Ozaydin Burak, Dogan Ihsan, Wheeler Bryan J, Baskaya Mustafa K
Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin.
Intraoperative Neuromonitoring Program, University of Wisconsin Hospital and Clinics, Madison, Wisconsin.
Oper Neurosurg. 2020 Apr 1;18(4):E127-E128. doi: 10.1093/ons/opz185.
Surgical treatment of the gliomas located in or adjacent to the eloquent areas poses significant challenge to neurosurgeons. The main goal of the surgery is to achieve maximal safe resection while preserving the neurological function. This might be possible with utilizing pre- and intraoperative adjuncts such as functional magnetic resonance imaging (MRI), image guidance, mapping of the function of interest, intraoperative MRI, and neurophysiological monitoring. In this video, we demonstrate the utilization of nonawake mapping and motor-evoked potential (MEP) monitoring for the resection of a right-sided posterior superior frontal gyrus grade IV astrocytoma adjacent to the primary motor cortex. The patient is a 69-yr-old woman presented with multiple episodes of simple partial seizures involving her left leg and spreading to the left arm. MRI and functional MRI examinations showed a heterogeneously enhancing mass with peritumoral edema adjacent to the primary motor cortex. Because the patient did not want to undergo an awake craniotomy, a decision was made to perform the resection of the tumor with nonawake motor mapping and continuous MEP monitoring. Nonawake motor mapping and MEP monitoring enabled us to perform gross total resection. Because it has been shown that supratotal resection may provide improved survival outcome,1,2 we extended the white matter resection beyond the contrast enhancing area in noneloquent parts of the tumor. Surgical steps in dealing with vascular anatomy as well as utilizing intraoperative adjuncts such as motor mapping and MEP monitoring to enhance the extent of resection while preserving the function are demonstrated in this 3-dimensional surgical video. The patient consented to publication of her operative video.
对于位于功能区或其附近的胶质瘤进行手术治疗，对神经外科医生来说是一项重大挑战。手术的主要目标是在保留神经功能的同时实现最大程度的安全切除。利用术前和术中辅助手段，如功能磁共振成像（MRI）、图像引导、感兴趣功能区映射、术中MRI和神经生理监测，这一目标或许能够实现。在本视频中，我们展示了利用非清醒状态下的功能区映射和运动诱发电位（MEP）监测，来切除一例位于右侧额上回后部、毗邻初级运动皮层的IV级星形细胞瘤。患者为一名69岁女性，表现为多次单纯部分性发作，累及左腿并扩散至左臂。MRI和功能MRI检查显示，在初级运动皮层附近有一个不均匀强化的肿块，并伴有瘤周水肿。由于患者不愿接受清醒开颅手术，因此决定在非清醒状态下进行运动功能区映射和持续MEP监测的肿瘤切除术。非清醒状态下的运动功能区映射和MEP监测使我们能够实现肿瘤全切。因为已有研究表明，超全切可能会改善生存预后，[1,2]所以我们在肿瘤非功能区的白质切除范围超出了强化区域。本三维手术视频展示了处理血管解剖结构的手术步骤，以及利用运动功能区映射和MEP监测等术中辅助手段，在保留功能的同时扩大切除范围。患者同意公布其手术视频。
