Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
Department of Neurosurgery, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany.
Handb Clin Neurol. 2022;186:133-149. doi: 10.1016/B978-0-12-819826-1.00013-2.
Many different methodologies and paradigms are available to guide surgery of supratentorial tumors with the aim to preserve quality of life of the patients and to increase the extent of tumor resection. Neurophysiologic monitoring techniques (such as different evoked potentials) may help to continuously assess functional integrity of the observed systems and warn about vascular injury. For neurophysiologic mapping methods, the focus is not only to preserve cortical sites, but also to prevent injury to subcortical pathways. Therefore, cortical mapping is not enough but should be combined with subcortical mapping to identify tracts. This may be done by alternating resection and stimulation, or by continuous mapping via an electrified surgical tool such as a stimulating suction tip. Increasingly refined techniques are evolving to improve mapping of complex motor networks as well as language and higher cortical functions. Finally, in deciding between an awake vs asleep intraoperative setting, various factors need to be considered, such as the surgical goal, patient expectation and cooperation, treating team expertise, and neurooncologic aspects including histopathology. Therefore, the choice of protocol depends on the clinical context and the experience of the interdisciplinary team treating the patients.
有许多不同的方法和范式可用于指导幕上肿瘤的手术，旨在保留患者的生活质量并增加肿瘤切除的范围。神经生理监测技术（如不同的诱发电位）可帮助持续评估观察系统的功能完整性并警告血管损伤。对于神经生理绘图方法，重点不仅在于保留皮质部位，还在于防止皮质下通路损伤。因此，皮质绘图是不够的，而应与皮质下绘图相结合以识别束。这可以通过交替切除和刺激来完成，也可以通过使用电外科工具（如刺激吸引头）进行连续绘图来完成。为了提高对复杂运动网络以及语言和高级皮质功能的绘图，正在不断发展越来越精细的技术。最后，在选择清醒与睡眠术中环境时，需要考虑许多因素，例如手术目标、患者的期望和配合、治疗团队的专业知识以及包括组织病理学在内的神经肿瘤学方面。因此，方案的选择取决于临床情况和治疗患者的跨学科团队的经验。
