摘要：

目的 探讨术中MRI 导航下显微外科手术切除位于脑功能区周围动-静脉畸形的有效性和安全性。 方法 对53 例脑功能区周围动-静脉畸形患者行术中MRI 导航联合术中电生理学监测下显微外科手术，同时于术前和术中行血氧水平依赖性功能磁共振成像（BOLD-fMRI）和扩散张量成像（DTI），将BOLD-fMRI 与DTI 图像融合，形成病变、脑功能区和锥体束的三维图像，观察手术前后三者的关系和变化。 结果 53 例脑功能区周围动-静脉畸形患者，畸形团直径2 ~ 7 cm、平均（3.41 ± 0.85）cm，病变毗邻感觉功能区6 例、运动功能区7 例、锥体束10 例、语言功能区14 例、视觉皮质2 例、视辐射9 例、基底节2 例、脑干3 例。49 例在保留重要功能前提下全切除畸形团，4 例因术中MRI 导航确定畸形团与脑功能区关系密切而残留部分畸形团。术后8 例新发神经功能障碍，其中双侧视野缺损1 例、肌张力降低3 例、面瘫1 例、失语2 例、肌张力降低合并运动性失语1 例。术后随访3 ~ 60 个月，中位时间［19.37（6.00，30.00）］个月，Glasgow 预后分级5 分45 例（84.91%）、4 分3 例（5.66%）、3 分2 例（3.77%）、2 分1 例（1.89%）、1 分2 例（3.77%），其中1 例于术后1 年死于呼吸衰竭，1 例死因不明。 结论 采用术中MRI 导航联合电生理学监测技术可以适当扩大位于脑功能区周围动?静脉畸形的手术适应证。

关键词: 颅内动静脉畸形, 磁共振成像, 显微外科手术

Abstract:

Objective To evaluate the efficacy and safety of intraoperative MRI navigation in the microsurgical treatment of arteriovenous malformations (AVM) located near the main functional areas of brain.  Methods  A total of 53 patients with AVM in the adjacent functional areas were treated by microsurgical operation with intraoperative MRI navigation and electrophysiological monitoring. Blood oxygenation level-dependent functional magnetic resonance imaging (BOLD-fMRI) and diffusion tensor imaging (DTI) examinations were performed before and during operation. We fused BOLD-fMRI and DTI images to form three-dimensional images containing lesions, important functional areas and pyramidal tract so as to study the relationship between them and their changes before and after operation.  Results  The diameter of malformations in 53 patients was 2-7 cm, on average of (3.41 ± 0.85) cm. There were 6 patients involved in sensory areas, 7 patients in motor areas, 10 patients in pyramidal tract, 14 patients in language areas, 2 patients in visual cortex, 9 patients in optic radiation, 2 patients in basal ganglia and 3 patients in brain stem. Gross total resection was achieved in 49 patients while full functionality was retained. The other 4 patients with intraoperative MRI navigation were found that malformations and functional areas were closely related, so the lesions were partially resected. There were 8 patients with new-onset postoperative neurological dysfunction, among whom one case was found bilateral visual field defects, 3 patients' muscle tone was lower than before, one case of facial paralysis, 2 cases of aphasia, one with decreased muscle tone and motor aphasia. Follow-up period varied from 3 to 60 months [median 19.37 (6.00, 30.00) months], and 2 cases died (one died of respiratory failure after one year, and the other was agnogenic). Glasgow Outcome Scale (GOS) score was 5 in 45 cases (84.91%), 4 in 3 cases (5.66%), 3 in 2 cases (3.77%), 2 in one case (1.89%) and one in 2 cases (3.77%).  Conclusions  With the application of intraoperative MRI navigation and electrophysiological monitoring, it may be appropriate to expand the surgical indications of AVM located near the main functional areas of brain.

Key words: Intracranial arteriovenous malformations,  Magnetic resonance imaging,  Microsurgery