Neurosurgery Service, Hôpital Nord, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France.
Acta Neurochir (Wien). 2013 Mar;155(3):437-48. doi: 10.1007/s00701-012-1580-1. Epub 2012 Dec 20.
For gliomas, the goal of surgery is to maximise the extent of resection (EOR) while minimising the postoperative morbidity. The purpose of this study was to evaluate the benefits of a protocol developed for the surgical management of gliomas located in language areas, where tractography-integrated navigation was used in conjunction with direct electrical stimulations (DES).
The authors included ten patients suffering of gliomas located in language areas. The preoperative planning for multimodal navigation was done by integrating anatomical magnetic resonance images and subcortical pathway volumes generated by diffusion tensor imaging. Six white matter fascicles implicated in language functions were reconstructed in each patient, including fibres for phonological processing (i.e. the arcuate fasciculus), fibres for lexical-semantic processing (i.e. the inferior frontooccipital fasciculus, inferior longitudinal fasciculus and uncinate fasciculus), and two premotor fasciculi involved in the preparation of speech movements (the subcallosal medialis fasciculus and cortical fibres originating from the medial and lateral premotor areas). During surgery, language fascicles were identified by direct visualisation on tractography-integrated navigation images and by observing transient language inhibition after subcortical DES. Language deficits were evaluated preoperatively and postoperatively, and compared with the EOR.
Tractography was successfully performed in all patients, preoperatively demonstrating the relationships between the tumours to resect and the language fascicles to preserve from injury. With the use of the tractography-integrated navigation system and intraoperative DES, language functions were preserved in all patients. The mean volumetric resection was 93.0 ± 10.4 % of the preoperative tumour volume, with a gross total resection in 60 % of patients.
The intraoperative combination of tractography and DES contributed to maximum safe resection of gliomas located in language areas.
对于脑胶质瘤，手术的目标是最大限度地切除肿瘤（EOR），同时最大限度地减少术后发病率。本研究的目的是评估一种针对位于语言区的胶质瘤手术管理方案的益处，该方案结合了纤维束示踪导航和直接电刺激（DES）。
作者纳入了 10 名患有位于语言区的脑胶质瘤的患者。多模态导航的术前规划通过整合解剖磁共振图像和弥散张量成像生成的皮质下通路容积来完成。在每位患者中重建了 6 条与语言功能相关的白质束，包括语音处理纤维（即弓状束）、词汇语义处理纤维（即下额枕束、下纵束和钩束），以及两条与言语运动准备相关的前运动束（前连合内束和来自内侧和外侧前运动区的皮质纤维）。在手术过程中，通过纤维束示踪导航图像上的直接可视化和皮质下 DES 后观察到的短暂语言抑制来识别语言束。在术前和术后评估语言缺陷，并与 EOR 进行比较。
所有患者均成功进行了纤维束示踪，术前显示了要切除的肿瘤与要保留的语言束之间的关系，以避免损伤。使用纤维束示踪导航系统和术中 DES，所有患者的语言功能均得到保留。肿瘤的平均体积切除率为术前肿瘤体积的 93.0±10.4%，60%的患者实现了大体全切除。
术中纤维束示踪和 DES 的结合有助于最大限度地安全切除位于语言区的脑胶质瘤。
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