3.0 T移动iMRI联合导航在显微切除脑功能区高级别胶质瘤手术中的应用

Application of 3.0 T mobile iMRI and neuronavigation in the microsurgical operation for the high grade gliomas in brain functional area

目的 探讨3.0 T移动iMRI联合导航在显微切除脑功能区高级别胶质瘤手术中的临床应用.方法 2012年4月至2014年8月,在磁共振复合手术室内显微切除47例脑功能区高级别胶质瘤,其中额叶运动区附近19例,优势半球语言区附近21例,7例累及多个脑叶;术前1d在术中磁共振复合手术室内采用3.0 T iMRI行T1-MPRAGE平扫及增强序列、弥散张量成像（DT I）序列及血氧水平依赖功能MR1 （BOLD-fMRI）序列扫描,制定计划.手术开始前导航下定位标记肿瘤前、后界及上、下极;显微镜下切除肿瘤,根据术中情况需要行1-4次iMRI平扫及增强扫描,提供肿瘤术中实时影像及重建皮质脊髓束,多次显微切除肿瘤,达到精确、安全切除功能区高级别胶质瘤. 结果 47例脑功能区高级别胶质瘤通过多次切除,全切除率由63.8％（30/47）提高至95.7％（45/47）,2例（4.3％）病变次全切除.随访患者神经系统症状,1-3个月复查3.0 TMR,随访期限3个月-2年.28例（59.6％）疗效良好,4例（8.5％）运动及语言障碍程度较前加重,15例（31.9％）症状加重,肿瘤复发.术后无死亡及严重致残病例,无颅内出血、感染等不良事件发生. 结论 3.0 T移动iMRI系统联合功能神经导航可在术中准确显示肿瘤与运动皮层、语言皮层及白质纤维束间的关系,实时显示肿瘤有无残余,准确评估肿瘤切除程度,提供外科再次切除残余肿瘤的可能性;及时纠正脑漂移,通过术中1次或多次切除肿瘤,显著提高脑功能区高级别胶质瘤安全、精准切除率.

Objective To investigate the clinical application of 3.0 T mobile iMRI and neuronavigation in the microsurgical operation for the high grade gliomas in brain functional area.Methods The clinical data of 47 cases which were operated from April,2012 to August,2014 assisted by intraoperative magnetic resonance and neruonavigation system were analyzed retrospectively,including 19 cases of near the frontal motor areas,21 cases of closed to the dominant hemisphere language areas,and 7 cases of involved multiple lobes of the brain.The operative plans were made before the operative day using 3.0 T iMRI for T1-MPRAGE plain and enhancement magnetic resonance imaging sequence,diffusion tensor imaging （DTI） sequence and blood oxygenation level dependent functional MRI （BOLD-fMRI） sequence scanning.Before the start of operation,the margin of the tumor was marked on the scalp,and removed the tumor under the microscopy,according to the need 1-4 iMRI plain scan and enhanced scan were applied to reconstruct the real-time imaging of the residual tumors and corticospinal tract,and gained once more chances to remove the tumor repeatedly,until the tumor was removed totally,accurately and safely.Results The total resection rate increased from 63.8% （30/47） to 95.7% （45/47） by repeated resection,and 2 cases （4.3% lesions） with subtotal resection.The dysfunction of motion and the language barrier got worse in 4 patients （8.5%）.No cases with sever complication such as death and severe disability after operation.There were no intracranial hemorrhage,infection and other adverse events.Patients were followed up with nervous system symptoms and head MRI,the follow-up period was 3 months-2 years.Twenty-eight cases （59.6%） ob-tained good clinical efficacy;the dysfunction of motion and the language barrier got worse in 4 cases （8.5%）;the symptoms and tumors recurrenced in 15 cases （31.9%）.Conclusion The 3.0 T mobile iMRI system combined with functional neuronavigation can accurately display the relationships among the motor and language cortex,tumors and white matter fiber bundles real-timely.The extent of the tumor resection can be assessed accurately by real-time images provided by iMRI,and the residual tumor have chames to be resected repeatedly,until the tumors were resected totally before operation finished.The iMRI system can correct intraoperative brain shift timely.The total resection rate can be improved safely and accurately by one or more times resection.