Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan.
Formerly Department of Neurosurgery, University of Basel and Division of Neurosurgery, Luzerner Kantonsspital, Lucerne, Switzerland.
Handb Clin Neurol. 2022;186:151-161. doi: 10.1016/B978-0-12-819826-1.00021-1.
The surgical morbidity of brainstem lesions is higher than in other areas of the central nervous system because the compact brainstem is highly concentrated with neural structures that are often distorted or even unrecognizable under microscopic view. Intraoperative neurophysiologic mapping helps identify critical neural structures to avoid damaging them. With the trans-fourth ventricular floor approach, identifying the facial colliculi and vagal and hypoglossal triangles enables incising and approaching the brainstem through the safe entry zones, the suprafacial or infrafacial triangle, with minimal injury. Corticospinal tract mapping is adopted in the case of brainstem surgery adjacent to the corticospinal tract. Intraoperative neurophysiologic monitoring techniques include motor evoked potentials (MEPs), corticobulbar MEPs, brainstem auditory evoked potentials, and somatosensory evoked potentials. These provide real-time feedback about the functional integrity of neural pathways, and the surgical team can reconsider and correct the surgical strategy accordingly. With multimodal mapping and monitoring, the brainstem is no longer "no man's land," and brainstem lesions can be treated surgically without formidable morbidity and mortality.
脑干病变的手术发病率高于中枢神经系统的其他区域，因为致密的脑干集中了大量的神经结构，这些结构在显微镜下往往变形甚至无法辨认。术中神经生理定位有助于识别关键的神经结构，以避免损伤它们。通过第四脑室底入路，可以识别面神经丘和迷走神经和舌下神经三角，从而通过安全进入区（表面三角或底面三角）切开并接近脑干，最大限度地减少损伤。在靠近皮质脊髓束的脑干手术中采用皮质脊髓束映射。术中神经生理监测技术包括运动诱发电位（MEPs）、皮质延髓 MEPs、脑干听觉诱发电位和体感诱发电位。这些技术提供了有关神经通路功能完整性的实时反馈，手术团队可以相应地重新考虑和纠正手术策略。通过多模态映射和监测，脑干不再是“无人区”，可以对脑干病变进行手术治疗，而不会出现严重的发病率和死亡率。
