神经导航和术中脑皮质电图监测切除脑海绵状血管畸形

目的 探讨神经导航和脑皮质电图监测切除脑海绵状血管畸形(CM)的手术适应证、手术方法和效果。方法 1997—2003年收治70例CM病人,男53例,女17例,年龄8～62岁(平均33岁)。首发症状：脑出血31例(44．3％),癫痫29例(41．4％),头痛5例(7．1％),神经功能缺损4例(5．7％),体检发现1例(1．4％)。病灶直径5～50min,平均21mm。病灶部位：大脑半球深部39例,底节、丘脑11例,脑干9例,小脑半球5例,多发6例。手术前头皮贴5个标记物行MRI扫描,将资料输入导航工作站,画出肿瘤轮廓,并完成三维重建。幕上病灶经皮质的脑沟和脑裂入路,手术显微镜下分离切除病灶。对29例合并癫痫的病人,手术中予以脑皮质电图监测,病灶切除后,多处皮质热灼术,消除癫痫波。结果 所有病例术后复查CT和／或MRI均未见残留。本组无手术死亡病例,手术后致残率8．6％。术后有4例病人出现一过性神经功能障碍。对术前有癫痫发作病例24例随访,时间6～24个月(平均19．4个月),其中19例(79．2％)无发作,5例(20．8％)癫痫症状改善。结论 对于有过出血史及药物难以控制的癫痫或病人不愿意长期服用抗癫痫药物的脑CM应考虑手术切除病变。应用神经导航和脑皮质电图监测切除脑CM手术是安全的,可以减少手术后致残率,并有效地控制癫痫。

Neuronavigation and electrocorticography monitoring in resection of brain cavernous malformations

Objective To investigate the indications, technical considerations, and effects of neuronavigation and electrocorticography (ECOG) monitoring in resection of brain cavernous malformations (CM). Methods From 1997 to 2003, 70 patients with CM, 53 males and 17 females, aged 33 (8-62), underwent resection of CM using neuronavigation and neurophysiological monitoring. The first episodes included hemorrhage (31 cases, 44.3%), seizure (29 cases, 41.4%), headache (5 cases, 7.1%), and focal neurological deficit (4 cases, 5.7%). One case was asymptomatic (1.4%), only discovered during physical examination. The size of CM focus was 21 mm (5-50 mm). The depth of tumor measured from the surface was 3-70 mm. Six patients had multiple lesions. The foci were located deep in the white matter of hemispheres in 39 cases, within the brainstem in 9 cases, within the basal ganglia or thalamus in 11 cases, within the cerebellum in 5 cases, and within the optic nerve in 1 case. Preoperatively a MRI procedure using 5 skin markers was performed with the data transferred to a neuronavigation workstation, thus reconstructing a three-dimensional image of the tumor. Supratentorial subcortical lobar cavernomas underwent microsurgery through sulcus and fissure approach. ECOG monitoring was performed on 29 patients with seizure during the operation and bipolar electrogulation on functional cortex was conducted. Follow-up was conducted for 19.4 months (6-24 months).Results No intraoperative death was found. Postoperative disability rate was 8.6%. Complete removal of the lesion demonstrated by postoperative MRI was obtained in all patients. New transitory neurological deficits occurred in 4 patients after operation and recovered within 1 month. Hemiparesis developed in 1 patient with thalamus CM (1.4%) and facial paralysis developed in 1 patient with pons CM,and both recovered in 6 mouths. Nineteen out of the 24 patients with preoperative seizure history(79.2%)were postoperatively free of seizure, five (20.8%) of them showed improvement.Conclusion Patients with asymptomatic CM can be kept under observation. CM deep in brain after the first bleeding is the indication of surgical treatment. Combination of neuronavigation and neurophysiological monitoring contributes to safety of operation and decrease of postoperative disability rate.