颅咽管瘤术后水钠代谢紊乱的治疗

2002年7月至2004年7月,我们手术切除颅咽管瘤36例,对术后出现的水钠代谢紊乱进行了积极治疗,效果满意。1临床资料1.1一般资料本组36例,男22例,女14例。年龄14～57岁,平均34岁。1.2临床表现首发症状为头痛15例,视力障碍11例,闭经4例,多饮多尿4例,性欲减退2例,病史1月～6年,70%以上的患者病程在1年以内。1.3术前实验室检查甲状腺功能低下16例,主要为T3、T4降低,TSH多正常,皮质醇降低12例,FSH、LH降低6例,PRL轻度增高(≤60ng/dl)16例。血钠异常4例,3例为高血钠,1例为低血钠。1.4影像学检查肿瘤位于鞍上25例,鞍上进入第三脑室5例,鞍内鞍上…     

颅咽管瘤MRI表现与术后水钠代谢紊乱关系分析

目的分析MRI上颅咽管瘤与第三脑室底的关系及对估计术后水钠代谢紊乱的意义.方法回顾性分析64例颅咽管瘤,根据术前MRI上颅咽管瘤与第三脑室底的关系将其分为4级,术后钠代谢情况分为正常、低钠、高钠及混合4组,尿量分为正常、轻度尿崩及严重尿崩3组,分别进行统计学分析.结果各级颅咽管瘤与钠代谢情况、尿量之间均有统计学差异.结论颅咽管瘤对第三脑室底侵袭越多,术后水钠代谢紊乱程度越重.分析MRI上颅咽管瘤与第三脑室底的关系,可以在一定程度上预测术后部分下丘脑反应的严重程度.     

颅咽管瘤术后水电解质平衡紊乱的治疗

目的探讨颅咽管瘤切除术后水电解质平衡紊乱的临床特点及治疗方法。方法36例行颅咽管瘤切除术患者,手术当日及术后每日定时检测电解质并观察尿量变化,根据其变化进行治疗。结果25例术后并发尿崩症,其中18例两周内恢复,6例4周内恢复,1例1年内恢复。电解质紊乱30例中,24例术后4周恢复,5例2个月内恢复,1例半年内恢复。结论颅咽管瘤患者术后绝大多数会出现水电解质代谢紊乱,尿崩症大多数在术后早期恢复,电解质异常需严密监测,针对监测结果进行治疗,效果满意。     

颅咽管瘤全切除术后血钠紊乱分析及治疗

目的总结颅咽管瘤全切除术后血钠紊乱的发生规律和治疗方法。方法回顾性分析46例颅咽管瘤病人术后血钠紊乱的情况,分析血钠紊乱与病人年龄、肿瘤位置的关系。结果术后出现血钠紊乱者42例(91.3%),其中单纯低钠型9例(19.6%),单纯高钠型6例(13.0%),混合型血钠紊乱27例(58.7%)。42例术后血钠紊乱者中,术后3个月内恢复正常40例;1例持续高钠血症者在术后1.5年恢复正常;另1例持续高钠血症者术后2个月死于肺栓塞。15例儿童病人中7例在围手术期出现癫疒间发作,31例成年病人无一例出现癫疒间发作。结论颅咽管瘤全切除后血钠紊乱的发生率显著高于术前(P<0.001);术后血钠紊乱的类型与年龄、肿瘤复发、肿瘤囊实性和肿瘤位置无关(P>0.05)。纠正血钠紊乱是儿童颅咽管瘤病人在围手术期预防癫疒间发作的关键。     

颅咽管瘤术后尿崩症的预防和治疗

颅咽管瘤是颅内最常见的先天性肿瘤，占颅内先天性肿瘤的60％。颅咽管瘤位置深在，手术切除易损伤视神经、垂体以及下丘脑等重要结构，造成严重后果。尿崩症是颅咽管瘤术后常见的并发症。本文总结了2000年至2005年间我们手术切除的34例颅咽管瘤病例的资料，旨在探讨颅咽管瘤术后尿崩症预防和治疗的经验。     

颅咽管瘤全切术后抗利尿激素分泌异常综合征的治疗

目的 探讨颅咽管瘤全切术后抗利尿激素分泌异常综合征(SIADH)的临床特点及治疗方法。方法 120例颅咽管瘤切除术病人，112例肿瘤全切除，手术当日及术后每日定时检测血钠及观察尿量变化。17例病人术前、术后当日、术后3d、7d、14d检测血清抗利尿激素(ADH)水平，并进行比较观察。结果 ①72例(60％)术后出现以低血钠为主要特征的抗利尿激素分泌异常综合征。其中37例(51.4％)单纯性低血钠，29例(40.3％)尿崩症伴高血钠后转为低血钠，6例(8.3％)低血钠后转为尿崩症伴高血钠。②17例病人术前、术后当日、术后3d、7d、14d血清ADH放射免疫学测定，示术后SIADH病人血清ADH水平与术前相比有所增高，但是经统计学分析无显性差别。结论 颅咽管瘤全切术后SIADH为常见术后合并症，可能是由于颅咽管瘤术后下丘脑ADH的释放不能随着体内晶体渗透压变化而改变所致。术前和术后2周内血清ADH水平变化没有显性差异。     

颅咽管瘤术后并发症临床分析

目的：探讨颅咽管瘤术后并发症的临床特点及发生机制。方法回顾性分析73例行显微外科治疗颅咽管瘤病人术后并发症的临床特点,并探讨其发生机制。结果颅咽管瘤术后并发症复杂。下丘脑损害发生率72.6％,垂体功能低下发生率52.1％,无菌性脑膜炎发生率23.3％,视力视野障碍发生率16.4％,其他并发症包括癫痫、脑脊液鼻漏等。结论颅咽管瘤术后并发症发生率高,临床表现多样化,发生机制复杂。     

颅咽管瘤切除术后水钠代谢紊乱机制研究

目的探讨颅咽管瘤术后水钠代谢紊乱的原因和最佳处理方式。方法对102例经胼胝体切开穹窿间入路切除巨大颅咽管瘤的病人，记录术后尿量、血电解质、抗利尿激素（ADH）、醛固酮（ALD）、皮质醇水平，比较术后激素水平变化与水、钠代谢紊乱的关系。结果本组均出现水、钠代谢紊乱，术后2周完全恢复52例，4周基本恢复33例，6周恢复12例，需长时间人工调整电解质水平5例。术后ADH、ALD和皮质醇的不足是导致术后水钠代谢紊乱的主要原因。结论颅咽管瘤切除术后水、钠代谢紊乱与手术损伤下丘脑有关，紊乱类型与ADH、ALD和醛固酮的缺乏情况有关；及时给予相应激素及对症治疗，可获满意疗效。     

颅咽管瘤全切除术及术后并发症的防治

目的 探讨颅咽管瘤全切除术的手术方法和并发症的防治措施。方法 24例鞍区颅咽管瘤，术前进行糖皮质激素的替代疗法和抗癫痫药物治疗。手术采取翼点人路，从鞍区各个手术间隙分块切除肿瘤。术后严密观测病人的意识、尿量和血清电解质，及时防治尿崩症、电解质紊乱等并发症。结果 22例达到全切，2例有少部分残余，无明显神经功能障碍。发生尿崩症16例，电解质紊乱12例，体温失衡6例。经过处理，电解质紊乱和体温失调完全纠正，13例尿崩症痊愈，3例缓解。结论 选用合适的手术入路，熟悉鞍区的各个手术间隙解剖是完成颅咽管瘤全切除术的关键。术前进行糖皮质激素替代治疗，术后严密监测尿量和血电解质，积极处理并发症，可以有效降低手术病死率。     

颅咽管瘤术前术后处理

颅咽管瘤的特点之一是术后并发症多,病情变化快而急,需抓住时机及时治疗。否则,术后病人不仅不能顺利恢复,还可增加手术的死亡率和病残率。 1985年1月至2001年12月,我科共手术治疗颅咽管瘤249例,摸索出了一些成功的治疗经验,取得了较好临床效果。1 术前处理1.1 实验室检查 除常规检查外,尚应做垂体功能及甲免全套检查,以决定术前给予垂体激素的种类及剂量。24h尿量、尿比重、尿钠含量及血尿渗透压以了解患者术前这些指标的基础值及异常程度。1.2 视力、视野、眼球活动及眼底检查 视力极差者,术后可能发生失明(手术干扰或减压综合征),应向病人及家属讲明以取得配合与理解。     

颅咽管瘤的显微手术治疗

目的探讨颅咽管瘤显微手术治疗的方法和入路.方法回顾性分析32例颅咽管瘤显微手术的方法、并发症和治疗结果,总结临床处置过程中的体会.结果 31例患者经翼点入路、1例经前胼胝体入路完成手术.经术中观察及术后CT和MRI复查证实,肿瘤全切除26例,次全切除3例,部分切除2例.术后出现尿崩症24例,高钠高氯血症18例,低钠血症5例,高热11例.临床痊愈出院12例,好转出院19例,死亡1例. 结论采用显微手术全切颅咽管瘤,效果良好;术前即有明显下丘脑功能损害者,手术风险较大,预后差;鞍区颅咽管瘤采用翼点入路是最佳选择.     

囊性颅咽管瘤内置管囊小剂量多次化疗的疗效观察

目的探索神经外科综合治疗位于视丘下部附近区域的囊性颅咽管瘤之方法。方法选择16例囊性或以囊性为主的颅咽管瘤,在CT介导立体定向内窥镜下切除部分囊壁或肿瘤实质,排除囊液减压后囊内置入Ommaya管,术后经反复抽吸囊液,并反复注入小剂量博来霉素30～40次。结果16例经治疗后视力、视野障碍明显好转,7例有颅内压增高者术后缓解。CT显示瘤腔缩小,无手术死亡,术后视丘下部功能紊乱反应轻。14例获随访2～3年,临床症状明显改善。结论该疗法安全、简便、有效,是采用微侵袭神经外科手段治疗颅咽管瘤的有效方法,有一定的临床应用价值。     

复发颅咽管瘤的显微手术治疗

目的 探讨复发性颅咽管瘤的手术治疗方法和技巧.方法 回顾性分析15例复发性颅咽瘤患者的临床资料.其中男10例,女5例;年龄10～56岁.手术采用原切口入路13例(翼点入路10例,额下入路3例),经纵裂胼胝体入路1例,联合入路1例.结果 肿瘤全切除9例,近全切除5例,大部切除1例.术中垂体柄保留6例,断离4例,未见垂体柄5例;术后大多数患者的视力改善,单眼失明1例;尿崩12例,电解质紊乱7例;垂体功能低下6例;癫痫3例;无死亡.结论 复发性颅咽管瘤与其周围结构关系紊乱、粘连重或钙化,但手术切除仍然是可行的治疗方法.     

Social and psycho-intellectual outcome following radical removal of craniopharyngiomas in childhood

Background A prospective study on childhood craniopharyngiomas (CPs) was conducted from 1994 to 1998 to appreciate the pre- and postoperative clinical, endocrine, mental, and intellectual status of the patients and to determine the incidence and severity of the postoperative hypothalamic syndrome.Methods The series included 14 consecutive CPs. Twelve were retrochiasmatic and intraventricular, and two were partly prechiasmatic and extraventricular. All were treated with the aim of total removal. The removal was total in nine cases but incomplete in the other five. Immediate postoperative follow-up was uncomplicated in all cases.Conclusion At 2-year follow-up, the two children with an extraventricular CP and a total tumor removal were intellectually normal, had no hypothalamic syndrome, and attended normal school with good results. The 12 others, although still intellectually normal, were more or less severely affected by a hypothalamic syndrome which altered their social insertion and caused academic failure. The authors conclude from this study that radical surgery should be reserved to extraventricular CPs only.     

儿童颅咽管瘤手术治疗和长期随访

目的探求在保护下丘脑功能的条件下，安全地伞切或近全切儿童颅咽管瘤。并长期随访术后病儿的生存情况。方法手术切除儿童颅咽管瘤202例。采用经胼胝体一透明隔间隙一穹隆问入路、经额部纵裂入路等八种入路切除鞍区和第三脑室内的颅咽管瘤。术前和术后采取积极措施预防和治疗下丘脑功能紊乱。并对其中的105例进行了12个月到6年的长期随访。结果全切＋近全切184例（91．1％），死亡2例（0．9％）。术后主要并发症为：尿崩症发生率80．7％，长期尿崩症率11．4％；血电解质紊乱74．8％；癫痫9．4％。术后第1年和第4年是死亡高峰。手术后5年生存率68．2％。结论选择合适的手术入路在直视下尽可能全切除颅咽管瘤，并保护第三脑室前下外侧壁（下丘脑）。术后积极防治血钠紊乱和癫痫是确保手术安全的重要措施。术后放疗可明显降低颅咽管瘤的复发率。     

颅咽管瘤全切除术后钠代谢紊乱及处理

目的分析颅咽管瘤全切除术后钠代谢紊乱的病理生理、诊断及处理。方法对我科86例巨大颅咽管瘤(直径>3.5cm)全切除患者进行回顾性分析,根据血钠、尿钠、渗透压以及中心静脉压等确定钠代谢紊乱类型,并进行相应处理。结果发生低钠血症29例(33.7％,29/86)、高钠血症13例(15.1％,13/86)、高钠及低钠血症交替9例(10.5％,9/86)。高钠及低钠血症平均开始时间分别为术后(2.3±0.7)d和(4.8±1.6)d。2例死于严重下丘脑反应,其余钠代谢紊乱均纠正良好,平均住院时间26 d。结论钠代谢紊乱是颅咽管瘤全切除术后常见表现之一。高钠血症与尿崩症关系密切,而低钠血症主要有两个原因:脑性盐耗综合征和抗利尿激素不适当分泌综合征,二者要仔细区分,前者着重补液、补盐,而后者应在补盐的基础上要适当限水和利尿。     

Outcomes and failure patterns in childhood craniopharyngiomas

Past studies of craniopharyngiomas in children have shown overall survival (OS) up to 95% at 5 years and 80% progression-free survival (PFS) at 5 years, although many of these series predate modern neuroimaging and current therapeutic management. Moreover, little mention has been made of failure patterns for craniopharyngioma in children. To obtain a contemporary assessment of outcome among pediatric craniopharyngioma patients, and also to determine the failure patterns for this tumor, we completed a retrospective study of a consecutive cohort of all children with craniopharyngioma diagnosed at the Johns Hopkins Hospital from 1980 to 1996. Resection was performed in 30 children, in 8 of whom gross total resection (GTR) was achieved. Initial treatment took the form of GTR followed by observation for 8, subtotal resection (STR) plus observation in 11, and STR followed immediately by radiotherapy in 8. The timing of radiotherapy following STR was unclear for 3. OS was 95.2% (SE= 4.7%) at 5 years, with only 2 children dying after 4 years from diagnosis. Five-year PFS was 59.4% (SE=10.2%). Before surgery, 19 children had visual loss and 15, endocrine deficits; after surgery, 21 children had visual loss and 29, endocrine deficits. Median time to relapse was 0.98 years (SD=2.5 years). Radiographic (n=4) and clinical (n=7) relapses did not differ in time to progression (P=0.32), but radiographic relapses were significantly associated with age at diagnosis less than 5 years (P=0.02). Degree of resection was not significantly associated with PFS (P=0.32) or with postoperative visual or endocrine deficits. Absence of calcification on diagnostic neuroimaging (n=8) was significantly associated with improved PFS [5-year PFS 100% vs. 42.9% (SE=14.7%), P=0.02], even when adjusted for extent of resection (P=0.03). Preoperative visual loss was predictive of postoperative visual loss (P=0.03). Survival for children diagnosed with craniopharyngioma in the current era is outstanding, even with relapse, although postoperative visual and endocrinological morbidities are high. Failures occurred both radiographically and clinically, typically in the first 3–4 years after surgery, suggesting a need for close surveillance initially with neuroimaging, particularly in younger children, and also clinical examination. The short times to relapse observed here may stem from a tendency to delay radiotherapy until recurrence. Lack of calcification at diagnosis is associated with a tendency to remain free of relapse. Received: 10 May 1998     

Application of endoscopy to the surgical management of craniopharyngiomas

Objective The purpose of this study was to evaluate the efficacy of a minimally invasive/endoscopic approach to craniopharyngiomas (CPGs) given that the surgical aim was a complete excision of the tumor as a single stage procedure. The endoscope can be used with both a subfrontal and a transsphenoidal approach.Methods This study is a retrospective review of 36 operative patients who were seen by one surgeon. All patients had attempted complete excision.Results Patients were divided into three groups according to their preoperative status. Those in group 1 had no previous treatment and fared well, although all developed postoperative diabetes insipidus. Those in group 2 had previous surgery only and also did well with repeat surgery. Those in group 3 had been treated previously with surgery and radiotherapy and, apart from a single exception, did poorly.Conclusion The endoscopic, minimally invasive approach is versatile and effective in the surgical management of both first-time and repeat cases of CPG. It offers superior visualization of surrounding neurovascular structures and allows a more complete resection of tumor. It can be used for a cranial or a nasal approach to these tumors. Sadly, it failed to prevent postoperative endocrinopathy.     

颅咽管瘤全切除术后低钠血症的诊断及处理

目的：探讨颅咽管瘤全切除患术后发生低钠血症的诊断及处理方法。方法: 回顾性分析我科近4年颅咽管瘤全切除术后并发低钠血症的36例患。根据实验室检查、 临床症状及中心静脉压确定低钠血症的类型并给予对症处理。结果：1例死于继发性脑梗塞，1例自动出院，34例患低钠血症状恢复。结论：中枢性低钠血 症包括脑性盐耗综合征（CSWS）和抗利尿激素不适当分泌综合征（SIADH）。前应予以充分补钠、补水,可通过肠内及静脉两种方式进行补充；后却需要限水治疗。     

颅咽管瘤的显微手术治疗及随访

目的探讨翼点入路为基础的颅咽管瘤全切除方法，并通过长期随访了解患者生存状态。方法根据肿瘤影像学表现的生长部位及扩展方向将翼点入路进行改良，对121例颅咽管瘤患者进行手术治疗，并对其中83例进行12-84个月的随访。结果本组全切除、近全切率分别为79．3％、19．0％，术后最常见的肿瘤残留部位位于肿瘤与第三脑室底部前端连续处。术后最常见的下丘脑反应为尿崩症（86、8％）及低钠、高钠血症（68、6％），其中高钠血症预示严重的下丘脑反应，但经过处理术后反应多可良好控制。围手术期死亡3例（2．5％）。11例随访期内复发，复发率13％。随访期患者复发最常见于术后2年内。结论根据肿瘤生长方向及大小，选择各种改良翼点入路进行积极的全切除，多数颅咽管瘤可以得到良好的长期控制和生存质量。