三叉神经鞘瘤的临床分型及其手术疗效分析

目的探讨三叉神经鞘瘤的临床分型及其手术疗效。方法回顾性分析2017年1月至2019年11月首都医科大学附属北京天坛医院神经外科手术治疗的51例(包括少见部位和肿瘤最大径≥6 cm的患者)三叉神经鞘瘤患者的临床资料。根据Yoshida和Kawase的MPE分型分别采用颞下经岩前入路(30例)、经额颞断颧弓入路(12例)、经额眶颧人路(4例)、经枕下乙状窦后入路(2例)、经乙状窦前入路(2例)和经远外侧入路(1例)。术后随访MRI、新发症状及脑神经功能的恢复情况。结果51例患者中,肿瘤全切除46例(90.2%),近全切除4例,大部切除1例,无手术死亡病例。其中6例中线-鞍上扩展亚型的患者,肿瘤全切除2例,近全切除3例,大部切除1例。7例肿瘤直径≥6 cm的患者中,肿瘤全切除6例,肿瘤卒中1例;其中4例行游离脂肪填塞结合颅底硬膜缝合的颅底重建。51例患者的随访时间为(20.2±2.7)个月(3~38个月)。24例术前面部麻木的患者中,12例(50.0%)随访期间仍存在重度三叉神经麻搏表现。51例患者中,有13例(25.5%)术后新发三叉神经功能异常的患者中,7例随访期间遗留轻度三叉神经麻搏症状。其余脑神经症状较术前有所恢复,并且术后新发神经功能障碍者大多恢复正常。6例中线-鞍上扩展亚型的患者术后神经功能恢复较差。结论三叉神经鞘瘤在MPE分型的基础上可增加中线-鞍上扩展亚型,该亚型相对少见,但其临床表现具有特征性,手术全切除困难。手术对于改善三叉神经鞘瘤面部麻木作用有限,术前伴有面部麻木者三叉神经功能预后较差。

Clinical classification and surgical efficacy of trigeminal schwannomas

Objective To investigate the clinical classification and surgical efficacy of trigeminal schwannomas(TS).Methods A retrospective analysis was conducted on the clinical data of 51 patients with TS(including those at rare locations and those with maximal diameter ≥6 cm)who underwent surgical treatment at Department of Neurosurgery,Beijing Tiantan Hospital,Capital Medical University from January 2017 to November 2019.According to MPE classification proposed by Yoshida and Kawase,tumor resection was performed via anterior transpetrous approach in 30 cases,via frontotemporal zygomatic approach in 12 cases,via fronto-orbito zygomatic approach in 4 cases,via retrosignioid approach in 2 cases,via presigmoid approach in 2 cases and via far-lateral approach in 1 case.Follow-up contents included MRI,newly-developed symptoms and recovery of neurological function.Results Among 51 patients,total resection was achieved in 46(90.2%)cases,near-total resection in 4,and subtotal resection in 1.There was no surgery-related death.Among 6 cases of supper-sellar TS,total resection was achieved in 2 cases,near-total resection in 3,and subtotal resection in 1.Among 7 cases with the tumor diameter ≥6 cm,total resection was achieved in 6 and tumorrelated stroke occurred in 1,and 4 cases underwent skull base reconstnaction with free-fat packing and skull base dural suture.All patients were followed up,with an average of 20.2±2.7 months(3-38 months).In 24 patients with preoperative facial numbness,12(50.0%)reported severe trigeminal nerve palsy during the followup.Among the 13(25.5%)cases with newly-developed trigeminal nerve dysfunction after operation,7 still had mild trigeminal nerve palsy during follow-up.Tlie symptoms related to other cranial nerves improved to some extent after operation,and most postoperative newly-developed neurological dysfunctions recovered during followup.Recovery of neurological functions was poor in 6 patients with midline-suprasellar extension subtype.Conclusions Although it is rare,the supper-sellar subtype could be an addition to the MPE classification of TS.Its clinical demonstrations are characteristics and total surgical resection is difficult.Therefore,it was advisable to add this subtype to the MEP classification.The surgical effect on the facial numbness seems limited.The functional prognosis of trigeniinal nene is worse in TS patients with preoperative facial numbness.