3.0T术中磁共振成像引导下唤醒麻醉联合术中语言皮质定位技术在语言区脑胶质瘤手术中的应用

目的 评价3.0 T术中磁共振成像(iMRI)下采用唤醒麻醉联合术中语言皮质定位技术辅助语言区脑胶质瘤切除的临床有效性.方法 2010年12月至2011年4月以集成3.0 TiMRI数字一体化神经外科手术中心为平台,采用唤醒麻醉、改良手术铺巾技术、联合直接电刺激语言皮质定位和iMRI实时影像神经导航,对11例右利手患者实施左侧语言区脑胶质瘤切除.术中采用简易语言任务模式,包括语言流利度、图片命名和文字测读,评估患者语言功能状况.围手术期采用汉语失语检查法,评估新技术的临床有效性.结果 通过iMRI实时影像导航,6/11的患者可以定量提升胶质瘤切除范围,其中影像学全切除率提高3/11,最终肿瘤全切除7例,次全切除4例.语言皮质定位阳性率为8/11.患者术后1周内出现一过性失语率为4/11,随访至术后1个月,所有患者语言功能均恢复到术前水平或以上;围手术期患者无肢体运动功能障碍.结论 应用3.0 T超高场强iMRI实时影像导航可在术前设计脑胶质瘤个体化手术方案,术中精确定位病灶,等体积定量切除肿瘤,提高肿瘤切除率;在唤醒麻醉下实施术中皮质电刺激定位语言区,能最大程度保护患者语言皮质,避免出现不可逆的语言功能损伤,提高术后社会生活质量.

Abstract：

Objectives To evaluate preliminary clinical experience for combining awake craniotomy and intraoperative language brain mapping within the integrated 3.0 T intraoperative maguetic resonance imaging (iMRI) suite.Methods From December 2010 to April 2011,11 right hand-dominant patients with left glioma were involved in, or adjacent to, eloquent cortex was carried out awake craniotomies with cortical stimulation within an integrated 3.0 T iMRI suite.Aphasia battery of Chinese was used to test the language function before the operation.During the procedure, after the occipital, temporal, and supraorbital nerves were blocked by the anesthesiologists, the head was fixed with a custom high-field MRI-compatible head holder.The skull and dura was opened as usual and language brain mapping was then performed.Language testing followed a set protocol:counting numbers from 1 to 50, naming objects, reading single words.Resection of the tumor was guided by neuronavigation system and continued until eloquent areas were encountered or the margin of assessment was reached.An interdissection MRI was aquired to evaluate the glioma removal in a movable MRI scanner after minimal draping. Meanwhile, adverse effects caused by electrical stimulation and iMRI were recorded.The follow-up speech tests were assessed on 7th day and 1 month at least after the operation.Results The combined use of 3.0 T iMRI and awake craniotomy was performed safely in all patients.No adverse effects were reported.The duration of surgery was prolonged by 2 to 4 h.The patients' perception of iMRI during surgery was favorable.First-look MRI studies led to further resection attempts in 6/11 cases as well as a 3/11 increase in the number of gross-total resections.One week after surgery, baseline language function worsened in 4 cases. However, no patients had a persistent language deficit one month after surgery. Conclusions Awake craniotomy and direct cortical electrical stimulation can be performed safely and effectively within a 3.0 T iMRI suite.The combination of high-field iMRI and awake craniotomy may facilitate safe removal of eloquent glioma.     

静态功能磁共振分析方法在脑胶质瘤术前语言皮质定位中的初步应用

目的 探讨静态功能磁共振(rsfMRI)分析方法在脑胶质瘤术前语言皮质定位中的应用价值.方法 12例主侧半球脑胶质瘤患者行术前rsfMRI,结合语言任务态血氧饱和依赖功能磁共振成像(BOLD fMRI)定位脑语言皮质,采用唤醒开颅结合术中皮质电刺激验证rsfMRI定位语言皮质的敏感性.结果 12例成功行rsfMRI扫描,10例配合完成语言BOLD fMRI扫描.12例唤醒开颅成功,每例各定位1～7个皮质语言阳性位点,共46个.其中22个语言阳性位点在rsfMRI上显示,其显示语言区的敏感度为47.8％(22/46,12例),13个语言阳性位点在语言BOLD fMRI上表现为激活,敏感度为35.1％(13/37,10例).结论 rsfMRI有助于脑胶质瘤术前语言区定位,但其敏感性有待提高.     

四氯化碳药物性肝损伤体外模型的改进

目的:建立一个较理想的CCl4药物性肝损伤体外模型.方法:分别采用传统方法和改进方法配制CCl4损伤液并诱导人肝HepG2细胞损伤,倒置相差显微镜观察细胞形态学变化,生化法检测上清液中ALT水平并采用MTT法测定细胞活性.结果:改进方法的CCl4诱导损伤效果明显优于传统方法,随着CCl4损伤液浓度的提高,上清液中ALT水平明显升高,而细胞活性显著降低,70％浓度CCl4损伤液诱导损伤4h可获得最佳损伤效果.结论:利用改进方法可在体外实验中建立较理想的CCl4药物性肝损伤模型,此模型可为进一步的体外实验研究奠定基础.     

绞股蓝多糖对四氯化碳急性肝损伤的保护作用

目的探讨绞股蓝多糖（gynostemma pentaphyllum makino polysaccharide,PGP）对四氯化碳（carbon tetrachloride,CCl4）急性肝损伤的保护作用。方法 48只雄性昆明小鼠随机分为正常对照组、CCl4损伤组、PGP保护组（PGP浓度分别为3 mg/kg、6 mg/kg、12 mg/kg、18 mg/kg 4组）,每组各8只。CCl4腹腔注射建立小鼠急性肝损伤模型。采用肝组织切片病理学观察,测定血清丙氨酸氨基转移酶（alanine aminotransferase,ALT）、天冬氨酸氨基转移酶（aspartate aminotransferase,AST）活性。结果与CCl4损伤组比较,PGP各保护组肝组织病理改变均明显减轻,PGP各保护组血清ALT、AST活性明显降低（P〈0.05）,以绞股蓝多糖浓度6 mg/kg保护效果最佳。结论 PGP对CCl4急性肝损伤有明显的保护作用,其机制可能与抗氧化,稳定细胞膜和溶酶体膜防止肝细胞坏死有关。     

一药多用——跌打丸

跌打丸为骨伤科常用成药,有活血化瘀、舒筋活络、行气止痛之功效,用于跌打损伤、瘀血、肿痛等症,一般多用于内服。临床观察发现,其外用还有下列多种用途。 急性乳腺炎 取跌打丸3～5粒,研细,加白酒适量调为稀糊状,将糊均匀冷敷于患     

弓状束纤维示踪与功能磁共振成像定位额叶语言皮质的比较研究

目的 联合弓状束纤维示踪技术和任务态fMRI,评价弓状束终末投影定位额叶语言皮质的临床可行性.方法 采用任务态fMRI定位语言皮质激活区,并纤维示踪定位弓状束终末端;将两者皮质投影在导航系统融合,比较两者吻合度.结果 弓状束终末投影区域与任务态fMRI语言皮质激活区高度吻合.弓状束投影区主要位于左侧中央前回腹侧部(87.5％)及左侧额下回(75.0％).弓状束终末投影平均半径(R1)=(12.4±5.3)mm;fMRl语言任务激活区平均半径(R2)=(10.9±4.6) mm;两者中心距离(D)=(10.6±6.9)mm.结论 弓状束纤维示踪不仅可用于定位和保护皮质下语言通路,还可用于额叶语言皮质定位,并与fMRI的定位结果吻合.     

绞股蓝多糖含药血清对四氯化碳肝细胞损伤的保护作用

目的 研究绞股蓝多糖(gynostemma pentaphyllum makino polysaccharide,PGP)含药血清对四氯化碳(carbon tetrachloride,CCl4)诱导的肝细胞损伤保护作用。方法 采用中药血清学方法收集PGP含药血清,用CCl4诱导肝HepG2细胞损伤,设正常对照组、CCl4损伤组和不同浓度PGP含药血清保护组;细胞形态学观察细胞凋亡,MTT法检测细胞活力,生化法检测细胞培养上清液中丙氨酸氨基转移酶(alanine aminotransferase, ALT/GPT)、天门冬氨酸氨基转移酶(aspartate aminotransferase, AST/GOT)活性及western blot凝胶电泳检测细胞色素P450 2E1的表达。结果 各PGP含药血清保护组肝细胞损伤程度明显减轻;细胞存活率显著升高(P<0.05);上清液中ALT、AST活性显著降低(P<0.05);CYP 2E1表达量显著增加。以4~8mg·kg-1·d-1保护组效果最佳。结论 PGP含药血清对CCl4诱导的HepG2细胞损伤有明显保护作用,以4~8mg·kg-1·d-1含药血清作用最显著。