三维可视化图像引导立体定位脑干及松果体区病灶活检术的研究

The technical report of three-dimension visualized image-guided stereotactic biopsy for lesions in pineal region and brain stem

目的 探讨三维可视化图像引导立体定位脑干、松果体区病灶活检技术的方法、技术要点和意义.方法 回顾性分析2010年1月至2013年2月中国人民解放军海军总医院的88例脑干、松果体区病灶活检资料,框架立体定位引导活检57例,CAS-2型无框架立体定位活检31例;所有活检靶点选取和穿刺路径设计均在三维可视化图像计划软件辅助下完成.松果体区病灶活检采取额前-经小脑幕裂孔的穿刺路径;中脑病变活检采用经侧脑室-丘脑自上而下路径;小脑中脚平面以下脑桥或桥臂的病灶采用枕下经小脑半球-桥臂穿刺路径.结果 所有病例均获得明确的病理学诊断,活检阳性率为100％.脑干病灶（中脑、脑桥）56例（占64％）,其中各级别胶质瘤38例（68％）,淋巴瘤3例（5％）,神经变性疾病2例（4％）,多发性硬化和瘤样脱髓鞘病6例（11％）,非特异性炎症2例（4％）,脑梗死2例（4％）,转移瘤2例（4％）,放射性坏死1例（1％）.松果体区病灶32例（占36％）,其中生殖细胞类肿瘤18例（56％）,胶质类肿瘤4例（13％）,松果体细胞起源肿瘤9例（28％）,Wemicke脑病1例（3％）.两区域活检手术直接相关死亡（出血）1例（1％）;靶区或针道少量出血,导致神经功能障碍加重、保守治疗3例（3％）;血肿稍大、神经功能障碍加重、定向下置管引流2例（2％）.结论 针对脑干、松果体区病变选择性实施立体定位活检术有助于疾病的诊断、后续治疗以及预后评估,三维手术计划软件能够术前虚拟演示手术操作,提高手术的安全性,减少术后并发症.

Objective To investigate the methodology,technical essential and significance of threedimension visualized image-guided stereotactic biopsy （SB） for lesions in pineal region and brain stem.Methods A total of 88 cases of lesions in pineal region and brain stem underwent image-guided SB in our department were retrospectively studied.Frame-based and CAS-2 type frameless SBs were performed in 57 and 31 cases respectively.Pre-biopsy three-dimension visualized image reconstruction was performed by SB planning software and the structure related to possible trajectory in each image slice was confirmed.The most suitable trajectory was selected accordingly.For lesions in pineal region,anterior-frontal trans-tentorium cerebella hiatus trajectory for avoiding tentorial margin was used.For lesions in mesencephalon,posteriorfrontal trans-lateral ventrical-thalamus trajectory via the vertical axis of brain stem was used.For pontal lesions,supra-occipital trans-pedunculus cerebellaris medius trajectory was used.Results Histological diagnosis was established in all 88 cases,which gave a high diagnostic yield （100%）.Fifty-six lesions （64%） located in brain stem （middle brain and pons） and 32 （36%） in pineal region.In 56 brain stem lesions,there were 38 cases （68%） of glioma,3（5%） lymphoma,2（4%） neurodegenerative disease,6 （11%） multiple sclerosis and tumefactive demyelinating lesion,2 （4%） non-specific inflammation,2 （4%）brain infarct,2（4%） brain metastases,and 1 （2%） radiation necrosis.For lesions in pineal region,there were 18 cases （56%） of germ cell tumor,4（13%） glioma,9 （28%） pineal cell tumor,and 1 （3%） Wemicke encephalopathy.One case （1%） died of biopsy-related hemorrhage.The neurological deficits became severe because of hemorrhage in 5 cases,the medical treatment was adopted in 3 cases （3%）and drainage in 2 （2%）.Conclusions Stereotactic biopsy for lesions in pineal region and brain stem was a safe and effective procedure that could help for the selection of clinical management and provide important prognostic information.Three-dimension visualized image-guided technique could realize virtually individual visualized intuitionistic view of biopsy trajectory.It could remarkably improve the safety and decrease the operative complications.