3.0T 术中磁共振实时影像功能导航联合术中神经电生理监测技术在岛叶胶质瘤手术中的应用

目的评价3.0 T术中磁共振成像(intraoperative magnetic resonance imaging,iMRI)联合弥散张量成像(diffusion tensor imaging,DTI)锥体束示踪导航及术中神经电生理监测(intraoperative neurophysiologicalmonitoring,IONM)技术在各种累及岛叶的胶质瘤切除手术中的应用价值。方法 2010年9月至2011年6月以3.0 T iMRI数字一体化神经外科手术中心为平台,在iMRI功能导航结合IONM下对18例累及岛叶的胶质瘤实施切除手术。其中对10例主侧半球肿瘤采用唤醒麻醉下术中直接皮质电刺激进行语言区定位。对所有18例岛叶胶质瘤,术中均采用DTI导航结合术中连续经皮质刺激运动诱发电位和皮质下电刺激进行锥体束定位。结果通过iMRI实时扫描,18例患者中有13例发现肿瘤残留,其中6例在iMRI实时影像导航下获得了进一步切除,使肿瘤的影像学全切除率从5/18提高至9/18。经Fisher检验,iMRI前、后的肿瘤切除率(包括全切除及次全切除)具有统计学意义(P=0.046)。9例因DTI导航或IONM提示切缘临近功能皮质或深部锥体束,而未强求全切除。10例主侧半球肿瘤患者中,术后近期(1周内)出现一过性语言功能障碍5例,随访至术后1个月,语言功能均恢复到术前水平或以上;18例患者中3例术后近期出现肢体运动功能障碍,随访至术后1个月,其中2例完全恢复。总体术后1个月的神经功能障碍仅1例。无iMRI及IONM相关的并发症发生。结论应用3.0 T iMRI术中实时影像导航联合DTI锥体束示踪成像技术及IONM技术有助于最大程度地安全切除岛叶胶质瘤。

Clinical application of 3T intraoperative magnetic resonance image-guided functional neuronavigation combined with intraoperative neurophysiological monitoring in resection of insular gliomas

Objective To evaluate the clinical application of 3.0T intraoperative magnetic resonance image(iMRI)-guided functional neuronavigation combined with intraoperative neurophysiological monitoring(IONM) in resection of insular gliomas.Methods From September 2010 to June 2011,18 gliomas involving insular lobe were resected in IMRIS 3.0 T iMRI integrated surgical suite.An intraoperative diffusion tensor imaging(DTI)-based navigation combined with continuing transcortical motor evoked potential(MEP) was performed to localize the pyramidal tracts in all patients.Furthermore,an awake craniotomy with direct cortical electrical stimulation mapping(ESM) was performed to locate the eloquent language area in 10 patients with tumors in dominant hemisphere.The results of intraoperative imaging,IONM and the surgical consequences were analyzed.Results Intraoperative imaging revealed residual tumors in 13 of 18 cases.Six patients with residual tumors further underwent iMR image-Guided resection to remove the tumors.As a result,the total removal rate of tumors increased from 5/18 to 9/18.The Fisher exact test demonstrated a statistically significance(P = 0.046).Tumors in nine cases were not completely removed because DTI navigation and IONM revealed that the lesions were closed to the functional cortex or deep pyramidal tract.Among ten patients with tumors in the primary hemisphere,five developed transient language dysfunction 1 week after operation.Their language function returned to preopoerative level or above by one month after surgery.Among total 18 patients,three developed postoperative motor dysfunction.By one month after operation,two of them had fully recovered their motor function while one patient still had neurologic dysfunction.No side effect or IMRI and the IONM related complications occurred.Conclusion A combination of 3T iMR image-based neuronavigation and IONM helps to maximize the safe removal of the insular cortex glioma.