岛叶胶质瘤手术的经额下岛阈入路。

The transfrontal isthmus approach for insular glioma surgery.

出版信息

J Neurosurg. 2022 Nov 11;139(1):20-28. doi: 10.3171/2022.8.JNS22923. Print 2023 Jul 1.

DOI:10.3171/2022.8.JNS22923

PMID:36681987

Abstract

OBJECTIVE

The classic transopercular or transsylvian approach to insular gliomas removes the tumor laterally through the insular cortex. This study describes a new anteroposterior approach through the frontal isthmus for insular glioma surgery.

METHODS

The authors detailed the surgical techniques for resection of insular gliomas through the transfrontal isthmus approach. Fifty-nine insular gliomas with at least Berger-Sanai zone I involvement were removed with the new approach, and extent of resection and postoperative neurological outcomes were assessed.

RESULTS

Fifty-nine patients were enrolled in the study, including 35 men and 24 women, with a mean (range) age 44.3 (19-75) years. According to the Berger-Sanai classification system, the most common tumor was a giant glioma (67.8%), followed by involvement of zones I and IV (18.6%). Twenty-two cases were Yaşargil type 3A/B, and 37 cases were Yaşargil type 5A/B. The average angle between the lateral plane of the putamen and sagittal line was 33.53°, and the average width of the isthmus near the anterior insular point was 33.33 mm. The average angle between the lateral plane of the putamen and the sagittal line was positively correlated with the width of the isthmus near the anterior insular point (r = 0.935, p < 0.0001). The median (interquartile range [IQR]) preoperative tumor volume was 67.82 (57.64-92.19) cm3. Of 39 low-grade gliomas, 26 (66.67%) were totally resected; of 20 high-grade gliomas, 19 (95%) were totally resected. The median (IQR) extent of resection of the whole group was 100% (73.7%-100%). Intraoperative diffusion-weighted imaging showed no cases of middle cerebral artery- or lenticulostriate artery-related stroke. Extent of insular tumor resection was positively correlated with the angle of the lateral plane of the putamen and sagittal line (r = -0.329, p = 0.011) and the width of the isthmus near the anterior insular point (r = -0.267, p = 0.041). At 3 months postoperatively, muscle strength grade exceeded 4 in all cases, and all patients exhibited essentially normal speech. The median (IQR) Karnofsky performance score at 3 months after surgery was 90 (80-90).

CONCLUSIONS

The transfrontal isthmus approach changes the working angle from lateral-medial to anterior-posterior, allowing for maximal safe removal of insular gliomas.

摘要

目的

经典的经侧裂或经岛叶入路通过岛叶皮质将肿瘤向外侧切除。本研究描述了一种通过额弓间部切除岛叶胶质瘤的新的前后入路方法。

方法

作者详细介绍了通过额弓间部切除岛叶胶质瘤的手术技术。采用新方法切除了至少 Berger-Sanai Ⅰ区受累的 59 例岛叶胶质瘤，评估了肿瘤切除程度和术后神经功能结果。

结果

研究纳入 59 例患者，男 35 例，女 24 例，平均（范围）年龄 44.3（19-75）岁。根据 Berger-Sanai 分类系统，最常见的肿瘤为巨大胶质瘤（67.8%），其次为Ⅰ区和Ⅳ区受累（18.6%）。22 例为 Yaşargil 3A/B 型，37 例为 Yaşargil 5A/B 型。外侧苍白球平面与矢状线之间的平均角度为 33.53°，前岛点附近的弓间部平均宽度为 33.33mm。外侧苍白球平面与矢状线之间的平均角度与前岛点附近弓间部的宽度呈正相关（r=0.935，p<0.0001）。术前肿瘤体积中位数（四分位距[IQR]）为 67.82（57.64-92.19）cm3。39 例低级别胶质瘤中，26 例（66.67%）全切；20 例高级别胶质瘤中，19 例（95%）全切。全组肿瘤切除程度中位数（IQR）为 100%（73.7%-100%）。术中弥散加权成像无大脑中动脉或纹状体动脉相关卒中。岛叶肿瘤切除程度与外侧苍白球平面与矢状线的角度（r=-0.329，p=0.011）和前岛点附近弓间部的宽度（r=-0.267，p=0.041）呈正相关。术后 3 个月时，所有病例的肌力等级均超过 4 级，所有患者的语言功能基本正常。术后 3 个月的 Karnofsky 表现评分中位数（IQR）为 90（80-90）。