应用导航经颅磁刺激（nTMS）研究视觉空间网络并预防脑肿瘤手术中的偏侧忽略
Application of Navigated Transcranial Magnetic Stimulation (nTMS) to Study the Visual-Spatial Network and Prevent Neglect in Brain Tumour Surgery.
作者信息
Bonaudo Camilla, Castaldi Elisa, Pedone Agnese, Capelli Federico, Enderage Don Shani, Pieropan Edoardo, Bianchi Andrea, Gobbo Marika, Maduli Giuseppe, Fedi Francesca, Baldanzi Fabrizio, Troiano Simone, Maiorelli Antonio, Muscas Giovanni, Battista Francesca, Campagnaro Luca, De Pellegrin Serena, Amadori Andrea, Fainardi Enrico, Carrai Riccardo, Grippo Antonello, Della Puppa Alessandro
机构信息
Neurosurgery, Department of Neuroscience, Psychology, Pharmacology and Child Health, University Hospital of Careggi, University of Florence, 50134 Florence, Italy.
Department of Neuroscience, Psychology, Pharmacology, and Child Health, University of Florence, 50121 Florence, Italy.
出版信息
Cancers (Basel). 2024 Dec 20;16(24):4250. doi: 10.3390/cancers16244250.
Navigated transcranial magnetic stimulation (nTMS) has seldom been used to study visuospatial (VS) circuits so far. Our work studied (I) VS functions in neurosurgical oncological patients by using repetitive nTMS (rnTMS), (II) the possible subcortical circuits underneath, and (III) the correspondence between nTMS and direct cortical stimulation (DCS) during awake procedures. We designed a monocentric prospective study, adopting a protocol to use rnTMS for preoperative planning, including VS functions for lesions potentially involving the VS network, including neurosurgical awake and asleep procedures. nTMS-based-DTI tractography allowed the visualization of subcortical circuits. Statistical analyses on nTMS/DCS points were performed. Clinical results were collected pre- and postoperatively. Finally, 27 patients with primitive intra-axial brain lesions were enrolled between April 2023 and March 2024. Specific tests and an experimental integrated VS test (VISA) were used. The clinical evaluation (at 5 ± 7, 30 ± 10, 90 ± 10 days after surgery) documented 33% of patients with neglect in the left hemisphere four days after surgery and, during the 3-month follow-up, preservation of visuospatial function/clinical recovery (90.62% in MMSE, 98.86% in the bell test, 80% in the clock test, and 98% in the OCS test). The surgical strategy was modulated according to the nTMS map. Subcortical bundles were traced to identify those most involved in these functions: SFLII > SLFII > SLFI. A comparison of the nTMS and DCS points in awake surgery (n = 10 patients) documented a sensitivity (Se) of 12%, a specificity (Sp) of 91.21%, a positive predictive value (PPV) of 42%, a negative predictive value (NPV) of 66%, and an accuracy of ~63.7%. Based on our preliminary results, nTMS is advantageous for studying cognitive functions, minimising neurological impairment. Further analyses are needed to validate our data.
导航经颅磁刺激（nTMS）到目前为止很少被用于研究视觉空间（VS）回路。我们的研究工作包括：（I）通过重复经颅磁刺激（rnTMS）研究神经外科肿瘤患者的VS功能；（II）探究其潜在的皮质下回路；（III）研究清醒手术过程中nTMS与直接皮质刺激（DCS）之间的对应关系。我们设计了一项单中心前瞻性研究，采用rnTMS用于术前规划的方案，包括对可能涉及VS网络的病变进行VS功能评估，涵盖神经外科清醒和睡眠手术。基于nTMS的弥散张量成像纤维束造影能够可视化皮质下回路。对nTMS/DCS位点进行了统计分析。术前和术后收集了临床结果。最后，在2023年4月至2024年3月期间纳入了27例原发性脑内病变患者。使用了特定测试和实验性综合VS测试（VISA）。临床评估（术后5±7天、30±10天、90±10天）记录了术后四天33%的左半球患者出现忽视症状，在3个月的随访期间，视觉空间功能得以保留/临床恢复（简易精神状态检查表（MMSE）中为90.62%，钟摆测试中为98.86%，时钟测试中为80%，视空间认知筛查（OCS）测试中为98%）。手术策略根据nTMS图谱进行了调整。追踪皮质下束以确定那些在这些功能中最相关的束：上纵束II > 上纵束II > 上纵束I。对清醒手术中10例患者的nTMS和DCS位点进行比较，结果显示灵敏度（Se）为12%，特异度（Sp）为91.21%，阳性预测值（PPV）为42%，阴性预测值（NPV）为66%，准确率约为63.7%。基于我们的初步结果，nTMS在研究认知功能、最小化神经损伤方面具有优势。需要进一步分析来验证我们的数据。
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