Department of Neurosurgery, Nagoya University School of Medicine, Nagoya.
Department of Neurosurgery, Fukushima Medical University, Fukushima.
J Neurosurg. 2017 Oct;127(4):790-797. doi: 10.3171/2016.9.JNS16152. Epub 2017 Jan 6.
OBJECTIVE Maximum extent of resection (EOR) for lower-grade and high-grade gliomas can increase survival rates of patients. However, these infiltrative gliomas are often observed near or within eloquent regions of the brain. Awake surgery is of known benefit for the treatment of gliomas associated with eloquent regions in that brain function can be preserved. On the other hand, intraoperative MRI (iMRI) has been successfully used to maximize the resection of tumors, which can detect small amounts of residual tumors. Therefore, the authors assessed the value of combining awake craniotomy and iMRI for the resection of brain tumors in eloquent areas of the brain. METHODS The authors retrospectively reviewed the records of 33 consecutive patients with glial tumors in the eloquent brain areas who underwent awake surgery using iMRI. Volumetric analysis of MRI studies was performed. The pre-, intra-, and postoperative tumor volumes were measured in all cases using MRI studies obtained before, during, and after tumor resection. RESULTS Intraoperative MRI was performed to check for the presence of residual tumor during awake surgery in a total of 25 patients. Initial iMRI confirmed no further tumor resection in 9 patients (36%) because all observable tumors had already been removed. In contrast, intraoperative confirmation of residual tumor during awake surgery led to further tumor resection in 16 cases (64%) and eventually an EOR of more than 90% in 8 of 16 cases (50%). Furthermore, EOR benefiting from iMRI by more than 15% was found in 7 of 16 cases (43.8%). Interestingly, the increase in EOR as a result of iMRI for tumors associated mainly with the insular lobe was significantly greater, at 15.1%, than it was for the other tumors, which was 8.0% (p = 0.001). CONCLUSIONS This study revealed that combining awake surgery with iMRI was associated with a favorable surgical outcome for intrinsic brain tumors associated with eloquent areas. In particular, these benefits were noted for patients with tumors with complex anatomy, such as those associated with the insular lobe.
最大限度地切除低级别和高级别胶质瘤可以提高患者的生存率。然而，这些浸润性胶质瘤通常位于大脑的功能区附近或内部。术中唤醒手术对治疗与功能区相关的胶质瘤有益，因为可以保留脑功能。另一方面，术中磁共振成像（iMRI）已成功用于最大限度地切除肿瘤，可检测到少量残留肿瘤。因此，作者评估了将术中唤醒与 iMRI 结合用于切除大脑功能区肿瘤的价值。
作者回顾性分析了 33 例在大脑功能区接受术中唤醒 iMRI 手术的胶质肿瘤患者的记录。对 MRI 研究进行了体积分析。所有病例均在术前、术中及肿瘤切除后获得的 MRI 研究中测量术前、术中及术后肿瘤体积。
共对 25 例患者在术中唤醒手术中进行了 iMRI 以检查是否存在残留肿瘤。初次 iMRI 证实 9 例（36%）患者无需进一步切除肿瘤，因为所有可见肿瘤已被切除。相比之下，术中在唤醒手术中确认存在残留肿瘤导致 16 例（64%）进一步切除肿瘤，最终 8 例（50%）患者的 EOR 超过 90%。此外，16 例中有 7 例（43.8%）的 EOR 因 iMRI 而增加超过 15%。有趣的是，iMRI 对主要与岛叶相关的肿瘤 EOR 增加幅度明显大于其他肿瘤（15.1%比 8.0%，p=0.001）。
本研究表明，将术中唤醒手术与 iMRI 结合使用与与大脑功能区相关的内在脑肿瘤的良好手术结果相关。对于具有复杂解剖结构的肿瘤患者，如与岛叶相关的肿瘤，这些获益更为显著。
