Awake craniotomy to maximize glioma resection: methods and technical nuances over a 27-year period
Awake craniotomy to maximize glioma resection: methods and technical nuances over a 27-year period
复制标题
DOI：
10.3171/2014.10.jns141520
复制
发表时间：
2015-08-01
影响因子：
4.1
通讯作者：
Berger, Mitchel S.
中科院分区：
文献类型：
--
作者：
Hervey-Jumper, Shawn L.;Li, Jing;Berger, Mitchel S.
目的清醒开颅术是目前在皮质和皮质下肿瘤切除术中帮助识别和保留功能区的一种有用的手术方法。随着时间的推移，方法已经发展到最大限度地提高患者的安全性，并使用这种技术将发病率降至最低。本研究的目的是分析单个外科医生在脑胶质瘤手术中的经验以及清醒语言和感觉运动图谱的演变方法。方法作者回顾了1986-2014年间接受清醒脑肿瘤手术的患者。最初的248名患者(1986-1997年)的手术在华盛顿大学完成，随后的611名患者(1997-2014年)的手术在加州大学旧金山分校完成。对后611例患者进行围术期危险因素和并发症评估。结果患者平均年龄42岁(13-84岁)。60%的患者Karnofsky Performance Status(KPS)评分在90-100之间，40%的患者KPS评分低于80。55%的患者接受了高级别胶质瘤的手术，42%的患者接受了低级别胶质瘤的手术，1%的患者接受了转移性病变的手术，2%的患者接受了其他病变(皮质发育不良、脑炎、坏死、脓肿和血管瘤)的手术。大多数患者属于美国麻醉学家协会(ASA)1级或2级(轻度全身疾病)；然而，患有严重全身疾病的患者并未被排除在清醒脑肿瘤手术之外，占研究参与者的15%。8例(1%)患者使用喉罩，最常用于肿块效应大于2 cm的大血管肿瘤。最常见的镇静方案是异丙酚+瑞芬太尼(54%)；然而，由于患者不耐受，42%的患者在切皮前需要调整到初始镇静方案。54%的病例使用甘露醇。12%的患者在手术时是活跃的吸烟者，这不影响术中标测程序的完成。3%的患者出现刺激诱发的癫痫发作，并用冰冷的林格氏液迅速终止。术前癫痫病史和肿瘤部位与刺激诱发癫痫的发生率增加有关。3例(0.5%)因术中癫痫发作(2例)和患者情绪不耐受(1例)而流产。总的围手术期并发症发生率为10%。结论根据本文描述的目前的最佳实践，并根据27年来使用的多种方案，得出结论：无论ASA分类、体重指数、吸烟状况、精神或情绪史、癫痫发作频率和持续时间、以及肿瘤的部位、大小和病理，清醒脑肿瘤手术都可以安全地进行，且并发症和失败率极低。
OBJECT Awake craniotomy is currently a useful surgical approach to help identify and preserve functional areas during cortical and subcortical tumor resections. Methodologies have evolved over time to maximize patient safety and minimize morbidity using this technique. The goal of this study is to analyze a single surgeon's experience and the evolving methodology of awake language and sensorimotor mapping for glioma surgery.METHODS The authors retrospectively studied patients undergoing awake brain tumor surgery between 1986 and 2014. Operations for the initial 248 patients (1986-1997) were completed at the University of Washington, and the subsequent surgeries in 611 patients (1997-2014) were completed at the University of California, San Francisco. Perioperative risk factors and complications were assessed using the latter 611 cases.RESULTS The median patient age was 42 years (range 13-84 years). Sixty percent of patients had Karnofsky Performance Status (KPS) scores of 90-100, and 40% had KPS scores less than 80. Fifty-five percent of patients underwent surgery for high-grade gliomas, 42% for low-grade gliomas, 1% for metastatic lesions, and 2% for other lesions (cortical dysplasia, encephalitis, necrosis, abscess, and hemangioma). The majority of patients were in American Society of Anesthesiologists (ASA) Class 1 or 2 (mild systemic disease); however, patients with severe systemic disease were not excluded from awake brain tumor surgery and represented 15% of study participants. Laryngeal mask airway was used in 8 patients (1%) and was most commonly used for large vascular tumors with more than 2 cm of mass effect. The most common sedation regimen was propofol plus remifentanil (54%); however, 42% of patients required an adjustment to the initial sedation regimen before skin incision due to patient intolerance. Mannitol was used in 54% of cases. Twelve percent of patients were active smokers at the time of surgery, which did not impact completion of the intraoperative mapping procedure. Stimulation-induced seizures occurred in 3% of patients and were rapidly terminated with ice-cold Ringer's solution. Preoperative seizure history and tumor location were associated with an increased incidence of stimulation-induced seizures. Mapping was aborted in 3 cases (0.5%) due to intraoperative seizures (2 cases) and patient emotional intolerance (1 case). The overall perioperative complication rate was 10%.CONCLUSIONS Based on the current best practice described here and developed from multiple regimens used over a 27-year period, it is concluded that awake brain tumor surgery can be safely performed with extremely low complication and failure rates regardless of ASA classification; body mass index; smoking status; psychiatric or emotional history; seizure frequency and duration; and tumor site, size, and pathology.