Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan.
J Neurosurg. 2012 Dec;117(6):1076-81. doi: 10.3171/2012.9.JNS12662. Epub 2012 Oct 5.
Maximal resection of symptomatic cavernous angioma (CA), including its surrounding gliosis if possible, has been recommended to minimize the risk of seizures or (re)bleeding. However, despite recent neurosurgical advances, such extensive CA removal is still a challenge in eloquent areas. The authors report a consecutive series of patients who underwent awake surgery for CA within the left dominant hemisphere in which intraoperative cortical-subcortical electrical stimulation was used.
Nine patients harboring a CA that was revealed by seizures in 6 cases and bleeding in 3 cases underwent resection. All CAs were located in the left dominant hemisphere: 3 temporal, 2 insular, 2 parietal, and 2 in the parietotemporal region. Awake mapping was performed in all cases by using intraoperative cortical-subcortical electrical stimulation and ultrasonography (except in 1 insular CA in which a neuronavigation system was used).
Total removal of the CA was achieved in all patients, with identification and preservation of language and sensory-motor structures. In addition, the pericavernomatous gliosis was removed in 7 cases, according to the functional boundaries provided by intraoperative subcortical stimulation. In 2 cases, subcortical mapping revealed eloquent areas within the surrounding gliosis, which was voluntarily avoided. There was no postsurgical permanent deficit, no rebleeding, and no epilepsy in 7 cases (2 patients had rare seizures in the 1st year or two after surgery, and then complete arrest), with a mean follow-up of 28.5 months (range 3-64 months).
These results suggest that intraoperative cortical-subcortical stimulation in awake patients represents a valuable adjunct to image-guided surgery with the aim of selecting the safer surgical approach for CAs involving eloquent areas. Moreover, such online mapping can be helpful when removing the pericavernomatous gliosis while preserving functional structures, which can persist within the hemosiderin rim. Thus, the authors propose that awake surgery be routinely considered, both to optimize the resection and to improve the quality of life through seizure control and avoidance of (re)bleeding for CAs located in the left dominant hemisphere.
为了最大限度地降低癫痫发作或（再）出血的风险，建议对有症状的海绵状血管畸形（CA）进行最大程度的切除，包括其周围的神经胶质增生，如果可能的话。然而，尽管最近神经外科取得了进展，但在功能区进行如此广泛的 CA 切除仍然是一个挑战。作者报告了一系列连续的患者，这些患者在左优势半球内接受了 CA 的清醒手术，术中使用了皮质-皮质下电刺激。
6 例因癫痫发作和 3 例因出血而发现 CA 的 9 例患者接受了切除术。所有 CA 均位于左优势半球：3 例颞叶、2 例岛叶、2 例顶叶和 2 例顶颞叶。所有病例均通过术中皮质-皮质下电刺激和超声（1 例岛叶 CA 除外，使用了神经导航系统）进行清醒映射。
所有患者均实现了 CA 的完全切除，同时识别和保护了语言和感觉运动结构。此外，根据术中皮质下刺激提供的功能边界，7 例切除了围 CA 神经胶质增生。在 2 例中，皮质下映射显示了周围神经胶质增生中的功能区，这些区域被自愿避开。7 例患者术后无永久性缺损、无再出血和无癫痫（2 例在术后 1 至 2 年内偶有癫痫发作，然后完全停止），平均随访 28.5 个月（范围 3-64 个月）。
这些结果表明，在清醒患者中进行皮质-皮质下刺激代表了一种有价值的辅助手段，可以结合图像引导手术，以选择更安全的手术方法来治疗涉及功能区的 CA。此外，当切除围 CA 神经胶质增生并保留功能结构时，这种在线映射也很有帮助，因为这些功能结构可能存在于含铁血黄素环内。因此，作者建议常规考虑清醒手术，不仅可以优化切除，还可以通过控制癫痫发作和避免（再）出血来提高生活质量，对于位于左优势半球的 CA 尤其如此。
