基于解剖结构的与 nTMS 基础的风险分层模型在预测脑肿瘤手术术后运动功能结果和切除范围的比较。

BACKGROUND: Two statistical models have been established to evaluate characteristics associated with postoperative motor outcome in patients with glioma associated to the motor cortex (M1) or the corticospinal tract (CST). One model is based on a clinicoradiological prognostic sum score (PrS) while the other one relies on navigated transcranial magnetic stimulation (nTMS) and diffusion-tensor-imaging (DTI) tractography. The objective was to compare the models regarding their prognostic value for postoperative motor outcome and extent of resection (EOR) with the aim of developing a combined, improved model. METHODS: We retrospectively analyzed a consecutive prospective cohort of patients who underwent resection for motor associated glioma between 2008 and 2020, and received a preoperative nTMS motor mapping with nTMS-based diffusion tensor imaging tractography. The primary outcomes were the EOR and the motor outcome (on the day of discharge and 3 months postoperatively according to the British Medical Research Council (BMRC) grading). For the nTMS model, the infiltration of M1, tumor-tract distance (TTD), resting motor threshold (RMT) and fractional anisotropy (FA) were assesed. For the PrS score (ranging from 1 to 8, lower scores indicating a higher risk), we assessed tumor margins, volume, presence of cysts, contrast agent enhancement, MRI index (grading white matter infiltration), preoperative seizures or sensorimotor deficits. RESULTS: Two hundred and three patients with a median age of 50 years (range: 20-81 years) were analyzed of whom 145 patients (71.4%) received a GTR. The rate of transient new motor deficits was 24.1% and of permanent new motor deficits 18.8%. The nTMS model demonstrated a good discrimination ability for the short-term motor outcome at day 7 of discharge (AUC = 0.79, 95 %CI: 0.72-0.86) and the long-term motor outcome after 3 months (AUC = 0.79, 95 %CI: 0.71-0.87). The PrS score was not capable to predict the postoperative motor outcome in this cohort but was moderately associated with the EOR (AUC = 0.64; CI 0.55-0.72). An improved, combined model was calculated to predict the EOR more accurately (AUC = 0.74, 95 %CI: 0.65-0.83). CONCLUSION: The nTMS model was superior to the clinicoradiological PrS model for potentially predicting the motor outcome. A combined, improved model was calculated to estimate the EOR. Thus, patient counseling and surgical planning in patients with motor-associated tumors should be performed using functional nTMS data combined with tractography.

背景：已经建立了两个统计模型来评估与运动皮层（M1）或皮质脊髓束（CST）相关的胶质瘤患者术后运动结局的相关特征。一个模型基于临床放射学预后总评分（PrS），另一个模型则依赖于经颅磁刺激导航（nTMS）和弥散张量成像（DTI）示踪。目的是比较这些模型在预测术后运动结局和切除程度（EOR）方面的预后价值，以期开发出一种综合的、改进的模型。

方法：我们回顾性分析了 2008 年至 2020 年间连续前瞻性队列中接受与运动相关的胶质瘤切除术的患者，并在术前进行了 nTMS 运动映射和 nTMS 基于弥散张量成像示踪的检查。主要结局是 EOR 和运动结局（根据英国医学研究委员会（BMRC）分级，在术后第 7 天和 3 个月时进行评估）。对于 nTMS 模型，评估了 M1 的浸润、肿瘤-束间距（TTD）、静息运动阈值（RMT）和各向异性分数（FA）。对于 PrS 评分（范围为 1 至 8，评分越低表示风险越高），评估了肿瘤边界、体积、是否存在囊肿、对比剂增强、MRI 指数（分级白质浸润）、术前癫痫发作或感觉运动缺陷。

结果：分析了 203 名中位年龄为 50 岁（范围：20-81 岁）的患者，其中 145 名患者（71.4%）接受了 GTR。暂时性新运动缺陷的发生率为 24.1%，永久性新运动缺陷的发生率为 18.8%。nTMS 模型对术后第 7 天的短期运动结局（AUC=0.79，95%CI：0.72-0.86）和术后 3 个月的长期运动结局（AUC=0.79，95%CI：0.71-0.87）具有良好的鉴别能力。PrS 评分在本队列中不能预测术后运动结局，但与 EOR 中度相关（AUC=0.64；CI 0.55-0.72）。计算出一种改进的、综合模型可以更准确地预测 EOR（AUC=0.74，95%CI：0.65-0.83）。

结论：nTMS 模型在预测运动结局方面优于临床放射学 PrS 模型。计算出一种改进的、综合的模型可以更好地估计 EOR。因此，在对运动相关肿瘤患者进行患者咨询和手术计划时，应使用功能 nTMS 数据结合示踪技术。