Duffau H, Capelle L, Sichez J P, Bitar A, Faillot T, Arthuis F, Van Effenterre R, Fohanno D
Service de Neurochirurgie 1, Hôpital de la Salpêtrière, Paris.
Rev Neurol (Paris). 1999 Sep;155(8):553-68.
Indications of surgical treatment for lesions in functional cerebral areas depend on the ratio between the definitive neurological deficit and the beneficial effect of resection. Detection of eloquent cortex is difficult because of important individual variability. Peroperative direct cortical and subcortical electrical stimulations (DCS) provide the most precise and reliable method currently available allowing identification and preservation of neurons essential for motricity, sensitivity++ and language. We report our preliminary experience with DCS in surgery of intracerebral infiltrative tumors with a consecutive series of 15 patients operated from November 96 through September 97 in our institution. Presenting symptoms in the 15 patients (8 males, 7 females, mean age 43 years) were seizures in 11 cases (73%) and neurological deficit in 4 cases (27%). Clinical examination was normal in 11 patients and revealed hemiparesia in 4. Magnetic resonance imaging (MRI) with three-dimensional reconstruction showed a precentral tumor in 10 cases, central lesion in one patient, postcentral lesion in two cases, right insular tumor (non-dominant hemisphere) in one case. All patients underwent surgical resection using DCS with detection in 13 cases of motor cortex and subcortical pathways under genera anesthesia, in one case of somatosensory area under local anesthesia, and in one case of language areas also under local anesthesia. The tumor was recurrent in two patients had been operated earlier but without DCS. Resection, verified by postoperative MRI, was total in 12 cases (80%) and estimated at 80% in 3 patients. Histological examination revealed an infiltrative glioma in 12 cases (8 low grade astrocytomas, 3 low grade oligodendrogliomas, and one anaplastic oligodendroglioma), and metastases in 3 cases. Eight patients had no postoperative deficit, while the other 7 patients were impaired, with, in all cases except one, complete recovery in 15 days to 2 months. Direct cortical and subcortical electrical stimulations offer a reliable, precise and safe method, allowing functional mapping especially useful in case of infiltrative cerebral tumors in eloquent areas. This technique allows improvement in the quality of tumoral resection and concurrently a minimization of the risk of definitive postoperative neurological deficit.
功能脑区病变的手术治疗指征取决于明确的神经功能缺损与切除带来的有益效果之间的比例。由于个体差异很大，明确的皮质很难检测。术中直接皮质和皮质下电刺激（DCS）提供了目前最精确、最可靠的方法，能够识别和保留对运动、感觉及语言功能至关重要的神经元。我们报告了我们在1996年11月至1997年9月期间，对15例脑内浸润性肿瘤患者进行手术时使用DCS的初步经验。15例患者（8例男性，7例女性，平均年龄43岁）中，11例（73%）表现为癫痫发作，4例（27%）表现为神经功能缺损。11例患者临床检查正常，4例显示偏瘫。三维重建磁共振成像（MRI）显示，10例为中央前回肿瘤，1例为中央区病变，2例为中央后回病变，1例为右侧岛叶肿瘤（非优势半球）。所有患者均在DCS辅助下接受手术切除，其中13例在全身麻醉下检测到运动皮质和皮质下通路，1例在局部麻醉下检测到躯体感觉区，1例在局部麻醉下检测到语言区。2例患者曾接受过早期手术，但未使用DCS，此次肿瘤复发。术后MRI证实，12例（80%）患者肿瘤完全切除，3例患者估计切除率为80%。组织学检查显示，12例为浸润性胶质瘤（8例低级别星形细胞瘤，3例低级别少突胶质细胞瘤，1例间变性少突胶质细胞瘤），3例为转移瘤。8例患者术后无功能缺损，其他7例患者有功能障碍，但除1例患者外，所有患者均在15天至2个月内完全恢复。直接皮质和皮质下电刺激提供了一种可靠、精确且安全的方法，可进行功能定位，这在明确脑区的浸润性脑肿瘤病例中尤其有用。该技术可提高肿瘤切除质量，同时将术后永久性神经功能缺损风险降至最低。
