Bravely breaking into the restricted area, how to overcome this case of thalamic space occupation?

For reference only for medical professionals, the thalamus is the most important sensory conduction relay station in the human body, and its surgical approach has always been a hot topic of discussion
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As the most important sensory conduction relay station in the human body, various sensory conduction pathways in the whole body except the sense of smell are replaced by neurons in the thalamus, and then projected to the cerebral cortex
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Because of its important role in sensation, language, etc.
, the operation of the thalamus is often cautious
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Recently, in the activity of "Three Walks in Urgency: Focusing on Techniques", Professor Su Lida of the Second Affiliated Hospital of Zhejiang University School of Medicine, Professor Liu Fang of Changzhou Second People's Hospital, and Director Liu Xin of Zhejiang Provincial People's Hospital sat down to discuss the Surgical techniques for orthotopic lesions, what are the alternative approaches for thalamic surgery? What skills are there for perioperative management? Let's do it one by one
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Looking at the surgical strategy for patients with thalamic glioma from the case, Director Liu Xin first shared a case of a 50-year-old female.
The patient was admitted to the hospital because of "numbness on the left side of the body for more than 4 months".
No nausea and vomiting, no limb weakness, pain, no chills and fever, no blurred vision
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He had a clavicle fracture operation in 2008, and his personal history is unremarkable
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Physical examination on admission showed that the patient's bilateral pupils were equal in size and round, sensitive to light reflex, gross visual acuity and visual field were normal, nasolabial folds were symmetrical, tongue extension was centered, muscle tension of the distal left upper limb was increased, and muscle tension of the remaining limbs was normal
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The muscle strength of the right limb was grade V, and the muscle strength of the left limb was grade III.
The superficial sensation of the left upper limb was less than that of the right side
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Enhanced MRI of the head showed that the patient's right thalamus occupies a space of 6.
3cm*5.
9cm*4.
8cm.
Considering the possibility of high-grade glioma, meningeal origin tumors are not excluded.
Magnetic resonance spectroscopy (MRS) is recommended.
There was mild interstitial edema around the lateral ventricle (Figure 1)
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Figure 1.
The patient's admission enhancement magnetic resonance imaging results.
Before surgery, the patient's diagnosis was considered to be a right thalamic tumor, a possible glioma, and a meningioma
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The surgical plan chose the superior lobular approach, and underwent craniotomy for right thalamic tumor resection.
During the operation, the tumor was cystic and solid, soft in texture, astringent and red, with moderate blood supply and unclear borders
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The pathology was consistent with glioma
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Postoperatively, the patient was unconscious, but had a high heart rate (102-133 bpm) and high blood pressure (139-160/76-92 mmHg)
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The patient had no history of hypertension or heart disease, so the above symptoms were considered to be related to the cardiovascular neuromodulation axis, because the anterior insula, anterior cingulate gyrus, amygdala, hypothalamus, periaqueductal gray matter, parabrachial nucleus, and part of the medulla oblongata Affects heart rate and myocardial contractility through the sympathetic and parasympathetic nervous systems
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After the treatment of the patient's primary disease (dehydration, nutritional nerve), esmolol 1 g + nicardipine 30 mg was pumped to control the heart rate and blood pressure, and the final heart rate and blood pressure were well controlled
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Director Liu Xin pointed out that the thalamus is hidden deep in the brain and is the main relay center of the brain, and its integration originates from different cortex and cerebellum regions The sensory and motor pathways of the patient are important in language and memory, so caution is often used when formulating surgical strategies
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For example, for patients with thalamic hemorrhage, the general surgical attitude is not very positive, because the patient is prone to long-term disturbance of consciousness after intervention for hemorrhage, and the risk is higher than that of simple basal ganglia hemorrhage
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Professor Spetzler, a major in the field of neurosurgery, once divided the thalamus into 6 different regions and selected different surgical approaches according to the thalamus that can be reached by the surgical approach: anterior inferior (orbitozygomatic approach), medial (the anterior half of the ipsilateral lesion).
Transcallosal approach of interhemispheric fissure), lateral (transcallosal approach of the anterior interhemispheric fissure contralateral to the lesion), posterosuperior (transcallosal approach of posterior interhemispheric fissure), lateral posterior inferior [parieto-occipital transcortical approach (apex-occipital transcallosal approach) lobule)], medial posterior inferior (paramedian infratentorial supracerebellar approach)
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Another professor in the field of thalamic surgery, Ugur ture, when using fiber microdissection techniques to study the thalamus, identified 4 different free surfaces of the thalamus (the most accessible surface of the thalamus and not covered by other brain tissues): the lateral ventricle Surface, surface of the midveil cavity, surface of the cistern, surface of the third ventricle
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The thalamic mass can be effectively accessed by exposing 1 of the 4 free surfaces
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In general, a transcortical approach is not recommended because of the need to incise the cortex and disrupt the normal brain tissue of the surgical access
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The interhemispheric and transverse fissure approaches provide the most reasonable access to the thalamus, which can be reached through the transcallosal or transcisternal approach, including the anterior interhemispheric transcallosal approach and the posterior interhemispheric fissure via the tentorium cerebellum.
Subcallosolar approach, paramedian infratentorial supracerebellar approach, and paramedian contralateral supra-pineal approach
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Professor Sulida believes that glioma is a common tumor in neurology, its anatomical location is critical, and the surgical risk is high, and the surgical approach needs to be selected carefully
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In addition, preoperative assessment, intraoperative anesthesia management, and postoperative hemodynamic (including volume and blood pressure) management cannot be ignored
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Thalamus surgery will have a significant impact on body temperature and blood pressure, which not only occurs in glioma surgery, but other tumors, such as meningioma surgery, will also fluctuate in body temperature and blood pressure, which requires clinical use of superb surgical skills to remove tumors at the same time.
It is also necessary to carefully titrate the drug in the perioperative period, and control the risk of rebleeding through rigorous postoperative monitoring
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Prof.
Fang Liu agrees with Prof.
Spetzler's summary of the six approaches for thalamic surgery, and believes that in clinical practice, different approaches should be selected according to the specific conditions of the patient's tumor.
Temporal lobostomy; if the tumor is more posterior, an infratentorial supracerebellar approach may be used
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The relationship between the lesion and the corticospinal tract can also be observed by magnetic resonance diffusion tensor imaging (DTI)
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If the corticospinal tract is pushed medially, a lateral temporal lobe fistula can be considered to avoid impairment of limb function after surgery
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In addition, lateral ventricle drainage can also be considered, and attention should be paid to residual bleeding and possible hydrocephalus after drainage
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In terms of auxiliary means, intraoperative ultrasound may be more meaningful than neuronavigation technology
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Conclusions For lesions in deep brain structures such as the thalamus and brainstem, the choice of approach is very important, even exceeding the technical requirements for resection of the lesion itself
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In addition to using skilled surgical skills to perform surgical treatment of patients, neurosurgeons also have an important impact on the prognosis of patients during the perioperative period.
The rational application of intravenous antihypertensive drugs represented by nicardipine can help improve the prognosis of patients.

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