Brain surface reformatted imaging (BSRI) in surgical planning for resections around eloquent cortex
脑表面重建成像(BSRI)在雄辩皮层周围手术规划中的应用
- David Araújo 大卫 · 阿劳霍,
- Hélio Rubens Machado,
- Ricardo Santos Oliveira,
- Vera Terra-Bustamante,
- Dráulio Barros de Araújo,
- Antônio Carlos Santos 安东尼奥 · 卡洛斯 · 桑托斯 &
- Américo Ceiki Sakamoto 美国人，坂本 Ceiki
Child's Nervous System volume 22, pages 1122–1126 (2006)Cite this article
Abstract
摘要
Background
背景资料
Resective surgeries around eloquent areas challenge neurosurgeons and neuroimaging professionals due to difficulties to find anatomic references during surgery. Advances in magnetic resonance (MR) may prevent such deficits and provide information for accurate surgical planning. However, most of these techniques are expensive and not feasible in most centers. Using brain surface reformatted imaging (BSRI) of 3-D MR images, we sought to obtain data for surgical planning in patients with lesions around the motor cortex.
由于在手术过程中很难找到解剖学参考资料，围绕神经外科医生和神经影像学专业人员的雄辩区域的切除手术是一个挑战。磁共振(MR)的进展可以预防这种缺陷，并为准确的手术计划提供信息。然而，这些技术中的大多数是昂贵的，在大多数中心不可行。利用脑表面重建成像(BSRI)的三维磁共振图像，我们试图获得数据为手术规划的病人周围的运动皮质病变。
Methods
方法
Thirteen patients with lesions around the eloquent areas and considered for resective surgery were evaluated. Patients had different ages with tumors and malformative lesions. They were scanned in a 1.5-T Siemens magnet with volumetric sequence after injection of Gadolinium. Postprocessing was done in an auxiliary console using MRI station software. We performed reformatting as described by Hattingen et al. [J Neurosurg 102:302–310, 2005] and used fixed skull and vascular structures as anatomical references. Distances to the reference points were measured to allow surgical planning and locate sites for cortical stimulation. Patients were also studied by blood-oxygen-level-dependent functional magnetic resonance imaging to locate the hand area before the surgical procedure. All patients had cortical stimulation during the resective procedure or chronic electrode stimulation before surgery.
评估了13例在雄辩区周围发生病变并考虑行切除手术的患者。患者年龄不同，有肿瘤和畸形性病变。他们被扫描在一个1.5-T 西门子磁体容量序列注射钆。后处理在一个辅助控制台上使用 MRI 站软件进行。我们按照哈廷根等人的描述进行了重新格式化[ J Neurosurg 102:302-310,2005] ，并使用固定的颅骨和血管结构作为解剖学参考。测量到参考点的距离，以便进行手术计划和确定皮层刺激的部位。在手术前，患者还通过血氧水平依赖性功能性磁共振成像来定位手部区域。所有患者在手术切除过程中或手术前进行慢性电极刺激。
Results
结果
There was concordance between data from functional and structural data. In one case, partial resection was performed due to the high risk of severe deficits. Even in this case, there were clinical improvements and no additional deficits were observed.
Conclusion
结论
BSRI may be a useful tool for surgical planning around eloquent areas. It can reduce surgical time and morbidity and showed correlation with functional studies. Added to this is the low cost and feasibility in most centers that have standard MR scanners with Multiplanar Reformatting software.
Introduction
简介
Recent advances in neuroimaging provide excellent presurgical evaluation of brain lesions, especially those arising near eloquent areas. Functional magnetic resonance imaging (fMRI) with blood oxygenation level-dependent (BOLD) contrast can show areas of activation during simple tasks, providing good anatomical localization in relation to the lesion when used in conjunction with high resolution anatomic images [1, 9, 10]. Multiplanar and 3-D sequences can provide accurate anatomic lesion localization. Magnetic resonance angiography can correlate the lesion to neighboring vessels, reducing morbidity due to vascular lesions [5, 6, 8].
神经影像学的最新进展为脑损伤，特别是那些发生在雄辩区域附近的脑损伤提供了极好的术前评估。具有血氧水平依赖(BOLD)对比度的功能性磁共振成像(fMRI)可以显示简单任务期间的激活区域，与高分辨率解剖图像一起使用时可以提供与病变相关的良好解剖定位[1,9,10]。多平面和三维序列可以提供准确的解剖病变定位。磁共振血管造影术可以将病变与相邻血管联系起来，减少血管病变引起的发病率。
However, these advances are still not transferable to the operating room in most cases. During surgery, the gyri and sulci does not seem as clear as they appear in imaging studies. Furthermore, some lesions do not have a clear delimitation with normal brain tissue.
然而，在大多数情况下，这些预付款仍然不能转入手术室。在手术过程中，脑回和脑沟似乎不像影像学研究中显示的那样清晰。此外，有些病变与正常脑组织没有明确的界限。
Some reconstruction techniques improved the visualization of the gyri and sulci of the convexity of the hemispheres. Curvilinear reconstruction can display anatomical structures around eloquent areas and provide very accurate depth information in relation to the cortical surface. It was already validated as a diagnostic tool in partial epilepsies due to cortical malformations and can also be used in surgical planning [3, 4]. However, its use is limited to Apple platforms and requires the purchase of a license of use.
一些重建技术改善了凸半球的脑回和脑沟的可视化。曲线重建可以显示解剖结构周围雄辩的区域，并提供非常准确的深度信息相关的皮质表面。它已经被确认为由于皮质畸形引起的部分癫痫的诊断工具，也可以用于手术计划[3,4]。然而，它的使用仅限于苹果平台，需要购买使用许可证。
Neuronavigation was developed to provide review of imaging studies during the surgical procedure, synchronized to the resection. The patient is scanned before the surgery with fiducial points. The set of data is transferred to a workstation that can be taken to the operating room. The surgeon operates on the patient while performing a virtual resection at the set of data previously acquired [5, 6, 11].
神经导航是为了在手术过程中提供影像学研究的回顾，与手术切除同步。手术前对病人进行基准点扫描。这组数据被传输到一个工作站，该工作站可以被带到手术室。外科医生对患者进行手术，同时对先前获得的一组数据进行虚拟切除[5,6,11]。
However, this technique is not available in most centers due to its high cost and the required training.
然而，这项技术并不适用于大多数中心，由于其高成本和所需的培训。
Brain surface reformatted imaging (BSRI) is a technique that was recently described to provide accurate localization of perirolandic lesions [7]. It is broadly available in most MRI systems and postprocessing is relatively easy and fast.
脑表面重建成像(BSRI)是一种最近被描述为提供准确定位周围病变的技术[7]。它广泛应用于大多数 MRI 系统，后处理相对容易和快速。
Anatomical structures such as major blood vessels, mainly cortical veins, and bone details can be used as reference points when they are clearly visible and related to neighboring eloquent structures [8]. Once their distance is carefully measured, the surgeon can guide the resection within safe limits.
解剖结构，如主要血管，主要是皮质静脉和骨细节，可以作为参考点时，他们是清楚可见的，并与邻近雄辩的结构有关[8]。一旦他们的距离被仔细测量，外科医生可以在安全范围内指导切除。
Our objective is to show one of the applications of the technique previously described (BSRI) that we are using as a surgical planning tool. In our institution, it is being used to tailor resections in dysplastic, neoplastic, and vascular lesions around eloquent areas.
我们的目标是展示我们作为手术计划工具使用的上述技术(BSRI)的应用之一。在我们的机构，它是用于裁剪切除发育不良，肿瘤，和血管病变周围雄辩的地区。
In their discussion, Hattingen et al. [7] consider the limitations of the method. One of the issues is the relative distortion of the distances in the cortical surface, preventing its use in image guidance systems.
在他们的讨论中，哈廷根等人考虑了这种方法的局限性。其中一个问题是皮层表面距离的相对失真，阻碍了其在图像制导系统中的应用。
We used the technique in conjunction with anatomical references derived from the same reconstruction, such as cortical vessels and bone structures, to provide the surgeon with coordinates to tailor the resection and reduce surgical time and morbidity.
我们使用该技术结合来自相同重建的解剖学参考，如皮质血管和骨结构，为外科医生提供坐标，以调整切除，并减少手术时间和发病率。
Materials and methods
材料和方法
Thirteen patients (six men) with ages ranging from 3 to 45 years of age (mean: 18.15; SD: 12.62), consecutively referred to our institution with a diagnosis of mass lesions around eloquent areas were enrolled. All patients were operated by the same neurosurgeon (HRM).
BOLD-fMRI was performed in all cases with finger tapping paradigm to locate the motor cortex before surgical resection.
所有病例均采用手指敲击式功能磁共振成像(BOLD-fMRI)定位手术切除前的运动皮层。
Neurophysiologic localization of eloquent areas was performed with either intraoperative or chronic cortical stimulation and recording with subdural electrode grids.
术中或慢性皮层刺激，硬膜下电极网格记录神经生理定位。
Intraoperative sonography was also used to evaluate the accuracy of the MRI protocol.
术中超声检查也用于评估 MRI 方案的准确性。
Imaging studies
影像学研究
All patients were scanned in a 1.5-T magnet (Siemens A/G, Erhlagen, Germany) with a protocol that included axial dual echo DP/T2, axial FLAIR, coronal FLAIR, axial SE T1, 3-D gradient-echo, and T1 weighted sequence after the injection of paramagnetic contrast medium (gadolinium). This protocol is part of the presurgical evaluation in all patients with mass lesions referred to our center, as published by Velasco et al. [13] and Wichert-Ana et al. [14].
Postprocessing was performed in an auxiliary console (Sunspark, Sun Microsystems, Santa Clara, USA) with software provided by the manufacturer.
后处理是在一个辅助控制台(阳光火花，昇阳电脑，圣克拉拉，美国)与软件提供的制造商。
Gradient-echo 3-D images were reformatted through the Multiplanar Reformatting Protocol in curved cuts parallel to the cortical surface, including veins and skull vault. This produced a set of consecutive images picturing “layers” of the structures and allowing the measurement of their distances and angles.
梯度回波三维图像通过多平面重构协议在平行于皮层表面的弯曲切口中进行重新格式化，包括静脉和颅骨穹隆。这样就产生了一组连续的图像，描绘出结构的“层”，并允许测量它们的距离和角度。
A neuroradiologist (DA) measured the distance between the nearest anatomical landmark to the presumed motor strip in the reformatted images. Some of the landmarks that were used were previous craniotomies, cortical veins, and skull sutures.
一位神经放射科医师(DA)测量了重新格式化图像中最近的解剖标志与假定的运动带之间的距离。一些被使用的地标是以前的开颅术，皮质静脉和颅骨缝合。
Results
结果
In all cases, the presumed eloquent areas and their relation to the mass lesion as delimited by imaging were highly concordant to neurophysiologic, functional, and sonographic findings. In all cases the difference of the distance between the area marked by the neuroradiologist and the eloquent area found in cortical stimulation was less than 0.2 cm.
在所有病例中，推测的雄辩区域及其与影像学所界定的肿块病变的关系与神经生理、功能和超声检查结果高度一致。在所有病例中，神经放射科医生标记的区域与皮层刺激发现的雄辩区域之间的差距小于0.2厘米。
There was also a reduction of surgical time spent mapping the motor strip. The imaging data helped direct the cortical stimulation without further time being spent in noneloquent adjacent gyri. This advantage could not be quantitatively evaluated and the main output was the opinion and expertise of the neurosurgeon and the surgical team.
手术时间也减少了绘制运动带的时间。成像数据有助于指导皮层刺激，而不需要进一步花费时间在非雄辩的邻近脑回。这种优势无法定量评估，主要输出是神经外科医生和外科团队的意见和专业知识。
Two cases had mild hemiparesis after the surgical resection without repercussions in quality of life compared to the previous neurological examination. In two cases, there was improvement of presurgical deficits from hemiparesis to normal strength.
两例患者在手术切除后出现轻度偏瘫，与之前的神经系统检查相比生活质量没有影响。两例患者术前功能缺损由偏瘫改善为正常力量。
In one patient, the surgical decision was to do a partial resection due to proximity to eloquent areas as depicted by imaging. Postsurgical MRI showed residual lesion over the left-hand motor cortex. Two years later, the patient returned with right hemiparesis and dysphasia. A new resection was made with no further deficits and the patient is being clinically followed to the date.
在一个病人，手术决定是做部分切除由于接近雄辩的区域所描述的成像。术后 MRI 显示左侧运动皮质有残余病变。两年后，患者返回与右侧偏瘫和语言障碍。一个新的切除没有进一步的缺陷和病人正在临床跟踪的日期。
Anaplastic ependimoma was the histopathologic diagnosis of a 17-year-old boy who came to our institution with a recurring disease and needed a resection close to the motor strip. The resection was complete as showed by postsurgical MRI and adjuvant therapy was started. This adjuvant therapy was described individually by Valera et al. [12].
间变性室管膜瘤是一名17岁男孩的组织病理学诊断，他来到我们的机构，患有复发性疾病，需要在运动带附近切除。术后核磁共振显示手术已经完成，辅助化疗已经开始。这种辅助化疗被瓦莱拉等人单独描述。
One patient had a frontoparietal juvenile glioblastoma multiforme and had total resection, as shown by postsurgical MRI. There were no deficits as depicted by neurological examination. One year later, however, the patient developed progressive headache with clouding of consciousness. MRI examination showed diffuse leptomeningeal enhancement and diffuse edema. The patient died in a few days and postmortem examination showed gliomatosis cerebri.
术后 MRI 显示，1例患者有额顶叶青少年胶质母细胞瘤并完全切除。没有神经系统检查所描述的缺陷。然而，一年后，病人出现进行性头痛，意识模糊。MRI 显示弥漫性软脑膜强化和弥漫性水肿。病人在几天内死亡，尸检显示大脑胶质瘤病。
All remaining patients are still on clinical follow up with no recurrence or further deficits.
所有其余患者仍在进行临床随访，无复发或进一步缺陷。
Table 1 provides the overall data on diagnosis, evaluation, and evolution in all cases.
表1提供了所有病例的诊断、评估和发展的总体数据。
In Fig. 1, we show an example of reformation with anatomical landmarks and lesion localization.
在图1中，我们显示了一个重建的例子与解剖标志和病变定位。
Oligodendroglioma. Female, 9 years old. a BSRI showing lesion posterior to the motor cortex. Distance between previous craniotomy and central sulcus is shown (2 cm). b Surgical picture showing electrode positioning for intraoperative cortical stimulation. The tip of the electrode strip is placed over the hand motor area. c fMRI map co-registered to T1-weighted MR image. Activation of motor cortex anterior to the lesion, during left finger tapping paradigm. a, b In anatomical positioning (L–R). c In radiological positioning (R–L)
少突胶质细胞瘤。女性，九岁。BSRI 显示运动皮质后部有损伤。以前的开颅手术和中央沟之间的距离显示(2厘米)。B 显示术中皮层刺激电极定位的手术图像。电极条的尖端放置在手动电机区域上方。共注册到 T1加权 MR 图像的 fMRI 图像。在左手指敲击范式中，损伤前的运动皮层被激活。解剖定位(L-R)。放射定位(R-L)
Discussion
讨论
In this paper, we showed a possible use for a protocol for neurosurgical planning (BSRI) that can be used in lesions around eloquent superficial areas. The correlation with surgical findings and neurophysiologic mapping by cortical stimulation (“golden standard” for brain localization) [2] was excellent in all cases. The post surgical morbidity was rare and in most cases, did not compromise quality of life.
在本文中，我们展示了一个可能的使用方案的神经外科手术规划(BSRI) ，可用于周围的病变雄辩浅表区域。在所有病例中，与手术结果和皮层刺激(脑定位的“黄金标准”)的神经生理映射相关性良好。手术后并发症很少见，在大多数情况下，并不影响生活质量。
In a very recent paper, Hattingen et al. [7] described this postprocessing protocol, resulting in tangential cortical images. Our paper addresses the question of intraoperative landmarks in addition to the correlation with neurophysiologic and BOLD-fMRI data.
在最近的一篇论文中，哈廷根等人描述了这种后处理方法，产生了切向皮层图像。我们的文章除了与神经生理学和 BOLD-fMRI 数据相关外，还讨论了术中的标志性问题。
BOLD-fMRI results were also highly correlated to neurophysiologic mapping and to curved cuts reformatting, adding functional accuracy to the method.
BOLD-fMRI 结果也与神经生理映射和曲线切割重新格式化高度相关，增加了功能准确性的方法。
The main advantage of the method is its low cost and broad availability. Most MRI machines have the capabilities to perform curved cuts and they can be performed without additional acquisition of sequences. Gradient echo 3-D sequences are generally acquired as part of tumor protocols in the majority of imaging departments. The images can be formatted “a posteriori,” in an auxiliary console.
该方法的主要优点是成本低，可用性广。大多数 MRI 机器有能力执行曲线切割，他们可以执行没有额外的序列获取。梯度回波三维序列通常作为肿瘤方案的一部分在大多数成像部门获得。图像可以在辅助控制台中进行“后验”格式化。
Anatomical landmarks in the scalp, skull vault, and cortical veins were of great importance to correlate lesions and eloquent areas after surgical exposure of brain gyration. The distances and angles calculated in relation to neurophysiologic mapping were highly accurate, reducing surgical time [7, 9].
头皮、颅骨穹隆和皮质静脉的解剖标志对于脑旋转手术暴露后病变的相关性和有说服力的区域具有重要意义。根据神经生理标测计算的距离和角度非常准确，减少了手术时间[7,9]。
This method does not replace neuronavigation or intraoperative sonography [5, 6, 11]. It may be very useful in cortical and subcortical lesions near the convexity of brain hemispheres and can be used in adjunction to these methods. For deep-seated lesions, it may not be as accurate as stated in Hattingen et al. [7]. Foreseeing these disadvantages, we didn’t attempt to use it in such cases.
这种方法不能代替神经导航或术中超声检查[5,6,11]。它可能是非常有用的皮质和皮质下病变附近的凸面大脑半球，可以用来配合这些方法。对于深部病变，它可能不像哈廷根等人所说的那样准确。预见到这些缺点，我们没有尝试在这种情况下使用它。
It can also be compared to reconstruction methods like the curvilinear reconstruction described by Bastos et al. [3, 4]. It does not add any cost to the surgical planning other than postprocessing time and runs in MRI console without platform-related issues. However, the adjunctive use of both methods could add significant advantages, mainly by using natural anatomical structures as landmarks for gyral location.
We believe that this approach may add safety and accuracy to neurosurgical planning with low cost and reliability. And it may add useful information even during the surgery itself by pointing anatomical landmarks to be followed by the neurosurgeon.
