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裂隙內(nèi)復(fù)雜的解剖結(jié)構(gòu)和附近的血管因素，島狀膠質(zhì)瘤代表了一種獨(dú)特的手術(shù)挑戰(zhàn)。對于某些腫瘤，經(jīng)Sylvian方法提供了一種合適的技術(shù)，以實(shí)現(xiàn)較大的順利切除。本手稿和視頻的目的是介紹和討論手術(shù)的細(xì)微差別和分割Sylvian裂隙的適當(dāng)應(yīng)用。我們希望這段視頻能夠強(qiáng)調(diào)經(jīng)幽門方法對適當(dāng)選擇的島狀膠質(zhì)瘤的順利性和合適性。

　　膠質(zhì)瘤是成年人較常見的原發(fā)性腦內(nèi)腫瘤，造成了嚴(yán)重的發(fā)病率和死亡率。全部膠質(zhì)瘤的發(fā)病率在每10萬人中4.7～5.7個(gè)，且因年齡而異；少突膠質(zhì)瘤在35～44歲年齡組較常見，而無細(xì)胞星形細(xì)胞瘤和膠質(zhì)母細(xì)胞瘤在75～84歲年齡組達(dá)到發(fā)病高峰 。一般來說，膠質(zhì)瘤在男性中比女性更常見，盡管柔毛性星形細(xì)胞瘤是一個(gè)例外。在過去的十年中，我們對腫瘤遺傳學(xué)的認(rèn)識(shí)有了很大的提高，較近的研究表明，膠質(zhì)瘤可以根據(jù)關(guān)鍵標(biāo)志物包括1p/19q缺失、IDH突變和TERT啟動(dòng)子突變等劃分為不同的分子亞組。這些標(biāo)志物具有重要的預(yù)后價(jià)值，可能有助于確定治療靶點(diǎn)。

　　經(jīng)皮層入路與圖像引導(dǎo)、皮層和皮層下圖譜等輔助手段一起使用時(shí)，是某些島狀病變的順利選擇。這種方法對于后部島狀病變（2區(qū)和3區(qū)）可能特別有用，因?yàn)樵谶@些病變中，經(jīng)皮層方法受到狹窄的Sylvian貯藏室的嚴(yán)重限制。在基于后部島狀病變的病例中，經(jīng)皮質(zhì)方法的一個(gè)重要考慮因素是，手術(shù)概況高度依賴于腦圖譜，因此難以在術(shù)前評估。此外，在后部島內(nèi)，由于Sylvian裂隙與前部Sylvian裂隙相比，Sylvian裂隙更深，有更大的對側(cè)厴面，因此經(jīng)皮質(zhì)入路更具挑戰(zhàn)性。這種方法的一個(gè)好處，特別是在后腦島，是皮質(zhì)和皮質(zhì)下的刺激允許順利的切除，而橫斷裂依賴于在一個(gè)狹窄的走廊中細(xì)致地解剖血管結(jié)構(gòu)，這解釋了早期報(bào)告中較高的并發(fā)癥發(fā)生率，盡管我們已經(jīng)表明，當(dāng)使用兩個(gè)外科醫(yī)生的方法時(shí)，它是順利和合適的。

　　原文鏈接：https://www.sci-hub.se/10.1007/s11060-016-2154-5

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