多模态技术联合术中唤醒麻醉在Broca区胶质瘤患者语言功能区定位中的作用  

Language mapping and surgical efficacy of multimodal techniques combined with awake anesthesia for gliomas involving Broca′s area

作　　者：吴斌 路俊锋 章捷 邱天明 庄冬晓 吴劲松 Wu Bin;Lu Junfeng;Zhang Jie;Qiu Tianming;Zhuang Dongxiao;Wu Jinsong(Department of Neurosurgery,Huashan Hospital,Fudan University,Shanghai 200040,China)

机构地区：[1]复旦大学附属华山医院神经外科,上海200040

出　　处：《中华神经外科杂志》2020年第2期124-129,共6页Chinese Journal of Neurosurgery

基　　金：国家"十二五"科技支撑计划(2014BAI04B05,2014BAI04B01);国家自然科学基金青年基金(81401395);上海市卫生计生系统优秀青年人才培养计划(2017YQ014)。

摘　　要：目的探讨多模态技术联合术中唤醒麻醉在Broca区胶质瘤患者语言功能区定位中的作用和手术疗效。方法回顾性分析2011年1月至2017年12月复旦大学附属华山医院神经外科行手术切除的Broca区胶质瘤患者的临床资料,共42例。术前采用功能磁共振成像和弥散张量成像技术重建语言皮质激活区域和皮质下传导通路,术中在唤醒麻醉下通过直接电刺激技术定位语言皮质和皮质下传导通路,并在术中磁共振、实时神经影像导航系统引导下行肿瘤切除。根据肿瘤是否侵犯中央前回腹侧部(vPMC)将患者分为未侵犯vPMC(仅侵犯额下回后部)组24例,侵犯vPMC组18例,评估并比较两组患者语言功能区定位情况和疗效。结果42例患者均完成术中语言功能区定位,34例(81.0%)至少有1个阳性定位点;3例(7.1%)在定位过程中出现癫痫局灶性发作。25例患者肿瘤为全切除,17例为非全切除。术后病理学证实世界卫生组织(WHO)肿瘤分级Ⅱ级者23例,Ⅲ级者14例,Ⅳ级者5例。术后1个月内(近期)16例(38.1%)患者有语言功能障碍,其中12例3个月内恢复,4例(9.5%)未恢复。术后所有患者随访6~84个月(中位数为24个月),14例出现肿瘤进展,其中11例死亡。与未侵犯vPMC组比较,侵犯vPMC组肿瘤的WHO级别高(P=0.011),术后近期语言功能障碍的发生比率高[分别为10/18、25.0%(6/24),P=0.044],无进展生存期[分别为(28.4±5.2)个月、(80.7±3.2)个月]和总生存期[分别为(38.8±5.8)个月、(80.8±3.2)个月]均短。差异均有统计学意义(均P<0.001)。结论多模态技术联合术中唤醒麻醉治疗Broca区胶质瘤有助于在最大化切除肿瘤的同时,保护患者的语言功能。其中肿瘤侵犯vPMC比仅侵犯额下回后部者引起近期语言功能障碍率更高,预后更差。Objective To investigate language mapping and surgical efficacy of multimodal techniques combined with awake anesthesia for gliomas involving Broca′s area.Methods A total of 42 patients with gliomas involving Broca′s area underwent surgical resection under awake anesthesia at Department of Neurosurgery,Huashan Hospital,Fudan University from January 2011 to December 2017 and were enrolled into this retrospective study.Language cortical activated areas and subcortical pathways were preoperatively reconstructed for surgical planning with functional magnetic resonance imaging(fMRI)and diffusion tensor imaging(DTI)tractography respectively.During the craniotomies,direct electrical stimulation was used to localize language cortical areas and subcortical pathways,and resection of tumor was assisted with intraoperative magnetic resonance image-guided real-time neuronavigation system.According to whether the gliomas invaded ventral premotor cortex(vPMC),the patients were divided into 2 groups.Out of the 42 patients,24 did not show invasion of vPMC(with merely invasion of posterior inferior frontal gyrus)and 18 did.The language mapping outcomes and surgical efficacy were evaluated and compared.Results Intraoperative language mapping was successfully performed in all patients,and in 34 patients(81.0%)at least 1 positive functional site was detected.Three patients(7.1%)experienced focal seizure attack during the mapping process.Gross total resection was achieved in 25 patients,and subtotal resection in 17.Histopathological results indicated 23 cases of World Health Organization(WHO)gradeⅡgliomas,14 cases of gradeⅢgliomas and 5 cases of gradeⅣgliomas.Sixteen patients(38.1%)experienced short-term language deficits after surgeries,out of whom 12 recovered in 3 months post operation and 4(9.5%)did not recover.The median follow-up time was 24 months(6-84 months)in 42 patients.Tumour progression was seen in 14 of the 42 patients,and 11 patients died.Compared to the group with tumors that not invaded vPMC,the group with t

关 键 词：神经胶质瘤 BROCA区 唤醒麻醉 语言功能区定位 多模态技术 

分 类 号：R614[医药卫生—麻醉学] R73[医药卫生—外科学]