1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
2University of Arizona College of Medicine-Phoenix, Arizona; and.
J Neurosurg. 2024 Mar 8;141(2):291-305. doi: 10.3171/2023.12.JNS232588. Print 2024 Aug 1.
Cerebral cavernous malformations (CMs) are pathological lesions that cause discrete cortical disruption with hemorrhage, and their transcortical resections can cause additional iatrogenic disruption. The analysis of microsurgically treated CMs might identify areas of "eloquent noneloquence," or cortex that is associated with unexpected deficits when injured or transgressed.
Patients from a consecutive microsurgical series of superficial cerebral CMs who presented to the authors' center over a 13-year period were retrospectively analyzed. Neurological outcomes were measured using the modified Rankin Scale (mRS), and new, permanent neurological or cognitive symptoms not detected by changes in mRS scores were measured as additional functional decline. Patients with multiple lesions and surgical encounters for different lesions within the study interval were represented within the cohort as multiple patient entries. Virtual object models for CMs and approach trajectories to subcortical lesions were merged into a template brain model for subtyping and Quicktome connectomic analyses. Parcellation outputs from the models were analyzed for regional cerebral clustering.
Overall, 362 CMs were resected in 346 patients, and convexity subtypes were the most common (132/362, 36.5%). Relative to the preoperative mRS score, 327 of 362 cases (90.3%) were in patients who improved or remained stable, 35 (9.7%) were in patients whose conditions worsened, and 47 (13.0%) were in patients who had additional functional decline. Machine learning analyses of lesion objects and trajectory cylinder mapping identified 7 hotspots of novel eloquence: supplementary motor area (bilateral), anterior cingulate cortex (bilateral), posterior cingulate cortex (bilateral), anterior insula (left), frontal pole (right), mesial temporal lobe (left), and occipital cortex (right).
Transgyral and transsulcal resections that circumvent areas of traditional eloquence and navigate areas of presumed noneloquence may nonetheless result in unfavorable outcomes, demonstrating that brain long considered by neurosurgeons to be noneloquent may be eloquent. Eloquent hotspots within multiple large-scale networks redefine the neurosurgical concept of eloquence and call for more refined dissection techniques that maximize transsulcal dissection, intracapsular resection, and tissue preservation. Human connectomics, awareness of brain networks, and prioritization of cognitive outcomes require that we update our concept of cortical eloquence and incorporate this information into our surgical strategies.
脑海绵状血管畸形（CMs）是病理性病变，可导致皮质离散性破坏并伴有出血，其皮质切除术可导致额外的医源性破坏。对显微治疗的 CMs 的分析可能会确定“非功能区的功能区”或与受伤或侵犯时出现意外缺陷相关的皮质区域。
对作者中心在 13 年内连续接受浅表性 CMs 显微手术的患者进行回顾性分析。采用改良 Rankin 量表（mRS）评估神经功能结局，采用 mRS 评分变化未检测到的新的永久性神经或认知症状来衡量额外的功能下降。同一患者在研究期间有多个病变并进行了不同病变的手术，在队列中代表多个患者。CMs 的虚拟物体模型和向皮质下病变的接近轨迹被合并到一个亚类型模板脑模型中，用于 Quicktome 连接组学分析。对模型的分割输出进行区域性脑聚类分析。
共切除 362 个 CMs，涉及 346 例患者，其中凸面型最常见（132/362，36.5%）。与术前 mRS 评分相比，362 例中有 327 例（90.3%）患者改善或保持稳定，35 例（9.7%）患者病情恶化，47 例（13.0%）患者出现额外的功能下降。对病变物体和轨迹柱映射的机器学习分析确定了 7 个新的功能区热点：辅助运动区（双侧）、扣带回皮质（双侧）、后扣带回皮质（双侧）、前岛叶（左侧）、额极（右侧）、内侧颞叶（左侧）和枕叶（右侧）。
避开传统功能区并避开假定的非功能区的经皮质和经软脑膜切除术，可能会导致不良结局，这表明神经外科医生长期认为非功能区的脑可能是有功能的。多个大型网络中的功能区热点重新定义了神经外科的功能区概念，并要求采用更精细的解剖技术，最大限度地进行经软脑膜切开、囊内切除和组织保留。人类连接组学、对脑网络的认识以及对认知结果的重视，要求我们更新皮质功能区的概念，并将其纳入我们的手术策略。
