术中唤醒麻醉下功能定位切除脑功能区胶质瘤及其致痫灶

Intra-operative awake anaesthesia and functional localization for resection of glioma and epilepto- genic foci in eloquent area

目的探讨唤醒麻醉下功能定位切除脑功能区胶质瘤及其致痫灶的方法及疗效。方法24例脑功能区胶质瘤继发癫痫的患者进行喉罩插管、全麻下开颅，术中停药唤醒麻醉，在清醒状态下通过皮层诱发电位及皮层电刺激的方法进行脑功能区感觉、运动及语言区定位，皮层脑电监测定位致痫区，辅助以术中B超定位肿瘤及切除程度，在术中神经电生理监测保护脑功能区的前题下切除肿瘤及妥善处理致痫灶，再于全麻下关颅。结果24例患者均顺利经过全麻-唤醒-再全麻的手术过程，术后无痛苦及恐惧回忆，其中15例术中保留喉罩，9例术中拔除喉罩进行语言定位后再插管。神经电生理监测技术定位出大脑功能区20例，皮层功能定位阴性4例，皮层脑电监测发现瘤周皮层致痫灶19例，给予多处软膜下横切术和（或）皮层低功率电凝热灼术。肿瘤全切18例，次全切6例，术后3d开始出现原有神经功能障碍加重13例，均于1个月内逐渐恢复，好于术前。癫痫发作完全消失16例，明显减少8例。结论唤醒麻醉下联合多种定位技术能最大程度地切除肿瘤，有效保护了脑功能及妥善处理了致痫灶，提高了功能区肿瘤的手术疗效。

Objective To investigate the surgical method and curative effect of intra-operative a- wake anaesthesia and functional localization for resection of glioma and epileptogenic loci in eloquent area. Methods Twenty-four consecutive patients with secondary epilepsy of glioma in eloquent area were treated with asleep-awake-asleep-technique. First, the craniotomy was performed under general anaesthesia with laryngeal mask. Then awake anaesthesia, functional mapping such as sensory, motion and language zone was judged by somatosensory evoked potential （SEP） and cortical electrical stimulation（CS）, epileptogenic foci was localized by electrocorticography（ECoG） monitoring, assisted with intra-operative real-time uhra- sound to locate the anatomical boundary of the tumors. Surgical resect tumor and epileptogenic loci under awaking by intra-operative neurophysiologic monitoring（IOM）. Last close the skull under general anaesthe- sia. Results All patients underwent asleep-awake-asleep successfully, and no painful and dread experi- ence in the operations. Fifteen patients remaining laryngeal mask, 9 patients pull out laryngeal mask and a- gain inserting it after language mapping. Twenty patients＇ cerebral eloquent area were located by IOM, 4 cases not found eloquent area. Ninteen cases discovered pefilesional cortex of epileptogenic loci by ECoG monitoring and were performed by multiple subpial transaction （MST） and/or cortex lower output powers thermocoagulation. Tumors were total resected in 18 cases, most resection in 6 cases. The preoperative dys- function aggravated in 13 cases postoperative three days, but all got a recovery and improvement gradually in one month. Sixteen cases epileptic seizure disappeared completely and 8 patients decreased obviously. Con- clusions Awake anaesthesia combined with multiple modem location technique can maximum remove the tumor, effectively protect the neurologic function, and improve the curative effect of glioma in eloquent area.