Moshel Yaron A, Marcus Joshua D S, Parker Erik C, Kelly Patrick J
Department of Neurosurgery, New York University School of Medicine, New York, New York 10016, USA.
J Neurosurg. 2008 Nov;109(5):825-34. doi: 10.3171/JNS/2008/109/11/0825.
The object of this study was to identify characteristic preoperative angiographic and MR imaging features of safely resectable insular gliomas and describe the surgical techniques and postoperative clinical outcomes.
Thirty-eight patients with insular gliomas underwent transsylvian resection between 1995 and 2007. Patient demographics, presenting symptoms, pathological findings, and neurological outcomes were retrospectively reviewed. Preoperative MR imaging-defined tumor volumes were superimposed onto the preoperative stereotactic cerebral angiograms to determine whether the insular tumor was confined lateral to (Group I) or extended medially around (Group II) the lenticulostriate arteries (LSAs).
Twenty-five patients (66%) had tumors situated lateral to the LSAs and 13 (34%) had tumors encasing the LSAs. Insular gliomas situated lateral to the LSAs led to significant medial displacement of these vessels (161 +/- 39%). In 20 (80%) of these 25 cases the boundaries between tumor and brain parenchyma were well demarcated on preoperative T2-weighted MR images. In contrast, there was less displacement of the LSAs (130 +/- 14%) in patients with insular gliomas extending around the LSAs on angiography. In 11 (85%) of these 13 cases, the tumor boundaries were diffuse on T2-weighted MR images. Postoperative hemiparesis or worsening of a preexisting hemiparesis, secondary to LSA compromise, occurred in 5 patients, all of whom had tumor volumes that extended medial to the LSAs. Gross-total or near-total resection was achieved more frequently in cases in which the insular glioma remained lateral to the LSAs (84 vs 54%).
Insular gliomas with an MR imaging-defined tumor volume located lateral to the LSAs on stereotactic angiography displace the LSAs medially by expanding the insula, have well-demarcated tumor boundaries on MR images, and can be completely resected with minimal neurological morbidity. In contrast, insular tumors that appear to surround the LSAs do not displace these vessels medially, are poorly demarcated from normal brain parenchyma on MR images, and are associated with higher rates of neurological morbidity if aggressive resection is pursued. Preoperative identification of these anatomical growth patterns can be of value in planning resection.
本研究的目的是确定可安全切除的岛叶胶质瘤的术前血管造影和磁共振成像特征，并描述手术技术及术后临床结果。
1995年至2007年间，38例岛叶胶质瘤患者接受了经外侧裂切除术。回顾性分析患者的人口统计学资料、症状表现、病理结果及神经学转归。将术前磁共振成像确定的肿瘤体积叠加到术前立体定向脑血管造影上，以确定岛叶肿瘤是局限于豆纹动脉（LSA）外侧（I组）还是向内侧围绕LSA延伸（II组）。
25例（66%）患者的肿瘤位于LSA外侧，13例（34%）患者的肿瘤包绕LSA。位于LSA外侧的岛叶胶质瘤导致这些血管明显向内侧移位（161±39%）。在这25例患者中的20例（80%），术前T2加权磁共振图像上肿瘤与脑实质之间的边界清晰。相比之下，血管造影显示岛叶胶质瘤向LSA周围延伸的患者中，LSA的移位较小（130±14%）。在这13例患者中的11例（85%），T2加权磁共振图像上肿瘤边界不清。5例患者术后出现因LSA受损继发的偏瘫或原有偏瘫加重，所有这些患者的肿瘤体积均向LSA内侧延伸。岛叶胶质瘤位于LSA外侧的病例更常实现全切除或近全切除（84%对54%）。
立体定向血管造影显示磁共振成像确定的肿瘤体积位于LSA外侧的岛叶胶质瘤，通过扩展岛叶使LSA向内侧移位，磁共振图像上肿瘤边界清晰，可在神经功能损伤最小的情况下完全切除。相比之下，似乎围绕LSA的岛叶肿瘤不会使这些血管向内侧移位，磁共振图像上与正常脑实质分界不清，若进行积极切除则神经功能损伤发生率较高。术前识别这些解剖学生长模式对手术切除规划有价值。
