BRAIN and NERVE－神経研究の進歩60巻8号

2008年08月発行

総説

覚醒下手術の脳神経外科および脳神経科学における役割

著者： 篠浦伸禎¹ 山田良治¹ 田部井勇助¹ 齊藤邦昭¹ 鈴木雄一² 吉田瑞穂³ 高橋雅道¹ 中村治¹ 高山吉弘³ 八木一夫²

所属機関： ¹東京都立駒込病院脳神経外科 ²首都大学東京健康福祉学部放射線科 ³東京大学医学部付属病院神経内科

ページ範囲：P.941 - P.947

文献概要

Ⅰ．はじめに

　脳神経外科領域の新しい治療法として，覚醒下手術が最近行われるようになった^1）。覚醒下手術とは，手術中に患者を覚醒させ，電気刺激で脳表の機能を落として機能局在を確認したり（マッピング），持続的に手足を動かしたり発話してもらうことにより神経症状の悪化がないか確認しながら手術を施行する方法である。神経症状の悪化を術中に確認し，その部位の手術を回避したり，悪化した場合には術中に回復を待って手術を再開することができるため，基本的には，神経症状を悪化させない一番安全な手術法であると考えられる。脳腫瘍摘出術に関しても，神経症状の悪化を最小限に抑えつつ腫瘍の摘出が可能であったという報告も多数なされている^1－3）。一方，脳神経科学の分野においても，術前に確認した神経線維の走行と覚醒下手術の術中の神経症状の変化を対照し，神経線維の機能を同定する報告が最近なされるようになった^4）。今回，われわれの施設における経験を踏まえ，覚醒下手術が脳神経外科および脳神経科学にどのように寄与しているか，文献的考察を含めて報告する。

参考文献

1) Haglund MM, Berger MS, Shamseldin M, Lettich E, Ojemann GA: Cortical localization of temporal lobe language sites in patients with gliomas. Neurosurgery 34: 567-576, 1994

2) Jaaskelainen J, Randell T: Awake craniotomy in glioma surgery. Acta Neurochir Suppl 88: 31-35, 2003

3) Weil RJ, Lonser RR: Selective excision of metastatic brain tumors originating in the motor cortex with preservation of function. J Clin Oncol 23: 1209-1217, 2005

4) Mandonnet E, Nouet A, Gatignol P, Capelle L, Duffau H: Does the left inferior longitudinal fasciculus play a role in language? A brain stimulation study. Brain 130: 623-629, 2007

5) Shinoura N, Yamada R, Kodama T, Suzuki Y, Takahashi M, et al: Preoperative fMRI, tractography and continuous task during awake surgery for maintenance of motor function following surgical resection of metastatic tumor spread to the primary motor area. Minim Invasive Neurosurg 48: 85-90, 2005

6) Meyer FB, Bates LM, Goerss SJ, Friedman JA, Windschitl WL, et al: Awake craniotomy for aggressive resection of primary gliomas located in eloquent brain. Mayo Clin Proc 76: 677-687, 2001

7) Steinmeier R, Sobottka SB, Reiss G, Bredow J, Gerber J, et al: Surgery of low-grade gliomas near speech-eloquent regions: brainmapping versus preoperative functional imaging. Onkologie 25: 552-557, 2002

8) Lurito JT, Lowe MJ, Sartorius C, Mathews VP: Comparison of fMRI and intraoperative direct cortical stimulation in localization of receptive language areas. J Comput Assist Tomogr 24: 99-105, 2000

9) Vinas FC, Zamorano L, Mueller RA, Jiang Z, Chugani H, et al: ［15O］-water PET and intraoperative brain mapping: a comparison in the localization of eloquent cortex. Neurol Res 19: 601-608, 1997

10) Shinoura N, Suzuki Y, Yamada R, Kodama T, Takahashi M, et al: Restored activation of primary motor area from motor reorganization and improved motor function after brain tumor resection. AJNR Am J Neuroradiol 27: 1275-1282, 2006

11) Yetkin FZ, Mueller WM, Morris GL, McAuliffe TL, Ulmer JL, et al: Functional MR activation correlated with intraoperative cortical mapping. AJNR Am J Neuroradiol 18: 1311-1315, 1997

12) White LE, Andrews TJ, Hulette C, Richards A, Groelle M, et al: Structure of the human sensorimotor system. II: Lateral symmetry. Cereb Cortex 7: 31-47, 1997

13) Shinoura N, Yamada R, Suzuki Y, Kodama T, Sekiguchi K, et al: fMRI is more reliable than SEP or mapping for the detection of M1 in proximity to a tumor. Stereotact Funct Neurosurg 85: 99-105, 2007

14) Mikuni N, Okada T, Enatsu R, Miki Y, Urayama SI, et al: Clinical significance of preoperative fibre-tracking to preserve the affected pyramidal tracts during resection of brain tumours in patients with preoperative motor weakness. J Neurol Neurosurg Psychiatry 78: 716-721, 2007

15) Shinoura N, Yamada R, Kodama T, Suzuki Y, Takahashi M, et al: Association of motor deficits with head position during awake surgery for resection of medial motor area brain tumors. Minim Invasive Neurosurg 48: 315-321, 2005b

16) Keifer JC, Dentchev D, Little K, Warner DS, Friedman AH, et al: A restrospective analysis of a remifentanil/propofol general anesthetic for craniotomy before awake functional brain mapping. Anesth Analg 101: 502-508, 2005

17) Taylor MD, Bernstein M: Awake craniotomy with brain mapping as the routine surgical approach to treating patients with supratentorial intraaxial tumors: a prospective trial of 200 cases. J Neurosurg 90: 35-41, 1999

18) Berger MS, Kincaid J, Ojemann GA, Lettich E: Brain mapping techniques to maximize resection, safety, and seizure control in children with brain tumors. Neurosurgery 25: 786-792, 1989

19) Maertens de Noordhout A, Born JD, Hans P, Remacle JM, Delwaide PJ: Intraoperative localization of the primary motor cortex using single electrical stimuli. J Neurol Neurosurg Psychiatry 60: 442-444, 1996

20) Shinoura N, Yamada R, Kodama T, Suzuki Y, Takahashi M, et al: Intraoperative cortical mapping has low sensitivity for the detection of motor function in proximity to a tumor in the primary motor area. Stereotact Funct Neurosurg 83: 135-141, 2005

21) Ebel H, Ebel M, Schillinger G, Klimek M, Sobesky J et al: Surgery of intrinsic cerebral neoplasms in eloquent areas under local anesthesia. Minim Invasive Neurosurg 43: 192-196, 2000

22) Duffau H, Capelle L, Sichez N, Denvil D, Lopes M, et al: Intraoperative mapping of the subcortical language pathways using direct stimulations. An anatomo-functional study. Brain 125: 199-214, 2002

23) Bello L, Gllucci M, Fava M, Carrabba G, Giussani C, et al: Intraoperative subcoritcal language tract mapping guides surgical removal of gliomas involving speech areas. Neurosurgery 60: 67-80, 2007

24) Shad A, Green A, Bojanic S, Aziz T: Awake stereotactic biopsy of brain stem lesions: technique and results. Acta Neurochir (Wien) 147: 47-49, 2005

25) Manninenn PH, Tan TK: Postoperative nausea and vomiting after craniotomy for tumor surgery: a comparison between awake craniotomy and general anesthesia. J Clin Anesth 14: 279-283, 2002

26) Blanshard HJ, Chung F, Manninen PH, Taylor MD, Bernstein M: Awake craniotomy for removal of intracranial tumor: considerations for early discharge. Anesth Analg 92: 89-94, 2001

27) Gil Robles S, Gatignol P, Capelle L, Mitchell MC, Duffau H: The role of dominant striatum in language: a study using intraoperative electrical stimulations. J Neurol Neurosurg Psychiatry 76: 940-946, 2005

28) Lubrano V, Roux FE, Demonet JF: Writing-specific sites in frontal areas: a cortical stimulation study. J Neurosurg 101: 787-798, 2004

29) Milea D, Lobel E, Lehericy S, Duffau H, Rivaud-Pechoux S, et al: Intraoperative eye field stimulation elicits ocular deviation and saccade suppression. Neuroreport 13: 1359-1364, 2002