颅内肿瘤手术体位及入路简明图示

FIGURE 1. Illustration showing Brodmann’s cortical areas of functional

behavior.

FIGURE 2. Illustration showing subcortical white matter fascicles connecting cortical functional regions.

FIGURE 3. T2-weighted axial MRI scan of a tumor occupying the left supplementary motor area. The motor pathways (white area) are seen to emerge from the anterior portion of the motor cortex, which is flanked posteriorly by the central sulcus.

FIGURE 4. Example of a set-up for MSI to localize functional regions preoperatively.

FIGURE 5. T2-weighted axial MRI scan of a tumor in the posterior frontal region on the left. The white area represents the superimposed DTI of the descending motor pathways.

FIGURE 6. Three-dimensional reconstructed DTI depiction of the descending motor pathways posteriorly located to the lesion.

FIGURE 7. DWI obtained 2 and 4 months postoperatively to identify areas of ischemia (bright signal DWI, dark signal void apparent diffusion coefficient) that enhances briefly postoperatively.

FIGURE 8. MRS image showing voxels of residual tumor (choline to NAA index  2) in areas adjacent to a gross total resection of a glioblastoma. Asterisks, high choline points.

额叶肿瘤

额叶肿瘤依据病变距中线的距离基本上可分为2个不同的位置。对于距中线4cm内的病变，患者的头位可在Mayfield头架固定后垂直或向对侧轻度偏斜摆放。这个头位同样可应用于Rolandic皮层（即中央区）前的扣带回前部的深处肿瘤。手术切口自颧弓至前发际，如果肿瘤非常靠前，则切口可向前额轻度延长。如果必要的话，切口术后采用皮内缝合或创可贴 (3M, St. Paul, MN)粘合，包括前额部(图9)。

FIGURE 9. Illustration showing the surgical position and scalp incision for frontal tumors within 4 cm of the midline.

对于距中线4cm之外的肿瘤，患者头部向对侧旋转约60°，同侧肩下垫圆枕（图10）。当这是在优势半球端操作时，切口基本上是相同的，头皮切口周围浸润是从颧弓到耳朵上方再到前额部的弧形切口。对于在Rolandic皮层（即中央区）1-2cm内的肿瘤，有必要暴露运动束以诱导刺激定位，如果因为先前开颅而未能得到充分暴露，可以用硬膜下电极片刺激运动皮层而获得暴露。

 

FIGURE 10. Illustration showing the surgical position and scalp incison for frontal tumors lateral to 4 cm of the midline.

颞叶肿瘤

对于前半颞叶内的肿瘤，病变侧头需向病变对侧旋转近90度，整个头部保持与地面平行。当病变延伸很深，邻近中线附近的大脑脚及钩回之上，此时头部应向地板弯曲10度。切口从颧弓延伸，沿耳廓上方，超越前发际线（图11，A和B）。如果肿瘤位于优势半球，先行头皮阻滞麻醉，再以圆周形式平行延伸切口。

FIGURE 11. Illustrations showing the surgical position and scalp incision for anterior (A) and posterior (B) temporal lobe tumors.

当肿瘤位于颞叶的后半部，头部定位仍然同前，但切口从颧弓上方开始，向后延伸，以马蹄形形式结束于耳廓后方。同时，如果肿瘤位于优势半球侧，切口范围需用药物行局部浸润麻醉。（图12，A-C）

 

FIGURE 12. Illustrations showing the scalp incision and local anesthetic infusion for parietal tumor resection (A), frontotemporoinsular tumors (B), and anterior temporal tumors (C) under awake mapping conditions.

岛叶肿瘤

岛叶肿瘤对于外科医生来说是一个特殊的挑战，正因如此，体位的摆放必须适于获得理想的视野暴露和手术切除，取决于病变在外侧裂上还是外侧裂下。对于大部分病变在外侧裂上的岛叶肿瘤，患者的头位摆放至少应该向肿瘤对侧倾斜60°，向上与地面呈15°。这样切除时就可以平行于岛叶血管进行，岛叶血管倾向颞叶侧(图13A)。

对于大部分病变在外侧裂下的岛叶肿瘤，患者头位摆放必须向对侧旋转几乎90°，翻转向下与地面成15°(图13B)。一旦切除或牵拉颞中回的上部后就可以直视岛叶的下部。头低位时同时也为钩束的下部提供了视野暴露。如果病变向后延伸很远，至少到达内囊后肢的末端，头部没有必要旋转90°，但仍需保留与直立体位时呈60°以适于暴露病变的后部。如果岛叶靠近优势半球，先行头皮阻滞麻醉，再以圆周形式平行延伸切口。经典的是从颧弓延伸于耳廓上方，向前直达前发际线。

FIGURE 13. Illustrations showing the surgical position and scalp incision for insular tumors mostly above (A) or below (B) the sylvian fissure.

顶枕部肿瘤

位于顶叶侧下方的肿瘤可以通过马蹄形的切口暴露，本质上是骑跨耳朵顶部并以此作为基底的一个切口(图14 A)。这种方法也被用于暴露侧脑室房部及其上的区域。如果肿瘤位于顶叶正中或其上半，或者基底位于扣带回的后部，患者需仰卧位，头部前曲45°，做沿中线数厘米，在运动区皮质前的切口，向后延伸越过耳上方，然后向前返折。骨瓣通常覆盖Rolandic皮层。然而，如果运动皮层需要被刺激，而骨瓣不在病变位置，则可插入一个硬膜下电极片寻找运动皮层。如果运动皮层被刺激，肿瘤将会接近顶叶；这种方法对于完全进入扣带回和扣带池病变是很必要的(图14B)。

FIGURE 14. Illustrations showing the surgical position and scalp incision for lateral (A) and mesial (B) parietal lobe tumors.    

当原始的肿瘤位于枕叶，最好患者摆放侧俯卧位，头部旋转使鼻尖近似对准地面，这种体位枕叶处于无负荷状态，对肿瘤腹侧没有任何压力，手臂悬吊于桌面，胸部下方垫圆枕以避免臂丛神经受压，以病变为中心做马蹄形切口，沿中线向上延伸，然后向侧方止于耳后方(图15)。

FIGURE 15. Illustration showing the surgical position and scalp incision for occipital lobe tumors.

FIGURE 16. Intraoperative electromyogram showing that the tonic-clonis movements induced by cortical stimulation quieted abruptly after cold water irrigation to the stimulated region of cortex.

FIGURE 17. Illustration showing the infiltration of the dura with lidocaine via a 30-gauge needle after the bone is removed to abolish dural-based pain.

FIGURE 18. Intraoperative electromyogram of the hand region showing and increase in stimulation currents.

FIGURE 19. Intraoperative map of non-dominant face motor cortex (A and B) with strip electrode inserted to identify the hand region. The tumor and face motor cortex are resected (C and D).

FIGURE 20. Strip electrode inserted along the dura to find the leg motor cortex after resection of a supplementary motor area tumor.

FIGURE 21. Intraoperative photograph showing the stimulator evoking motor responses when the subcortical motor tracts are identified.

FIGURE 22. Stimulation induced after discharge potentials during intraoperative electrocorticography recordings.

FIGURE 23. Object naming task during intraoperative mapping.

FIGURE 24. A, MRI scan showing a posterior superior temporal lobe tumor in the dominant hemisphere. B and C, intraoperative maps depicting the number 25 as a stimulation-induced anomia before (B) and after (C) tumor resection. D, postresection T1-weighted MRI scans of the resection cavity.

FIGURE 25. Intraoperative tumor identification using IV ICG (A), which shows up white under the fluorescent microscope (B).

FIGURE 26. Functional mapping of the cortex during verb generation tasks using grid electrodes. The red star and pink arrow identify high gamma activity in the cortical area that is activated during verb generation.

原文：Neurosurgery 61[SHC Suppl 1]:SHC-279–SHC-305, 2007；SURGERY OF INTRINSIC CEREBRAL TUMORS；DOI:10.1227/01.NEU.0000255489.88321.18；作者：Mitchel S. Berger, M.D.