Duffau H, Capelle L, Sichez J, Faillot T, Abdennour L, Law Koune J D, Dadoun S, Bitar A, Arthuis F, Van Effenterre R, Fohanno D
Department of Neurosurgery 1, Hôpital de la Salpêtrière, Paris, France.
Acta Neurochir (Wien). 1999;141(11):1157-67. doi: 10.1007/s007010050413.
Indications of surgical treatment for lesions in the central nervous system depend on the risk of a definitive neurological deficit, related to the benefit of resection. Detection of eloquent areas is then necessary because of major individual variability. Neuro-imaging functional techniques are in development and are beginning to be efficient for cortical sensorymotor mapping, but still lack sensitivity and specificity for language mapping, and remain unable to give real-time data during surgery and to perform sub-cortical mapping. The more precise and reliable method of functional mapping is represented by the intra-operative direct electrical stimulations (DES), which allow identification and preservation of essential pathways for motricity, sensibility and language, at each level of the central nervous system (cortico-subcortical). We report our experience of DES in the surgery of tumours and vascular malformations located in supra-tentorial brain eloquent areas, with a consecutive series of 60 patients operated on under general or local anaesthesia, from November 1996 until May 1999 in our department at La Salpêtrière Hospital. Presenting symptoms in the 60 subjects (39 males, 21 females, mean age: 45 years) were seizures in 37 cases with normal clinical examination, and mild neurological deficit in 29 cases. MRI showed 60 supra-tentorial brain lesions: 30 precentral, 12 postcentral, 14 perisylvian in the dominant hemisphere, 4 deep-seated. All subjects underwent surgical resection using DES, with supratentorial cortico-subcortical mapping under general anaesthesia for motor areas detection in 43 cases and under local anaesthesia for sensori-motor and/or language tasks in 17 cases. The final histological diagnosis was 44 gliomas (31 low-grade and 13 high-grade), 9 metastasis, 3 cavernomas, 4 arteriovenous malformations (AVM). Resection was total or subtotal in 52 cases (87%) and partial in 8 cases (13%). 29 patients had no post-operative deficit, while the other 31 patients were impaired post-operatively, with in all cases, except 3, a complete recovery delayed for 15 days to 3 months (overall morbidity: 5%). The median follow up was 14 months. Intra-operative direct electrical stimulations of the central nervous system constitute a reliable, precise and safe method, allowing the realization of a functional mapping useful for all operations of lesions located in eloquent areas. This technique allows a minimization of definitive post-operative neurological deficit, and concurrently an improvement in the quality of resection.
中枢神经系统病变的手术治疗指征取决于与切除益处相关的明确神经功能缺损风险。由于个体差异很大，因此有必要检测明确功能区。神经影像学功能技术正在发展，并且开始在皮质感觉运动映射方面发挥作用，但在语言映射方面仍缺乏敏感性和特异性，并且仍然无法在手术期间提供实时数据以及进行皮质下映射。功能映射更精确、可靠的方法是术中直接电刺激（DES），它可以在中枢神经系统的每个层面（皮质 - 皮质下）识别并保留运动、感觉和语言的基本通路。我们报告了在位于幕上脑明确功能区的肿瘤和血管畸形手术中使用DES的经验，自1996年11月至1999年5月，在我们位于萨尔佩特里埃医院的科室中，连续对60例接受全身或局部麻醉手术的患者进行了研究。60名受试者（39名男性，21名女性，平均年龄：45岁）的主要症状为37例发作且临床检查正常，29例有轻度神经功能缺损。MRI显示60个幕上脑病变：30个中央前回病变，12个中央后回病变，优势半球14个外侧裂周围病变，4个深部病变。所有受试者均接受了使用DES的手术切除，43例在全身麻醉下进行幕上皮质 - 皮质下映射以检测运动区，17例在局部麻醉下进行感觉运动和/或语言任务映射。最终组织学诊断为44例胶质瘤（31例低级别和13例高级别），9例转移瘤，3例海绵状血管瘤，4例动静脉畸形（AVM）。52例（87%）切除为全切或次全切，8例（13%）为部分切除。29例患者术后无神经功能缺损，而其他31例患者术后出现神经功能障碍，除3例患者外，所有患者的完全恢复延迟15天至3个月（总体发病率：5%）。中位随访时间为14个月。术中对中枢神经系统进行直接电刺激是一种可靠、精确且安全的方法，可实现对位于明确功能区病变的所有手术都有用的功能映射。该技术可将术后明确的神经功能缺损降至最低，同时提高切除质量。
