术中磁共振成像联合神经电生理监测在脑功能区胶质瘤切除术中的应用价值

Application of intraoperative MRI combined with neurophysiological monitoring in glioma resection in eloquent areas

目的探讨脑功能区胶质瘤切除术应用术中磁共振成像(intraoperative magnetic resonance imaging,iMRI)联合神经电生理监测对脑功能区的保护作用。方法2022年6-12月吉林大学第一医院诊治脑功能区胶质瘤患者26例,均行手术治疗。术前行多模态MRI检查,图像融合后导入神经导航系统,拟定手术切口及入路。全身麻醉下开颅,术中唤醒麻醉行皮层/皮层下直接电刺激定位运动、语言和感觉区皮层及皮下通路后切除肿瘤,肿瘤切除满意、脑移位明显、肿瘤边缘达到电生理预警(<5 mm)时恢复全身麻醉行iMRI检查判断肿瘤残留情况。如发现肿瘤残留,将残留肿瘤重新标记并投射在显微镜下切除残留肿瘤至满意,然后再次行皮层下电刺激确定弓状束、锥体束的完整性。术后常规给予降颅压、营养神经及对症治疗,术后组织病理证实高级别胶质瘤患者于术后2~3周行替莫唑胺同步放化疗。记录术中iMRI显示的肿瘤全切除、次全切除率;记录术后并发症发生情况;比较术前及术后1、3个月KPS评分;随访至2023年4月,行MRI检查观察肿瘤复发情况。结果(1)26例中首次iMRI显示肿瘤全切20例,6例肿瘤残留者二次切除,再次iMRI显示4例肿瘤全切、2例肿瘤次全切除,首次肿瘤全切率为76.9%(20/26),再次肿瘤全切率为92.3%(24/26)。(2)术后发生一过性语言加重3例,运动障碍加重5例,癫痫发作2例,给予尼莫地平、甲泼尼龙、甘露醇及丙戊酸钠治疗后逐渐恢复,无感染、颅内出血、癫痫持续状态及死亡发生。(3)随访至2023年4月,26例肿瘤均未复发。术前[(83.02±4.76)分]及术后1、3个月KPS评分[(90.31±5.76)、(95.23±6.71)分]比较差异有统计学意义(F=4.845,P=0.010),术后1、3个月KPS评分均高于术前(t=4.975,P<0.001;t=7.568,P<0.001)。结论脑功能区胶质瘤切除术应用iMRI联合神经电生理监测可在保护神经功能的前提下最大化切除肿瘤,高级别胶质瘤患者术后行替莫唑胺同步放化疗可改善预后。

Objective To investigate the protective effect of intraoperative MRI(iMRI)combined with neurophysiological monitoring on eloquent areas in glioma resection.Methods From June to December in 2022,26patients with glioma in eloquent areas were performed surgery in the First Hospital of Jilin University.Preoperative multimodality MRI examination was performed,the images were imported into neuronavigation system after fusion to propose the incision and approach.Craniotomy was done under general anesthesia/awakening anesthesia.The eloquent cortical areas and fiber bundles were determined under intraoperative microscope,and were reconfirmed under neurophysiological monitoring before glioma resection.When the tumor resection was satisfactory,brain shift was obvious,and the tumor edge reached the electrophysiological warning(<5 mm),iMRI examination was done to determine the residual tumor.The residual tumor was relabelled and projected under the microscope to remove the residual tumor to satisfaction,and subcortical electrical stimulation was performed again to determine the integrity of the arcuate tracts and pyramidal tracts.Intracranial pressure reduction,neurotrophic therapy and symptomatic treatment were routinely given after surgery,and postoperative histopathologically confirmed high-grade tumors patients underwent concurrent chemoradiotherapy with temozolomide 2 to 3 weeks after surgery.The total resection rate and subtotal resection rate of the tumors shown by intraoperative iMRI were recorded;the occurrence of postoperative complications was recorded;the KPS scores were compared before surgery and 1 and 3 months after surgery.The follow-up was done till April 2023 and MRI was performed to observe the tumor recurrence.Results(1)Among 26 cases,the first iMRI showed total resection in 20 cases,6 cases with residual tumor received continuous resection,and the second iMRI showed total resection in 4 cases and subtotal resection in 2 cases.The first total resection rate was 76.9%(20/26),and the second total resection rate was 92.3%(24/26).(2)Transient language aggravation occurred in 3 cases,dyskinesia aggravation occurred in 5 cases,and seizures occurred in 2 cases after surgery,which were gradually relieved after treatment with ni modipine,methylprednisolone,mannitol and sodium valproate,and no infection,intracranial hemorrhage,status epilepticus,or death was found.(3)During follow-up till April 2023,no recurrence developed in 26cases.There were significant differences in KPS scores before surgery(83.02±4.76),1 month after surgery(90.31±5.76)and 3 months after surgery(95.23±6.71)(F=4.845,P=0.010),and KPS score was higher 1 and 3 months after surgery than that before surgery(t=4.975,P<0.001;t=7.568,P<0.001),Conclusion The combination of iMRI and neurophysiological monitoring in the resection of glioma in eloquent areas can maximize tumor resection under the premise of protecting neurological function,and postoperative concurrent chemoradiotherapy with temozolomide can improve the prognosis of patients with high-grade glioma.