功能区胶质瘤继发癫痫的手术治疗  

The surgical treatment of secondary epilepsy caused by glioma in the eloquent cortical areas

作　　者：郭效东[1] 王本瀚[1] 张长远[1] 熊家锐[1] 李经纶[1] 陆卫风[1] 唐斌[1] 吴艳芝[1] 王振华[1] 赵鸽[1] 

机构地区：[1]解放军第153医院全军神经外科中心,郑州450042

出　　处：《中华神经外科杂志》2013年第1期17-21,共5页Chinese Journal of Neurosurgery

摘　　要：目的探讨唤醒麻醉下联合多种神经功能定位技术切除脑功能区胶质瘤及其致痫灶的方法、安全性及疗效。方法2006年6月至2011年9月，对解放军第153医院31例功能区胶质瘤继发癫痫的患者，结合MRI、fMRI、弥散张量纤维束成像（DTY）制定手术方案，在唤醒麻醉技术下开颅，术中实时B超定位，在患者清醒状态下，通过术中神经电生理监测（IOM）技术定位感觉、运动及语言功能区，皮层脑电图（ECoG）监测定位致痫区，显微镜下切除肿瘤及处理致痫灶。结果31例中28例顺利经过全麻一唤醒一再全麻的过程，其中18例术中保留喉罩，10例术中拔除喉罩，语言测试后再置人喉罩。术后除1例高龄患者出现短时间谵妄状态外均无痛苦及恐惧回忆。IOM定位出感兴趣功能区23例（82％，23／28），皮层功能定位阴性5例；ECoG发现致痫灶21例，未发现明显异常7例；肿瘤全切21例，次全切7例。术后原有神经功能障碍略有加重5例，术后2d开始出现原有神经功能障碍加重或新发功能障碍17例，均于1个月内恢复至术前水平，无新的神经功能丧失。病理：星形细胞瘤（WHO）Ⅰ～Ⅱ级14例、Ⅲ-Ⅳ级3例，少突胶质细胞瘤4例，神经节细胞瘤及胶质母细胞瘤各2例，间变性星形细胞瘤、间变少枝胶质细胞瘤及混合型（少突一星形）细胞瘤各1例。随访8个月-4．3年，平均2．3年，癫痫发作完全消失（EngeⅡ级）18例，发作次数明显减少（EngelⅡ～Ⅲ级）10例，总有效率100％。肿瘤原位复发16例（57％，16／28），9例再次手术，4例放射治疗，2例胶质母细胞瘤及1例问变性（恶性）星形细胞瘤患者（11％，3／28）放弃治疗，2例（7％，2／28）老年患者死于心衰及肺部感染。结论术中全麻-唤醒状态下联合多种现代神经功能定位技术治疗功能区胶质瘤继发癫痫，是一种精准、安全、有效的微创方Objective To investigate surgical methods, secure and curative effects under intra- operative awake anesthesia combined with a multimodal approach of cerebral functional localization for the resection of glioma and epileptogenic loci in eloquent Cortical area. Methods 31 Consecutive patients suffering from secondary epilepsy caused by glioma in the eloquent area were treated with the asleep - awake -asleep- technique. According to MRIs, DTT and functional MRIs design operative plans before the operations. Craniotomy was performed under general anesthesia with the laryngeal mask. Then, awake anesthesia, and functional mapping, such as sense, motion, and language zones, was judged via intra - operative nenrophysiologic monitoring （IOM）. Epileptogenic loci were localized by electrocorticography （ECoG） monitoring and assisted with an intra- operative real -time ultrasound to locate the anatomical boundary of the tumors. Surgical resected tumors and epileptogenic loci were performed under awake surgery. Finally, the skull was closed under general anesthesia. Results 28 patients underwent asleep - awake - asleep successfully in 31 cases; other than a short period of delirium post operation in older patients, no painful or dreaded experiences occurred before and after operations. 18 patients remained on laryngeal masks, while 10 patients pulled out the laryngeal mask before language mapping and reinserted the maskafter mapping was finished. 23 patients＇ cerebral functional areas were located by IOM; in five cases, eloquent areas were not found. Epileptogenic foei were discovered in 21 eases through ECoG monitoring. Total resection was achieved in 21 patients and subtotal resection in 7. Preoperative dysfunctions aggravated in 17 cases 2 days after operation, but all patients recovered in one month; no permanent or new complications were noted. Pathology： astrocytoma Ⅰ - Ⅱ grade was noted in 14 patients, Ⅲ - Ⅳggrade in 3, oligodendroglioma in 4, oligodendroglioma and glioblastoma in 2, and other types

关 键 词：功能区 神经胶质瘤 继发性癫痫 唤醒麻醉 术中神经电生理监测 皮层 脑电图 

分 类 号：R651.1[医药卫生—外科学]