神经电生理监测技术在功能区胶质瘤术中的应用
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摘要
目的探讨神经电生理监测在功能区胶质瘤术中的应用价值。方法对2012年1月至2014年12月术中行神经电生理监测的738例功能区胶质瘤的临床资料进行回顾性分析。结果 608例在全麻下行术中神经电生理监测,130例在唤醒麻醉下行运动和或语言功能定位。所有病例术后近期运动障碍发生率为11.7%,远期为3.8%;语言区胶质瘤术后近期的失语率为28.8%,远期为4.1%。术中MRI辅助下进行电生理监测347例,全切率为89.3%。全麻下3.6%的患者术中出现癫痫大发作;唤醒麻醉下2.3%的患者出现一侧肢体或嘴角抽搐,仅1例(0.8%)出现癫痫大发作。结论根据胶质瘤所在的部位选择适当的术中神经电生理监测技术,有助于最大程度切除肿瘤的同时,保护患者的功能皮层和皮层下重要功能通路,降低致残率,提高远期生活质量。
Objective To explore the value of intraoperative neuroelectrophysiologic monitoring(IONM) to the surgery for gliomasin eloquent function brain regions.Method The clinical data of 738 patients with gliomas in eloquent function brain regions, whounderwent surgery under IONM from January, 2012 to December, 2014, were analyzed retrospectively.ResultsOf 738 patients, 608 underwent somatosensory evoked potential or motor evoked potential monitoring under general anesthesia and 130 did cortical andsubcortical motor mapping or awake language mapping. Eighty-six patients(11.7%) suffered from early motor deficit after the surgery.Late motor deficit was observed in 28 patients(3.8%). Twenty-one patients(28.8%, 21/73) had early speech deficit and late speechdeficit was only observed in 3 patients(4.1%, 3/73). The rate of gross total resection of the tumors was 89.3% in 738 patients.ConclusionsIONM can be applied safely and effectively to the resection of gliomas in the eloquent function brain regions because it ishelpful to the protection of the eloquent function cortexes and subcortical pathways and total resection of the tumors as possible in thepatients with gliomas in eloquent function brain regions.
Objective To explore the value of intraoperative neuroelectrophysiologic monitoring(IONM) to the surgery for gliomasin eloquent function brain regions.Method The clinical data of 738 patients with gliomas in eloquent function brain regions, whounderwent surgery under IONM from January, 2012 to December, 2014, were analyzed retrospectively.ResultsOf 738 patients, 608 underwent somatosensory evoked potential or motor evoked potential monitoring under general anesthesia and 130 did cortical andsubcortical motor mapping or awake language mapping. Eighty-six patients(11.7%) suffered from early motor deficit after the surgery.Late motor deficit was observed in 28 patients(3.8%). Twenty-one patients(28.8%, 21/73) had early speech deficit and late speechdeficit was only observed in 3 patients(4.1%, 3/73). The rate of gross total resection of the tumors was 89.3% in 738 patients.ConclusionsIONM can be applied safely and effectively to the resection of gliomas in the eloquent function brain regions because it ishelpful to the protection of the eloquent function cortexes and subcortical pathways and total resection of the tumors as possible in thepatients with gliomas in eloquent function brain regions.
引文
[1]《中国中枢神经系统胶质瘤诊断和治疗指南》编写组.中国中枢神经系统胶质瘤诊断和治疗指南(2012精简版)[J].中华医学杂志,2012,92(33):2309-2313.
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[4]陈正和,陈忠平.术中神经电生理监护对保护神经功能的应用[J].中国神经肿瘤杂志,2013,11(3):194-198.
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[6]中国脑胶质瘤协作组.唤醒状态下切除脑功能区胶质瘤手术技术的专家共识[J].中国微侵袭神经外科杂志,2013,18(3):143-149.
[7]路俊锋,章捷,吴劲松,等.3.0 T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[J].中华外科杂志,2011,49(8):693-698.
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[9]De Witt Hamer PC,Robles SG,Zwinderman AH,et al.Impact of intraoperative stimulation brain mapping on glioma surgery outcome:a meta-analysis[J].J Clin Oncol,2012,30(20):2559-2565.
[10]Duffau H,Lopes M,Arthuis F,et al.Contribution of intraoperative electrical stimulations in surgery of low grade gliomas:a comparative study between two series without(1985-96)and with(1996-2003)functional mapping in the same institution[J].J Neurol Neurosurg Psychiatry,2005,76(6):845-851.
[11]Carrabba G,Fava E,Giussani C,et al.Cortical and subcortical motor mapping in rolandic and perirolandic glioma surgery:impact on postoperative morbidity and extent of resection[J].J Neurosurg Sci,2007,51(2):45-51.
[12]Keles GE,Lundin DA,Lamborn KR,et al.Intraoperative subcortical stimulation mapping for hemispherical perirolandic gliomas located within or adjacent to the descending motor pathways:evaluation of morbidity and assessment of functional outcome in 294 patients[J].J Neurosurg,2004,100(3):369-375.
[13]Krieg SM,Shiban E,Droese D,et al.Predictive value and safety of intraoperative neurophysiological monitoring with motor evoked potentials in glioma surgery[J].Neurosurgery,2012,70(5):1060-1061.
[14]Krieg SM,Schaffner M,Shiban E,et al.Reliability of intraoperative neurophysiological monitoring using motor evoked potentials during resection of metastases in motor-eloquent brain regions:clinical article[J].J Neurosurg,2013,118(6):1269-1278.
[15]Neuloh G,Pechstein U,Schramm J.Motor tract monitoring during insular glioma surgery[J].J Neurosurg,2007,106(4):582-592.
[16]Zhu FP,Wu JS,Song YY,et al.Clinical application of motor pathway mapping using diffusion tensor imaging tractography and intraoperative direct subcortical stimulation in cerebral glioma surgery:a prospective cohort study[J].Neurosurgery,2012,71(6):1170-1184.
[17]Sanai N,Mirzadeh Z,Berger MS.Functional outcome after language mapping for glioma resection[J].N Engl J Med,2008,358(1):18-27.
[18]Duffau H,Capelle L,Sichez N,et al.Intraoperative mapping of the subcortical language pathways using direct stimulations.An anatomo-functional study[J].Brain,2002,125(Pt1):199-214.
[19]Bello L,Gambini A,Castellano A,et al.Motor and language DTI Fiber Tracking combined with intraoperative subcortical mapping for surgical removal of gliomas[J].Neuroimage,2008,39(1):369-382.
[2]周琪琪,张小锋.神经监测技术在临床手术中的应用[M].北京:中国社会出版社,2005.
[3]窦万臣.术中神经电生理监测[M].北京:人民卫生出版社,2009.
[4]陈正和,陈忠平.术中神经电生理监护对保护神经功能的应用[J].中国神经肿瘤杂志,2013,11(3):194-198.
[5]路俊锋,吴劲松,朱国行.神经电生理学检查和术中应用[M].见:周良辅.现代神经外科学.第二版.上海:复旦大学出版社,2015.158-198.
[6]中国脑胶质瘤协作组.唤醒状态下切除脑功能区胶质瘤手术技术的专家共识[J].中国微侵袭神经外科杂志,2013,18(3):143-149.
[7]路俊锋,章捷,吴劲松,等.3.0 T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[J].中华外科杂志,2011,49(8):693-698.
[8]Lu J,Wu J,Yao C,Zhuang D,et al.Awake language mapping and 3-Tesla intraoperative MRI-guided volumetric resection for gliomas in language areas[J].J Clin Neurosci,2013,20(9):1280-1287.
[9]De Witt Hamer PC,Robles SG,Zwinderman AH,et al.Impact of intraoperative stimulation brain mapping on glioma surgery outcome:a meta-analysis[J].J Clin Oncol,2012,30(20):2559-2565.
[10]Duffau H,Lopes M,Arthuis F,et al.Contribution of intraoperative electrical stimulations in surgery of low grade gliomas:a comparative study between two series without(1985-96)and with(1996-2003)functional mapping in the same institution[J].J Neurol Neurosurg Psychiatry,2005,76(6):845-851.
[11]Carrabba G,Fava E,Giussani C,et al.Cortical and subcortical motor mapping in rolandic and perirolandic glioma surgery:impact on postoperative morbidity and extent of resection[J].J Neurosurg Sci,2007,51(2):45-51.
[12]Keles GE,Lundin DA,Lamborn KR,et al.Intraoperative subcortical stimulation mapping for hemispherical perirolandic gliomas located within or adjacent to the descending motor pathways:evaluation of morbidity and assessment of functional outcome in 294 patients[J].J Neurosurg,2004,100(3):369-375.
[13]Krieg SM,Shiban E,Droese D,et al.Predictive value and safety of intraoperative neurophysiological monitoring with motor evoked potentials in glioma surgery[J].Neurosurgery,2012,70(5):1060-1061.
[14]Krieg SM,Schaffner M,Shiban E,et al.Reliability of intraoperative neurophysiological monitoring using motor evoked potentials during resection of metastases in motor-eloquent brain regions:clinical article[J].J Neurosurg,2013,118(6):1269-1278.
[15]Neuloh G,Pechstein U,Schramm J.Motor tract monitoring during insular glioma surgery[J].J Neurosurg,2007,106(4):582-592.
[16]Zhu FP,Wu JS,Song YY,et al.Clinical application of motor pathway mapping using diffusion tensor imaging tractography and intraoperative direct subcortical stimulation in cerebral glioma surgery:a prospective cohort study[J].Neurosurgery,2012,71(6):1170-1184.
[17]Sanai N,Mirzadeh Z,Berger MS.Functional outcome after language mapping for glioma resection[J].N Engl J Med,2008,358(1):18-27.
[18]Duffau H,Capelle L,Sichez N,et al.Intraoperative mapping of the subcortical language pathways using direct stimulations.An anatomo-functional study[J].Brain,2002,125(Pt1):199-214.
[19]Bello L,Gambini A,Castellano A,et al.Motor and language DTI Fiber Tracking combined with intraoperative subcortical mapping for surgical removal of gliomas[J].Neuroimage,2008,39(1):369-382.