*Department of Neurosurgery, First Medical Faculty, Charles University in Prague, Central Military Hospital-Military University Hospital Prague, Czech Republic; ‡Department of Radiology, Central Military Hospital-Military University Hospital Prague, Czech Republic; and §Department of Developmental Epileptology, Institute of Physiology, Academy of Sciences of the Czech Republic, Prague, Czech Republic.
Neurosurgery. 2013 Nov;73(5):797-807; discussion 806-7. doi: 10.1227/NEU.0000000000000087.
Primary brain tumors in motor eloquent areas are associated with high-risk surgical procedures because of potentially permanent and often disabling motor deficits. Intraoperative primary motor cortex mapping and corticospinal tract (CST) monitoring are well-developed and reliable techniques. Imaging of the CST by diffusion tensor tractography (DTT) is also feasible.
To evaluate the practical value of 3.0T intraoperative MRI (iMRI) with intraoperative DTT (iDTT) in surgery close to the CST, and to compare high-field iDTT with intraoperative neurophysiological CST mapping during glioma and metastasis resection in a routine setting.
Twenty-five patients (13 males, 12 females, median 47 years) were enrolled prospectively from June 2010 to June 2012. Patients were included if they had a solitary supratentorial intracerebral lesion compressing or infiltrating the CST according to preoperative MRI. Subcortical CST mapping was performed by monopolar (cathodal) stimulation (500 Hz, 400 μs, 5 pulses). CST DTT was made both at preoperative and intraoperative 3.0T MRI. Subcortical motor-evoked potential threshold current and probe-CST distance were recorded at 155 points before and at 103 points after iMRI. Current-distance correlations were performed both for pre-iMRI and for post-iMRI data.
The correlation coefficient pre-iMRI was R = 0.470 (P < .001); post-iMRI, the correlation coefficient was R = 0.338 (P < .001). MRI radical resection was achieved in 17 patients (68%), subtotal in 5 (24%), and partial in 3 (12%). Postoperative paresis developed in 8 patients (32%); the paresis was permanent in 1 case (4%).
The linear current-distance correlation was found both in pre-iMRI and in post-iMRI data. Intraoperative image distortion appeared in 36%. Neurophysiological subcortical mapping remains superior to DTT. Combining these 2 methods in selected cases can help increase the safety of tumor resection close to the CST.
原发性大脑肿瘤位于运动功能区，由于可能导致永久性和常常致残的运动功能缺损，因此手术风险较高。术中皮质运动区映射和皮质脊髓束 (CST) 监测是成熟且可靠的技术。通过弥散张量纤维束成像 (DTT) 对 CST 进行成像也是可行的。
评估术中磁共振成像 (iMRI) 联合术中 DTT (iDTT) 在接近 CST 的手术中的实际价值，并比较高场强 iDTT 与常规胶质瘤和转移瘤切除术中的术中神经生理学 CST 映射。
2010 年 6 月至 2012 年 6 月，前瞻性纳入 25 例患者（男性 13 例，女性 12 例，中位年龄 47 岁）。患者入选标准为术前 MRI 显示单发幕上脑内病变，压迫或浸润 CST。皮层下 CST 采用单极（阴极）刺激（500 Hz，400 μs，5 脉冲）进行定位。术前和术中 3.0T MRI 均进行 CST DTT。记录 iMRI 前后共 155 个点的皮层下运动诱发电位阈电流和探头-CST 距离，对术前和术后数据进行电流-距离相关性分析。
术前 iMRI 的相关系数为 R = 0.470（P <.001）；术后 iMRI 的相关系数为 R = 0.338（P <.001）。17 例（68%）患者达到 MRI 根治性切除，5 例（24%）患者达到次全切除，3 例（12%）患者达到部分切除。术后出现 8 例（32%）瘫痪，其中 1 例（4%）为永久性瘫痪。
在术前和术后 iMRI 数据中均发现了线性电流-距离相关性。术中出现 36%的图像失真。皮层下神经生理学定位仍然优于 DTT。在选择的病例中结合这两种方法可以帮助提高接近 CST 的肿瘤切除的安全性。
