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高场强术中磁共振成像及神经导航在累及视放射的颞叶胶质瘤手术中的应用

Intraoperative high-field magnetic resonance imaging combined with functional neuronavigation in resection of low-grade temporal lobe tumors involving optic radiation

摘要:

目的 探讨高场强术中磁共振成像(iMRI)及功能神经导航在累及视放射的颞叶胶质瘤手术中的临床应用价值.方法 2009年4月至2013年9月解放军总医院神经外科对65例累及视放射的颞叶胶质瘤患者在iMRI及功能神经导航辅助下进行手术.使用弥散张量成像(DTI)技术重建视放射,将其与解剖图像融合后导入导航系统用于镜下导航,并利用iMRI进行术中解剖及功能结构影像的更新.所有术前及术中肿瘤体积均应用软件3D Slicer进行体积分析.术前及术后随访时对所有患者进行了视野评估.组间比较应用t检验,癫痫预后的相关因素分析采用Spearman相关分析.结果 术前平均肿瘤体积(78 ±40) cm3.经过iMRI扫描,29例发现肿瘤残余并继续进行切除,切除率从76.2%提高至92.7%(t=7.314,P<0.01).最终19例(29.2%)获得全切除,其中8例得益于iMRI.2例患者失访,其他患者术后随访13 ~59个月,平均(33±13)个月.3例肿瘤进展,视野缺损新发或恶化者4例(6.2%).对于术前有癫痫症状的患者,术后恩格分级Ⅰ级者占89.7%.Spearman等级相关分析显示恩格分级与切除率(r=-0.452,P=0.004,95% CI:-0.636~-0.261)及肿瘤体积(r=0.391,P=0.014,95% CI:0.178 ~0.484)相关.结论 高场强iMRI及功能神经导航能够用以评估病变切除程度及定位视放射,对累及视放射的颞叶低级别胶质瘤切除过程中视野的保护很有帮助.

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Objective To investigate the clinical value of high-field-strength intraoperative magnetic resonance imaging (iMRI) combined with optic radiation neuro-navigation for the resection of temporal lobe low-grade gliomas.Methods From April 2009 to September 2013,65 patients with temporal lobe lowgrade gliomas (WHO grade Ⅱ) involving optic radiation were operated with iMRI and functional neuronavigation.Diffusion tensor imaging (DTI) based fiber tracking was used to delineate optic radiation.The reconstructed optic radiations were integrated into a navigation system,in order to achieve intraoperative microscopic-based functional neuro-navigation,iMRI was used to update the images for both optic radiations and residual tumors.Volumetric analyses were performed using 3D Slicer for pre-and intra-operative tumor volumes in all cases.All patients were evaluated for visual field deficits preoperatively and postoperatively.The Student t test was used to evaluate the average rate of extent of resection between groups.Spearman rank correlation analysis was used to assess correlations between predictors and epilepsy prognosis.Results Preoperative tumor volumes were (78 ±40) cm3.In 29 cases,iMRI scan detected residual tumor that could be further resected,and extent of resection were increased from 76.2% to 92.7% (t =7.314,P <0.01).In 19 cases (29.2%),gross total resection was accomplished,and iMRI contributed directly to 8 of these cases.Postsurgical follow-up period varied from 13 months to 59 months,mean (33 ± 13) months.Tumor progression were observed in 3 patients,newly developed or deteriorated visual field defects occurred in 4 patients (6.2%).For patients with pre-operative seizures,Engel Class Ⅰ were achieved for 89.7% of them.Spearman rank correlation analysis revealed that seizure outcome (Engel Class) was related to increased excision of ratio (r =-0.452,P =0.004,95% CI:-0.636--0.261) and larger tumors (r =0.391,P =0.014,95% CI:0.178-0.484).Conclusions With iMRI and functional neuro-navigation,the optic radiation can be accurately located,while extent of resection can be evaluated intra-operatively.This technique is safe and helpful for preservation of visual field for the resection of temporal lobe low-grade gliomas involving optic radiation.

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