Surgery versus Botulinum Toxin A for Treatment of Post-Stroke Upper-Limb Spasticity: White Matter Changes, Function, and Quality-of-Life-A Randomized Controlled Trial.

INTRODUCTION

A magnetic resonance image (MRI) study recently described greater improvements in gray matter volume and cortical thickness in post-stroke patients with upper-limb spasticity treated with surgery versus botulinum toxin-A (BoNT-A).

OBJECTIVE

To compare changes in the white matter of these patients after surgical versus BoNT-A treatment and to relate findings to upper-limb function and quality-of-life.

METHODS

In a two-arm randomized controlled clinical trial, 30 post-stroke patients (>12 months) with spastic upper limbs were recruited and randomly assigned (1:1) to surgery or BoNT-A treatment (controls). Functional and quality-of-life parameters were studied at baseline (pre-intervention) and at 6 months, while brain MRI scans of the white matter were taken at the same time points using a Siemens 3T Prisma MRI scanner. Although baseline MRI scans were obtained in all 30 participants, complete longitudinal MRI data were available for only 14 participants because of contraindications or refusal of follow-up imaging. Therefore, the imaging analyses were considered only exploratory and hypothesis-generating.

RESULTS

Increased post- versus pre-surgery fractional anisotropy (FA) values were associated with Carer Burden and House functional scale scores, and decreased FA values with Ashworth, Fugl-Meyer, pain visual analogue scale, and SF-36 scores. Reduced mean diffusivity (MD) values for inferior fronto-occipital fasciculus, cingulum parahippocampal parietal, uncinate fasciculus, and reticular tract were associated with improvements in Fugl-Meyer motor recovery scores.

CONCLUSION

The post-pre increase in FA of white matter tracts in the experimental versus control group may suggest differences in white matter microstructure between treatment groups, potentially reflecting neuroplastic changes. These findings suggest that changes in white matter microstructure might be associated with improvements in motor function, independence, and caregiver burden. However, given the small longitudinal MRI sample, the tract-specific findings should be considered hypothesis-generating and require confirmation in larger studies.