Prächirurgische funktionelle Magnetresonanztomographie (fMRT) bei Patienten mit rolandischen Hirntumoren: Indikation, Untersuchungsstrategie, Möglichkeiten und Grenzen der klinischen Anwendung

Zusammenfassung

Die prächirurgische funktionelle Magnetresonanztomographie (fMRT) bildet motorische und somatosensible Hirnaktivierung nicht invasiv in Relation zu rolandischen Tumoren ab und erfasst plastische Veränderungen. Funktionelle Landmarken ermöglichen die Prüfung der Operationsindikation sowie die Planung und Durchführung funktionsschonender Resektionen, selbst wenn morphologische Landmarken tumorbedingt nicht mehr identifizierbar sind. Derzeit kann die fMRT noch nicht als klinisch etabliertes diagnostisches Verfahren angesehen werden, da praktikable Stimulationssysteme, standardisierte Untersuchungsprotokolle und für medizinische Anwendungen zugelassene Auswertungsprogramme fehlen. In dieser Arbeit werden, nach einer kurzen Rekapitulation der funktionellen und bildmorphologischen Neuroanatomie, die Indikationen zur prächirurgischen fMRT bei Patienten mit rolandischen Hirntumoren dargestellt. Ein robustes Basisprotokoll erlaubt zuverlässig prächirurgische fMRT-Untersuchungen während kontralateraler Handbewegungen auf klinischen MR-Tomographen mit Feldstärken ab 1,0 Tesla. Optimierte Untersuchungsstrategien und praktikable Stimulationsmodalitäten werden für Patienten mit „handferner” rolandischer Tumorlokalisation, vorbestehenden sensorimotorischen Defiziten oder mangelnder Kooperationsfähigkeit vorgestellt und in der Anwendung durch Fallbeispiele veranschaulicht. Möglichkeiten und Grenzen der klinischen Anwendung werden aufgezeigt und diskutiert.

Abstract

Preoperative functional magnetic resonance imaging (fMRI) localizes the primary motor and somatosensory cortex in relation to rolandic brain tumors and determines plastic cortical reorganization. Functional landmarks help to assess the indication for surgery and to plan for safer surgical procedures that protect the functional cortex during resection even when morphologic landmarks are no longer identifiable on anatomic images. Despite its successful application, preoperative fMRI has not yet reached the status of an established clinical diagnostic procedure since special stimulation systems, standardized fMRI protocols and medically approved software are still lacking. Following a brief review of the image display of the functional and morphologic anatomy, the different indications for preoperative fMRI in patients with rolandic brain tumors are presented. A robust preoperative protocol enables clinical MR units with magnetic field strengths of 1.0 Tesla or higher to perform reliable fMRI during contralateral hand movements. Optimized investigation strategies and stimulation modalities are proposed for patients with rolandic tumors distant from the cortical hand representation, for patients with preexisting sensorimotor deficits and for patients with poor compliance. Representative cases illustrate the clinical application. Possibilities and limitations of preoperative fMRI are presented and discussed.

fMRI, clinical application - fMRI, sensorimotor cortex - surgery - brain tumor

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