唤醒麻醉和术中功能定位切除语言区胶质瘤

目的探讨语言功能区胶质瘤的手术策略。方法回顾性分析手术治疗30例语言功能区胶质瘤。在唤醒麻醉下应用术中直接皮质电刺激确定语言区,根据功能边界切除肿瘤。评价患者的功能结果及切除程度。结果术中语言功能区监测成功20例;未监测到4例;因麻醉或术中高颅压不能进行监测6例。随访3个月,3例患者存在中度语言功能障碍。全切14例,近全切12例,大部切除4例。结论术中皮质电刺激确定语言功能区准确、安全、可靠。唤醒麻醉下进行术中皮质电刺激结合术前神经功能影像技术,确定切除肿瘤的功能边界,能够最大程度切除肿瘤,同时保护正常的语言功能,使术后语言障碍的风险降到最低。     

低级别胶质瘤累及区对运动功能影响的影象学定量分析研究

目的 通过基于体素的影像学定量分析探讨累及运动区的低级别胶质瘤与肌力改变的关系,在体素水平计算肿瘤累及引起肌力改变的风险值,绘制肌力变化风险图.方法 将52例低级别胶质瘤患者的肿瘤占位区域分别标记并配准到MNI坐标系标准脑图谱上,在标准空间内叠加所有患者的肿瘤占位影像.计算每个体素有肌力变化的病例数占总叠加层数的百分比,并通过色阶将风险率显示在标准脑图谱上.结果 得到基于体素的低级别胶质瘤运动区占位与肌力改变发生率风险图谱,定量显示出运动区及其周围低级别胶质瘤占位对肌力影响的风险值,M1区手结区的外侧及次级运动区风险值多处在30％左右,而从M1区手结区向内侧风险值逐渐提高,从40％逐渐增至80％,前内侧最高,达80％以上.并依据风险值的差异将手结区层面运动区分为三个风险级别不同的区域.结论 基于影像学分析得到运动中枢风险图谱能够有效的反应低级别胶质瘤运动区占位与肌力改变的相关性,预测性的评估运动区肿瘤性损害对患者肌力改变情况.     

低级别胶质瘤继发癫痫的手术治疗

目的 探讨低级别胶质瘤继发癫痫的手术治疗方法.方法 采用视频脑电、脑磁图定位致痫灶、功能区,手术中联合应用立体定向引导、术中B超、术中皮质电刺激等技术治疗继发癫痫的低级别胶质瘤13例.结果 全部患者在手术切除、保护神经功能的同时,控制了癫痫发作,临床效果良好.结论 多种定位技术的联合应用,可在最大程度切除肿瘤、致痫灶的同时减少脑组织损伤,保留脑功能区皮质,控制癫痫发作,提高患者生活质量.

Abstract：

Objective To explore the methods of surgical treatment of low-grade glioma with secondary epilepsy.Method Video-EEG,magnetoeneephalography ( MEG) were performed to localizated the epileptogenic zone and domain in 13 patients,and stereotactic technology,ultrasound,electrocorticogram (EcoG) were performed intraoperative combinating to treat the low-grade gliomas that lead to epilepsy.Results The seizure was controlled while the tumor was resected and the neural function were protected in all patients.The clinical effect was significant.Conclusions The combination of multiple technology to localize the epileptogenic can resect the tumor or the epileptogenic zone maximum, reduce the injury of normal brain tissue,protect the cortex of brain domain,control the epileptic seizure and improve the patients' quality of life.     

低级别胶质瘤与癫痫

低级别胶质瘤与癫痫的发生密切相关,但是机制不明.目前研究发现不同肿瘤类型,不同病理级别,不同部位及功能区与非功能区癫痫发生率却有显著的差别.口服抗癫痫药物,治疗原发性肿瘤包括手术,放化疗及生物治疗等措施均能够较好的控制癫痫发作.本文就低级别胶质瘤与癫痫的关系及低级别胶质瘤患者中癫痫的控制作一综述.     

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。     

低级别胶质瘤的显微手术治疗

中枢神经系统低级别胶质瘤侵及范围广泛且发病早期多无明显症状及体征，作出临床诊断时肿瘤体积已经较大，肿瘤活检加放疗的效果很不满意。作者自1998年3月至2005年1月应用显微外科技术治疗低级别胶质瘤17例，术后进行放射治疗，取得了良好效果，现报道如下：     

直接皮质刺激运动诱发电位在累及运动区胶质瘤切除术中运动通路保护研究

目的在累及运动区的胶质瘤切除术中．利用直接皮质刺激产生的运动诱发电位（MEP）去判断运动传导通路纤维的数量和功能，并分析其变化和术后病人四肢运动功能的关系。方法对42例累及运动区的胶质瘤病人．术中利用微弱电流直接刺激运动区皮质并记录产生的运动诱发电位，比较肿瘤切除前、中、后MEP的变化，分析肿瘤切除后MEP下降程度和术后3个月四肢运动功能的关系。结果切瘤后MEP较切瘤前波幅下降50％以上26例，其中出现严重运动功能障碍17例（65．4％）．轻度运动功能障碍9例（34．5％）；MEP下降50％以下16例，其中出现严重运动功能障碍2例（1.3％），轻度运动功能障碍10例（62．5％）．基本正常4例（25．0％）。两组严重运动功能障碍经Х^2检验，P〈0．05，差异有统计学意义。结论术中行直接皮质刺激运动诱发电位监测可直接反映运动传导纤维的数量和功能，预测术后肢体运动情况。MEP波幅下降50％可作为将发生严重运动功能障碍的临界警戒点．     

低级别胶质瘤临床治疗现状

<正>胶质瘤是颅内最常见的原发性恶性肿瘤。根据病理学特点,世界卫生组织将胶质瘤分为I-IV级,其中I-II级为低级别胶质瘤(low-grade gliomas,LGGs),III-IV级为高级别胶质瘤(high-grade gliomas,HGGs)。LGGs约占颅内胶质瘤的15%,生长缓慢,平均生存时间比HGGs长,会发生间变或去分化形成致命性的HGGs。故对于那些年轻的,症状不明显的,靠近功能区的LGGs患者,是否应积极     

脑功能定位和连接性及可塑性概念在幕上低级别胶质瘤术中应用的研究

手术是腑内可切除性病变．尤其是脑肿瘤的首选治疗方法之一。然而，由于许多肿瘤具有侵袭性，尤其是(低级别)胶质瘤，病灶常侵犯脑功能区；另外由于个体之间存在解剖和功能的变异，故需应用脑功能定位方法定位脑功能区皮质及皮质下边界，用以个体化指导切除范围。除术前可采用功能成像(fMRI)进行术前计划外，切除肿瘤过程中还可应用术中电刺激，当需定位病人的语言区和其他认知功能区时，可使用局部麻醉。术中电刺激是一种确定脑功能区皮质及皮质下结构简单、准确、可信度高的安全方法，具有以下特点：①切除肿瘤前可定位每一个病人的功能区皮质；②了解被病灶侵犯区域，如辅助运动区、岛叶、运动前皮质、缘上回及角回的的病理生理功能；③在整个切除病灶过程中，可持续定位皮质下结构，用以了解解剖与功能的联系(皮质-皮质环及皮质-皮质下环路)；④利用皮质重复电刺激可实时研究短期可塑性机制；⑤可根据功能界线进行病灶切除，以最大程度切除病灶，并尽量减小术后永久性功能障碍的风险，提高效益／风险比。此外，术中电刺激还可与围手术期各种功能神经影像技术相结合，如fMRI、PET、脑磁图(MEG)、矢量专题信息(digital thematic information，DTI)，用以提高术前计划的可靠性．帮助了解因肿瘤生长及手术切除过程中短期和长期内功能区皮质重塑及连接性改变的机理，该模式从而可最终改善手术计划。     

立体定向等体积切除幕上低级别胶质瘤

目的 探讨立体定向等体积切除术在低级别胶质瘤手术中的应用价值。方法 利用MR导向立体定向等体积切除方法切除大脑半球不同部位的低级别胶质瘤58例，其中功能区39例。对本术式的手术疗效、优越性及注意事项进行分析。结果 全组病例均达到肿瘤影像学全切除。术后症状改善或无变化51例(87．9％)，症状加重7例，除1例未恢复外，其余6例均在短期内恢复。结论 立体定向等体积切除术可以精确定位并确定手术切除范围，有助于提高低级别胶质瘤的全切除率及降低手术并发症的发生。     

Intraoperative cortico-subcortical stimulations in surgery of low-grade gliomas

In order to increase the impact of surgery on the natural history of low-grade glioma, resection should be of maximum importance. Nevertheless, since low-grade gliomas are frequently located in eloquent structures, function needs to be preserved. Therefore, studying the functional organization of the brain is mandatory for each patient due to the inter-individual anatomofunctional variability, increased in tumors due to cerebral plasticity. This strategy enables performance of a resection according to functional boundaries. However, preoperative neurofunctional imaging only allows the study of the gray matter. Consequently, since low-grade glioma invades cortical and subcortical structures and shows an infiltrative progression along the fibers, the goal of this review is to focus on the techniques able to map both cortical and subcortical regions. In addition to diffusion tensor imaging, which gives only anatomical information and still needs to be validated, intraoperative direct cortico-subcortical electrostimulation is the sole current method allowing a reliable study of the individual anatomofunctional connectivity, concerning sensorimotor, language and other cognitive functions. Its actual contribution is detailed, both in clinical issues, especially the improvement of the benefit/risk ratio of low-grade glioma resection, and in fundamental applications--namely, a new door to the connectionism and cerebral plasticity.     

唤醒麻醉和术中功能定位切除临近语言区致痫灶(附3例报告)

目的 探讨切除功能区致痫灶的手术策略及术后疗效.方法 在唤醒麻醉下应用术中皮层电刺激确定语言功能区,根据功能区边界选择处理致痫灶.评价患者的功能结果及癫痫控制程度.结果 3例患者术后随访,均未出现语言障碍,癫痫发作完全控制,符合Engel分级Ⅰ级.致痫灶全切2例,近全切+致痫皮层热灼1例.结论 借助唤醒麻醉进行术中皮质电刺激确定语言功能区准确、安全、可靠.唤醒麻醉下进行术中皮质电刺激结合影像学资料、借助颅内皮层电极的皮质电刺激进行功能区定位,能够最大可能地切除致痫灶而最小化功能区的损害.     

Intraoperative mapping of motor areas during brain tumor surgery: electrical stimulation patterns

Brain mapping with direct electrical stimulation is usefull when the tumor is located near or has infiltrated the central lobe. OBJECTIVE: To analyze the surgical findings with direct electrical stimulation of the cortex and white matter under general anesthesia during surgery for brain tumors related to the central lobe. METHOD: We studied 42 patients operated on from June 2000 to June 2003. We analyzed surgical findings and details of brain mapping. RESULTS: The mean value of the intensity of the stimulus was greater among those who presented motor deficit prior to surgery (p = 0.0425) and edema on MRI (p = 0.0468) or during anesthesia with continuous propofol (p = 0.001). CONCLUSION: The functional mapping of the central lobe may be influenced by severe motor deficit, edema on MRI and propofol's anesthesia.     

Intraoperative electrical stimulation mapping as an aid for surgery of intracranial lesions involving motor areas in children

Objective We analysed the usefulness of intraoperative electrical stimulation mapping (ESM) for locating motor pathways in pediatric patients harboring cerebral lesions closely related to motor areas.Methods We applied ESM in 17 consecutive pediatric patients operated on under general anesthesia. It was possible to locate motor function in 15 patients and in all children 5 years old and younger, as well as in all patients presenting with severe motor deficits, using relatively high current intensities. Intraoperative seizures occurred in 20% of our patients. A macroscopically complete removal of the lesion was carried out in 12 cases out of 17 with no definitive postoperative aggravation. Motor function improved for all patients presenting preoperatively with a severe paresis.Conclusion In our experience ESM revealed to be an useful tool for allowing us to push the resection of any lesion infringing on eloquent cortex up to the limit of functional areas, even in cases in very young and severely paretic children.     

外侧裂区胶质瘤的显微外科治疗

目的提高外侧裂区胶质瘤的手术治疗水平,降低该区域重要血管、功能组织损伤,有效减少并发症。方法回顾性分析2007-01—2010-12收治的35例外侧裂区胶质瘤的临床资料,所有病例均经显微手术治疗。结果本组无死亡,全切23例,次全切除12例。术后肢体肌力下降8例,其中6例经治疗6个月后肢体肌力恢复。结论外侧裂区胶质瘤在手术显微镜下可以及时切除。     

Awake surgery in low-grade gliomas harboring eloquent areas: 3-year mean follow-up

Low-grade gliomas are slow-growing tumors invading eloquent areas and white matter pathways. For many decades these tumors were considered inoperable because of their high tropism for eloquent areas. However, the young age of the patients and the inescapable anaplastic transformation have recently suggested more aggressive treatments. We analyzed the neurological and neuro-oncological outcome of 12 patients who underwent surgery fully awake for the resection of LGG, harboring eloquent areas. 10 right- and 2 left-handed patients underwent pre-operative assessment: Karnofsky Performance Status, Edinburgh Handedness Inventory Score; neuropsychological and neurophysiological evaluations, according to the tumor location. During surgery we performed: sensory-motor-evoked potentials, continuous electro-corticography and bipolar/monopolar cortico-subcortical mapping during neuropsychological tests. The resection rate was calculated with neuro-imaging elaboration software. No permanent post-operative deficits were reported; 2 patients improved after surgery. No impairment of cognitive functions was reported. The KPS improved in 8 patients and was steady in the others. The mean resection rate was 78.3%. The resection allowed the control of pre-operative seizures without increasing the drug intake. Awake surgery allowed a good resection rate despite the eloquent location of the tumors, without post-operative deficit. The neuropsychological outcome was unchanged after surgery. The resection seems to improve seizure control. All the patients came back to normal life and work. In conclusion, awake surgery is reliable and feasible in removal of LGG, even if invading the main eloquent areas and networks. All the patients experienced a normal life after surgery, without permanent deficits.