Strategien zur Resektion von Gliomen in eloquenten Hirnarealen

Zusammenfassung

Die kritische Wertung der aktuellen Literatur zeigt, dass das Ausmaß der Resektion eines hirneigenen Tumors entscheidend die Lebenserwartung bzw. das rezidivfreie Überleben beeinflusst. Die Beweislage ist bei höhergradigen Tumoren noch eindeutiger als bei den niedergradigen. Eine besondere Herausforderung ergibt sich bei Gliomen in “eloquenter”, also funktionell wichtiger Lage, da das Prinzip des “nihil nocere” auch hier nicht verletzt werden sollte.

Innerhalb der letzten Jahre wurden eine Reihe von technologischen Hilfen zur Identifikation funktionell relevanter Hirnareale entwickelt mit dem Ziel, diese während der Operation zu schonen, gleichzeitig aber ein Maximum an Resektion zu erlauben. Sie lassen sich grundsätzlich einteilen in Hilfsmittel zur Lokalisation/Resektion und zur funktionellen Steuerung des Eingriffs. Die Neuronavigation mit z. B. Integration der funktionellen MRT, der Faserbahndarstellung, des Ultraschalls, der Tumorfluoreszens gehört zu den Erstgenannten Hilfsmitteln, ebenso wie die intraoperative Bildgebung (MRT, CT). Die Hilfsmittel zur funktionellen Steuerung des Eingriffs betreffen die intraoperative Elektrophysiologie, die den Goldstandard des intraoperativen Neuromonitorings darstellt, da die bildgebenden Verfahren noch keine ausreichende Sicherheit und Genauigkeit bieten.

Bei kombiniertem Einsatz dieser Technologien und Anwendung einer adäquaten mikrochirurgischen Technik ist es heute möglich, mit einem hohen Maß an Sicherheit für den Patienten, hirneigene Tumoren zu resezieren, die noch vor Kurzem als inoperabel angesehen wurden.

Summary

A critical review of the recent literature shows, that the extent of surgical resection is a key factor for overall survival and progression-free survival in the treatment of gliomas. The level of evidence is even better in high-grade than in low-grade gliomas. A distinct challenge is therefore the maximum resection of gliomas in functionally important, i.e. eloquent areas of the brain, because the principle of “nihil nocere” should not be violated.

Several technologies were recently developed in order to allowa maximum of tumour resection and avoid functional damage. These devices can be subdivided into tools for localization/resection and for functional guidance. Among the first group is neuronavigation with integration of functional MRI, fiber tracking, ultrasound, tumour fluorescence etc. as well as intra-operative MRI and CT. The latter comprises all types of intra-operative electrophysiology, which is still the gold standard for intra-operative monitoring, because functional image-guidance does not have a sufficient reliability for the time being.

Using a combination of these technologies and an adequate microsurgical technique, it is possible to safely resect intrinsic brain tumours in eloquent areas of the brain, which were deemed inoperable only recently.

Schlüsselwörter

Gliome - eloquente Hirnareale - Neuronavigation - intraoperatives Monitoring

Keywords

Glioma - eloquent area - neuronavigation - intraoperative monitoring

• Literatur

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