两种感兴趣区选择方法示踪锥体束在病变性癫痫手术中的初步对照研究

发布时间：2018-03-19 20:04

本文选题：弥散张量成像　切入点：功能磁共振　出处：《安徽医科大学》2015年硕士论文　论文类型：学位论文

【摘要】：目的采用术中直接皮层下电刺激技术(DsCS),验证并对比以功能磁共振运动激活区为感兴趣区示踪(BOLD-fMRI guided DTI-FT)的锥体束和以传统解剖初级运动皮层为感兴趣区进行示踪的锥体束,并进一步探讨以功能磁共振运动激活区为感兴趣区示踪锥体束方法和以传统解剖初级运动皮层为感兴趣区进行示踪的锥体束方法的精确性及可靠性,以改进以传统方法重建的纤维传导束为界的手术方法,使功能区手术更准确、安全、有效,大大降低该类手术的神经功能障碍发生率并有效控制癫痫发作。方法对18例涉及中央区的病变性癫痫患者行BOLD-fMRI及DTI检查,BOLD-fMRI采用手的大拇指食指对指运动和足的拇指背屈运动作为任务刺激。所有数据进行离线后处理,使用stealthviz软件对DTI数据进行后处理,得到FA图及DEC图,并将BOLD-fMRI激活区图像与DEC图像融合,以BOLD-fMRI运动激活区、大脑脚为感兴趣的改进方法和以中央前回、大脑脚为感兴趣区的传统方法分别示踪锥体束。功能神经导航引导下实施皮层下电刺激,术中记录同一电刺激阳性点与两种方法成像下的锥体束之间的距离,并比较两种方法所成像的锥体束与DsCS的符合率,最后在皮层下电刺激辅助下切除病变及致痫皮层,保留功能皮层及锥体束。结果除1例患者按BOLD-fMRI激活区示踪成像锥体束方法失败,1例电刺激结果阴性,余患者均成功使用两种方法成像锥体束,并应用于术中在功能神经导航引导下的皮质电刺激辅助下行病灶切除术。两种方法成像锥体束与DsCS的符合率分别为74%和58%,23个DsCS阳性位点距离两种方法成像的锥体束之间的平均最短距离分别为(4.5±2.5)mm和(6.4±2.4)mm,因改进方法成像的锥体束比传统方法成像的锥体束在相同刺激强度下离同一电刺激阳性点较短,故相对更准确(t=0.573,P=0.0120.05),且改进成像方法与皮层下电刺激的符合率也高于传统方法(χ2=7.804,P=0.0080.05)。手术全切除16例,次全切除2例,术后5例患者病变对侧肢体暂时性偏瘫,3例上肢暂时性偏瘫,余10例患者手术前后肌力无改变,术后1周6例肢体运动同术前或较术前好转,余2例仍有偏瘫,Fugl-Meyer评分平均92.1分,WAB言语功能评分平均94.3,术后口服1～2种抗癫痫药物,癫痫控制满意。结论对于涉及中央区的病变性癫痫手术,以功能磁共振运动激活区为感兴趣区示踪锥体束的方法,在准确性及可靠性上优于传统的锥体束示踪方法,在神经导航辅助下可同时保护功能皮层和锥体束并切除病变,但仍需联合应用皮层及皮层下电刺激技术,更加有助于妥善处理病变并有效保护脑功能区,从而避免术后永久性神经功能障碍,改善癫痫控制效果。
[Abstract]:Objective to verify and compare the intraoperative direct subcortical electrical stimulation (DsCSA) technique in detecting the pyramidal tracer of BOLD-fMRI guided DTI-FTI with the functional magnetic resonance (fMRI) activation region as the region of interest and the conventional anatomical primary motor cortex as the tracer of the region of interest. The accuracy and reliability of the pyramidal tracer method using the fMRI motion-activated region as the region of interest and the traditional anatomical primary motor cortex as the tracer of the region of interest were also discussed. In order to make the operation of functional area more accurate, safe and effective by improving the traditional method of reconstruction of fiber conduction bundle as the boundary, The incidence of neurologic dysfunction was greatly reduced and seizures were effectively controlled. Methods 18 patients with central lesion epilepsy were examined by BOLD-fMRI and DTI using thumb index finger movement and thumb movement of the foot. Digital dorsiflexion movement as a task stimulus. All data were treated offline, Using stealthviz software to post-process DTI data, FA map and DEC map were obtained, and the BOLD-fMRI activation region image was fused with DEC image. The improvement method of BOLD-fMRI motor activation area, brain foot and precentral gyrus were used. The traditional method of tracing the pyramidal tracer tracts the pyramidal tract respectively. Guided by functional neuronavigation, subcortical electrical stimulation was performed. The distance between the positive spot of the same electrical stimulation and the pyramidal bundle under the imaging of the two methods was recorded during the operation. The coincidence rate between the pyramidal tracts and DsCS was compared. Finally, the lesion and epileptiform cortex were excised with subcortical electrical stimulation. Results except for the failure of BOLD-fMRI tracer imaging of pyramidal tract in one patient and negative electrical stimulation in 1 case, the other two methods were successfully used for the imaging of pyramidal tract. The coincidence rates of two methods for imaging pyramidal tract and DsCS were 74% and 58, respectively. The distance between 23 DsCS positive sites and two imaging methods were 74% and 58, respectively. The average shortest distance between beams was 4.5 卤2.5mm and 6.4 卤2.4mm, respectively. Because the pyramidal bundle with the improved method was shorter than that of the conventional method at the same stimulus intensity, the positive point of the same electrical stimulation was shorter than that of the conventional method. Therefore, it is more accurate than the traditional method (蠂 ~ 2 / 7.804 / P ~ (0.0080.05)), and the coincidence rate between the improved imaging method and subcortical electrical stimulation is higher than that of the traditional method (蠂 ~ 2 / 7.804). Total resection was performed in 16 cases, subtotal resection in 2 cases, and temporary hemiplegia in the contralateral extremities in 3 cases after operation, and 3 cases with temporary hemiplegia in the contralateral extremities after operation. There was no change in muscle strength in the remaining 10 patients before and after operation, 6 patients with limb movement improved before and after operation, 2 patients with hemiplegia with Fugl-Meyer score averaging 92.3 with WAB speech function score, and 1 with 1 antiepileptic drugs taken orally after operation, the other 2 patients still had hemiplegia and the average score of Fugl-Meyer score was 92.3. Conclusion the method of tracking pyramidal tract in the area of motor activation of functional magnetic resonance (fMRI) is superior to the traditional tracer method in accuracy and reliability for epileptic surgery involving the central region. The functional cortex and pyramidal tract can be protected and excised with the aid of neuronavigation, but it is still necessary to apply the technique of electrical stimulation of cortex and subcortical simultaneously, which is more helpful for the proper management of the lesions and the effective protection of the functional areas of the brain. In order to avoid postoperative permanent neurological dysfunction, improve epilepsy control effect.
【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R651.1

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