Gamble Alexander J, Schaffer Sarah G, Nardi Dominic J, Chalif David J, Katz Jeffery, Dehdashti Amir R
Department of Neurosurgery, Cushing Neuroscience Institute, Hofstra North Shore-LIJ School of Medicine, North Shore University Hospital, Manhasset, New York, USA.
Department of Neurology, Cushing Neuroscience Institute, Hofstra North Shore-LIJ School of Medicine, North Shore University Hospital, Manhasset, New York, USA.
World Neurosurg. 2015 Nov;84(5):1394-401. doi: 10.1016/j.wneu.2015.06.059. Epub 2015 Jul 2.
Awake craniotomy for removal of intra-axial lesions is a well-established procedure. Few studies, however, have investigated the usefulness of this approach for resection of arteriovenous malformations adjacent to eloquent language areas. We demonstrate our experience by using cortical stimulation mapping and report for the first time on the usefulness of subcortical stimulation with interrogation of language function during resection of arteriovenous malformations (AVMs) located near language zones.
Patients undergoing awake craniotomy for AVMs located in language zones and at least 5 mm away from the closest functional magnetic resonance imaging activation were analyzed. During surgery, cortical bipolar stimulation at 50 Hz, with an intensity of 2 mA, increased to a maximum of 10 mA was performed in the region around the AVM before claiming it negative for language function. In positive language site, the area was restimulated 3 times to confirm the functional deficit. The AVM resection was started based on cortical mapping findings. Further subcortical stimulation performed in concert with speech interrogation by the neuropsychologist continued at key points throughout the resection as feasible. The usefulness of cortical and subcortical stimulation in addition to patient outcomes was analyzed.
Between March 2009 and September 2014, 42 brain AVM resections were performed. Four patients with left-sided language zone AVMs underwent awake craniotomy. The AVM locations were fronto-opercular in 2 patients and posterior temporal in 2. The AVM Spetzler-Martin grades were II (2 patients) and III (2 patients). In 1 patient, complete speech arrest was noticed during mapping of the peri-malformation zone, which was not breached during resection. In a second patient who initially demonstrated negative cortical mapping, a speech deficit was noticed during resection and subcortical stimulation. This guided the approach to protect and avoid the sensitive zone. This patient experienced mild postoperative expressive dysphasia that improved to normal within 6 weeks. Complete resection was achieved in all 4 patients. There were no other complications and no permanent neurological morbidity, resulting in good outcome in all 4 patients.
Language mapping, both cortical and subcortical during AVM resection, may be valuable in a very select group of AVMs in language zones. Defining safe margins and feedback to the surgeon may provide the highest chances of a surgical cure while minimizing the risk of incurring a language deficit.
清醒开颅切除脑内病变是一种成熟的手术方法。然而，很少有研究探讨这种方法用于切除毗邻明确语言区的动静脉畸形的有效性。我们通过使用皮质刺激图谱展示了我们的经验，并首次报告了在切除位于语言区附近的动静脉畸形（AVM）过程中，进行皮质下刺激并询问语言功能的有效性。
对因位于语言区且距功能磁共振成像激活区至少5毫米的AVM而接受清醒开颅手术的患者进行分析。手术期间，在AVM周围区域进行50赫兹的皮质双极刺激，强度为2毫安，最大增至10毫安，然后判定该区域无语言功能。在语言功能阳性部位，对该区域再次刺激3次以确认功能缺陷。根据皮质图谱结果开始切除AVM。在整个切除过程的关键点，只要可行，就继续进行与神经心理学家的言语询问相结合的皮质下刺激。分析了皮质和皮质下刺激的有效性以及患者的预后情况。
2009年3月至2014年9月期间，共进行了42例脑AVM切除术。4例左侧语言区AVM患者接受了清醒开颅手术。2例患者的AVM位于额岛叶，2例位于颞叶后部。AVM的斯佩茨勒-马丁分级为Ⅱ级（2例患者）和Ⅲ级（2例患者）。1例患者在畸形周边区域图谱绘制期间出现完全性言语停顿，切除过程中未突破该区域。另1例患者最初皮质图谱显示为阴性，但在切除和皮质下刺激期间出现言语缺陷。这指导了保护和避开敏感区的手术方法。该患者术后出现轻度表达性失语，6周内恢复正常。4例患者均实现了完全切除。无其他并发症，也无永久性神经功能障碍，4例患者预后均良好。
在AVM切除过程中进行皮质和皮质下语言图谱绘制，对于非常特定的一组位于语言区的AVM可能具有重要价值。确定安全边界并向外科医生提供反馈，可能为手术治愈提供最大机会，同时将出现语言缺陷的风险降至最低。
