磁共振弥散张量成像及皮层电刺激在脑运动区病变手术中的初步联合应用

Clinical application of diffusion tensor imaging and cortex electrical stimulation in the resection of lesions in eloquent areas.

目的:初步探讨磁共振弥散张量成像(DTI)及皮层电刺激在涉及运动通路脑肿瘤手术中的联合应用价值。方法:采用GE1.5T MRI成像系统,对6例临近运动皮质及锥体束的病变(Ⅲ-Ⅳ级胶质瘤1例,Ⅱ-Ⅲ级胶质瘤1例3例,Ⅰ-Ⅱ级胶质瘤1例,炎性假瘤1例)进行磁共振DTI检查,用dTV.Ⅱ软件进行处理,显示部分各向异性图及彩色部分各向异性方向(FA)图;并采用种子方法重建双侧皮质脊髓束的三维纤维束成像图,评估纤维束的移位、连续性及破坏情况。在气管插管静脉复合麻醉下开颅,神经导航解剖及边界定位;经过术中麻醉唤醒,在清醒状态行皮质电刺激确定额叶运动区及可能的皮质与皮层下脑组织切除范围,在保护脑运动功能的前提下切除肿瘤。结果:6例肿瘤FA图显示良好,纤维束重建后4例可见锥体束的消蚀破坏,其中3例伴有变形及移位;2例可见锥体束的单纯变形及受压移位。6例肿瘤均成功获得神经导航定位并确定肿瘤边界及其与运动功能区的关系;显微镜下全切除肿瘤4例,次全切除2例,术后肢体运动功能同术前或较术前好转4例,偏瘫加重2例,经治疗于1周内恢复术前水平。无其它手术并发症。结论:DTI可以清晰地观察瘤体、功能区及白质纤维三者关系,辅助术前手术方案的制定。皮质电刺激可实时定位额叶功能区,最大限度保护运动功能。二者的有效、合理应用有助于更安全准确地切除肿瘤,提高涉及运动通路脑肿瘤病人术后生活质量。

Objective： To discuss the value of the clinical application of diffusion tensor imaging （DTI） and cortex electrical stimulation in the resection of lesions in eloquant areas concerned of motor pathway. Method： Six patients with lesions near the motor area or pyramidal tracts （1 case of grade 3-4 glioma, 3 cases of grade 2- 3 glioma, 1 case of grade 1- 2 glioma, and 1case of inflammatory pseudotumor） were imaged with GE 1.5 T MRI DTI, and analyzed by dTV. Ⅱ soft system. The fiber bundles of bilateral corticospinal tract were reconstructed as 3D images. The anatomic displacement and destruction of the fibers were analysed on fractional anisotropy （FA） imaging, color tensor imaging and tractographic imaging. All patients were undergone awaking surgery assisted with neuron - navigation system and direct cortex electrical stimulation under awaking anaesthesia.Resnlts： The FA images of all patients showed that： the fiber bundles of 4 cases were destroyed and 3 cases of them incorporate d with distortion or displacemant, the other 2 cases were only distorted or displaced. The 6 cases of patients with lesions in eloquent areas were positioned correctly with neuron - navigation system and direct cortex electrical stimulation, 4 of the lesions were total resected and 2 partial resected. There were no deterioration of neurofunction after operation, and no other applications. Results： The relationship of lesions, eloquent areas and fiber bundles can be observed dearly through DTI. Cortex electrical stimulation can be used to locate the eloquent area at any time. The combination of DTI and cortex electrical stimulation allows a maximum resection of the lesions and protection of the normal function.