初级皮质运动区和锥体束的可视化研究及应用

目的探讨基于血氧水平依赖功能磁共振成像(BOLD-fMRI)和弥散张量成像(DTI)的功能神经导航技术在神经外科手术中对脑功能区进行显微镜下可视化的可行性。方法连续收集2009年2月-2010年7月初级运动皮质及锥体束附近病变患者278例,男156例,女122例,年龄40.7±15.9(7~79)岁。278例中胶质瘤231例,转移瘤5例,脑膜瘤16例,海绵状血管瘤18例,动静脉畸形2例,血管内皮细胞瘤1例,生殖细胞瘤3例,淋巴细胞瘤2例,均在功能神经导航下行手术切除。术前应用BOLD-fMRI及DTI技术进行扫描,通过导航工作站重建手运动区和锥体束并将导航影像投射至手术显微镜,用于镜下导航。比较患者术前及术后的肌力、运动功能及KPS评分,并统计手术并发症发生情况。结果 278例患者中217例(78.1%)病变切除≥95%,246例(88.5%)病变切除≥90%,259例(93.2%)病变切除≥80%;术后1周内神经功能障碍加重发生率为22.3%(62/278),随访1~6个月神经功能障碍发生率为6.8%(19/278)。结论在神经外科手术中应用fMRI及DTI结合功能神经导航对脑功能区进行显微镜下可视化是可行的,可最大限度地切除病变,减轻神经功能损伤,有利于术后功能恢复。     

神经外科术中磁共振成像对麻醉的影响

目的探讨MRI技术用于神经外科手术时对麻醉的影响。方法选取60例胶质瘤患者,随机分为两组,30例在术中磁共振成像(iMRI)及功能神经导航指导下行开颅胶质瘤切除(iMRI组),30例在功能神经导航指导下行传统开颅胶质瘤切除(N组),记录两组患者一般情况、麻醉时间、手术准备时间、手术时间、术中出血量、输液量、输血率、术前及术后血红蛋白浓度、术后体温、肌肉松弛剂用量、围术期与iMRI及麻醉相关的意外情况等。结果与N组比较,iMRI组患者一般情况、麻醉时间、术中出血量、输液量、输血率、血红蛋白浓度及术后体温均无显著差异(P>0.05),但手术准备时间、手术时间明显延长,肌松药用量明显增加(P<0.05)。两组均无与iMRI及麻醉相关的意外发生。结论 iMRI用于神经外科手术提高了手术精确度,使肿瘤切除更彻底,但手术时间明显延长,而其他围术期特点与传统神经外科手术并无差别。iMRI用于神经外科手术时的麻醉处理在遵循一般神经外科麻醉处理原则的基础上,还应关注长时间手术的麻醉调控。     

现代微侵袭神经外科进展

微侵袭神经外科（Minimallyinvasiveneurosurgery）这一命名是1992年德国学者Hellwig和Baner首先提出的,当时仅指神经内窥镜术（Neuroendoscopy）。后来这一概念扩大,除神经内窥镜术外,还包括介人神经放射（血管内神经外科）,立体定向神经外科,放射神经外科以及显微神经外科。微侵袭技术在神经外科中的应用主要体现在以下几个方面。1内窥镜在神经外科的应用早在本世纪初就有神经外科医生应用内窥镜（脑室镜、膀胱镜）电凝侧脑室中的脉络丛或在第三脑室底造屡以治疗脑积水,但因内窥镜本身性能所限阻碍了它的发展。1970年以后随着光导…     

终末期肾病患者伴认知障碍的多模态磁共振研究进展

终末期肾病（end-stage renal disease,ESRD）作为慢性肾脏病的严重转归,常伴随多系统并发症,其中认知功能损伤在ESRD患者中普遍存在。神经影像学是探究认知损伤潜在机制的有效手段,多模态磁共振成像的深入应用可从脑结构及功能改变的角度提供客观的神经影像学线索。本文对ESRD伴认知障碍患者的相关多模态磁共振成像研究进展进行综述。     

脑梗死后运动功能障碍重塑的MRI研究进展

脑梗死严重危害人类健康和生活。脑梗死后患者会遗留有不同程度功能障碍,但随发病时间延长,梗死患者运动功能障碍会有不同程度恢复。近年来采用多模态磁共振成像技术研究发现,脑梗死后病灶周围或远隔病灶的脑结构会发生结构或功能改变,对患者的临床预后有重要作用。本文综述了脑梗死后脑结构和功能改变的多模态磁共振表现,从而进一步揭示脑梗死后脑重塑机制。     

SonoWand超声神经导航系统在脑肿瘤手术中的应用

目的 评价术中三维超声神经导航系统在脑肿瘤手术中的应用价值.方法 应用SonoWand超声神经外科系统,对术前计算机体层摄影术/磁共振成像资料进行手术计划和术中导航,也可在术中直接应用三维超声进行导航.结果 本组进行脑肿瘤手术13例,共14个病灶;全切除13个(92.9%),次全切除1个(7.1%);手术切口和骨瓣较常规开颅手术小;病灶邻近运动区的7例患者,5例术后肌力未受影响,2例出现一过性肌力下降,2周后恢复至术前水平.本组无症状恶化及死亡者,未发现应用超声神经导航系统导致的手术并发症.结论 SonoWand超声神经导航系统具有定位准确、微侵袭、安全可靠等特点,通过术中实时超声扫描,解决了脑组织移位问题,有助于提高脑肿瘤的全切除率.     

大脑功能组织可视化及fMRI术中导航在脑肿瘤切除术中的应用

目的 探讨术前功能组织三维可视化及功能信息引导下无框架立体定向导航技术于脑肿瘤切除术中的应用价值。材料与方法 将我院收治的拟行立体导航的中央沟附近脑肿瘤患者随机分配到功能导航组及普通导航组,各30例。功能组所有患者均行术前功能组织定位,并将信息导入神经外科导航仪行术中功能区导航。普通导航组患者术中未加入功能信息。比较两组患者手术疗效、肿瘤切除率、运动功能改善情况以及术后肿瘤患者生存质量。结果 功能导航组均于术前完成功能组织可视化,且于术中成功标定肿瘤、中央沟及运动区。术中功能信息在开颅前（辅助设计皮瓣;确定骨窗位置及大小,减少骨瓣大小;确定肿瘤和运动区投影的边界及相互关系;确定肿瘤手术切除的方向和深度）及开颅后（打开硬膜前、后实时导航功能区与病变的位置;确定病变及运动区相对位置的术中超声定位,修正由于脑脊液流出、肿瘤塌陷所致的功能区及病变的移位）均起到明显效果。随访结果显示：在手术疗效（u =2.646, P=0.008）、肿瘤切除率（?2 ＝7.200, P<0.01）、患者术后运动功能改善情况（u =2.231, P=0.026）及术后生存质量（KPS评分 uc=2.664, P=0.008; Zubrod-ECOG-WHO评分 uc =2.135, P=0.033）等方面,功能组均优于普通组。结论 应用术前功能组织可视化辅助手术计划,实施术中功能信息引导下的神经导航技术,结合术中超声的准确定位,能够正确判断脑功能区与病变的关系,使手术方案个体化,实现在尽可能保护功能区的情况下最大限度切除肿瘤的目的,提高术后患者的生存质量。     

超声-MRI融合导航技术在神经外科手术中价值的初步探讨

目的:通过与MRI神经导航进行对比分析,评价超声-MRI融合导航技术在神经外科手术中的应用价值.方法:纳入2018年1月—2018年12月在我院接受神经外科手术患者,分为试验组(超声-MRI融合导航组,34例)和对照组(MRI神经导航组,62例),所有患者均经病理证实.对比分析2组患者一般资料(性别、年龄、病灶大小、病...     

急性酒精中毒对记忆功能影响的功能性磁共振研究进展

随着磁共振成像技术的不断发展,多模态磁共振研究急性酒精中毒如何影响记忆、情感及奖励机制取得了一定进步,功能磁共振成像能够提供非侵入性的脑功能检测,评价认知功能.然而单一的成像方法难以阐明急慢性酒精相关性脑损害的功能和结构特征,同时运用两种或多种神经成像方法,例如动脉自旋标记(ASL)、功能磁共振成像(fM-RI)、基于体素的形态学分析法(VBM)和磁共振波谱成像(MRS)等在临床工作中已变得越来越重要.本文就急性酒精中毒的磁共振脑功能成像的相关研究进展进行综述.     

微侵袭神经外科

微侵袭神经外科是现代高科技成果在神经外科领域内应用的综合体现,是在神经影像学、微导管技术、立体定向技术、光学设备系统、激光技术、超声技术、放射医学和计算机科学等迅速发展的基础上形成的。这些技术的相互结合,增加了治疗的安全性和精确性,扩大了治疗的范围,形成了神经外科领域中一个极具活力的部分。目前应用这些技术,已可以最小的损伤治疗某些神经外科疾病,达到既可较安全地治愈疾病又能最大限度地保全神经功能的目的。这无疑是神经外科病人的福音。同时也促使神经外科工作者积极地熟悉和驾驭这些新技术和新方法。1　内窥镜神经…     

全脑3D-MRI在神经导航术中的应用

目的:探讨全脑3D-MRI在神经导航手术中的应用价值。方法:回顾分析30例脑肿瘤患者,根据不同的类型选择相应的MRI序列进行全脑3D-T2WI或3D-T1WI扫描,定位线上缘超出头顶,下缘包括鼻尖,然后图像在导航系统工作站进行三维重建,建立起脑部立体图像,导航定位并指导手术操作。结果:本组30例患者图像均采集成功,MRI原始图像与导航系统计算机融合后,三维立体重建效果满意,所有病例病灶均达到术前计划的实施全切(16例)或部分切除(14例),术后临床症状均有不同程度的改善,与以往类似患者的手术时间相比,呈缩短趋势。结论:全脑3D-MRI为神经外科术中导航提供了原始的影像资料,对于手术精确定位及路径选择具有重要的意义。     

进步中的介入神经血管内治疗

在临床医学高速发展的今天,随着材料科学的进步和计算机技术的不断改进,作为微创医学重要组成部分的经血管内介入治疗技术已进入了一个全新的发展阶段,并具备患者痛苦小、治疗效益高的优势,逐渐被广大患者和临床医生所接受.经过近30年的努力,国内的神经介入工作已形成了由神经外科、神经内科、血管外科和放射科医生组成的强强组合,遵循着...     

Computer-based imaging and interventional MRI: applications for neurosurgery.

Advances in computer technology and the development of open MRI systems definitely enhanced intraoperative image-guidance in neurosurgery. Based upon the integration of previously acquired and processed 3D information and the corresponding anatomy of the patient, this requires computerized image-processing methods (segmentation, registration, and display) and fast image integration techniques. Open MR systems equipped with instrument tracking systems, provide an interactive environment in which biopsies and minimally invasive interventions or open surgeries can be performed. Enhanced by the integration of multimodal imaging these techniques significantly improve the available treatment options and can change the prognosis for patients with surgically treatable diseases.     

术中灰阶及彩色多普勒超声在颅内占位性病变切除术中的应用

目的评价灰阶及彩色多普勒超声技术在颅内占位性病变手术中的应用价值.资料与方法回顾性分析经头颅 CT、MRI 证实的26例颅内占位性病变患者的临床资料,对比患者术前 CT 或 MRI 与术中实时超声显示的病变范围、病变周围组织变化的差异;对其中17例脑内实体性占位病灶的矢状位、冠状位和轴位径线进行测量并计算体积,与术前影像学结果进行对比;通过术中超声指导手术切除占位病变,与术后 MRI 对比,总结手术全切率.结果术中超声对26例患者的病灶范围、周围脑组织变化情况及病变的血流分布情况均能有效显示,并与术前 CT 或 MRI 结果一致;且术中超声对实体性占位体积的测量结果与术前影像学结果相一致(t =1.757, P >0.05),术后经超声探查未发现术腔残留,与术后头颅 MRI 复查对比证实术中超声引导下的占位全切除率为93%.结论术中超声对颅内病灶定位的准确性与 CT、MRI 相当,并且能实时便捷地在术中应用,指导神经外科微创手术治疗.     

Intraoperative MR-guided neurosurgery

For more than a decade neurosurgeons have become increasingly dependent on image guidance to perform safe, efficient, and cost-effective surgery. Neuronavigation is frame-based or frameless and requires obtaining computed tomography or magnetic resonance imaging (MRI) scans several days or immediately before surgery. Unfortunately, these systems do not allow the neurosurgeon to adjust for the brain shift that occurs once the cranium is open. This technical inability has led to the development of intraoperative MRI (ioMRI) systems ranging from 0.12-3.0T in strength. The advantages of ioMRI are the excellent soft tissue discrimination and the ability to view the operative site in three dimensions. Enhanced visualization of the intracranial lesion enables the neurosurgeon to choose a safe surgical trajectory that avoids critical structures, to maximize the extent of the tumor resection, and to exclude an intraoperative hemorrhage. All ioMRI systems provide basic T1- and T2-weighted imaging capabilities but high-field (1.5T) systems can also perform MR spectroscopy (MRS), MR venography (MRV), MR angiography (MRA), brain activation studies, chemical shift imaging, and diffusion-weighted imaging. Identifying vascular structures by MRA or MRV may prevent injury during surgery. Demonstrating elevated phosphocholine within a tumor may improve the diagnostic yield of brain biopsy. Mapping out neurologic function may influence the surgical approach to a tumor. The optimal strength for MR-guided neurosurgery is currently under investigation.     

神经外科新进展

目的调研神经外科专业现状和发展动态,为确定军队神经外科研究方向提供参考。方法采用情报调研方法,检索近5年来部分国内外神经外科研究文献,分析全军神经外科领域基础研究与临床工作取得的新进展。结果十一五期间,军队神经外科在保持颅脑战、创伤研究等传统优势领域的同时,在脑与脊髓肿瘤、血管内治疗、功能性神经外科疾病等领域取得了巨大成效,共获得军队科技进步和医疗成果奖47项。人才梯队建设成果斐然。但是,神经外科专业在军内、军地、地区之间的发展还不很均衡,需要进一步加强技术合作。结论在今后一个时期,军队神经外科既要紧跟世界神经外科发展趋势,重视基础和临床研究,又要推进军事特色技术创新,在颅脑创伤救治、防护设备研制、非专科治疗等方面加强研究工作。     

Preoperative imaging as the basis for image-guided neurosurgery

With the progressive development of soft- and hardware, the acceptance of image-guided neurosurgery has increased dramatically. Additional image data are required to analyze the nature and the dimensions of pathological processes and the surrounding tissue. In this context, fMRI, SPECT, PET, as well as special modalities of CT and MR imaging, are routinely used. Secondary post-processing options are used to detect intracerebral lesions as well as adjacent functional eloquent regions in the parenchymatous organ pre- and intraoperatively. The integration of different image information guarantees the precise planning and realization of surgical maneuvers. The segmentation of interesting structures and risk structures, as well as their implementation in the neuronavigation systems, help to avoid additional intraoperative traumatization and offer a higher level of safety and precision. In this article the value and limitations of presurgical imaging will be discussed.     

Reformatted imaging to define the intercommissural line for CT-guided stereotaxic functional neurosurgery

Functional stereotaxic neurosurgery has traditionally required definition of the line between the anterior and posterior commissures as the basis for defining the target site for a procedure such as stereotaxic thalamotomy. While axial computed tomographic (CT) imaging precisely defines the third ventricle and the commissures, the planes of the axial images are not necessarily parallel to the important intercommissural line. A technique is described in which coronal oblique reformations are obtained, with the reformations passing through both the anterior and posterior commissures. Stereotaxic coordinates of the target obtained from this reformatted image are directly transferable to the CT-compatible Leksell frame. Both imaging and surgery are performed on the scanner, which is located in an operating room especially designed for CT-guided surgical procedures.     

Tc-99m exametazime-labeled leukocyte scans in the study of infections in skull neurosurgery

Diagnosis and follow-up of skull infections are usually performed by neurologic examination, laboratory tests and instrumental diagnostic methods such as computed tomography (CT) and magnetic resonance imaging (MRI). These have, however, shown some limitations for specificity. The aim of the current study was to evaluate the overall contribution of Tc-99m exametazime-labeled leukocyte imaging scan Tc-99m hexamethylpropyleneamine (HMPAO) labeled white blood cells (WBC) in the diagnosis and management of infections in skull neurosurgery. Thirty-four patients were subdivided into 4 groups on the basis of the suspected pathology: intracerebral lesions on CT or MRI (group A, n = 20), suspected postsurgical infections (group B, n = 6), suspected deep infection of the surgical wound (group C, n = 4), and suspected infection of the ventriculoperitoneal shunt (group D, n = 4). All patients underwent CT, MRI, and Tc-99m HMPAO WBC imaging. Patients in group C also underwent bacteriologic and culture examinations of wound secretions if present. In positive cases in group A, Tc-99m HMPAO WBC imaging was repeated. The scintigraphic results were compared with histologic findings in patients who underwent surgery and with the results of a 12-month clinical follow-up in the remaining patients. Tc-99m HMPAO WBC scans correctly detected the infections in all groups. Furthermore, such imaging proved to be able to document recovery from the disease in all of the assessed cerebral abscesses. This study may have an important role both in the diagnosis and in the management of infections in skull neurosurgery, which, it is hoped, will be confirmed in the future.