Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.
World Neurosurg. 2010 Jul;74(1):153-61. doi: 10.1016/j.wneu.2010.03.022.
Our goal is to indicate the importance of combining intraoperative tractography with motor-evoked potential (MEP) monitoring for glioma surgery in motor eloquent areas.
Tumor removal was performed in 28 patients with gliomas in and around the corticospinal tract (CST), in an operation theater equipped with an integrated high-field intraoperative magnetic resonance imaging and a neuronavigation system. Diffusion-tensor imaging-based tractography of the CST was implemented preoperatively and intraoperatively. When the surgically manipulated area came close to the corticospinal pathway, MEP responses were elicited by subcortical stimulation. Responsive areas were compared with the locations of fibers traced by preoperative and intraoperative tractography. Imaging and functional outcomes were reviewed.
Intraoperative tractography demonstrated significant inward or outward shift during surgery. MEP responses were observed around the tract at various intensities, and the distance between MEP responsive sites and intraoperative tractography was significantly correlated with the stimulation intensity (P < 0.01). The distance from preoperative tractography was not correlated. A more than subtotal resection was achieved in 24 patients (85.7%). Transient motor deterioration was seen in 12 patients (42.8%), and a permanent deficit was seen in 1 patient (3.5%).
We found that intraoperative tractography demonstrated the location of the CST more accurately than preoperative tractography. The results of the linear regression between distance and stimulation intensity were informative for guiding approaches to tumor remnants without impinging on the CST. The combination of intraoperative tractography and MEP monitoring can enhance the quality of surgery for gliomas in motor eloquent areas.
我们的目标是表明在语言运动区胶质瘤手术中，将术中轨迹与运动诱发电位（MEP）监测相结合的重要性。
在配备集成高场术中磁共振成像和神经导航系统的手术室中，对 28 例位于皮质脊髓束（CST）内和周围的胶质瘤患者进行肿瘤切除。术前和术中均进行基于弥散张量成像的 CST 轨迹描记。当手术操作区域接近皮质脊髓束时，通过皮质下刺激引出 MEP 反应。将反应区域与术前和术中轨迹描记的纤维位置进行比较。对影像学和功能结果进行了回顾。
术中轨迹描记在手术过程中显示出明显的向内或向外移位。在轨迹的各个部位观察到不同强度的 MEP 反应，MEP 反应部位与术中轨迹描记之间的距离与刺激强度呈显著相关性（P<0.01）。与术前轨迹描记的距离无相关性。24 例患者（85.7%）达到了超过次全切除。12 例患者（42.8%）出现短暂的运动恶化，1 例患者（3.5%）出现永久性缺陷。
我们发现术中轨迹描记比术前轨迹描记更准确地显示 CST 的位置。距离与刺激强度之间线性回归的结果为指导不影响 CST 的肿瘤残迹的方法提供了信息。术中轨迹描记与 MEP 监测相结合，可以提高语言运动区胶质瘤手术的质量。
