Department of Neurosurgery, Tokai University School of Medicine, Kanagawa, Japan.
World Neurosurg. 2011 Jul-Aug;76(1-2):120-7. doi: 10.1016/j.wneu.2011.02.005.
OBJECTIVE: To compare intraoperative magnetic resonance imaging (MRI)-guided resection with resection guided by 5-aminolevulinic acid (5-ALA)-induced fluorescence in patients with gliomas and to evaluate the impact of intraoperative MRI in glioma surgery. METHODS: From January 2005 to February 2009, 33 patients with gliomas (6 with World Health Organization [WHO] grade II, 7 with WHO grade III, 20 with WHO grade IV) who underwent craniotomy with neuronavigation and received 5-ALA by the same neurosurgeon were investigated retrospectively. In 19 patients, operations were performed using a combination of 5-ALA with intraoperative 1.5-T MRI. All patients were subjected to postoperative 1.5-T MRI to confirm the extent of resection. RESULTS: Of 33 patients with gliomas, 21 (4 with WHO grade III and 17 with WHO grade IV) were 5-ALA-induced fluorescence-positive (5-ALA (+)). Surgery with intraoperative MRI was performed in 10 of the 21 patients, and the average resection rate was 92.6%. The average resection rate of patients who underwent surgery without intraoperative MRI was 91.8%. 5-ALA-induced fluorescence was not detected in 12 patients (6 with WHO grade II, 3 with WHO grade III, and 3 with WHO grade IV) with gliomas. Surgery with intraoperative MRI was performed in 9 of 12 patients, and the average resection rate was 89.2%. The average resection rate of patients who underwent surgery without intraoperative MRI was 68.7%. Intraoperative MRI-guided tumor resection resulted in a better resection rate in patients with 5-ALA-induced fluorescence-negative (5-ALA (-)) gliomas than in patients with 5-ALA (+) gliomas (20.5% vs 0.8%). CONCLUSIONS: Intraoperative MRI-guided resection is a powerful tool to treat 5-ALA (-) gliomas (mostly low grade), and 5-ALA is useful for high-grade gliomas. The combination of intraoperative MRI and 5-ALA has a synergistic effect in glioma surgery. Additionally, precise tumor grading in preoperative imaging studies can be difficult. Surgery for gliomas should be performed using both 5-ALA-induced fluorescence and intraoperative MRI-guided resection.
目的：比较术中磁共振成像（MRI）引导切除与 5-氨基酮戊酸（5-ALA）诱导荧光引导切除在胶质瘤患者中的应用，并评估术中 MRI 在胶质瘤手术中的影响。
方法：回顾性分析 2005 年 1 月至 2009 年 2 月间 33 例接受神经导航开颅手术和同一位神经外科医生使用 5-ALA 的胶质瘤患者。其中 6 例为世界卫生组织（WHO）Ⅱ级，7 例为 WHO Ⅲ级，20 例为 WHO Ⅳ级。19 例患者术中联合使用 5-ALA 和 1.5-T MRI。所有患者均在术后接受 1.5-T MRI 以确认切除范围。
结果：33 例胶质瘤患者中，21 例（4 例为 WHO Ⅲ级，17 例为 WHO Ⅳ级）为 5-ALA 诱导荧光阳性（5-ALA（+））。其中 10 例行术中 MRI 手术，平均切除率为 92.6%。未行术中 MRI 手术的患者平均切除率为 91.8%。12 例（6 例为 WHO Ⅱ级，3 例为 WHO Ⅲ级，3 例为 WHO Ⅳ级）胶质瘤患者 5-ALA 诱导荧光未检出。其中 9 例行术中 MRI 手术，平均切除率为 89.2%。未行术中 MRI 手术的患者平均切除率为 68.7%。术中 MRI 引导肿瘤切除可提高 5-ALA 诱导荧光阴性（5-ALA（-））胶质瘤患者的切除率，优于 5-ALA（+）胶质瘤患者（20.5%比 0.8%）。
结论：术中 MRI 引导切除是治疗 5-ALA（-）胶质瘤（多为低级别）的有效工具，5-ALA 对高级别胶质瘤也有帮助。术中 MRI 与 5-ALA 联合应用在胶质瘤手术中具有协同作用。此外，术前影像学研究中肿瘤分级的准确性可能较低。胶质瘤手术应同时采用 5-ALA 诱导荧光和术中 MRI 引导切除。
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