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首页> 外文期刊>Neurocirugia >Tratamiento de los tumores cerebrales intrínsecos de áreas motoras elocuentes: Resultados de un protocolo basado en la navegación, tractografía y monitorización neurofisiológica de estructuras corticales y subcorticales
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Tratamiento de los tumores cerebrales intrínsecos de áreas motoras elocuentes: Resultados de un protocolo basado en la navegación, tractografía y monitorización neurofisiológica de estructuras corticales y subcorticales

机译：雄辩运动区固有性脑肿瘤的治疗：基于导航，体层照相术和皮层和皮层下结构神经生理监测的协议结果

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Objectives: The role of the microsurgical management of intrinsic brain tumors is to maximize the volumetric resection of the tumoral tissue minimizing the postoperative morbidity. The purpose of our paper has been to study the benefits of an original protocol developed for the microsurgical treatment of tumors located in eloquent motor areas where the navigation and electrical stimulation of motor subcortical pathways have been implemented. Materials and methods: A total of 17 patients operated on for resection of cortical or subcortical tumors in motor areas were included in the series. Preoperative planning for multimodal navigation was done integrating anatomic studies, motor functional MRI (f-MRI) and subcortical pathways volumes generated by diffusion tensor imaging (DTI). Intraoperative neuromonitorization included motor mapping by direct cortical and subcortical electrical stimulation (CS and sCS) and localization of the central sulcus using cortical multipolar electrodes and the N20 wave inversion technique. The location of all cortical and subcortical stimulated points with positive motor response was stored in the navigator and correlated with the cortical or subcortical motor functional structures defined preoperatively. Results: The mean tumoral volumetric resection was 89.1±14.2% of the preoperative volume, with a total resection (≥100%) in twelve patients. Preoperatively a total of 58.8% of the patients had some motor deficit, increasing 24 hours after surgery to 76.5% and decreasing to 41.1% a month later. There was a great correlation between anatomic and functional data, both cortically and subcortically. However, in six cases it was not possible to identify the central sulcus and in many cases fMRI gave contradictory information. A total of 52 cortical points submitted to CS had positive motor response, with a positive correlation of 83.7%. Also, a total of 55 subcortical points had positive motor response, being in these cases 7.3±3.1mm the mean distance from the stimulated point to the subcortical tract. Conclusions: The integration of preoperative and intraoperative anatomic and functional studies allows a safe functional resection of the brain tumors located in eloquent areas, compared to the tumoral resection based on anatomic imaging studies. Multimodal navigation allows the integration and correlation among preoperative and intraoperative anatomic and functional data. Cortical motor functional areas are anatomically and functionally located preoperatively thanks to MRI and fMRI and subcortical motor pathways with TDI and tractography. Intraoperative confirmation is done with CS and N20 inversion wave for cortical structures and with sCS for subcortical pathways. With this protocol we achieved a mean of 90% of volumetric resection in cortical and subcortical tumors located in eloquent motor areas with an increase of neurological deficits in the immediate postoperative period that significantly decreased one month later. Ongoing studies will define the safe limits for functional resection taking into account the intraoperative brain shift. Finally, it must be demonstrated if this protocol has any benefit for patients concerning disease free or everall survival.
机译：目的：内在性脑肿瘤的显微外科手术的作用是使肿瘤组织的体积切除最大化，从而将术后发病率降至最低。我们本文的目的是研究一种原始协议的好处，该协议是为雄辩的运动区域（已实施运动和皮层下皮质通路的电刺激）的显微外科手术治疗而开发的。材料和方法：该系列共包括17例手术切除运动区域的皮质或皮质下肿瘤的患者。结合解剖学研究，运动功能MRI（f-MRI）和弥散张量成像（DTI）生成的皮层下通路体积，完成了多模式导航的术前计划。术中神经监测包括通过直接皮层和皮层下电刺激（CS和sCS）进行运动定位，以及使用皮层多极电极和N20波反转技术对中央沟进行定位。具有正面运动反应的所有皮质和皮质下刺激点的位置均存储在导航器中，并与术前定义的皮质或皮质下运动功能结构相关。结果：平均肿瘤体积切除为术前体积的89.1±14.2％，其中十二例患者全部切除（≥100％）。术前共有58.8％的患者出现运动障碍，手术后24小时增加到76.5％，一个月后减少到41.1％。皮层和皮层下的解剖和功能数据之间存在很大的相关性。然而，在六种情况下，无法识别中央沟，而在许多情况下，fMRI提供了相互矛盾的信息。提交给CS的总共52个皮质点的运动反应阳性，正相关率为83.7％。此外，总共55个皮质下点具有正向运动反应，在这种情况下，从刺激点到皮质下道的平均距离为7.3±3.1mm。结论：与基于解剖成像研究的肿瘤切除术相比，术前和术中解剖学和功能研究的整合使安全的切除位于雄辩区域的脑肿瘤的功能性切除成为可能。多模式导航允许在术前和术中解剖和功能数据之间进行整合和关联。术前通过MRI和fMRI以及TDI和束线术在皮质下运动通路，可以在解剖学上和功能上确定皮质运动功能区的位置。术中确认是通过CS和N20倒置波用于皮层结构，而sCS用于皮层下路径。通过该协议，我们在雄辩运动区的皮层和皮层下肿瘤中，平均切除了90％的体积，而术后即刻的神经功能缺损则有所增加，一个月后明显减少。正在进行的研究将在考虑术中脑转移的情况下确定功能性切除术的安全极限。最后，必须证明该方案对无病生存或永远生存的患者是否有任何益处。

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