have been reported
previously, but only ever found secondary to stroke or congenital pyramidal tract
malformations.
CLINICAL PRESENTATION: Herein, we report a case of ipsilateral corticospinal tract
innervation discovered incidentally with intraoperative monitoring during a microsur-
gical resection of a vestibular schwannoma. Intraoperative monitoring with electrical
transcranial stimulation of the frontal scalp triggered motor-evoked potentials in the
ipsilateral arms. The uncrossed pathways were later confirmed with MRI tractography using
diffusion tensor imaging.
CONCLUSION: To the best of our knowledge, this is the first case of isolated ipsilateral
motor innervation of the corticospinal tract discovered incidentally during a neurosur-
gical procedure. Given the increasing use of intraoperative monitoring, this case under-
scores the importance of cautious interpretation of seemingly discordant neurophysio-
logical findings. Once technical issues have been ruled out, ipsilateral motor innervation
may be considered as a possible explanation and neurosurgeons should be aware of the
existence of this rare anatomic variant.
KEY WORDS: Ipsilateral motor innervation, Corticospinal tract, Intraoperative monitoring, Diffusion-weighted
imaging, Tractography
Neurosurgery 80:E194–E200, 2017 DOI:10.1093/neuros/nyw074 www.neurosurgery-online.com

Copyright 
C 2016 by the BACKGROUND AND IMPORTANCE
Congress of Neurological Surgeons
Although a variable proportion of fibers cross
within the corticospinal tracts in humans,1
lesions rostral to the medullary pyramids
almost universally cause contralateral extremity
weakness. Rare cases of supratentorial lesions
causing ipsilateral motor deficits have been
reported previously, but only ever found
secondary to stroke2-5 or congenital pyramidal
tract malformations.4,6,7
We report a case of ipsilateral corticospinal
tract innervation discovered incidentally with
intraoperative monitoring during a microsur-
gical resection of a vestibular schwannoma.
The uncrossed pathways were confirmed with
diffusion tensor imaging (DTI). The anatomy
of the corticospinal tracts, neurobiology of
fiber crossing, methods for investigating human
motor pathways, and implications in intraoper-
ative monitoring are discussed within the context
of this unusual nervous system variant.
CLINICAL PRESENTATION
A 28-year-old right-handed Caucasian female
presented with progressive right ear hearing loss,
numbness of the chin, cheek and tongue, right
eye tearing, and imbalance developing over 6
months. There was no facial motor asymmetry at
baseline. The patient was previously healthy with
an unremarkable family history. Physical exami-
nation revealed horizontal end-gaze nystagmus,
decreased right V2 and V3 sensation, and dimin-
ished right-sided corneal and gag reflexes. An
audiogram showed right unilateral sensorineural
hearing loss. A brain MRI demonstrated a 3.0 ×
2.4 × 3.0 cm right-sided intracanalicular internal
auditory canal and cerebellopontine angle mass,
displacing the trigeminal nerve superiorly and

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FIGURE 1. Preoperative axial fat-saturated T1-weighted MRI post-
gadolinium administration. A 3.0 × 2.4 × 3.0 cm mass is visualized in the
right internal auditory canal (white arrow) and cerebellopontine angle (black
arrow), consistent with a vestibular schwannoma.
extending inferiorly past the jugular foramen (Figure 1). Mild
distortion of the pons was noted. The clinical picture and
imaging were consistent with a right vestibular schwannoma.
Informed consent was received from the patient for a retrosigmoid
craniotomy for microsurgical resection.
Operative Procedure
After left lateral decubitus positioning, neurophysio-
logical intraoperative monitoring of median and tibial nerve
somatosensory evoked potential (SSEP) and facial and
upper limb motor evoked potential (MEP) were established
(Figure 2). With stimulation of the median nerve at the wrist and
the tibial nerve at the ankle, SSEP responses were registered in the
peripheral and cortical channels. Stimuli consisted of repetitive
rectangle electrical pulses with the pulse width of 200 μs and
intensity of 25 mA for the median nerve and 50 mA for the tibial
nerve, delivered at 4.7 Hz. Cortical SSEP responses were recorded
with scalp electrodes at CPc (active)/CPi (reference) following
activation of the median nerve and at CPz (active)/FPz (reference)
and CPz (active) /CPc (reference) following stimulation of the
tibial nerve. Peripheral SSEP responses were recorded at the
medial surface of the arm 2 and 5 cm above the cubital crease
(Brp and Brd, respectively). MEPs were elicited with transcranial
electrical stimulation (TcES) and obtained from the bilateral
first dorsal interosseous and flexor carpi ulnaris (Figure 2B).
MEPs from the lower extremities were not assessed. Pulse train
NEUROSURGERY
IPSILATERAL MOTOR INNERVATION
stimulation was applied with spiral needle electrodes at C3 or
C4 (anode) and Cz (cathode). Each pulse train consisted of 3
electrical pulses of 100 μs in width and 150 to 160 V in intensity
with an interstimulus interval (ISI) of 1 μs. Facial MEPs were
produced with TcES applied at an electrode on the left frontal
scalp (C3) referenced to Cz and recorded from the right orbic-
ularis oris (Figure 2C). Stimuli consisted of trains of 6 pulses of
100 μs in width and 160 V with an ISI of 1 μs. Left facial MEPs
were not assessed.
While obtaining baseline tracings, electrical transcranial stimu-
lation of the frontal scalp triggered MEPs in the ipsilateral
arms. After comprehensive troubleshooting and verification of
proper monitoring techniques, a technical etiology was excluded.
Functionally uncrossed corticospinal tracts were the presumed
cause, and the case proceeded without incident. Of note, the
SSEPs were appropriately contralaterally innervated. A gross total
resection was achieved with no intraoperative or postoperative
complications.
Postoperative Course
The patient reported marked improvement in unsteadiness
postoperatively. Audiograms indicated residual hearing in the
right ear. Her facial function remained normal. There was still
mild nystagmus on right lateral gaze. An immediate postoperative
MRI including DTI demonstrated resection of the right acoustic
neuroma with findings consistent with postoperative granulation
tissue (Figure 3). A delayed follow-up MRI with repeat DTI was
also obtained 2 years later, once the parenchymal distortion and
postsurgical changes had resolved (Figure 4). MRI scans were
performed on a Siemens Aera 1.5T scanner with a 20-channel
receive-only head coil (Siemens, Munich, Germany). Standard
DTI using 20 diffusion directions and 5 mm slices was performed
of the whole head including the skull base. Postprocessing was
performed using the SyngoVia thin-client (Siemens) at a picture
archiving and communication system workstation by a neurora-
diologist. Both immediate postoperative and delayed follow-up
scans confirmed the uncrossed corticospinal tracts on DTI. No
further brain anatomic abnormalities were present.
DISCUSSION
Intraoperative monitoring is increasingly used to monitor
nervous tissue function during brain and spine surgery when
eloquent structures are at risk.8-10 Extremity and facial MEPs are
highly sensitive to detect corticospinal and corticobulbar injury
during surgery.8-10 When monitoring abnormalities occur, the
surgical team must determine if they are related to events at
the surgical site or due to confounding factors. Gradual gener-
alized MEP reductions suggest systemic factors such as anesthesia
depth or fade, whereas more abrupt generalized reduction may be
seen with stimulus failure, sedation boluses, abrupt hypotension,
neuromuscular blockade, or bilateral intracranial air.11 Focal
MEP deterioration is the hallmark of surgical neurological
injury, but can also be due to confounding factors such as
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KU ET AL

FIGURE 2. A, Illustration of scalp electrodes placed for eliciting MEP and SSEP. Letters and numbers are according to the International 10–20 System of Electrode
Placement. B, Stimulation of the left motor cortex (C3/Cz) showed MEPs in the left first dorsal interosseous (DI) and flexor carpi ulnaris (FCU), and stimulation of
the right motor cortex (C4/Cz) showed MEPs in the right first DI and FCU, with no activity on the contralateral side. C, Stimulation of the left frontal scalp produced
right facial MEP and left first DI MEP.

downward electrode displacement, brachial plexus, or peripheral
nerve conduction failure due to limb malpositioning, pressure
or ischemia, or asymmetric intracranial air.11 Seemingly spurious
ipsilateral MEPs may be secondary to incorrect set up of the
cranial or limb electrodes, and therefore technical issues should
first be excluded.10 Subsequently, decussation anomalies can be
assessed with trials of alternating bilateral and unilateral SSEP and
MEP recordings to demonstrate hemispheric origin.12 Ideally, this
should be done before interpreting or monitoring evoked poten-
tials but this may be done at any time during the operation should
the need arise.11,12 In our case, the correct lateralization of the
monitoring leads and electrodes were verified intraoperatively,
and uncrossed corticospinal tracts were later confirmed to be the
cause using tractography. To the best of our knowledge, this is
the first case of isolated ipsilateral motor innervation discovered
incidentally with intraoperative monitoring during a neurosur-
gical procedure.
Only a few cases of clinically ipsilateral innervation of the corti-
cospinal tract have been reported in the literature. 3-5,12-21 These
patients were diagnosed in the context of vascular insults proximal
to the pyramidal decussations or congenital disorders, using a
variety of methods (Table). Unlike other cases, our patient did
not have any other structural brain anomalies.
DTI is a method for imaging the diffusion of water molecules
within the brain on MRI. Water molecules will preferentially
diffuse along the length of an axonal structure (anisotropic
diffusion), and this provides the basis for tractography using
diffusion MRI.22 In our case, DTI was used to visualize the corti-
cospinal tract and to determine lack of decussation in the medulla.
Similar methods have previously been used to visualize ipsilateral
motor innervation.4,17,21
Approximately 60% of axons in the corticospinal tract
originate in the primary motor cortex.23 Fibers of the corti-
cospinal tract pass through the posterior limb of the internal

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FIGURE 3. Postoperative axial fat-saturated T1-weighted MR image post-
gadolinium administration. Resection of the cerebellopontine angle and
internal auditory canal mass with a small amount of enhancing scar tissue
is visualized (black arrow).
capsule, the cerebral peduncle, and basis pontis and then 75%
decussate at the medullary pyramids to form the lateral corti-
cospinal tract.24 Ten percent of axons remain uncrossed in the
ipsilateral lateral corticospinal tract and the remaining 15% form
an ipsilateral uncrossed anterior corticospinal tract.25 Although
human cadaveric studies have demonstrated substantial variations
in crossing patterns,26 lesions proximal to the pyramidal decussa-
tions nearly universally cause contralateral extremity deficits.
The embryology of the corticospinal tracts has been eluci-
dated with animal models and limited human studies.6 Layer V
neurons of the cortical plate extend projections distally during
embryogenesis and they continue developing postnatally, with
myelination occurring within the first years of life.6,7 Decus-
sation at the medullary pyramids is completed by 17 weeks of
gestation.6 A number of diffusible molecules mediate axonal
guidance toward midline and decussation. The absence of
netrin-1 or its receptor in mice causes impaired pyramidal decus-
sation.27 The Roundabout (ROBO) family of receptors are
known to guide axons toward and away from the midline in
vertebrates.28 Interestingly, a gene mutation in ROBO3 was
recently implicated in horizontal gaze palsy with progressive
scoliosis, seminally linking the molecular underpinnings of axonal
guidance with human disorders of pyramidal decussation.16
In addition, in Situ hybridization has demonstrated abundant
expression of this gene in the basis pontis of the human fetal
brain at 15 and 19 weeks of gestation, consistent with its role
NEUROSURGERY
IPSILATERAL MOTOR INNERVATION
in pyramidal decussation.16 The existence of individuals with
uncrossed pyramidal tracts raises fascinating questions into the
origins and evolutionary significance of pathway crossing in the
central nervous system.
The most comprehensive theory on why pathways cross the
midline was first articulated by Santiago Ramon y Cajal over 100
years ago.7,29 Cajal postulated that visual pathway crossing was
necessary to restore image continuity in the brain that would
otherwise be disrupted by image inversion through the lens.7,29
Sensory pathways then crossed to allow for a global representation
contralateral to the stimulus. Motor decussation then followed so
that ipsilateral sensory stimuli would activate motor function in
the ipsilateral limb. Indeed, the corticospinal tract is phylogenet-
ically a young tract found only in a few mammals capable of fine
motor movements.30 Computational models of 3-D spatial repre-
sentation have demonstrated a mathematical advantage for infor-
mation crossing in the central nervous system.31 Crossing allows
for faster processing speed, reduces the amount of information
necessary to impart somatotopy, and carries a lower likelihood
of miswiring errors from occurring compared with uncrossed
arrangements.31 Although a number of advantages to pyramidal
decussation have been proposed, the existence of asymptomatic
normally functioning individuals with uncrossed pyramidal tracts
suggests that pathways crossing in the central nervous system
may not be a necessary requirement for normal neurological
functioning.
CONCLUSION
Nondecussated pyramidal tract is a rare congenital occur-
rence that can either occur as part of a clinical syndrome or
in isolation and without deficits. In isolated cases of uncrossed
motor innervation, this congenital variant is only discovered
based on ipsilateral motor findings secondary to a unilateral struc-
tural injury proximal to the pyramidal decussations. Patients
with uncrossed corticospinal pathways have been further inves-
tigated with MRI, fMRI, transcranial stimulation for MEPs
and SSEPs, and visualized with DTI tractography. In this case,
our patient was found to have ipsilateral motor innervation
incidentally discovered by intraoperative monitoring of MEPs,
and confirmed via DTI tractography. Given the increasing use
of intraoperative monitoring, this case underscores the impor-
tance of cautious interpretation of seemingly discordant neuro-
physiological findings. Once technical issues have been ruled out,
ipsilateral motor innervation as a possible explanation may be
considered, and neurosurgeons should be aware of the existence
of this rare anatomic variant.
Disclosure
The authors have no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
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KU ET AL

FIGURE 4. A, DTI tractography in a coronal reformat, encoded such that blue fibers represent craniocaudal tracts,
red transverse, and green anteroposterior. This demonstrates lack of crossing of the corticospinal tracts (black arrows)
in the medulla. B, DTI composite image selectively showing the corticospinal tract in blue. Note that the tract remains
ipsilateral (white arrow). C, DTI tractography in a normal control subject for comparison, with crossing of portions
of the corticospinal tracts (black arrows).

TABLE. Cases of Ipsilateral Corticospinal Tract Reported In the Literature

Article Clinical context Other anatomical abnormalities

Cuatico (1979)13 Ipsilateral hemiparesis following left anterior cerebral artery occlusion None reported
for treatment of anterior communicating artery aneurysm. Ipsilateral
CST suspected based on clinical picture
Lagger (1979)14 Following death due to unrelated causes, ipsilateral CST visualized on Dandy-Walker malformation
postmortem serial sections of the brain stem and spinal cord in 2
patients with Dandy-Walker syndrome
Kudo and Uno (1984)15 Ipsilateral hemiparesis following ruptured middle cerebral artery None reported
aneurysm diagnosed with head CT and cerebral angiogram

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 IPSILATERAL MOTOR INNERVATION

TABLE. Continued

Article Clinical context Other anatomical abnormalities

Hosokawa et al (1996)3
Terakawa et al (2000)5
Jen et al (2004)16
MacDonald et al (2004)12
Mori et al (2005)17
Amoiridis et al (2006)18
MacDonald et al (2007)19
Abu-Amero et al (2009)20
Ng et al. (2011)4
Alurkar et al (2012)21
Ipsilateral hemiparesis following right internal capsule and Flat medulla on MRI.
thalamic hemorrhage. Ipsilateral CST confirmed with MRI Ipsilateral SSEP
visualization of Wallerian degeneration and with MEP
Ipsilateral hemiparesis following right putamenal hemorrhage. Wedge-shaped medulla on MRI.
Ipsilateral CST confirmed with MEP and fMRI Ipsilateral SSEP
Case series of patents with HGPSS. Ipsilateral MEP in all of the HGPSS.
patients assessed (n = 4) Pontine hypoplasia and “butterfly” medulla in
all patients assessed with MRI (n = 8).
Ipsilateral SSEP in all patients assessed (n = 4)
Ipsilateral MEP in patient with HGPPS undergoing scoliosis HGPSS. Ipsilateral SSEP. Pontine hypoplasia
surgery and “butterfly” medulla on MRI
In a patient with HGPSS, DTI visualized uncrossed right pyramidal HGPSS. Pontine hypoplasia
tracts and incompletely crossed left pyramidal tracts and “butterfly” medulla on MRI
Case series of patients with HGPSS. Ipsilateral MEP in all patients HGPSS. Ipsilateral SSEP
assessed (n = 2)
Review of 206 spine surgeries with intraoperative monitoring. HGPSS. Ipsilateral SSEP
Ipsilateral MEP in 4 patients with HGPPS
Case series of patients with HGPSS. Ipsilateral hemiparesis in HGPPS. Pontine hypoplasia and “butterfly”
1 patient following traumatic subdural hematoma. Ipsilateral medulla in all patients assessed with MRI
MEP in 7 patients with HGPPS undergoing scoliosis surgery (n = 5) Ipsilateral SSEP
Ipsilateral hemiparesis following left subcortical ischemic stroke. HGPPS. Pontine hypoplasia and “butterfly”
Ipsilateral CST confirmed with DTI medulla on MRI
Ipsilateral hemiparesis following right subcortical ischemic None reported
stroke. Ipsilateral CST confirmed with DTI

CST, corticospinal tract; DTI, diffusion tensor imaging; HGPSS, horizontal gaze palsy with progressive scoliosis; MEP, motor evoked potentials; SSEP, somatosensory evoked poten-
tials.

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COMMENTS
T he authors describe an interesting case of uncrossed corticospinal
tracts discovered incidentally during intraoperative monitoring.
They have demonstrated the presence of uncrossed fibers using DTI and
discussed the peculiar problems this benign anatomical variant can cause
when detected during intraoperative monitoring. The anatomy and the
physiology of the corticospinal tracts discussed in the paper makes an
interesting read.
However, I suspect that this phenomenon may not be as uncommon
as it appears. The widespread use of DTI and MEPs may detect these
anatomical variations more commonly as evident from Table in the paper.
The presence of this anomaly with changes in MEP during spinal surgery
(especially intramedullary tumors) can be extremely tricky to interpret if
the surgeon is unaware of such a variant. The surgeon and electrophys-
iologist therefore should be aware of these variations, since discordant
readings during surgery can often be a potential source of worry. On the
other hand, it is important to perform a thorough search for technical
problems before anatomical variations can be presumed to be present.
Chandan Mohanty
Mumbai, India
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