Resection of malignant brain tumors in eloquent cortical areas: a new multimodal approach combining 5-aminolevulinic acid and intraoperative monitoring Clinical article
Resection of malignant brain tumors in eloquent cortical areas: a new multimodal approach combining 5-aminolevulinic acid and intraoperative monitoring Clinical article
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DOI：
10.3171/2009.10.jns09447
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发表时间：
2010-08-01
影响因子：
4.1
通讯作者：
Tatagiba, Marcos S.
中科院分区：
文献类型：
--
作者：
Feigl, Guenther C.;Ritz, Rainer;Tatagiba, Marcos S.
对象。多项研究表明，恶性脑肿瘤的总切除（GTR）对患者的生存有显著影响。然而，GTR往往无法实现，因为在恶性脑肿瘤的浸润区，健康大脑和病变组织之间的边界是模糊的。特别是在雄辩的皮质区域，切除经常在完全切除之前停止，以避免引起神经功能缺损。有趣的是，5-氨基乙酰丙酸（5-ALA）已被证明有助于术中肿瘤组织的可视化，因此可以显著提高原发性恶性脑肿瘤实现GTR的可能性。本研究的目的是进一步评估基于多模态功能成像数据的术中监测相结合的荧光引导下切除重要皮质区原发性恶性脑肿瘤的实用性和局限性。本前瞻性研究纳入18例雄辩区原发性恶性脑肿瘤患者。术前神经影像学检查包括磁共振成像磁化制备快速梯度回波（MPRAGE），功能磁共振成像和扩散张量成像序列，以显示功能区和纤维束。成像数据离线分析，加载到神经导航系统中，并在术中切除时使用。所有患者在手术前6小时接受5-ALA治疗。荧光引导肿瘤切除术结合术中监测和皮层及皮层下刺激，术中定位功能区域和纤维束。在连续18例患者中进行了25次手术。在24%的手术中，切除停止是因为在切除区域发现了功能区域或皮质束，或者术中仍可见荧光肿瘤细胞的区域运动诱发电位振幅降低。16例（64%）手术可实现全切除，保留了所有功能区域和纤维束。2例患者术前偏瘫在术后加重，其中1例患者在第二次手术切除后出现新的同质性偏视。作者的第一个结果表明，5-ALA联合术中皮质刺激切除肿瘤具有两种方法的优点，因此，在切除重要区域的原发性恶性脑肿瘤时，为神经外科医生提供了额外的安全性。然而，需要更多的案例和更多的研究来进一步证明这种多模式战略的优势。(DOI: 10.3171/2009.10。JNS09447)
Object. Several studies have revealed that the gross-total resection (GTR) of malignant brain tumors has a significant influence on patient survival. Frequently, however, GTR cannot be achieved because the borders between healthy brain and diseased tissue are blurred in the infiltration zones of malignant brain tumors. Especially in eloquent cortical areas, resection is frequently stopped before total removal is achieved to avoid causing neurological deficits. Interestingly, 5-aminolevulinic acid (5-ALA) has been shown to help visualize tumor tissue intraoperatively and, thus, can significantly improve the possibility of achieving GTR of primary malignant brain tumors. The aim of this study was to go one step further and evaluate the utility and limitations of fluorescence-guided resections of primary malignant brain tumors in eloquent cortical areas in combination with intraoperative monitoring based on multimodal functional imaging data.Methods. Eighteen patients with primary malignant brain tumors in eloquent areas were included in this prospective study. Preoperative neuroradiological examinations included MR imaging with magnetization-prepared rapid gradient echo (MPRAGE), functional MR, and diffusion tensor imaging sequences to visualize functional areas and fiber tracts. Imaging data were analyzed offline, loaded into a neuronavigational system, and used intraoperatively during resections. All patients received 5-ALA 6 hours before surgery. Fluorescence-guided tumor resections were combined with intraoperative monitoring and cortical as well as subcortical stimulation to localize functional areas and fiber tracts during surgery.Results. Twenty-five procedures were performed in 18 consecutive patients. In 24% of all surgeries, resection was stopped because a functional area or cortical tract was identified in the resection area or because motor evoked potential amplitudes were reduced in an area where fluorescent tumor cells were still seen intraoperatively. Gross-total resection could be achieved in 16 (64%) of the surgeries with preservation of all functional areas and fiber tracts. In 2 patients presurgical hemiparesis became accentuated postoperatively, and 1 of these patients also suffered from a new homonymous hemianopia following a second resection.Conclusions. The authors' first results show that tumor resections with 5-ALA in combination with intraoperative cortical stimulation have the advantages of both methods and, thus, provide additional safety for the neurosurgeon during resections of primary malignant brain tumors in eloquent areas. Nonetheless, more cases and additional studies are necessary to further prove the advantages of this multimodal strategy. (DOI: 10.3171/2009.10.JNS09447 )