FIGURE 1. Illustration showing Brodmann’s cortical areas of functional

behavior.

FIGURE 2. Illustration showing subcortical white matter fascicles connecting cortical functional regions.

FIGURE 3. T2-weighted axial MRI scan of a tumor occupying the left supplementary motor area. The motor pathways (white area) are seen to emerge from the anterior portion of the motor cortex, which is flanked posteriorly by the central sulcus.

FIGURE 4. Example of a set-up for MSI to localize functional regions preoperatively.

FIGURE 5. T2-weighted axial MRI scan of a tumor in the posterior frontal region on the left. The white area represents the superimposed DTI of the descending motor pathways.

FIGURE 6. Three-dimensional reconstructed DTI depiction of the descending motor pathways posteriorly located to the lesion.

FIGURE 7. DWI obtained 2 and 4 months postoperatively to identify areas of ischemia (bright signal DWI, dark signal void apparent diffusion coefficient) that enhances briefly postoperatively.

FIGURE 8. MRS image showing voxels of residual tumor (choline to NAA index  2) in areas adjacent to a gross total resection of a glioblastoma. Asterisks, high choline points.

額葉腫瘤

額葉腫瘤依據(jù)病變距中線的距離基本上可分為2個不同的位置。對于距中線4cm內(nèi)的病變，患者的頭位可在Mayfield頭架固定后垂直或向?qū)?cè)輕度偏斜擺放。這個頭位同樣可應(yīng)用于Rolandic皮層（即中央?yún)^(qū)）前的扣帶回前部的深處腫瘤。手術(shù)切口自顴弓至前發(fā)際，如果腫瘤非常靠前，則切口可向前額輕度延長。如果必要的話，切口術(shù)后采用皮內(nèi)縫合或創(chuàng)可貼 (3M, St. Paul, MN)粘合，包括前額部(圖9)。

FIGURE 9. Illustration showing the surgical position and scalp incision for frontal tumors within 4 cm of the midline.

對于距中線4cm之外的腫瘤，患者頭部向?qū)?cè)旋轉(zhuǎn)約60°，同側(cè)肩下墊圓枕（圖10）。當這是在優(yōu)勢半球端操作時，切口基本上是相同的，頭皮切口周圍浸潤是從顴弓到耳朵上方再到前額部的弧形切口。對于在Rolandic皮層（即中央?yún)^(qū)）1-2cm內(nèi)的腫瘤，有必要暴露運動束以誘導(dǎo)刺激定位，如果因為先前開顱而未能得到充分暴露，可以用硬膜下電極片刺激運動皮層而獲得暴露。

FIGURE 10. Illustration showing the surgical position and scalp incison for frontal tumors lateral to 4 cm of the midline.

顳葉腫瘤

對于前半顳葉內(nèi)的腫瘤，病變側(cè)頭需向病變對側(cè)旋轉(zhuǎn)近90度，整個頭部保持與地面平行。當病變延伸很深，鄰近中線附近的大腦腳及鉤回之上，此時頭部應(yīng)向地板彎曲10度。切口從顴弓延伸，沿耳廓上方，超越前發(fā)際線（圖11，A和B）。如果腫瘤位于優(yōu)勢半球，先行頭皮阻滯麻醉，再以圓周形式平行延伸切口。

FIGURE 11. Illustrations showing the surgical position and scalp incision for anterior (A) and posterior (B) temporal lobe tumors.

當腫瘤位于顳葉的后半部，頭部定位仍然同前，但切口從顴弓上方開始，向后延伸，以馬蹄形形式結(jié)束于耳廓后方。同時，如果腫瘤位于優(yōu)勢半球側(cè)，切口范圍需用藥物行局部浸潤麻醉。（圖12，A-C）

FIGURE 12. Illustrations showing the scalp incision and local anesthetic infusion for parietal tumor resection (A), frontotemporoinsular tumors (B), and anterior temporal tumors (C) under awake mapping conditions.

島葉腫瘤

島葉腫瘤對于外科醫(yī)生來說是一個特殊的挑戰(zhàn)，正因如此，體位的擺放必須適于獲得理想的視野暴露和手術(shù)切除，取決于病變在外側(cè)裂上還是外側(cè)裂下。對于大部分病變在外側(cè)裂上的島葉腫瘤，患者的頭位擺放至少應(yīng)該向腫瘤對側(cè)傾斜60°，向上與地面呈15°。這樣切除時就可以平行于島葉血管進行，島葉血管傾向顳葉側(cè)(圖13A)。

對于大部分病變在外側(cè)裂下的島葉腫瘤，患者頭位擺放必須向對側(cè)旋轉(zhuǎn)幾乎90°，翻轉(zhuǎn)向下與地面成15°(圖13B)。一旦切除或牽拉顳中回的上部后就可以直視島葉的下部。頭低位時同時也為鉤束的下部提供了視野暴露。如果病變向后延伸很遠，至少到達內(nèi)囊后肢的末端，頭部沒有必要旋轉(zhuǎn)90°，但仍需保留與直立體位時呈60°以適于暴露病變的后部。如果島葉靠近優(yōu)勢半球，先行頭皮阻滯麻醉，再以圓周形式平行延伸切口。經(jīng)典的是從顴弓延伸于耳廓上方，向前直達前發(fā)際線。

FIGURE 13. Illustrations showing the surgical position and scalp incision for insular tumors mostly above (A) or below (B) the sylvian fissure.

頂枕部腫瘤

位于頂葉側(cè)下方的腫瘤可以通過馬蹄形的切口暴露，本質(zhì)上是騎跨耳朵頂部并以此作為基底的一個切口(圖14 A)。這種方法也被用于暴露側(cè)腦室房部及其上的區(qū)域。如果腫瘤位于頂葉正中或其上半，或者基底位于扣帶回的后部，患者需仰臥位，頭部前曲45°，做沿中線數(shù)厘米，在運動區(qū)皮質(zhì)前的切口，向后延伸越過耳上方，然后向前返折。骨瓣通常覆蓋Rolandic皮層。然而，如果運動皮層需要被刺激，而骨瓣不在病變位置，則可插入一個硬膜下電極片尋找運動皮層。如果運動皮層被刺激，腫瘤將會接近頂葉；這種方法對于完全進入扣帶回和扣帶池病變是很必要的(圖14B)。

FIGURE 14. Illustrations showing the surgical position and scalp incision for lateral (A) and mesial (B) parietal lobe tumors.    

當原始的腫瘤位于枕葉，最好患者擺放側(cè)俯臥位，頭部旋轉(zhuǎn)使鼻尖近似對準地面，這種體位枕葉處于無負荷狀態(tài)，對腫瘤腹側(cè)沒有任何壓力，手臂懸吊于桌面，胸部下方墊圓枕以避免臂叢神經(jīng)受壓，以病變?yōu)橹行淖鲴R蹄形切口，沿中線向上延伸，然后向側(cè)方止于耳后方(圖15)。

FIGURE 15. Illustration showing the surgical position and scalp incision for occipital lobe tumors.

FIGURE 16. Intraoperative electromyogram showing that the tonic-clonis movements induced by cortical stimulation quieted abruptly after cold water irrigation to the stimulated region of cortex.

FIGURE 17. Illustration showing the infiltration of the dura with lidocaine via a 30-gauge needle after the bone is removed to abolish dural-based pain.

FIGURE 18. Intraoperative electromyogram of the hand region showing and increase in stimulation currents.

FIGURE 19. Intraoperative map of non-dominant face motor cortex (A and B) with strip electrode inserted to identify the hand region. The tumor and face motor cortex are resected (C and D).

FIGURE 20. Strip electrode inserted along the dura to find the leg motor cortex after resection of a supplementary motor area tumor.

FIGURE 21. Intraoperative photograph showing the stimulator evoking motor responses when the subcortical motor tracts are identified.

FIGURE 22. Stimulation induced after discharge potentials during intraoperative electrocorticography recordings.

FIGURE 23. Object naming task during intraoperative mapping.

FIGURE 24. A, MRI scan showing a posterior superior temporal lobe tumor in the dominant hemisphere. B and C, intraoperative maps depicting the number 25 as a stimulation-induced anomia before (B) and after (C) tumor resection. D, postresection T1-weighted MRI scans of the resection cavity.

FIGURE 25. Intraoperative tumor identification using IV ICG (A), which shows up white under the fluorescent microscope (B).

FIGURE 26. Functional mapping of the cortex during verb generation tasks using grid electrodes. The red star and pink arrow identify high gamma activity in the cortical area that is activated during verb generation.