Lauer Monika, Lauer Arne, You Se-Jong, Kluge Sara, Hattingen Elke, Harter Patrick N, Senft Christian, Wagner Marlies, Voss Martin
1Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt am Main.
2Edinger Institute (Institute of Neurology), Goethe University, Frankfurt am Main.
Neurosurg Focus. 2021 Jan;50(1):E12. doi: 10.3171/2020.10.FOCUS20402.
Intraoperative MRI with Gd-based contrast agent (GBCA) improves the extent of resection of contrast-enhancing brain tumors. Signal changes of CSF due to perioperative GBCA leakage in the subarachnoid space have been reported. However, although GBCA potentially exhibits neurotoxic effects, so far no associated complications have been described. In this case series, the authors report a single-center cohort of patients with subarachnoid GBCA extravasation after intraoperative MRI and discuss potential neurotoxic complications and potential ways of avoiding them.
All patients with CSF signal increase on unenhanced T1-weighted and FLAIR images on postoperative MRI, who had previously undergone tumor resection with use of intraoperative MRI, were retrospectively included and compared with a control cohort. The control group was matched in age, tumor characteristics, and extent of resection; comparisons were made regarding postoperative seizures and ICU stay. A subgroup with initially diagnosed malignant glioma was additionally analyzed for potential delay of initiation of adjuvant treatment and overall survival.
Seven patients with postoperative GBCA accumulation in the subarachnoid space were identified; 5 presented with focal seizures and altered mental status postoperatively. Poor patient condition led to extended ICU stay and prolonged delay of the initiation of adjuvant treatment in patients with newly diagnosed malignant glioma. Overall survival was reduced compared to the matched control group.
The results suggest that there might be a risk of neurotoxic complications if GBCA that is intravenously applied during neurosurgery leaks into the subarachnoid space. Patients with highly vascularized tumors with intraoperative bleeding seem to be especially at risk for GBCA accumulation and neurotoxic complications. Therefore, awareness of the potential risk of complicating GBCA leakage is mandatory in the application of intraoperative GBCA.
使用基于钆的造影剂（GBCA）的术中磁共振成像（MRI）可提高增强型脑肿瘤的切除范围。已有报道称蛛网膜下腔围手术期GBCA渗漏会导致脑脊液信号改变。然而，尽管GBCA可能具有神经毒性作用，但迄今为止尚未描述相关并发症。在本病例系列中，作者报告了一组术中MRI后发生蛛网膜下腔GBCA外渗的单中心患者队列，并讨论了潜在的神经毒性并发症及避免这些并发症的潜在方法。
回顾性纳入所有术后MRI未增强T1加权像和液体衰减反转恢复（FLAIR）像上脑脊液信号增强、此前接受过术中MRI肿瘤切除术的患者，并与对照组进行比较。对照组在年龄、肿瘤特征和切除范围方面进行匹配；比较术后癫痫发作情况和重症监护病房（ICU）住院时间。对最初诊断为恶性胶质瘤的亚组患者，额外分析辅助治疗开始的潜在延迟情况和总生存期。
确定了7例术后GBCA在蛛网膜下腔积聚的患者；5例术后出现局灶性癫痫发作和精神状态改变。患者状况不佳导致新诊断为恶性胶质瘤的患者ICU住院时间延长，辅助治疗开始延迟。与匹配的对照组相比，总生存期缩短。
结果表明，如果神经外科手术期间静脉注射的GBCA漏入蛛网膜下腔，可能存在神经毒性并发症风险。术中出血的高血管化肿瘤患者似乎尤其有GBCA积聚和神经毒性并发症的风险。因此，在应用术中GBCA时，必须意识到GBCA渗漏导致并发症的潜在风险。
