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首页> 外文期刊>Neurosurgical focus >Multimodal navigation in the functional microsurgical resection of intrinsic brain tumors located in eloquent motor areas: role of tractography
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Multimodal navigation in the functional microsurgical resection of intrinsic brain tumors located in eloquent motor areas: role of tractography

机译：多发性导航在雄辩的运动区域内的固有性脑肿瘤的功能性显微外科切除术中的应用：超声成像的作用

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Object Nowadays the role of microsurgical management of intrinsic brain tumors is to maximize the volumetric resection of the tumoral tissue, minimizing the postoperative morbidity. The purpose of this paper was 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. Methods A total of 17 patients who underwent resection of cortical or subcortical tumors in motor areas have been included in the series. The preoperative planning for multimodal navigation was done by integrating anatomical studies, motor functional MR (fMR) imaging, and subcortical pathway volumes generated by diffusion tensor (DT) imaging. Intraoperative neuromonitoring included motor mapping by direct cortical stimulation (CS) and subcortical stimulation (sCS), and localization of the central sulcus by using cortical multipolar electrodes and the N20 wave inversion technique. The location of all cortically and subcortically stimulated points with positive motor response was stored in the navigator and correlated with the cortical and 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 8 patients. Preoperatively a total of 58.8% of the patients had some kind of motor neurological deficit, increasing 24 hours after surgery to 70.6% and decreasing to 47.1% at 1 month later. There was a great correlation between anatomical and functional data, both cortically and subcortically. 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; in these cases the mean distance from the stimulated point to the subcortical tract was 7.3 ± 3.1 mm. Conclusions The integration of anatomical and functional studies allows a safe functional resection of the brain tumors located in eloquent areas. Multimodal navigation allows integration and correlation among preoperative and intraoperative anatomical and functional data. Cortical motor functional areas are anatomically and functionally located preoperatively thanks to MR and fMR imaging and subcortical motor pathways with DT imaging and tractography. Intraoperative confirmation is done with CS and N20 inversion wave for cortical structures and with sCS for subcortical pathways. With this protocol the authors achieved a good volumetric resection in cortical and subcortical tumors located in eloquent motor areas, with an increase in the incidence of neurological deficits in the immediate postoperative period that significantly decreased 1 month later. Ongoing studies must define the safe limits for functional resection, taking into account the intraoperative brain shift. Finally, it must be demonstrated whether this protocol has any long-term benefit for patients by prolonging the disease-free interval, the time to recurrence, or the survival time.
机译：目标如今，显微手术处理内在性脑部肿瘤的作用是使肿瘤组织的体积切除最大化，使术后发病率最小化。本文的目的是研究针对雄辩的运动区中已实施导航和电刺激运动的皮层下途径的肿瘤进行显微外科治疗而开发的原始协议的益处。方法该系列共包括17例行运动区皮质或皮质下肿瘤切除的患者。多模式导航的术前计划是通过整合解剖学研究，运动功能性MR（fMR）成像以及弥散张量（DT）成像生成的皮层下通路体积来完成的。术中神经监测包括通过直接皮层刺激（CS）和皮层下刺激（sCS）进行运动作图，以及通过使用皮质多极电极和N20波反转技术对中央沟进行定位。具有正向运动反应的所有皮质和皮质下刺激点的位置存储在导航器中，并与术前定义的皮质和皮质下运动功能结构相关。结果平均肿瘤体积切除率为术前体积的89.1±14.2％，其中8例患者全部切除（≥100％）。术前共有58.8％的患者患有某种运动​​神经功能缺损，术后24小时增加到70.6％，在1个月后减少到47.1％。皮层和皮层下的解剖和功能数据之间存在很大的相关性。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％。另外，共有55个皮质下点运动反应阳性。在这些情况下，从刺激点到皮层下束的平均距离为7.3±3.1 mm。结论解剖学和功能学研究的整合允许安全地切除雄辩部位的脑肿瘤。多模式导航允许在术前，术中解剖和功能数据之间进行整合和关联。借助MR和fMR成像以及DT成像和束缚术，皮层下运动通路可在术前解剖和功能上确定皮质运动功能区。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。通过该方案，作者对运动部位活跃的皮层和皮层下肿瘤进行了良好的容积切除，术后即刻，神经功能缺损的发生率显着增加，此后1个月明显减少。正在进行的研究必须确定术中脑转移的安全范围，以确保功能性切除的安全性。最后，必须证明通过延长无病间隔，复发时间或生存时间，该方案对患者是否具有长期益处。

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