Klinische Studie zur Anwendung der hochfrequenten monopolaren Kortexstimulation (MKS) für die intraoperative Ortung und Überwachung motorischer Hirnareale bei Eingriffen in der Nähe der Zentralregion

Zusammenfassung

Die Radikalität der Exstirpation von Hirntumoren wird durch das Risiko postoperativer neurologischer Ausfälle eingeschränkt. Aus diesem Grund ist die Anwendung intraoperativer neurophysiologischer Untersuchungsmethoden bei Operationen im Bereich motorischer Funktionsareale unerlässlich. Diese Methoden basieren auf der elektrischen Erregbarkeit der menschlichen Hirnrinde. Die bis dato als Routineuntersuchung verwandte direkte bipolare Kortexstimulation ist jedoch durch die Gefahr epileptischer Anfälle, intraoperativer Massenbewegungen sowie durch eine lange Untersuchungsdauer eingeschränkt. In der vorliegenden Studie wurde bei 184 zerebralen Eingriffen in motorisch eloquenten Arealen untersucht, ob die erst von wenigen Autoren beschriebene monopolare Kortexstimulation (MKS) sowohl eine zuverlässige intraoperative Lokalisation (Mapping) als auch eine kontinuierliche Überwachung (Monitoring) motorischer Funktionszentren ermöglicht. Die hierfür benötigten Stimulations- und Ableitparameter sowie Zusammenhänge zwischen operativen Manövern, intraoperativen Potenzialveränderungen und der postoperativen klinischen Symptomatik sollten untersucht werden. Die Ortung motorischer Rindenareale (MKS-Mapping) war in 91,8 % der Fälle möglich. Die Ableitung von Muskelaktionspotenzialen (CMAPs) erfolgte, gemäß dem großen Repräsentationsareal von Hand und Unterarm in der primären motorischen Hirnrinde, hauptsächlich über die Thenarmuskulatur und die Unterarmflexoren. Die am häufigsten erfolgreich eingesetzten Stimulationsparameter waren eine Stimulationsfrequenz von 400 Hz mit einer Impulssequenz von fünf Impulsen und einer Impulsdauer von 0,3 ms. Die hierunter benötigten Stimulationsstärke lag im Durchschnitt bei 15,3 ± 8,2 mA. Die im Verlauf der intraoperativen Funktionsüberwachung (MKS-Monitoring) untersuchten Parameter Latenz, Potenzialbreite und Amplitude hatten eine große individuelle Variationsbreite; so konnten Latenzschwankungen von bis zu 5 % ohne pathologisches Korrelat beobachtet werden. Es zeigte sich jedoch, dass eine spontane Verlängerung der Latenz um mehr als 15 % sowie eine abrupte Reduktion der Amplitude um mehr als 80 % als intraoperatives Warnsignal angesehen werden können. Die MKS unterliegt, ebenso wie andere intraoperative neurophysiologische Untersuchungsmethoden, technischen, anatomischen und neurophysiologischen Einschränkungen. Ein „Mapping” und „Monitoring” motorischer Funktionsareale mithilfe der MKS scheint einem bipolaren Untersuchungsaufbau jedoch mehr als nur gleichwertig zu sein. So dienen Potenzialveränderungen nicht nur als intraoperatives Warnsignal, sie haben auch prognostische Aussagekraft. Komplikationen wie epileptische Anfälle oder intraoperativ störende Massenbewegungen sind während der MKS nicht aufgetreten.

Abstract

The extent of brain tumour resection is limited by the risk of postoperative neurological deficits. For this reason, intraoperative neurophysiological examination techniques are indispensable for surgery in motor function regions. These methods are based on the electric excitability of the human cerebral cortex. Direct bipolar cortex stimulation, which has been routinely applied so far, is however limited due to the risk of epileptic seizures and intraoperative mass movements as well as the long examination times. This study on 184 cerebral interventions in eloquent motor areas of the brain examined whether reliable intraoperative localisation and monitoring of motor function centres is possible with monopolar cortex stimulation (MCS) as recently described by some authors. The aim was to investigate stimulation and recording parameters, as well as to answer the question whether there is a connection between intraoperative potential alterations, surgical manipulation and postoperative clinical symptoms. MCS-mapping of the motor cortex was successful in 91.8 % of the cases. Compound muscle action potentials (CMAPs) were recorded primarily from the thenar and the forearm flexors in accordance with the large representational area of the hand and forearm in the primary motor cortex of the brain. The most common successfully used stimulation parameters were: frequency 400 Hz; impulse sequence of 5 impulses; impulse duration 0.3 ms. The stimulation intensity was 15.3 ± 8.2 mA. Since the parameters examined during MCS-Monitoring (latency, potential width and amplitude) had such a wide variation range, individual latency fluctuations of up to 5 % were observed without a pathological correlate. However, it was found that a spontaneous prolongation of latency of more than 15 % and an abrupt amplitude reduction of more than 80 % should be considered as an intraoperative warning signal. Monopolar cortex stimulation is subject to technical, anatomical and neurophysiological restrictions just as other intraoperative neurophysiological examination methods. Nevertheless, mapping and monitoring motor function regions using monopolar cortex stimulation seem to be more than just equivalent to a bipolar study design. Potential alterations not only serve as an intraoperative warning signal but also have prognostic value. Complications like epileptic seizures or intraoperatively disturbing mass movements did not occur during monopolar cortex stimulation.

Key words

Intraoperative mapping - intraoperative monitoring - direct cortex stimulation - monopolar cortex stimulation

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