Wang Anthony C, Ibrahim George M, Poliakov Andrew V, Wang Page I, Fallah Aria, Mathern Gary W, Buckley Robert T, Collins Kelly, Weil Alexander G, Shurtleff Hillary A, Warner Molly H, Perez Francisco A, Shaw Dennis W, Wright Jason N, Saneto Russell P, Novotny Edward J, Lee Amy, Browd Samuel R, Ojemann Jeffrey G
Departments of1Neurosurgery and.
3Division of Neurosurgery, Hospital for Sick Children and Toronto Western Hospital, Toronto, Ontario, Canada; Departments of.
J Neurosurg Pediatr. 2018 Jan;21(1):81-89. doi: 10.3171/2017.7.PEDS17137. Epub 2017 Nov 3.
OBJECTIVE The potential loss of motor function after cerebral hemispherectomy is a common cause of anguish for patients, their families, and their physicians. The deficits these patients face are individually unique, but as a whole they provide a framework to understand the mechanisms underlying cortical reorganization of motor function. This study investigated whether preoperative functional MRI (fMRI) and diffusion tensor imaging (DTI) could predict the postoperative preservation of hand motor function. METHODS Thirteen independent reviewers analyzed sensorimotor fMRI and colored fractional anisotropy (CoFA)-DTI maps in 25 patients undergoing functional hemispherectomy for treatment of intractable seizures. Pre- and postoperative gross hand motor function were categorized and correlated with fMRI and DTI findings, specifically, abnormally located motor activation on fMRI and corticospinal tract atrophy on DTI. RESULTS Normal sensorimotor cortical activation on preoperative fMRI was significantly associated with severe decline in postoperative motor function, demonstrating 92.9% sensitivity (95% CI 0.661-0.998) and 100% specificity (95% CI 0.715-1.00). Bilaterally robust, symmetric corticospinal tracts on CoFA-DTI maps were significantly associated with severe postoperative motor decline, demonstrating 85.7% sensitivity (95% CI 0.572-0.982) and 100% specificity (95% CI 0.715-1.00). Interpreting the fMR images, the reviewers achieved a Fleiss' kappa coefficient (κ) for interrater agreement of κ = 0.69, indicating good agreement (p < 0.01). When interpreting the CoFA-DTI maps, the reviewers achieved κ = 0.64, again indicating good agreement (p < 0.01). CONCLUSIONS Functional hemispherectomy offers a high potential for seizure freedom without debilitating functional deficits in certain instances. Patients likely to retain preoperative motor function can be identified prior to hemispherectomy, where fMRI or DTI suggests that cortical reorganization of motor function has occurred prior to the operation.
目的 大脑半球切除术后运动功能的潜在丧失是患者、其家属和医生共同面临的困扰。这些患者面临的缺陷各不相同，但总体上为理解运动功能皮质重组的潜在机制提供了一个框架。本研究调查术前功能磁共振成像（fMRI）和弥散张量成像（DTI）是否能够预测术后手部运动功能的保留情况。方法 13名独立评估者分析了25例因顽固性癫痫接受功能性半球切除术患者的感觉运动fMRI和彩色分数各向异性（CoFA）-DTI图谱。术前和术后的手部总体运动功能进行分类，并与fMRI和DTI结果相关联，具体而言，fMRI上运动激活位置异常和DTI上皮质脊髓束萎缩。结果 术前fMRI上感觉运动皮质激活正常与术后运动功能严重下降显著相关，敏感性为92.9%（95%CI 0.661 - 0.998），特异性为100%（95%CI 0.715 - 1.00）。CoFA-DTI图谱上双侧强大、对称的皮质脊髓束与术后严重运动功能下降显著相关，敏感性为85.7%（95%CI 0.572 - 0.982），特异性为100%（95%CI 0.715 - 1.00）。在解读fMRI图像时，评估者间一致性的Fleiss' kappa系数（κ）为κ = 0.69，表明一致性良好（p < 0.01）。在解读CoFA-DTI图谱时，评估者间κ = 0.64，同样表明一致性良好（p < 0.01）。结论 在某些情况下，功能性半球切除术有很大潜力实现无癫痫发作且不导致功能缺陷。在半球切除术之前，当fMRI或DTI提示手术前运动功能已发生皮质重组时，有可能识别出可能保留术前运动功能的患者。
