摘要：

目的: 探讨术中唤醒定位脑功能区并切除复发胶质瘤的可行性、有效性和安全性。方法: 选择2020年1月至2023年12月在南部战区总医院行唤醒开颅手术的36例脑功能区复发胶质瘤患者，并以唤醒开颅手术治疗的38例新诊断胶质瘤患者作为对照，均于术中唤醒直接电刺激定位皮质和(或)皮质下重要脑功能区，在保护神经功能的前提下最大程度切除肿瘤。结果: 36例复发胶质瘤患者中27例(75%)术中直接皮质或皮质下电刺激后呈阳性反应；肿瘤全切除26例(72.22%)、次全切除6例(16.67%)、部分切除4例(11.11%)；术后早期(术后7 ~ 10 d) 25例(69.44%)新发神经功能障碍或原有神经功能障碍加重，轻度14例(38.89%)、中度2例(5.56%)、重度9例(25%)；术后晚期(术后3个月) 6例(16.67%)神经功能障碍加重，轻度、中度、重度各2例(5.56%)。与新诊断胶质瘤患者相比，唤醒开颅手术治疗脑功能区复发胶质瘤术中达功能边界最大程度切除的比例较低(χ² = 9.187，P = 0.002)，而术中直接皮质或皮质下电刺激阳性反应率(χ² = 1.690，P = 0.194)、肿瘤全切除-次全切除率(Fisher确切概率法：P = 1.000)、术后早期神经功能障碍发生率(χ² = 0.009，P = 0.924)、术后晚期神经功能障碍发生率(χ² = 0.599，P = 0.439)和术后癫痫发作控制率(Fisher确切概率法：P = 1.000)相当。结论: 唤醒开颅手术治疗脑功能区复发胶质瘤可行且安全、有效，有助于提高肿瘤切除程度、延长患者生存期，可以作为治疗脑功能区复发胶质瘤的重要方法。

关键词: 神经胶质瘤, 肿瘤复发，局部, 清醒镇静, 监测，手术中, 大脑皮质, 电刺激

Abstract:

Objective: To investigate the feasibility, efficacy and safety of awake craniotomy with brain functional mapping for the interoperative resection of recurrent gliomas in eloquent areas. Methods: A total of 36 patients who underwent awake craniotomy for recurrent gliomas at General Hospital of Southern Theatre Command from January 2020 to December 2023 were enrolled, with 38 newly diagnosed glioma patients treated via awake craniotomy as control. Cortical and/or subcortical functional areas were mapped using direct electrical stimulation (DES) during the awake phase, and maximal tumor resection was achieved while preserving neurological function. Results: Among 36 recurrent glioma patients, 27 cases (75%) exhibited positive responses to intraoperative cortical or subcortical DES. Postoperative MRI within 48 h revealed the lesion total resection in 26 cases (72.22%), subtotal resection in 6 cases (16.67%), and partial resection in 4 cases (11.11%). Early postoperative (7-10 d) neurological dysfunction (new or worsened) occurred in 25 cases (69.44%), including mild 14 cases (38.89%), moderate 2 cases (5.56%), and severe 9 cases (25%). Late postoperative (3 months) neurological dysfunction was observed in 6 cases (16.67%), with mild, moderate and severe each accounting for 2 cases (5.56%). Compared to newly diagnosed gliomas, recurrent gliomas treated with awake craniotomy had a lower rate of achieving functional boundary-based maximal resection (χ² = 9.187, P = 0.002). However, no significant differences were found in intraoperative cortical or subcortical DES rates (χ² = 1.690, P = 0.194), total/subtotal tumor resection rates (Fisher's exact probability: P = 1.000), early postoperative neurological dysfunction (χ² = 0.009, P = 0.924), late postoperative neurological dysfunction (χ² = 0.599, P = 0.439), or postoperative seizure control (Fisher's exact probability: P = 1.000). Conclusions: Awake craniotomy for recurrent gliomas in eloquent brain areas is feasible, effective and safe. It enhances the tumor resection extent and prolongs survival, serving as a critical approach for managing recurrent gliomas in eloquent areas.

Key words: Glioma, Neoplasm recurrence, local, Conscious sedation, Monitoring, intraoperative, Cerebral cortex, Electric stimulation