弥散张量纤维束成像在脑深部肿瘤手术中的应用

目的探讨弥散张量纤维束成像（DTT）在指导脑深部肿瘤手术中的价值。方法对25例脑深部肿瘤病人（实验组）利用DTT对肿瘤与毗邻纤维束的位置关系及纤维束状态进行评估,结合常规MRI设计手术入路及切除范围;另24例病人（对照组）仅根据常规MRI设计手术人路及切除范围。对两组肿瘤的全切除率及术后致残率进行对比分析。结果实验组中,肿瘤全切除18例,部分切除7例;术后出现神经功能缺损或障碍加重3例。对照组中,肿瘤全切除13例,部分切除11例;术后出现神经功能缺损或障碍加重11例。两组肿瘤全切除率差异无统计学意义（P〉0．05）,而对照组术后致残率明显高于实验组（P〈0．01）。结论DTT能清楚显示脑深部肿瘤与毗邻纤维束的位置关系及纤维束被侵犯的程度,有助于设计合理手术入路及切除范围．对最大程度切除肿瘤同时减少术后功能缺损具有重要作用。     

术中磁共振联合神经导航在丘脑胶质瘤手术中的应用

目的探讨术中磁共振(iMRI)联合神经导航在丘脑胶质瘤的应用价值。方法回顾性分析2014-01—2017-02应用3.0T术中磁共振联合神经导航的28例丘脑胶质瘤手术患者的临床资料,评估术后肿瘤切除程度及术后功能状态。结果 28例患者第一次iMRI扫描17例仍有病变残留,进行扩大切除9例达到完整切除,全切率从39.3%提高到71.4%,8例肿瘤边缘累及运动功能皮质或皮质脊髓束无法行完整切除。术后6个月28例丘脑胶质瘤患者神经功能改善者20例,无变化6例,下降2例。结论术中磁共振联合神经导航有助于提高丘脑胶质瘤手术精准性和安全性,提高肿瘤切除程度,最小限度减少脑功能损伤,为术后手术效果提供帮助。     

DTI对脑深部胶质瘤手术入路设计的临床意义

目的探讨术前DTI检查及脑白质纤维束重建对设计脑深部胶质瘤手术入路的临床意义。方法随机选取脑深部胶质瘤病人60例,30例术前仅行MRI检查作为对照组,根据易达及避开功能区的原则选择手术入路;30例术前行MRI+DTI检查作为DTI组,行脑白质纤维三维重建,明确脑白质纤维束与肿瘤的三维空间结构关系,以避开重要纤维束及功能区的原则设计手术入路;比较两组病人术后1个月KPS评分的差异。结果对照组镜下全切19例,次全切7例,部分切除4例,全切率63.3%;DTI组镜下全切18例,次全切7例,部分切除5例,全切率60.0%。两组镜下全切率比较,差异无统计学意义(P0.05)。对照组KPS评分为(81.67±20.69)分,DTI组KPS评分为(91.67±16.42)分;两组KPS评分比较,差异有统计学意义(P0.05)。结论术前DTI检查及脑白质纤维束重建对设计脑深部胶质瘤手术入路有重要指导意义,起到保护重要白质纤维束和降低病残率的作用。     

神经导航及电生理监测下中央区单发转移瘤11例临床分析

目的总结中央区单发转移瘤外科治疗的相关经验,以期提高患者生存率,改善疾病预后。方法本组病例分为Ⅰ型7例(皮质脊髓束位于肿瘤前方)和Ⅱ型4例(旁中央小叶受侵,皮质脊髓束位于肿瘤外侧)。分别选择经中央沟入路和对侧纵裂经大脑镰入路切除肿瘤,术后开展辅助治疗。结果肿瘤均全切,72.7%为肺腺癌转移。10例(90.9%)患者术后一个月神经功能稳定改善,无严重并发症,8例(72.7%)患者功能状态评分大于等于70。术后随访6～31个月,中位生存时间21个月。结论单发中央区转移瘤应积极开展以规范化手术切除为主的综合治疗。个体化分型和手术入路有利于全切肿瘤、保护重要神经功能、改善疾病预后。     

弥散张量成像对丘脑肿瘤手术的临床意义

目的探讨弥散张量成像(DTI)对提高丘脑肿瘤的全切率和降低其致残率的临床意义。方法 2009～2010年收治的18例丘脑肿瘤患者作为DTI组,术前在MRI平扫加增强的基础行DTI检查,并结合纤维束示踪技术,重建锥体束,根据肿瘤与锥体束的三维空间关系设计手术入路。2007～2009年收治的25例未行DTI检查的丘脑肿瘤患者作为对照组。两组均在神经导航下显微手术切除肿瘤,比较两组患者肿瘤全切率及术后致残率的差异。结果 DTI组肿瘤全切除12例(66.7%,12/18),部分切除4例,活检2例;术后神经功能改善10例(55.5%,10/18),无明显变化6例,恶化2例。对照组肿瘤全切除8例(32.0%,8/25),部分切除10,活检7例;术后神经功能改善7例(28.0%,7/25),无明显变化6例,恶化10,死亡2例。DTI组肿瘤全切率及术后神经功能改善率均明显高于对照组(P<0.05)。结论 DTI有助于提高丘脑肿瘤在导航下手术全切率,并有可能降低其术后致残率。     

神经电生理监测在脑深部病变手术中的应用研究

目的探索神经电生理监测在脑深部病变手术中的作用。方法回顾性分析脑深部病变切除手术62例,使用多功能神经电生理监护仪,实施体感诱发电位、脑干听觉诱发电位、运动诱发电位、肌电图、皮质脑电图和直接皮质电刺激等,术中应用B超或无框架导航技术定位病变,尽可能全切病变。结果病灶全切除40例,次全切除22例。术后病人运动功能障碍短暂加重6例,术后3个月均恢复正常,术后神经功能立即改善45例,无明显变化11例。术后病理：海绵状血管瘤15例,脑脓肿5例,胶质瘤28例,脑寄生虫5例,脑膜瘤5例,其他4例。随访0.5～6年,平均3年,全切除病例均未见复发,次全切病例未见进展。结论使用多种神经电生理监护手段可大幅增加脑深部病变手术安全性。     

多模态多维影像融合技术在脑胶质瘤手术中的应用

目的总结1.5T术中磁共振成像联合神经导航技术用于脑胶质瘤外科手术的初步经验。方法回顾49例脑深层或功能区胶质瘤患者临床资料,分析高场强术中磁共振成像联合神经导航技术对其手术策略、肿瘤切除程度、神经功能保留情况及对神经功能转归的影响。结果每例患者均于术中行磁共振成像扫描1～3次,平均(1.57±0.68)次。首次术中磁共振成像肿瘤全切除者17例、不同程度肿瘤残留者32例,显著影响手术策略构成比约为65.31%(32/49)。残留者中9例术中磁共振成像或神经电生理监测提示肿瘤边缘毗邻脑功能区或重要解剖结构,未行全切除;余23例重新注册经导航指引最终实现影像学全切除。初次手术肿瘤全切除率为34.69%(17/49),术中磁共振成像联合神经导航辅助下实现全切除率46.94%(23/49);最终影像学全切除率提高至81.63%(40/49)。术后6个月随访,19例神经功能改善,30例神经功能恢复或接近术前水平;无一例肿瘤进展。结论高场强磁共振成像联合神经导航技术用于脑胶质瘤外科手术可提高肿瘤全切除率,保护患者神经功能。     

高场强术中磁共振成像对脑胶质瘤全切率的影响及其评估

目的 探讨高场强术中磁共振成像(iMRI)对脑胶质瘤手术全切率的影响及其意义.方法 自2009年2月至6月应用高场强iMRI施行脑胶质瘤切除术40例.运用术中影像数据对胶质瘤体积及全切率做回顾性分析.结果 术中第1次行iMRI扫描仅10例胶质瘤完全切除,30例肿瘤仍有残留,23例行进一步切除,其中21例胶质瘤最终全切除.最终肿瘤的伞切率从25%提高到78%,残存肿瘤的体积也明显下降.结论 高场强iMRI的应用显著提高脑胶质瘤手术的全切率.     

脑磁图及弥散张量成像在中央区低级别胶质瘤手术中的应用

目的 探讨联合利用脑磁图(MEG)、弥散张量成像技术(DTI)和神经导航技术,在中央区低级别胶质瘤切除中神经功能保护的作用.方法 对40例涉及中央区的Ⅱ级脑胶质瘤患者,随机分成对照组和试验组两组,每组20例.对照组按照常规神经导航定位肿瘤行手术切除;试验组将脑磁图、DTI与神经导航序列影像融合进行术中导航,术中可视下定位脑皮质功能区及皮质下传导束,来实现精确切除病灶.术后3d内行MRI、DTI检查,比较两组患者的肿瘤切除程度、神经传导束完整性及术后1个月神经功能恢复情况、KPS评分.结果 试验组肿瘤全切除率85％ (17/20)显著高于对照组55％ (11/20);试验组术后致瘫率25％ (5/20)显著低于对照组60％(12/20);试验组术后1个月平均KPS评分(84.50±21.6)分显著高于对照组(64.05±33.36)分.两组在肿瘤切除率、纤维束(FA值)、神经功能保存、KPS评分上的比较,差异均具有统计学意义(均P＜0.05).结论 通过联合利用MEG、DTI及神经导航技术,可最大限度地切除中央区胶质瘤,并更好地保留患者的神经功能,提高其生存质量.     

实时超声引导下显微手术切除脑深部病灶

目的探讨术中超声引导在脑深部病灶显微手术中的应用价值。方法自2004年开始我们在脑深部病灶显微手术中采用实时超声引导病灶定位,指引手术中皮层入路及路径的选择,并使用术中超声影像动态了解病变位置的变化情况、手术切除的范围,利用实时影像辅助判断病变切除程度。结果28例脑深部病灶,病灶直径为1.0～5.9cm,病理诊断包括蛛网膜囊肿5例,海绵状血管瘤2例,动静脉畸形2例,肿瘤7例,脑内血肿12例。所有病例均显微镜下全切,术后28例患者均恢复良好,神经功能保存良好,无新的神经功能损害,无手术并发症。结论术中超声引导是一种简便有效的脑深部病灶定位方法,操作简便,定位准确,能够实时指引手术路径和动态了解手术切除病灶的范围,与显微神经外科配合能够有效地避免额外的手术损伤,提高手术精度。     

Surgical treatment and prognosis of adult patients with brainstem gliomas

The paper presents 47 adult patients who were surgically treated due to brainstem gliomas. Thirteen patients presented with contrast-enhancing Grades III and IV gliomas, according to the WHO classification, 13 patients with contrast-enhancing tumours originating from the glial cells (Grade I; WHO classification), 9 patients with diffuse gliomas, 5 patients with tectal brainstem gliomas and 7 patients with exophytic brainstem gliomas. During the surgical procedure, neuronavigation and the diffusion tensor tractography (DTI) of the corticospinal tract were used with the examination of motor evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs) with direct stimulation of the fundus of the fourth brain ventricle in order to define the localization of the nuclei of nerves VII, IX, X and XII. Cerebellar dysfunction, damage to cranial nerves and dysphagia were the most frequent postoperative sequelae which were also the most difficult to resolve. The Karnofsky score established preoperatively and the extent of tumour resection were the factors affecting the prognosis. The mean time of progression-free survival (14 months) and the mean survival time after surgery (20 months) were the shortest for malignant brainstem gliomas. In the group with tectal brainstem gliomas, no cases of progression were found and none of the patients died during the follow-up. Some patients were professionally active. Partial resection of diffuse brainstem gliomas did not prolong the mean survival above 5 years. However, some patients survived over 5 years in good condition.     

Surgical treatment of paraventricular cavernous angioma: Fibre tracking for visualizing the corticospinal tract and determining surgical approach

Surgical treatment of deep-seated lesions involving the corticospinal tract is one of the most challenging areas of contemporary neurosurgery, even given the recent development of radiological methods including three-dimensional anisotropy contrast magnetic resonance imaging (MRI) axonography. Fibre tracking using diffusion tensor imaging is another MRI technique that can be used to visualize anisotropy and the orientation of white matter tracts in the brain. We report herein a patient with a paraventricular cavernous angioma manifesting as hemiparesis caused by haemorrhage. Preoperative conventional MRI failed to determine the anatomical relationship between the paraventricular lesion and the corticospinal tract, whereas fibre tracking using free software (dTV for MR-DTI analysis) indicated that the corticospinal tract was displaced anterolaterally from the medial side. The paraventricular lesion was completely removed without damaging the corticospinal tract using a transcortical transventricular approach. Preoperative fibre tracking is useful in surgical planning for procedures involving deep-seated lesions adjacent to the corticospinal tract, and may avoid postoperative morbidity due to corticospinal tract injury.     

The earliest MR imaging and proton MR spectroscopy abnormalities in adult-onset Krabbe disease

BACKGROUND: Adult-onset Krabbe disease is an uncommon form of leukodystrophy. Its magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) manifestations are not well documented. AIM OF THE STUDY: To describe early MR findings in adult-onset Krabbe disease. MATERIALS AND METHODS: A 28-year-old woman who had spastic paraparesis and a 5-year history of gait problems underwent MRI of the brain and cervical spine. Proton MRS was performed at 1.5 T using a short echo time. Metabolites were analyzed in the areas of MR signal abnormalities and normal-appearing brain. Six healthy volunteers were examined as controls. RESULTS: MRI revealed changes in the upper corticospinal tracts, splenium and, minimally, adjacent to the atria of the lateral ventricles. MRS showed decreased creatine, choline, N-acetylaspartate and glutamate and probably elevated lactate in the upper corticospinal tract but not in the normal-appearing frontal lobe. The spinal cord was thin. Laboratory tests verified Krabbe disease. CONCLUSIONS: These results indicate early involvement of the upper corticospinal tract in adult-onset Krabbe disease. The cases reported earlier had imaging changes indicating a more advanced disease or no MR findings. Thinning of the spinal cord is a new finding in Krabbe disease.     

Intraoperative diffusion tensor imaging predicts the recovery of motor dysfunction after insular lesions

Insular lesions remain surgically challenging because of the need to balance aggressive resection and functional protection. Motor function deficits due to corticospinal tract injury are a common complication of surgery for lesions adjacent to the internal capsule and it is therefore essential to evaluate the corticospinal tract adjacent to the lesion. We used diffusion tensor imaging to evaluate the corticospinal tract in 89 patients with insular lobe lesions who underwent surgery in Chinese PLA General Hospital from February 2009 to May 2011. Postoperative motor function evaluation revealed that 57 patients had no changes in motor function, and 32 patients suffered motor dysfunction or aggravated motor dysfunction. Of the affected patients, 20 recovered motor function during the 6-12-month follow-up, and an additional 12 patients did not recover over more than 12 months of follow-up. Following reconstruction of the corticospinal tract, fractional anisotropy comparison demonstrated that preoperative, intraoperative and follow-up normalized fractional anisotropy in the stable group was higher than in the transient deficits group or the long-term deficits group. Compared with the transient deficits group, intraoperative normalized fractional anisotropy significantly decreased in the long-term deficits group. We conclude that intraoperative fractional anisotropy values of the corticospinal tracts can be used as a prognostic indicator of motor function outcome.     

Immunohistochemical detection of calcium/calmodulin-dependent protein kinase II in the spinal cord of the rat and monkey with special reference to the corticospinal tract

Calcium/ calmodulin-dependent protein kinase II is a prominent enzyme in the mammalian brain that phosphorylates a variety of substrate proteins. In the present study, monoclonal antibodies that specifically recognize either the α or the β isoforms of this enzyme were used to determine the distribution of these isoforms within the rat and monkey spinal cord. In the rat, the corticospinal tract consists of two components: the dorsal corticospinal tract, which occupies the ventralmost aspect of the dorsal funiculus; and the ventral corticospinal tract, which occupies an area adjacent to the ventral median fissure. Both dorsal and ventral corticospinal tract fibers were strongly immunopositive for the α-antibody. Unilateral ablation of the sensorimotor cortex of the rat eliminated the α-immunoreactive staining in the contralateral dorsal corticospinal tract. The neuropil in the superficial laminae of the dorsal horn (Rexed's laminae I and II) was densely stained with the α-antibody, whereas the neuropil in laminae IV-X was immunonegative. Dense α-immunopositive neurons were also distributed in the head of the dorsal horn (laminae I-IV). In contrast to the strong α-immunoreactivity seen in the dorsal corticospinal tract fibers, only very weak β-immunoreactivity was observed in this tract. Moderate β-immunoreactive products were distributed homogenously throughout the neuropil of the gray matter, although the neuropil of the superficial laminae of the dorsal horn (laminae I and II) was stained more strongly than the other regions of the gray matter (laminae III-X). Neuronal components in all laminae were immunopositive for the β-antibody. Thus, motoneurons in the ventral horn, which were immunonegative for the α-antibody, were immunopositive for the β-antibody. This selective distribution pattern of immunoreactivity of α- and β-antibodies in the rat was also present in the monkey spinal cord, although the α-immunopositive corticospinal tract fibers in the monkey descended in the lateral funiculus as the lateral corticospinal tract instead of passing through the dorsal funiculus, as is the case in the rat. The differential distribution of immunoreactivity in the spinal cord suggests that these two isoforms of calcium/ calmodulin-dependent protein kinase II may have different functional roles in the spinal cord. © Wiley-Liss, Inc.     

胶质瘤生物学特性与相毗邻纤维束状态的相关性研究

目的 探讨胶质瘤生物学特性与相毗邻纤维束状态的相关性. 方法 对24例经手术及组织病理学证实的胶质瘤患者,术前行常规MRI、DTI检查,重建出肿瘤周围纤维束三维图,获得瘤周纤维束的状态:被推移、浸润或者破坏.应用SP免疫组织化学方法对瘤实体标本的MMP-9、CD44、VEGF、Ki-67的表达进行检测分析. 结果 VEGF与Ki-67的表达在高级别胶质瘤中高于低级别胶质瘤(P＜0.05),而MMP-9与CD44的表达在低级别和高级别胶质瘤中均无显著性差异(P＞0.05).高级别胶质瘤周围的纤维束较低级别胶质瘤其被侵犯的程度重(P＞0.05).此外,高表达VEGF或者Ki-67的胶质瘤,瘤周纤维束被侵犯的程度较低表达的胶质瘤重(P＜0.05);而CD44与MMP-9的表达与瘤周纤维束的状态则不具有相关性(P＞0.05). 结论 DTI可清楚显示胶质瘤与周围白质纤维的解剖位置关系及纤维束病理状态,胶质瘤的病理等级和增殖性可影响瘤周纤维束的状态,而其浸润性对瘤周纤维束的状态影响不大,有助于在影像学上对胶质瘤的生物学特性进行判断,指导治疗方案的制定.     

Fractional anisotropy of the corticospinal tract in normal adults Preliminary study using a diffusion tensor imaging technique

BACKGROUND: The corticospinal tract is an important tract for conducting motor function. The majority of studies focus on lesions of the corticospinal tract on appearance and function, whereas observation of normal corticospinal pathways can also improve understanding of lesion outcomes. OBJECTIVE: To observe the normal adult corticospinal tract using a diffusion tensor imaging technique to analyze fractional anisotropy (FA) in different levels of the brain. DESIGN, TIME AND SETTING: Neuroimaging observation was performed in the MRI Department, First Affiliated Hospital of Kunming Medical College in China, from October 2005 to October 2008. PARTICIPANTS: A total of 30 healthy adults were selected from the Department of MRI, First Affiliated Hospital of Kunming Medical College in China, from October 2005 to October 2008, and people with nervous system symptoms and signs were excluded. METHODS: Participants with normal conventional MRI results underwent diffusion tensor imaging examination in a 1.5 T GE MRI (slice thickness 4-5 mm, slice gap 0) for gradient data acquisition from 15 directions. The scanning involved the entire brain from the inferior medulla oblongata to the inferior cranial plate. Imaging post-processing was performed to obtain FA values; a paired Mest was applied for statistical analysis.MAIN OUTCOME MEASURES: FA values of the bilateral corticospinal tract in the medulla oblongata, pons, cerebral peduncle, basal ganglia, corona radiata, and centrum semiovale. RESULTS: FA values in the medulla oblongata and centrum semiovale were similar (P> 0.01). FA values of left corticospinal tract were significantly greater than the right side in the pons, cerebral peduncle, basal ganglia and corona radiata (P< 0.01). CONCLUSION: FA values vary by brain levels, including pons, cerebral peduncle, basal ganglia, and corona radiata. Moreover, FA values of the left corticospinal tract pathway were greater than the right side, which may relate to right handedness.     

Can stroke patients walk after complete lateral corticospinal tract injury of the affected hemisphere?

The lateral corticospinal tract is the major motor pathway in humans. The role of this tract on walking, however, is uncertain. The development of diffusion tensor tractography enables corticospinal tract status to be visualized at the subcortical level. In the present study, we undertook to demonstrate that some stroke patients can walk despite complete lateral corticospinal tract injury. Ten stroke patients who were able to walk with evidence of complete unilateral lateral corticospinal tract injury, as determined by clinical course, brain magnetic resonance imaging, and diffusion tensor tractography, were recruited. We conclude that some stroke patients can walk despite complete lateral corticospinal tract injury of the affected hemisphere.     

Reorganization of the corticospinal tract following neonatal unilateral cortical ablation in rats

The corticospinal tract in the rat after neonatal ablation of the unilateral cerebral cortex was studied morphologically and histochemically using the retrograde and antegrade horseradish peroxidase (HRP) tracing methods. The normal corticospinal tract in the lumbar cord was composed of a number of small and some large axons. In the atrophic corticospinal tract related to the ablated cerebral cortex, the small axons were decreased in number two weeks after the operation. However, new myelinated small axons appeared around day 28 and their diameters increased gradually from after day 56 to day 84. The original large axon in the atrophic corticospinal tract was much more increased in size than that in the corticospinal tract of the non-operated-on control. When HRP was injected into the left cervical cord of the adult rat whose right cerebral cortex had been ablated during the neonatal period, a considerable number of HRP-labeled neurons was seen in the healthy left cerebral cortex. When the corticospinal tract was traced antegradely by injecting HRP into the healthy left cerebral cortex, an aberrant corticospinal tract reaching into the ipsilateral dorsal funiculus was observed. These results give a morphological basis for the well known fact that children who have had brain damage during the neonatal period and early infancy have the capacity for recovery of motor function.     

Prognostication Value of Descending Corticospinal Tract DWI Signal in Neonatal Cerebral Sinovenous Thrombosis

BackgroundDescending corticospinal tract diffusion-weighted magnetic resonance imaging (MRI) signal is predictive of poor motor outcome in neonatal and childhood arterial ischemic stroke. However, descending corticospinal tract diffusion-weighted MRI signal has not been documented in the setting of cerebral sinovenous thrombosis, and its role is not understood.ObjectiveWe describe a neonate with cerebral sinovenous thrombosis, extensive diffusion restriction, and bilateral descending corticospinal tract diffusion-weighted MRI signal on MRI of the brain. We discuss the underlying mechanisms and implications of these findings in venous ischemia.ConclusionThe prognostic value of descending corticospinal tract diffusion-weighted MRI signal differs when observed in cerebral sinovenous thrombosis from when observed in arterial ischemic stroke. Consequently, caution should be exercised in using descending corticospinal tract diffusion-weighted MRI signal to predict outcome in children with cerebral sinovenous thrombosis.