汪 樺,魯曉杰,藺玉昌,繆亦鋒△

(南京醫(yī)科大學(xué)附屬無錫第二醫(yī)院:1.影像科;2.腦科中心,江蘇 214002)

DTI融合神經(jīng)導(dǎo)航技術(shù)在17例腦腫瘤術(shù)前計(jì)劃中的應(yīng)用

汪 樺1,魯曉杰2,藺玉昌2,繆亦鋒2△

(南京醫(yī)科大學(xué)附屬無錫第二醫(yī)院:1.影像科;2.腦科中心,江蘇 214002)

目的探討磁共振彌散張量成像(DTI)融合神經(jīng)導(dǎo)航技術(shù)在腦腫瘤術(shù)前計(jì)劃中的作用?方法 采用DTI-神經(jīng)導(dǎo)航圖像融合技術(shù)對(duì)17例腦腫瘤患者實(shí)施神經(jīng)導(dǎo)航手術(shù)?結(jié)果DTI-神經(jīng)導(dǎo)航圖像配準(zhǔn)融合結(jié)果良好,融合圖像成功用于17例腦腫瘤神經(jīng)導(dǎo)航,其中5例(29%)患者進(jìn)行了皮質(zhì)切口改良,11例(65%)患者腫瘤切除范圍進(jìn)行了重新設(shè)定?術(shù)后13例(76%)患者術(shù)前癥狀好轉(zhuǎn),生存質(zhì)量提高?結(jié)論DTI磁共振圖像在神經(jīng)導(dǎo)航中的配準(zhǔn)融合,為顱腦病變術(shù)前制訂手術(shù)計(jì)劃?術(shù)中保護(hù)正常腦功能及為腦功能研究提供了有力的工具?

磁共振成像;神經(jīng)導(dǎo)航;腦腫瘤;術(shù)前計(jì)劃

磁共振彌散張量成像(diffusion tensor imaging,DTI)是目前在活體上測(cè)量水分子彌散運(yùn)動(dòng)與成像的惟一方法,能清晰顯示腦白質(zhì)結(jié)構(gòu),尤其是錐體束?胼胝體?視放射?基底節(jié)內(nèi)外囊?腦白質(zhì)半卵圓中心以及放射冠等主要的白質(zhì)纖維[1-3]?本研究將顯示白質(zhì)傳導(dǎo)束的DTI影像與顯示大體解剖結(jié)構(gòu)的MRI導(dǎo)航序列影像相融合,對(duì)腦腫瘤進(jìn)行術(shù)前計(jì)劃,并與常規(guī)手術(shù)計(jì)劃相比較,探討DTI融合神經(jīng)導(dǎo)航技術(shù)的臨床應(yīng)用價(jià)值?

1 資料與方法

1.1 一般資料 選擇2008年9月至2009年9月腦腫瘤患者17例,其中男10例,女7例,年齡19～73歲,平均(43±12)歲?腫瘤部位:右側(cè)10例,左側(cè)7例;額葉5例,頂葉4例,額頂葉2例,顳頂葉2例,顳葉2例,枕葉1例,基底節(jié)區(qū)1例?所有患者均被告知治療情況,并自愿參加實(shí)驗(yàn)?同時(shí)選擇2007年8月至2008年8月常規(guī)手術(shù)患者17例作為對(duì)照,其中男9例,女8例,年齡17～74歲,平均(42±14)歲?腫瘤部位:右側(cè)11例,左側(cè)6例;額葉6例,頂葉6例,額頂葉3例,顳頂葉 2例?

1.2 DTI掃描及圖像重建 采用Signa EXCITE磁共振成像設(shè)備,DTI掃描參數(shù):TR 9 000 ms,TE 84 ms,27層,層厚5 mm,Dist factor 10%,掃描野(FOV)為 230 mm×230 mm,成像體素1.8 mm×1.8 mm×3 mm,信噪比 1?使用 Leonardosyngo工作站生成各向異性分?jǐn)?shù)(FA)?FA-color?平均擴(kuò)散系數(shù)(ADC)等參數(shù)圖?根據(jù)橫軸位FA圖或彌散加權(quán)成像(diffusion weighted imaging,DWI)橫軸位像上的內(nèi)囊后支前2/3?大腦腳?延髓水平標(biāo)記興趣區(qū)(region of interest,ROI)獲得腫瘤與纖維束關(guān)系圖,以DICOM格式保存?

1.3 DTI融合神經(jīng)導(dǎo)航數(shù)據(jù)處理 手術(shù)前1 d,患者頭皮粘貼標(biāo)志點(diǎn),進(jìn)行導(dǎo)航結(jié)構(gòu)像(T1)掃描?將T1?DTI和含有標(biāo)志區(qū)的DWI圖(均為DICOM 格式)經(jīng)醫(yī)院PACS系統(tǒng)傳輸?shù)紸SA-610V神經(jīng)導(dǎo)航工作站,以線性融合方式分別與導(dǎo)航T1結(jié)構(gòu)像進(jìn)行配準(zhǔn)融合,獲得含有纖維束與腫瘤界面標(biāo)志區(qū)的T1融合像及FA等DWI參數(shù)融合圖像?

1.4 腦腫瘤術(shù)前計(jì)劃 術(shù)前根據(jù)DTI融合神經(jīng)導(dǎo)航圖像設(shè)計(jì)手術(shù)入路及皮質(zhì)切口,同時(shí)描繪出腫瘤切除的邊界?其中皮質(zhì)切口和腫瘤預(yù)測(cè)切除邊界作為兩個(gè)獨(dú)立因素,被用于評(píng)估DTI融合神經(jīng)導(dǎo)航技術(shù)對(duì)神經(jīng)外科醫(yī)生術(shù)前計(jì)劃的精確性?

1.5 臨床評(píng)價(jià)及隨訪 所有患者在術(shù)前?術(shù)后1個(gè)月進(jìn)行臨床評(píng)估,尤其關(guān)注涉及到錐體束?視放射及弓狀束的癥狀?應(yīng)用改良NIHSS評(píng)分量表評(píng)估患者功能:運(yùn)動(dòng)得分0～3分(0分:無障礙,1分:輕度運(yùn)動(dòng)障礙,2分:重度運(yùn)動(dòng)障礙,3分:肢體完全不能動(dòng));視力得分 0～2分(0分:無障礙,1分:不全性偏盲,2分:完全偏盲);語言得分0～2分(0分:無障礙,1分:輕度失語,2分:重度失語)?術(shù)后3～6個(gè)月采用信訪?電話或門診隨訪方式,應(yīng)用Karnofsky生存質(zhì)量預(yù)后評(píng)分表(KPS)評(píng)價(jià)患者生存質(zhì)量?所有患者均由同一神經(jīng)外科醫(yī)師評(píng)分,并根據(jù)評(píng)分評(píng)級(jí)為:癥狀惡化?平穩(wěn)?好轉(zhuǎn)?

1.6 統(tǒng)計(jì)學(xué)處理 應(yīng)用SPSS13.0統(tǒng)計(jì)軟件進(jìn)行統(tǒng)計(jì)分析,組間頻數(shù)應(yīng)用卡方檢驗(yàn),以P0.05為差異有統(tǒng)計(jì)學(xué)意義?

2 結(jié) 果

2.2 腫瘤病理學(xué)結(jié)果 DTI-導(dǎo)航組中12例神經(jīng)上皮性腫瘤,根據(jù)WHO病理分級(jí):Ⅰ級(jí)1例,Ⅱ～Ⅲ級(jí)9例,Ⅳ級(jí)2例;3例腦轉(zhuǎn)移性腫瘤,2例原發(fā)性中樞神經(jīng)淋巴瘤?對(duì)照組中13例神經(jīng)上皮性腫瘤,根據(jù)WHO病理分級(jí):Ⅰ級(jí)1例,Ⅱ～Ⅲ級(jí)10例,Ⅳ級(jí)2例;4例腦轉(zhuǎn)移性腫瘤?

2.2 手術(shù)療效分析 術(shù)后1個(gè)月隨訪發(fā)現(xiàn)DTI-導(dǎo)航組中1例患者出現(xiàn)不全性感覺性失語,3例患者癥狀無明顯改善,13例患者術(shù)后1個(gè)月纖維束癥狀好轉(zhuǎn),應(yīng)用改良NIHSS評(píng)分量表評(píng)估患者功能,癥狀好轉(zhuǎn)13例(76%),平穩(wěn) 3例(18%),惡化1例(6%)?術(shù)后生存質(zhì)量評(píng)分大于或等于70分 15例(88%)?對(duì)照組中2例患者出現(xiàn)不全性運(yùn)動(dòng)性失語,1例患者出現(xiàn)不全性感覺性失語,2例患者術(shù)后出現(xiàn)偏癱,4例患者癥狀無明顯改善,8例患者術(shù)后1個(gè)月纖維束癥狀好轉(zhuǎn),改良NIHSS評(píng)分量表評(píng)估患者功能,癥狀好轉(zhuǎn)8例(47%),平穩(wěn)4例(24%),惡化5例(29%)?術(shù)后生存質(zhì)量評(píng)分大于或等于70分11例(65%),見表1?

表1 DTI融合神經(jīng)導(dǎo)航技術(shù)輔助腦腫瘤切除術(shù)療效分析[n(%)]

2.3 DTI融合神經(jīng)導(dǎo)航技術(shù)對(duì)術(shù)前計(jì)劃的影響 所有患者的癥狀與纖維束相關(guān),根據(jù)DTI-融合神經(jīng)導(dǎo)航,共觀察到25束纖維束與腫瘤相關(guān),相比常規(guī)根據(jù)術(shù)前常規(guī)增強(qiáng)M RI影像設(shè)計(jì)手術(shù)入路及皮質(zhì)切口,DTI-導(dǎo)航組中有5例(29%)患者的皮質(zhì)切口進(jìn)行了改良,11例(65%)患者的腫瘤切除范圍進(jìn)行了重新定義,其中3例同時(shí)進(jìn)行了皮質(zhì)切口改良和腫瘤切除范圍重新定義,共13例(76%)患者通過DTI-FT融合神經(jīng)導(dǎo)航技術(shù)進(jìn)行了術(shù)前計(jì)劃改良?

3 討 論

本研究應(yīng)用DTI融合神經(jīng)導(dǎo)航技術(shù)觀察到25束纖維束與腫瘤相關(guān)?與傳統(tǒng)術(shù)前常規(guī)檢查相比,對(duì)5例(29%)患者的皮質(zhì)切口進(jìn)行了改良,11例患者的腫瘤切除范圍進(jìn)行了重新定義?術(shù)后13例(76%)患者癥狀好轉(zhuǎn),平穩(wěn)3例(18%),惡化1例(6%)?對(duì)照組癥狀好轉(zhuǎn) 8例(47%),平穩(wěn) 4例(24%),惡化5例(29%)?DTI-導(dǎo)航組手術(shù)療效優(yōu)于對(duì)照組?

DTI成像是目前在活體上測(cè)量水分子彌散運(yùn)動(dòng)與成像的惟一方法[4-5],最常用的主要包括DWI和 DTI[6]?DTI可顯示腦白質(zhì)神經(jīng)傳導(dǎo)束更精確的微觀結(jié)構(gòu),同時(shí)還可分辨不同神經(jīng)傳導(dǎo)束和纖維投射方向?解剖學(xué)的對(duì)照研究證實(shí)[7],DTI可以清晰準(zhǔn)確地描繪腦白質(zhì)內(nèi)主要神經(jīng)纖維束的生理解剖圖譜,包括:(1)聯(lián)絡(luò)纖維,如弓形纖維?上縱束?下縱束?鉤束和扣帶束等;(2)連合纖維,如胼胝體和前連合等;(3)投射纖維,如內(nèi)囊?外囊?放射冠?錐體束?內(nèi)囊?聽放射?視放射以及一些錐體外系傳導(dǎo)束等?

由于DTI影像的特殊性,融合神經(jīng)導(dǎo)航對(duì)于立體判斷神經(jīng)纖維束起到了重要作用?傳統(tǒng)方法主要是用MRI或皮質(zhì)電刺激進(jìn)行灰質(zhì)成像以達(dá)到手術(shù)定位的目的,不僅不能進(jìn)行白質(zhì)成像,準(zhǔn)確性較差,而且手術(shù)時(shí)間長(zhǎng),術(shù)野暴露過大?DTI解決了這一關(guān)鍵難題,在DTI影像上,由于錐體束等白質(zhì)纖維傳導(dǎo)束密集,呈現(xiàn)顯著的高信號(hào)影?通過DTI和導(dǎo)航序列影像的融合?三維重建及各向分割,在矢狀位?冠狀位和水平位均可表現(xiàn)出特征性的高信號(hào)的束狀結(jié)構(gòu),從而準(zhǔn)確判定錐體束的結(jié)構(gòu)?走行?移位以及與鄰近腫瘤的空間毗鄰?DTI導(dǎo)航術(shù)中,在判別腫瘤邊界的同時(shí),還可以準(zhǔn)確定位鄰近的錐體束?腫瘤切除和錐體束功能結(jié)構(gòu)的保存在影像學(xué)上得到定量,手術(shù)切除范圍可以更加充分?因此,可最大限度地切除腫瘤,保存鄰近錐體束?

雖然膠質(zhì)瘤的研究包括腫瘤干細(xì)胞[8]?分子靶向治療[9]?新型化療藥物[10-11]的發(fā)明等進(jìn)展很快,但是根據(jù)術(shù)前腫瘤影像學(xué)設(shè)計(jì)手術(shù)入路及皮質(zhì)切口,最大范圍切除腫瘤及最大可能保留神經(jīng)功能仍是腦膠質(zhì)瘤治療的基本方法?但是由于神經(jīng)解剖的復(fù)雜性,最廣泛的切除顱內(nèi)腫瘤同時(shí)最大化的保留神經(jīng)功能一直是神經(jīng)外科醫(yī)師追求的境界[12]?磁共振彌散張量成像-纖維追蹤(DTI-FT)技術(shù)能夠顯示纖維束與腫瘤的關(guān)系,目前被認(rèn)為在神經(jīng)外科手術(shù)術(shù)前計(jì)劃中非常重要?但是融合DTI-FT的功能神經(jīng)導(dǎo)航同樣存在腦漂移問題[13],因此,前期工作主要側(cè)重于DTI融合神經(jīng)導(dǎo)航技術(shù)在腦腫瘤術(shù)前計(jì)劃中的作用?本研究以手術(shù)皮質(zhì)切口和腫瘤預(yù)測(cè)切除邊界作為兩個(gè)獨(dú)立因素來判斷術(shù)前計(jì)劃,發(fā)現(xiàn)DTI融合神經(jīng)導(dǎo)航技術(shù)與常規(guī)影像術(shù)前計(jì)劃相比,DTI融合神經(jīng)導(dǎo)航技術(shù)能給神經(jīng)外科醫(yī)生提供關(guān)于神經(jīng)纖維束豐富的信息,對(duì)于術(shù)前設(shè)計(jì)合理的手術(shù)切口?判斷腫瘤切除范圍?針對(duì)性家屬談話等方面起到明顯作用,從而可以明顯提高腦腫瘤手術(shù)療效和患者術(shù)后生存質(zhì)量?

隨著神經(jīng)電生理[14]?神經(jīng)三維 B超[15]?術(shù)中 MRI[16]等技術(shù)的發(fā)展,DTI融合神經(jīng)導(dǎo)航技術(shù)在術(shù)中實(shí)時(shí)指導(dǎo)手術(shù)將使手術(shù)更加精確,也是此領(lǐng)域進(jìn)一步研究的方向?

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Application of trajectories of fibre tracts by DTI technique in pre-surgical planning of brain tumors

(1.Department of Image;2.Department of Brain,Af filicated Wuxi Second Hospital,Nanjing Medical University,Jiangsu,Wuxi 214002,China)

ObjectiveTo evaluate the possible identification of trajectories of fibre tracts by DTI technique.MethodsSeventeen brain neoplasms patients were prospectively and consecutively studied.All the patients were clinically assessed by a neurologist in both pre-and post-surgical phases.ResultsThe trajectories were considered suitable for surgical planning if there were no interruptions of any of the layers at the level of the lesion.The assessment of the 11 visualised trajectories close to the tumour resulted in a modification of the surgical approach to corticotomy in five patients(29%);the impact on the definition of the resection margins during surgery was 65%(11 cases).In 13 cases(76%),the symptoms had been improved.ConclusionOur study shows that M R-tractography provides the neurosurgeon with a new anatomical view that has an impact on the surgical resection planning for brain neoplasms.

magnetic resonance imaging;neuronavigation;brain neoplasms;pre-surgical planning

10.3969/j.issn.1671-8348.2011.01.020

A

1671-8348(2011)01-0046-03Wang Hua1,Lu Xiaojie2,Lin Yuchang2,MiuYi feng2△

△通訊作者,電話:(0510)82727501;E-mail:yifengmwx@hotmail.com?

2010-02-10

2010-05-15)

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