Duffau Hugues, Peggy Gatignol S T, Mandonnet Emmanuel, Capelle Laurent, Taillandier Luc
Department of Neurosurgery, Hôpital Gui de Chauliac, Montpellier, Paris, France.
J Neurosurg. 2008 Sep;109(3):461-71. doi: 10.3171/JNS/2008/109/9/0461.
Despite better knowledge of cortical language organization, its subcortical anatomofunctional connectivity remains poorly understood. The authors used intraoperative subcortical stimulation in awake patients undergoing operation for a glioma in the left dominant hemisphere to map the language pathways and to determine the contribution of such a method to surgical results.
One hundred fifteen patients harboring a World Health Organization Grade II glioma within language areas underwent operation after induction of local anesthesia, using direct electrical stimulation to perform online cortical and subcortical language mapping throughout the resection.
After detection of cortical language sites, the authors identified 1 or several of the following subcortical language pathways in all patients: 1) arcuate fasciculus, eliciting phonemic paraphasia when stimulated; 2) inferior frontooccipital fasciculus, generating semantic paraphasia when stimulated; 3) subcallosal fasciculus, inducing transcortical motor aphasia during stimulation; 4) frontoparietal phonological loop, eliciting speech apraxia during stimulation; and 5) fibers coming from the ventral premotor cortex, inducing anarthria when stimulated. These structures were preserved, representing the limits of the resection. Despite a transient immediate postoperative worsening, all but 2 patients (98%) returned to baseline or better. On control MR imaging, 83% of resections were total or subtotal.
These results represent the largest experience with human subcortical language mapping ever reported. The use of intraoperative cortical and subcortical stimulation gives a unique opportunity to perform an accurate and reliable real-time anatomofunctional study of language connectivity. Such knowledge of the individual organization of language networks enables practitioners to optimize the benefit-to-risk ratio of surgery for Grade II glioma within the left dominant hemisphere.
尽管对皮质语言组织有了更深入的了解，但其皮质下解剖功能连接仍知之甚少。作者在接受左侧优势半球胶质瘤手术的清醒患者中使用术中皮质下刺激来绘制语言通路，并确定这种方法对手术结果的贡献。
115例语言区域内患有世界卫生组织二级胶质瘤的患者在局部麻醉诱导后接受手术，在整个切除过程中使用直接电刺激进行在线皮质和皮质下语言映射。
在检测到皮质语言部位后，作者在所有患者中识别出以下1种或几种皮质下语言通路：1）弓状束，刺激时引发音素性错语；2）额枕下束，刺激时产生语义性错语；3）胼胝体下束，刺激时诱发经皮质运动性失语；4）额顶音韵环路，刺激时引发言语失用症；5）来自腹侧运动前皮质的纤维，刺激时诱发构音障碍。这些结构得以保留，代表了切除的边界。尽管术后立即出现短暂恶化，但除2例患者外（98%），所有患者均恢复至基线水平或更好。在对照磁共振成像上，83%的切除为全切或次全切。
这些结果代表了迄今为止报道的关于人类皮质下语言映射的最大规模经验。术中皮质和皮质下刺激的使用为进行语言连接的准确可靠的实时解剖功能研究提供了独特的机会。这种对语言网络个体组织的了解使从业者能够优化左侧优势半球二级胶质瘤手术的风险效益比。
