术中唤醒直接电刺激在运动区胶质瘤切除术中的应用

目的探讨术中唤醒直接电刺激在运动区胶质瘤切除术中的应用效果。方法回顾性分析2015年3月至2017年7月南部战区总医院神经外科收治的34例位于运动区胶质瘤患者的临床资料。其中肿瘤位于左侧16例,右侧18例;肿瘤位于辅助运动区或运动前区23例,中央叶9例,从辅助运动区或运动前区侵袭到中央叶2例。患者均采用全身麻醉术中唤醒技术,神经导航和(或)术中超声定位病变位置,直接电刺激定位皮质和皮质下重要功能区,按照功能边界切除胶质瘤。患者术后均行神经功能和肿瘤切除程度的评估。结果34例患者中,有24例术中直接皮质电刺激后出现运动反应,13例有异常感觉,10例定位出语言相关皮质。皮质下电刺激有24例出现运动反应,1例有异常感觉,8例语言紊乱。共有30例(88.2%)肿瘤切除达到功能边界,另外4例(11.8%)皮质下电刺激未发现功能纤维,均为高级别胶质瘤患者。34例患者术后48 h内复查头颅MRI显示,肿瘤全切除22例(64.7%),次全切除9例(26.5%),部分切除3例(8.8%)。34例患者的随访时间为(23.6±8.6)个月(11.3~39.3个月),其中29例(85.3%)术后早期新发神经功能障碍或原有神经功能障碍加重;发生晚期神经功能障碍较术前加重者3例(8.8%),其中轻度1例、中度1例、重度1例(2.9%)。术前存在神经功能障碍或颅内压增高的16例患者中,术后3个月有13例神经功能好转,2例维持在术前状态,1例为重度神经功能障碍。结论术中唤醒状态下直接电刺激定位和持续监测运动区皮质和皮质下白质纤维,可最大程度地安全切除运动区胶质瘤,其远期重度神经功能障碍的发生率较低,术后生命质量提高。

Application of direct electrical stimulation in awake craniotomy for glioma resection in the motor area

Objective To explore the effect of direct electrical stimulation in awake craniotomy for glioma resection in the motor area.Methods We conducted a retrospective analysis of clinical data of 34 patients with gliomas in the motor area who were admitted to Department of Neurosurgery,General Hospital of Southern Theatre Command from March 2015 to July 2017.The tumor was located in the left hemisphere in 16 patients and right hemisphere in 18.The gliomas were in supplementary motor area or premotor cortex in 23 cases,the central area in 9 cases,and supplementary motor area or premotor cortex invading the central area in 2 cases.All patients underwent awake craniotomy under general anesthesia.Neuronavigation and/or intraoperative ultrasound were employed to locate the lesion.Direct electrical stimulation was used for cortical and subcortical mapping of the important eloquent areas.The tumors were removed according to the functional boundary.Neural function and the degree of tumor resection were evaluated after operation.Results Of the 34 patients,24 had a motor response after direct cortical electrical stimulation,13 had abnormal sensations,and 10 revealed language-related cortices through mapping.For subcortical electrical stimulation,there were 24 cases of motor response,1 case of abnormal sensation,and 8 cases of language disorders.A total of 30 cases(88.2%)of tumor removal reached functional boundaries,and subcortical electrical stimulation did not identify functional fiber in the remaining 4(11.8%)cases which were all high-grade gliomas.Within 48 hours post surgery,the head MRI indicated total resection of tumor in 22 cases(64.7%),subtotal resection in 9(26.5%),and partial resection in 3(8.8%).The follow-up time of 34 patients was(23.6±8.6)months(11.3-39.3)months.There were 29 cases(85.3%)which showed early postoperative neurofunctional disorders or worsening of pre-existing neurological deficits.Three cases(8.8%)developed late postoperative neurological dysfunction worse than preoperative conditions,of which 1 case was mild,1 case was moderate and 1 case(2.9%)was severe.Of the 16 patients with preoperative neurological dysfunction or increased intracranial pressure,13 had improved neurological function in 3 months after surgery,2 were maintained in preoperative state and 1 had severe neurological deficits.Conclusions Functional mapping through direct electrical stimulation and continuous monitoring of the cortical and subcortical white fibers in the motor area during awake craniotomy could maximize the safe resection of glioma in the motor area,the incidence of long-term severe neurological deficits is low,and the quality of life could be improved after surgery.