CAJ | 학술논문

目的探讨术中唤醒麻醉技术下脑功能区肿瘤继发癫痫切除术的适应证、技术要点及疗效. 方法选择解放军第一五三医院神经外科自2006年6月至2012年6月收治的脑功能区33例胶质瘤及16例脑膜瘤继发癫痫患者,采用MRI进行肿瘤定位,弥散张量纤维束成像(DTT)显示白质纤维束与肿瘤位置关系,功能磁共振成像(fMRI)定位运动功能区,在全麻-唤醒-再全麻技术下开颅,实时B超、皮层脑电图(ECoG)定位肿瘤及致痫区,显微手术切除肿瘤及处理致病灶.结果有44例患者顺利经过全麻-唤醒-再全麻的过程,其中28例术中持续保留喉罩；16例语言区肿瘤唤醒后拔除喉罩,语言区定位及功能测试后再置入喉罩全麻.年龄偏大的3例胶质瘤及2例脑膜瘤患者因唤醒时躁动、憋气,脑组织膨出明显,放弃唤醒麻醉.术中神经电生理监测(IOM)定位出脑功能区36例,皮层功能定位阴性8例；ECoG监测发现瘤周皮层致病灶31例.胶质瘤全切22例,次全切8例；脑膜瘤全切13例,次全切1例,术中未出现癫痫发作现象.术后暂时性神经功能障碍加重或新发功能障碍26例,均于1月内恢复；术前原有功能障碍均好转.癫病发作完全消失31例,发作次数明显减少13例. 结论术中全麻唤醒下手术治疗功能区肿瘤继发癫痫疗效好、风险低.术前适应证的选择、术中合适的手术体位的摆放及有效预防癫痫发作是手术成功的重要因素.
목적 탐토술중환성마취기술하뇌공능구종류계발전간절제술적괄응증、기술요점급료효. 방법 선택해방군제일오삼의원신경외과자2006년6월지2012년6월수치적뇌공능구33례효질류급16례뇌막류계발전간환자,채용MRI진행종류정위,미산장량섬유속성상(DTT)현시백질섬유속여종류위치관계,공능자공진성상(fMRI)정위운동공능구,재전마-환성-재전마기술하개로,실시B초、피층뇌전도(ECoG)정위종류급치간구,현미수술절제종류급처리치병조.결과 유44례환자순리경과전마-환성-재전마적과정,기중28례술중지속보류후조；16례어언구종류환성후발제후조,어언구정위급공능측시후재치입후조전마.년령편대적3례효질류급2례뇌막류환자인환성시조동、별기,뇌조직팽출명현,방기환성마취.술중신경전생리감측(IOM)정위출뇌공능구36례,피층공능정위음성8례；ECoG감측발현류주피층치병조31례.효질류전절22례,차전절8례；뇌막류전절13례,차전절1례,술중미출현전간발작현상.술후잠시성신경공능장애가중혹신발공능장애26례,균우1월내회복；술전원유공능장애균호전.전병발작완전소실31례,발작차수명현감소13례. 결론 술중전마환성하수술치료공능구종류계발전간료효호、풍험저.술전괄응증적선택、술중합괄적수술체위적파방급유효예방전간발작시수술성공적중요인소.
Objective To investigate the indication,operative main points of resection of tumor and epileptogenic foci in eloquent cortical area and its curative effect under intra-operative awake anaesthesia.Methods Forty-nine consecutive patients suffering from epilepsy secondary to gliomas (n=33) and meningomas (n=16) in eloquent area,admitted to our hospital from June 2006 to June 2012,were chosen in our study.MRI was employed to detect the location of the tumors; diffusion tensor imaging (DTT) was used to display the location of white matter fiber tracts with the tumor,and functional magnetic resonance imaging (fMRI) was used to detect the motion functional zone; the epileptogenic foci and the anatomical boundary of the tumors were localized by electrocorticography (ECoG) monitoring and real-time ultrasound,respectively; microneurosurgery was under asleep-awake-asleep-technique performed to resect the tumors and epileptogenic foci.Results Forty-four patients underwent surgery under asleep-awake-asleep,successfully,including 28 remaining laryngeal mask,16 pulling out laryngeal mask and again inserting it after language mapping.Five old patients gave up awake-anaesthesia because of restlessness,breath holding and brain tissue being bulged severely.The cerebral functional zones of 36 patients were located by IOM and 8 were without noting eloquent area.Epileptogenic foci were discovered in 31 patients by ECoG monitoring.Gliomas total resection was achieved in 22,and subtotal resection in 8.Meningoma total resection was achieved in 13 and subtotal resection in 1.No seizures happened during the operations.The temporary or new dysfunctions aggravated in 26 after the operation,but all got recovery in one month.All patients' dysfunction got an improvement obviously.Epileptic seizure disappeared completely in 31 patients and decreased obviously in 13 patients.Conclusion Surgery of tumors and epileptogenic foci in eloquent cortical area under awake-anaesthesia can maximally remove the tumors safely,protect cerebral function maximally and treat secondary epileptogenic foci safely; selection of preoperative indications,intra-operative proper operative position and effective prevention of epileptic seizure are the keys of success surgery.