INC美国Michael Lawton 教授：经外侧裂入路切除岛状胶质瘤分离Sylvian裂隙的技术细微差别

　　Insular gliomas represent a unique surgical challenge due to the complex anatomy and nearby vascular elements associated within the Sylvian fissure. For certain tumors, the transsylvian approach provides an effective technique for achieving maximal safe resection. The goal of this manuscript and video are to present and discuss the surgical nuances and appropriate application of splitting the Sylvian fissure. Our hope is that this video highlights the safety and efficacy of the transsylvian approach for appropriately selected insular gliomas.

　　Introduction

　　Gliomas are the most common primary intraparenchymal brain tumors in adults and cause significant morbidity and mortality [1]. Incidence rates for all gliomas range from 4.7 to 5.7 per 100,000 persons and vary by age; oligodendrogliomas are more common in the 35–44 year-old age group, while anaplastic astrocytoma and glioblastoma reach a peak incidence in the 75–84 year-old age group . In general, gliomas are more common in men than women, although pilocytic astrocytomas represent an exception . Our understanding of tumor genetics has grown tremendously over the past decade and recent studies have shown that gliomas can be classified into molecular subgroups based on key markers including 1p/19q codeletion, IDH mutation, and TERT promoter mutations. These markers provide important prognostic value and may help identify therapeutic targets.

　　由于Sylvian裂隙内复杂的解剖结构和附近的血管因素，岛状胶质瘤代表了一种独特的手术挑战。对于某些肿瘤，经Sylvian方法提供了一种合适的技术，以实现较大的顺利切除。本手稿和视频的目的是介绍和讨论手术的细微差别和分割Sylvian裂隙的适当应用。我们希望这段视频能够强调经幽门方法对适当选择的岛状胶质瘤的顺利性和合适性。

　　胶质瘤是成年人较常见的原发性脑内肿瘤，造成了严重的发病率和死亡率。全部胶质瘤的发病率在每10万人中4.7～5.7个，且因年龄而异；少突胶质瘤在35～44岁年龄组较常见，而无细胞星形细胞瘤和胶质母细胞瘤在75～84岁年龄组达到发病高峰 。一般来说，胶质瘤在男性中比女性更常见，尽管柔毛性星形细胞瘤是一个例外。在过去的十年中，我们对肿瘤遗传学的认识有了很大的提高，较近的研究表明，胶质瘤可以根据关键标志物包括1p/19q缺失、IDH突变和TERT启动子突变等划分为不同的分子亚组。这些标志物具有重要的预后价值，可能有助于确定治疗靶点。

　　经皮层入路与图像引导、皮层和皮层下图谱等辅助手段一起使用时，是某些岛状病变的顺利选择。这种方法对于后部岛状病变（2区和3区）可能特别有用，因为在这些病变中，经皮层方法受到狭窄的Sylvian贮藏室的严重限制。在基于后部岛状病变的病例中，经皮质方法的一个重要考虑因素是，手术概况高度依赖于脑图谱，因此难以在术前评估。此外，在后部岛内，由于Sylvian裂隙与前部Sylvian裂隙相比，Sylvian裂隙更深，有更大的对侧厣面，因此经皮质入路更具挑战性。这种方法的一个好处，特别是在后脑岛，是皮质和皮质下的刺激允许顺利的切除，而横断裂依赖于在一个狭窄的走廊中细致地解剖血管结构，这解释了早期报告中较高的并发症发生率，尽管我们已经表明，当使用两个外科医生的方法时，它是顺利和合适的。

　　原文链接：https://www.sci-hub.se/10.1007/s11060-016-2154-5