经眶上锁孔入路切除鞍区颅咽管瘤

目的探讨经眶上锁孔入路切除鞍区颅咽管瘤的应用价值。方法对7例位于鞍上,肿瘤上下径为3．5～6cm的颅咽管瘤患者(部分囊性变者4例,完全实性者3例),作眉弓内弧形小切口,在眶上铣开一直径为2．5cm的半圆形小骨瓣,术中根据肿瘤位置,从视交叉前间隙,视神经外侧间隙和颈内动脉外侧间隙切除肿瘤。术中除注意保护视神经、垂体柄、下丘脑之外,还应防止损伤颈内动脉、后交通动脉、脉络膜前动脉和大脑后动脉发出的到下丘脑和前穿质部位穿通动脉的损伤。结果术中6例病人肿瘤全切除,1例病人次全切除,术后5例病人出现不同程度的尿崩症及电解质紊乱,经药物治疗后好转,6例病人视力改善。结论眶上锁孔入路切口小,但能提供鞍上区足够的手术空间,足以显露鞍区病变及其邻近结构,且减少了脑牵拉和手术创伤,有利于颅咽管瘤的全切除,是一种安全有效的处理鞍区病灶手术入路途径。     

Supraciliary keyhole craniotomy for anterior frontal lesions in children

Treatment for anterior frontal space occupying lesions such as epidural hematoma, vascular malformations or brain tumors, have typically involved invasive craniotomies. This method often requires large incisions with wide exposure and may be associated with high morbidity rates. The basis for the “keyhole” method is that a minimally invasive craniotomy is often sufficient for exposing large areas deep in tissue, and may limit exposure and decrease surgically related morbidity while enabling adequate removal and decompression. The supraciliary method includes a cut above the eyebrow and a small craniotomy to uncover the base of the frontal lobe and the orbital roof. We demonstrate our experience with this method. We identified children who were operated via the supraciliary approach between January 2009 and December 2013, and gathered their pre- and post-operative clinical and radiological statistics. Fourteen patients were identified. Pathologies included tumors, abscesses and epidural hematomas. Nine were operated due to epidural hematoma, two due to tumors, two due to brain abscesses, and one for anterior encephalocele. No significant peri-operative or post-operative complications were observed. Long-term follow-up shows that the surgical scars were nearly invisible. The supraciliary approach is a safe, effective and elegant technique for treating lesions in the anterior skull base. The method should be weighed alongside traditional methods on a case-by-case basis.     

锁孔手术切除垂体腺瘤及听神经瘤的初步体会

随着颅内肿瘤早期诊断水平的提高和手术技巧的发展,对神经外科手术的要求越来越高,减小手术创伤、减少手术并发症、缩短住院时间,已成为神经外科医师关注的重要议题.我们从1998至2001年经眉弓锁孔入路切除垂体腺瘤22例,经乳突后锁孔入路切除听神经瘤7例,报告如下,讨论垂体腺瘤及听神经瘤的微创治疗.     

锁孔入路开颅手术(附106例报告)

目的：评价用锁孔入路开颅术显微切除垂体腺瘤、颅咽管瘤、鞍结节脑膜瘤、脑胶质瘤、听神经瘤及直视下夹闭后交通动脉瘤、前交通动脉瘤的效果及安全性。方法：对垂体腺瘤、颅咽管瘤、脑膜瘤、后交通动脉瘤及前交通动脉瘤于眶上外侧，右颞叶胶质瘤于右颞，听神经瘤于耳后，分别作一直径2．5cm骨瓣，显微镜下切除肿瘤或直视下夹闭动脉瘤。结果：垂体腺瘤77例中65例达到全切除，12例为次全切除；颅咽管瘤11例、鞍结节脑膜瘤6例、胶质瘤1例及听神经瘤7例，均予全切；4例颅内动脉瘤均夹闭成功。 所有患恢复良好，未发生与手术入路有关的并发症。结论：采用锁孔入路，能够安全切除直径在55mm 以下的大型、巨大型垂体腺瘤，以及30－70mm的颅咽管瘤、鞍结节脑膜瘤、听神经瘤，并可直视下夹闭前、后交通动脉瘤。     

翼点眶上小骨窗开颅显微手术切除大型鞍区肿瘤

目的 探讨应用翼点眶上小骨窗入路显微手术冶疗大型鞍区肿瘤的临床效果。方法 21例大型鞍区肿瘤均采用经翼点皮切口眶上小骨窗入路进行开颅手术。皮瓣按翼点入路切开，但仅采用经眶上小骨窗开颅，骨窗呈椭圆形，最大直径仅为3．5～4．0cm，前部尽量靠近颅前窝底，应用显微外科技术将鞍区肿瘤切除。结果 取得显微镜下全切除18例，次全切除3例，无1例手术死亡。仅有1例64岁老年病人术后并发高血压脑出血，于术后3个月死于8市部感染。其他多数病人术后仅出现较为短暂的多尿和低钠血症，经应用脑垂体后叶素和(或)长效尿崩停以及浓氯化钠溶液后效果良好，术后恢复良好。结论 采用经翼点皮切口眶上小骨窗入路显微外科技术切除鞍区大型肿瘤，均可做到显微镜下全切除或次全切除，且对脑组织损伤轻，肿瘤显露好，是较为理想的鞍区肿瘤手术入路。     

锁孔手术切除颅内肿瘤

目的 探讨锁孔手术切除颅内肿瘤的手术技巧和适应证。方法 分别经眶上、翼点、眉间、纵裂、侧脑室和枕下乙状窦后锁孔入路采用显微外科技术或内窥镜辅助的显微外科技术切除颅内肿瘤42例。结果 本组采用显微外科技术切除肿瘤30例，内窥镜辅助的显微外科技术切除肿瘤12例。肿瘤全切除27例，次全切除11例，大部分切除4例。无锁孔入路相关严重并发症和手术死亡。结论 锁孔入路显微手术切除颅内肿瘤具有刨伤小、恢复快的优点，适合于颅底肿瘤、脑室内肿瘤和镰旁脑膜瘤。     

儿童全厚植皮供皮区的优化选择及切口设计

背景：儿童与成人皮肤的生理特点存在差异，有必要制定适合儿童个体皮肤特点的全厚植皮供皮区的优化选则及切口设计方案。 目的：探讨儿童全厚植皮供皮区的优化选择及切口设计的最佳方案。 设计、时间及地点：病例分析，于2005-01/2007-12在重庆医科大学儿童医院烧伤整形科完成。 对象：181例患儿，瘢痕挛缩畸形114例，先天性畸形37例，外伤皮肤缺损等30例。男105例，女78例，年龄4个月~14岁。 方法：对181例行全厚植皮术的患儿，针对皮肤缺损的部位、面积，结合患儿的年龄、性别等特点选择最佳的供皮区：①切口部位应尽可能隐蔽。②供皮后的供区创口应能完全缝合。 ③供皮区皮肤的质地应与受区相近。④受区条件欠佳时尽量选择皮肤较薄的供皮区。⑤供皮区创口要便于护理。⑥修复大面积创面可由多部位同时供皮。 ⑦分次手术皮源紧张时可由原供皮区二次供皮。并针对儿童不同部位供皮区的个体特点进行切口设计：①切口形状应能保证获取足够面积的皮片。②缝合后的切口形状应尽量呈曲线，并顺应皮纹或皮肤张力线。③应避免切口缝合后使临近器官或皮肤体表标志变形，移位。④切口应避开体毛生长区。 主要观察指标：移植皮片的存活率及存活后皮片的质量。供皮区切口的隐蔽性、瘢痕性状，局部皮肤的正常生理特点有无破坏。 结果：171例移植皮片完全存活，32例发生表皮坏死，经换药痊愈，供皮区伤口均一期愈合。术后随访3个月~3年，移植皮肤性状良好，供皮区创痕呈线状，部位隐蔽。 结论：针对儿童个体特点进行全厚植皮供皮区选择及切口设计，可在保证切取皮片面积足够的前提下，使皮片质地尽可能与受区接近，且供区创口隐蔽，美观，符合生理及美容的要求。     

T型切口在复杂颅脑损伤急诊开颅术中的应用

目的 探讨T型切口在复杂颅脑损伤急诊开颅手术中的应用效果。方法 回顾性分析2016年8月至2018年3月应用T型切口进行开颅手术救治的42例复杂颅脑损伤的临床资料。42例均急诊进行开颅探查+血肿清除术,根据术前头部CT表现均选择T型切口,其中第一次手术双侧T型切口15例,术中按照阶梯减压执行,双侧开颅采用双侧控制技术。结果 双侧硬膜下血肿7例,双侧硬膜外血肿2例,双侧脑挫裂伤伴脑内血肿5例,一侧硬膜外血肿合并对侧脑挫裂伤伴脑内血肿或硬膜下血肿9例,一侧硬膜下血肿合并对侧脑挫裂伤伴脑内血肿或硬膜外血肿19例。术后2例颅后窝开颅切口处因是直接着力点,愈合差,经重新缝合及换药处理均愈合;其他40例伤口愈合良好。术后1周神志好转25例,神志清楚6例,无变化11例;术后1个月神志好转18例,神志清楚14例。术后3个月按GOS评分评估预后:恢复良好11例,中残15例,重残2例,植物状态6例,死亡8例。结论 在复杂颅脑损伤急诊手术中,特别是需要双侧开颅手术时,以及可能出现进展、变化的病例,T型切口具有一定的优势,有助解决复杂颅脑损伤急诊开颅手术中的切口设计难题。     

Risk factors for developing epilepsy after craniotomy in children

Introduction We performed a retrospective analysis of children undergoing supratentorial craniotomy, attempting to identify possible risk factors for postoperative epilepsy and the need for prophylactic anticonvulsant therapy.Materials and methods We analysed 107 consecutive patients (55% males) who had supratentorial craniotomy for a variety of diagnoses (tumours, trauma, infection, vascular malformations and others) during 1995–1999. Mean age at operation was 89 months (range: 1–180 months). Patients who presented with epilepsy were excluded. Postoperative epilepsy was considered present if patients required systematic pharmacological treatment, at a minimum follow-up of 6 months. Linear regression was used to analyse the effect of sex, anticonvulsant prophylaxis, duration of operation, closure of dura, postoperative infection, the diagnosis, anatomical region of brain affected, operation type (craniotomy/craniectomy) and the need for brain resection.Results Prophylactic anticonvulsants were given to 52% of the patients; 97% had craniotomy; in five patients, the dura was left open; in 33%, some kind of brain tissue resection had been performed; two patients (1.8%) developed postoperative infection; one patient died. Only 13 patients (12%) developed postoperative epilepsy. The only two factors with statistical significance were female sex (p=0.045) and the absence of dural closure (p=0.001). All other factors were not significant (p>0.258).Conclusions Postoperative epilepsy after supratentorial craniotomy is uncommon in children, incidence being 12%. The administration of prophylactic anticonvulsants does not appear to influence the risk of epilepsy. Surprisingly, females have statistically higher risk. Lack of dural closure has higher risk of epilepsy, but this may reflect the type of pathology.The material of this paper was presented at the 18th Biannual Congress of the European Society for Pediatric Neurosurgery, Kiruna, 15 June 2002.     

冠状切口双侧去骨瓣减压术在广泛性脑挫裂伤中的应用

我科从2000年1月至2005年10月在救治重型颅脑损伤，广泛额颞叶脑挫裂伤及脑疝患者采用冠状切口双侧去骨瓣减压术共53例，手术疗效较好，现总结报告。     

Abnormalities of water metabolism in children and adolescents following craniotomy for a brain tumor

We conducted a retrospective analysis of the cases of 122 children operated on for various brain tumors, to determine the incidence and natural history of post-operative diabetes insipidus (DI), and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Abnormalities of water homeostasis were observed in 15 patients (12%). DI, with or without SIADH, was observed in 10 patients (8%), while SIADH alone was seen in five (4%). DI was permanent in five subjects (50%), whereas SIADH resolved completely in all affected individuals. Parenteral desmopressin (dDAVP) was an effective mode of therapy in the postoperative period. The effect did not correlate with a dosage strictly based on body weight.     

儿童后颅窝肿瘤手术入路及骨瓣复位

目的：根据后颅窝肿瘤不同部位选择最佳手术入路。后颅窝开颅术改咬骨窗为开骨瓣。方法：蚓部肿瘤选择后颅窝正中入路。小脑半球肿瘤行正中钩形切口，肿瘤偏外选择外侧钩形切口。上蚓部肿瘤选择Ｐｏｐｐｅｎ入路。三种骨瓣：正中骨瓣、单侧骨瓣、单侧跨中线骨瓣。术毕骨瓣复位。结果：实施３８例儿童后颅窝肿瘤全切除术，髓母细胞瘤２３例，星形细胞瘤１０例，室管膜瘤３例，血管母细胞瘤１例，脑脓肿１例。无皮下积液发生，３例术后１０天内发烧。结论：后颅窝开骨瓣术、硬膜缝合、骨瓣复位符合解剖复位原则，术后并发症少，避免了因颅骨缺损造成的对儿童心理发育的不良影响     

Early decompressive craniotomy in children with severe traumatic brain injury

Introduction Decompressive craniectomy remains a controversial procedure in the treatment of raised intracranial pressure (ICP) associated with post-traumatic brain swelling. Although there are a number of studies in adults published in the literature on this topic, most commonly as a salvage procedure in the treatment of refractory raised ICP, there are few that investigate it primarily in children with head injuries.Aim Our aim was to report the experience with decompressive craniotomy in children with severe traumatic brain injury (TBI) at the Red Cross Children's' hospital.Methods This study reports five patients in whom decompressive craniectomy or craniotomy with duraplasty was used as an early, aggressive treatment of raised ICP causing secondary acute neurological deterioration after head injury. The rationale was to save the patient from acute cerebral herniation and to prevent exposure to a prolonged course of intracranial hypertension.Results All patients benefited from the procedure, demonstrating control of ICP, radiological improvement and neurological recovery. Long-term follow-up was available, with outcome assessed at a minimum of 14 months after injury.Discussion The early approach to the use of decompressive craniotomy in the treatment of severe traumatic brain injury (TBI) with secondary deterioration due to raised ICP is emphasised. A favourable outcome was achieved in all of the cases presented. The potential benefit of decompressive craniectomy/craniotomy in the management of children with severe TBI is discussed.     

经眉弓锁孔入路垂体腺瘤切除术的临床研究

目的探讨经眉弓锁孔入路手术切除垂体腺瘤的方法及疗效。方法回顾性分析2008年1月至2009年6月经眉弓锁孔入路手术切除垂体腺瘤的20例患者的临床资料。结果术后复查MRI显示,垂体腺瘤全切15例,次全切5例。术后并发症包括尿崩14倒,数日至数月后恢复正常;视力下降2例;硬膜外血肿1例,近期随访良好。无手术死亡病例。结论眉弓锁孔手术可用于鞍区垂体腺瘤的手术切除。有手术路径短、操作方便、微创、切除率满意和疗效佳等特点。内镜术中辅助可提离肿瘤全切率,减少对神经血管结构的损伤。     

Review: Peering through a keyhole: liquid biopsy in primary and metastatic central nervous system tumours

Tumour molecular profiling by liquid biopsy is being investigated for a wide range of research and clinical purposes. The possibility of repeatedly interrogating the tumour profile using minimally invasive procedures is helping to understand spatial and temporal tumour heterogeneity, and to shed a light on mechanisms of resistance to targeted therapies. Moreover, this approach has been already implemented in clinical practice to address specific decisions regarding patients’ follow‐up and therapeutic management. For central nervous system (CNS) tumours, molecular profiling is particularly relevant for the proper characterization of primary neoplasms, while CNS metastases can significantly diverge from primary disease or extra‐CNS metastases, thus compelling a dedicated assessment. Based on these considerations, effective liquid biopsy tools for CNS tumours are highly warranted and a significant amount of data have been accrued over the last few years. These results have shown that liquid biopsy can provide clinically meaningful information about both primary and metastatic CNS tumours, but specific considerations must be taken into account, for example, when choosing the source of liquid biopsy. Nevertheless, this approach is especially attractive for CNS tumours, as repeated tumour sampling is not feasible. The aim of our review was to thoroughly report the state‐of‐the‐art regarding the opportunities and challenges posed by liquid biopsy in both primary and secondary CNS tumours.     

颞下锁孔入路手术治疗基底动脉顶端动脉瘤

目的探讨经颞下锁孔入路手术治疗基底动脉顶端动脉瘤的疗效及手术技巧。方法自2002年7月至2010年4月收治基底动脉顶端动脉瘤患者7例,均在神经内镜辅助下经颞下锁孔入路手术治疗。入院时Hunt-Huess分级0和1级各1例,Ⅱ级3例,Ⅲ和Ⅳ各1例。结果 6例完全夹闭,1例部分残留。无手术死亡病例;术后出现术侧动眼神经麻痹3例,均在6月内恢复。术后随访8月至6年,恢复工作或生活自理5例,一侧肢体偏瘫1例,植物生存1例。结论经颞下锁孔入路手术治疗基底动脉顶端动脉瘤效果良好,尤其对于动脉瘤瘤颈位于后床突下方或瘤体后突者;神经内镜是必不可少的辅助手段。