Tamura Manabu, Kurihara Hiroyuki, Saito Taiichi, Nitta Masayuki, Maruyama Takashi, Tsuzuki Shunsuke, Fukui Atsushi, Koriyama Shunichi, Kawamata Takakazu, Muragaki Yoshihiro
Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Tokyo, Japan.
Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan.
Front Neurol. 2022 Jan 20;12:805952. doi: 10.3389/fneur.2021.805952. eCollection 2021.
We developed a navigation system that superimposes the fractional anisotropy (FA) color map of pre-operative diffusion tensor imaging (DTI) and intraoperative magnetic resonance imaging (MRI). The current study aimed to investigate the usefulness of this system for neurophysiological monitoring and examination under awake craniotomy during tumor removal.
A total of 10 glioma patients (4 patients with right-side tumors; 5 men and 5 women; average age, 34 years) were evaluated. Among them, the tumor was localized to the frontal lobe, insular cortex, and parietal lobe in 8, 1, and 1 patient, respectively. There were 3 patients who underwent surgery on general anesthesia, while 7 patients underwent awake craniotomy. The index of DTI anisotropy taken pre-operatively (magnetic field: 3 tesla, 6 motion probing gradient directions) was analyzed as a color map (FA color map) and concurrently co-registered in the intraoperative MRI within the navigation. In addition to localization of the bipolar coagulator and the cortical stimulator for brain mapping on intraoperative MRI, the pre-operative FA color map was also concurrently integrated and displayed on the navigation monitor. This white matter nerve functional information was confirmed directly by using neurological examination and referring to the electrophysiological monitoring.
Intraoperative MRI, integrated pre-operative FA color map, and microscopic surgical view were displayed on one screen in all 10 patients, and white matter fibers including the pyramidal tract were displayed as a reference in blue. Regarding motor function, motor-evoked potential was monitored as appropriate in all cases, and removal was possible while directly confirming motor symptoms under awake craniotomy. Furthermore, the white matter fibers including the superior longitudinal fasciculus were displayed in green. Importantly, it was useful not only to localize the resection site, but to identify language-related, eye movement-related, and motor fibers at the electrical stimulation site. All motor and/or language white matter tracts were identified and visualized with the co-registration and then with an acceptable post-operative neurological outcome.
Co-registering an intraoperative MR images and a pre-operative FA color map is a practical and useful method to predict the localization of critical white matter nerve functions intraoperatively in glioma surgery.
我们开发了一种导航系统，该系统可叠加术前弥散张量成像（DTI）的分数各向异性（FA）彩色图和术中磁共振成像（MRI）。本研究旨在探讨该系统在肿瘤切除术中清醒开颅手术期间用于神经生理监测和检查的有效性。
共评估了10例胶质瘤患者（4例右侧肿瘤患者；5例男性和5例女性；平均年龄34岁）。其中，肿瘤分别定位于额叶、岛叶皮质和顶叶的患者有8例、1例和1例。3例患者接受全身麻醉手术，7例患者接受清醒开颅手术。术前采集的DTI各向异性指数（磁场：3特斯拉，6个运动探测梯度方向）作为彩色图（FA彩色图）进行分析，并在导航系统的术中MRI中同时进行配准。除了在术中MRI上定位双极电凝器和用于脑图谱绘制的皮质刺激器外，术前FA彩色图也同时整合并显示在导航监视器上。通过神经学检查并参考电生理监测直接确认这种白质神经功能信息。
所有10例患者的术中MRI、整合的术前FA彩色图和显微镜下手术视野均显示在一个屏幕上，包括锥体束在内的白质纤维以蓝色显示作为参考。关于运动功能，所有病例均适当监测运动诱发电位，并且在清醒开颅手术期间直接确认运动症状的同时可以进行切除。此外，包括上纵束在内的白质纤维以绿色显示。重要的是，这不仅有助于定位切除部位，还能在电刺激部位识别与语言、眼球运动和运动相关的纤维。所有运动和/或语言白质束通过配准被识别并可视化，术后神经功能结果良好。
术中MR图像与术前FA彩色图配准是一种在胶质瘤手术中术中预测关键白质神经功能定位的实用且有效的方法。
