D'Elia Alessandro, Lavalle Laura, Bua Antonella, Schiano DI Cola Mario, Ciavarro Marco, Esposito Vincenzo
Department of Neurosurgery, IRCCS Neuromed, Pozzilli, Isernia, Italy.
Department of Neurosurgery, IRCCS Neuromed, Pozzilli, Isernia, Italy -
J Neurosurg Sci. 2024 Oct;68(5):519-525. doi: 10.23736/S0390-5616.22.05819-2. Epub 2022 Jun 28.
Actual challenge in surgical treatment of intra-axial gliomas involving eloquent areas is maximal safe resection. Mapping and monitoring of cortical and subcortical motor functions are important tools to avoid postoperative deficits. In the present study, we present our experience with a continuous dynamic motor mapping technique pairing a traditional monopolar stimulator with a Cavitron ultrasonic surgical aspirator (CUSA) to perform a continuous stimulation of the white matter avoiding removal interruption.
We describe a single center retrospective analysis of 1-year consecutive patients with intraxial tumors located adjacent to corticospinal tract and treated with surgical resection adopting "continuous dynamic mapping technique." With the support of a reconstruction software (3D Slicer), we classified the extent of resection (EOR) as gross total resection (GTR) (>98%), sub-total resection (STR) (from 90% to 97%), and partial resection (<90%). Medical Research Council (MRC) grading was adopted to evaluate neurological outcomes (from 0 to 5), assessed on first postoperative day, at 1 week, 1 month and 3 months.
From July 2017 to July 2018, 29 patients underwent to surgical removal of intraxial tumor adjacent to motor areas, using continuous dynamic subcortical mapping. Median age was 54 years old (range 12-75 years). At preoperative MRI tractography reconstruction, mean distance between tumor and corticospinal tract was 4.4 mm (range At 1 week postoperative assessment, motor deficits were still present in 12 patients (41%). At 1 month, 10 patients (35%) had persisting deficits, which required admission to rehabilitation department. At 3 months, 4 patients (14%) had persistent motor impairment and overall 28 patients (98%) were able to walk by themselves.
Our early experience showed that a combination of dynamic subcortical mapping with transcranial and cortical strip MEP (motor evoked potentials) monitoring is useful in tumors close to motor eloquent areas to extend surgical resection avoiding permanent consequences. However, we need for further experience to consolidate and improve this technique.
手术治疗涉及功能区的脑内胶质瘤时，实际面临的挑战是实现最大程度的安全切除。对皮质和皮质下运动功能进行定位和监测是避免术后功能缺损的重要手段。在本研究中，我们介绍了一种连续动态运动定位技术的经验，该技术将传统单极刺激器与卡维超声外科吸引器（CUSA）相结合，对白质进行连续刺激，避免切除过程中断。
我们对采用“连续动态定位技术”手术切除位于皮质脊髓束附近的脑内肿瘤的连续1年患者进行了单中心回顾性分析。在重建软件（3D Slicer）的支持下，我们将切除范围（EOR）分为全切除（GTR）（>98%）、次全切除（STR）（90%至97%）和部分切除（<90%）。采用医学研究委员会（MRC）分级评估神经功能结果（0至5级），在术后第1天、1周、1个月和3个月进行评估。
2017年7月至2018年7月，29例患者采用连续动态皮质下定位技术手术切除运动区附近的脑内肿瘤。中位年龄为54岁（范围12 - 75岁）。术前MRI纤维束成像重建显示，肿瘤与皮质脊髓束的平均距离为4.4毫米（范围……）。术后1周评估时，12例患者（41%）仍存在运动功能缺损。1个月时，10例患者（35%）仍有持续性缺损，需要入住康复科。3个月时，4例患者（14%）存在持续性运动障碍，总体上28例患者（98%）能够自行行走。
我们的早期经验表明，动态皮质下定位与经颅和皮质条带运动诱发电位（MEP）监测相结合，对于靠近运动功能区的肿瘤扩大手术切除范围、避免永久性后果是有用的。然而，我们需要更多经验来巩固和改进这项技术。
