3T高场强功能MRI在脑功能区胶质瘤皮质电刺激手术中的应用

The application of preoperative functional MRI in neurosurgical treatment of intraoperative electrical stimulation for gliomas involving motor areas at 3 T

目的研究应用3T 高场强功能 MRI(fMRI)定位脑运动功能区,及在脑胶质瘤直接皮质电刺激手术中的指导作用。方法 26例邻近或累及脑运动功能区的胶质瘤患者术前采用双手握拳刺激策略,根据血氧水平依赖(BOLD)原理进行功能成像。经工作站提供的 BOLD 功能图像分析软件包进行分析,获得脑运动功能区的激活图像,制定手术方案。所有患者均在唤醒麻醉下进行显微外科手术,在术前 fMRI 指导下利用直接皮质电刺激定位运动区。在保护脑功能不受损的前提下,最大程度地切除胶质瘤。术前、术后均行 Karnofsky 生活状态(KPS)评分,判断患者的状态。结果26例术前 BOLD 运动 fMRI 有23例获得良好的手运动脑功能区激活图像。患者在唤醒麻醉下,在术前 fMRI 指导下利用直接皮质电刺激快捷、准确定位初级运动皮质区,并且两者具有良好的一致性。同时术前 fMRI 提供术中未检测到的脑功能区的信息,相互补充。术前 KPS 评分80.0～90.0分患者21例(平均85.7分)术后恢复至平均95.2分,术前 KPS 评分40.0～70.0分患者5例(平均68.0分)术后恢复至平均90.0分。结论术前 fMRI 可活体和无创地描绘出脑运动功能区与肿瘤的功能解剖位置关系,优化手术方案,在唤醒麻醉下指导直接皮质电刺激定位运动区的手术,实现最大程度保护脑功能,并最大程度地切除肿瘤。

Objective To assess the value of preoperative blood oxygen level dependent （BOLD） 3 T functional magnetic resonance imaging （fMRI） to identify motor cortical areas in neurosurgieal treatment of intraoperative electrical stimulation for gliomas involving motor areas. Methods The study included 26 consecutive preoperative BOLD-fMRI sessions in patients with brain gliomas in or near senorimotor cortices. The bilateral hand movement fMRI paradigm was preformed in all patients. The BOLD data were analyzed by the workstation （ Leonardo Syngo 2003A, Siemens） to obtain the BOLD-fMRI images, which were used to guide the preoperative neurosurgieal planning. With guidance of preoperative mapping, all patients received mierosurgery under anaesthesia retaining consciousness using intraoperative motor functional brain mapping with the method of direct electrical stimulations. The brain lesions were removed as far as possible in the ease of eloquent areas preservation. The preoperative and postoperative KPS of all patients were operated to evaluate the state of patients. Results The preoperative mappings of the hand area on primary sensorimotor cortex using BOLD-fMRI were obtained successfully in twenty-three of twenty-six patients. Under anaesthesia retaining consciousness, the primary motor area was monitored by the method of direct electrical stimulations with the guidance of preoperative BOLD-fMRI. There was good correlation between preoperative fMRI findings and intraoperative cortical stimulation. Furthermore, the preoperative mappings could make up for the un-monitored areas during operative cortical stimulation. For the 21 patients of the pre-KPS from 80.0 to 90. 0, the pre-KPS and post-KPS are 85.7 and 95.2 respectively, and for the 5 patients of the pre-KPS from 40. 0 to 70. 0, the pre-KPS and post-KPS are 68.0 and 90.0 respectively. Conclusion The preoperative mapping of the hand area on primary sensorimotor cortex using BOLD-fMRI could non-invasively localize the brain motor cortex and lesions in vivo to optimize the surgical planning, guide the microsurgery under anaesthesia retaining consciousness using intraoperative motor functional brain mapping with the method of direct electrical stimulations and remove brain tumors as far as possible in the case of eloquent areas preservation.