第四脑室肿瘤的显微外科治疗

目的探讨第四脑室肿瘤手术入路和显微手术技巧,以提高第四脑室肿瘤的手术疗效。方法84例第四脑室肿瘤患者,行显微镜下切除肿瘤、后颅窝骨瓣成形及复位术。其中,61例采用正中孔-小脑蚓部入路,19例采用小脑延髓裂入路,4例取正中孔-小脑蚓部与小脑延髓裂联合入路。术前行侧脑室外引流4例,术中行侧脑室-枕大池分流3例,术后行侧脑室外引流术1例。结果本组全切除肿瘤63例(75.0%),次全切除21例(25.0%),无手术死亡病例。术后并发症:上消化道出血6例,小脑缄默症2例,四脑室血肿1例,脑积水1例,颅神经功能障碍1例。随访82例,平均38.4个月,死亡9例。结论术前正确判断肿瘤性质及其基底部所在位置,选择适宜的手术入路,熟练应用显微外科技术,是手术成功治疗的第四脑室肿瘤关键。     

经小脑延髓裂入路显微手术切除儿童第四脑室肿瘤

目的 报道经小脑延髓裂入路显微外科手术切除儿童第四脑室肿瘤的临床疗效。方法 采用枕下正中切口、小脑延髓裂入路在手术显微镜下切除第四脑室肿瘤18例。结果 手术治疗18例，其中肿瘤全切除13例，近全切除5例。术后无l例出现小脑性缄默综合征。出现脑积水3例，2例经行侧脑室．腹腔分流后好转，l例因急性梗阻性脑积水死亡。结论 经小脑延髓裂入路，不需切开小脑蚓部，可避免损伤正常小脑组织，应用显微外科技术有助切除第四脑室肿瘤，提高手术疗效。     

第三脑室肿瘤的显微手术治疗

目的 报道第三脑室肿瘤手术入路及显微手术切除临床效果.方法 回顾分析经显微手术治疗的第三脑室肿瘤58例,其中采用经胼胝体前部入路20例,经终板-翼点联合入路19例,枕部小脑幕入路6例,经皮质-侧脑室入路5例.另有8例应用脑室镜切除肿瘤并行终板造瘘术. 结果 手术全切除37例(63.8%),次全切除14例(24.1%),部分切除7例(8.6%),死亡1例(1.7%).术后症状改善40例(69.0%),症状基本同前11例(19.0%).54例随访5个月～6年,生活自理者51例(94.4%),复发3例(5.6%). 结论 合理的选择手术入路,术中应用显微外科技术妥善处理和保护血管、神经、丘脑等,能较彻底地切除第三脑室肿瘤和提高患者生存质量.     

脑干肿瘤的显微手术治疗体会

目的 :总结 1 0例脑干肿瘤进行 1 0次显微手术的经验。方法 :根据肿瘤生长部位及方向不同选择不同的入路。肿瘤位于延脑突向IV脑室者取后颅窝枕下中线开颅 ,切开小脑蚓部 ;突向桥小脑角者选择单侧乳突后入路 ,切除部分小脑。手术在显微镜下直视瘤内小块切除。结果 :8例获得较好的疗效。随访 5个月～ 2年半。 3例恢复工作、学习 ,2例生活自理 ,3例需人照料 ,恢复过程良好 ,术后死亡 2例。结论 :脑干肿瘤积极手术治疗是获得良好疗效的关键 ,MRI是脑干肿瘤首选的检查方法。术后并发症防治至关重要。     

脑干肿瘤的显微手术治疗

目的：总结１５例脑干肿瘤进行１６次显微手术的经验。方法：根据肿瘤生长部位及方向不同选择不同的入路。肿瘤位于延脑突向ＩＶ脑室取后颅窝枕下中线开颅，切开小脑蚓部；突向桥小脑血者选择单侧乳突后入路，切除部分小脑。手术在显微镜下直视瘤内分小块切除。结果：１０例获得较好的疗效。随访５个月至２年半。３例恢复工作、学习，３例生活自理，４例需人照料，恢复过程良好。结论：选择手术入路是成功的关键，ＭＲＩ是脑干肿瘤首     

侧脑室肿瘤的显微手术治疗

目的探讨侧脑室肿瘤显微手术的临床价值. 方法 1996年5月～2002年8月我科运用显微外科技术,治疗侧脑室肿瘤14例.根据肿瘤生长部位,选择靠近瘤体的手术入路,保护神经组织和脑室深静脉系统,分块切除肿瘤. 结果 13例(92.9%)全切除,1例次全切除(7.1%).术后并发症11例:颅内感染3例,偏瘫2例,脑积水1例,额叶精神症状3例,脑室内血肿1例,命名性失语1例;除1例偏瘫,生活不能自理,余10例恢复良好.随访9例,时间8～60个月,平均29个月,2例星形细胞瘤复发. 结论显微手术照明良好,创伤小,提高肿瘤的全切除率.     

经胼胝体-穹窿间入路显微手术切除第三脑室肿瘤

目的探讨经胼胝体-穹窿间入路显微手术切除第三脑室肿瘤的方法，并对相应的显微解剖学基础加以讨论。方法经胼胝体-穹窿间入路显微手术切除第三脑室肿瘤12例，其中突入第三脑室颅咽管瘤8例，丘脑内侧型胶质瘤2型，室管膜瘤1例，畸胎瘤1例。结论10例在手术显微镜下肿瘤全切，2例次全切除，全切除率83．3％，其中8例颅咽管瘤中7例全切，术后复查头颅MR未见肿瘤残留及复发。无死亡病例，近期并发症主要为多饮、多尿、电解质紊乱。经处理后1-2周消失。远期并发症为2例脑积水，其中1例半年后行脑室腹腔分流，2例硬膜下积液，3月后自行吸收。全组病例随访最短2个月，最长2年半，1例颅咽管瘤大部切除8月后复发，1例丘脑胶质瘤术后1年复发，其余10例中9例生活正常，1例生活自理。结论经胼胝体-穹窿间入路显微手术切除第三脑室肿瘤系通过胚胎组织残留的组织间隙进入第三脑室，几乎不损伤正常脑组织，手术视野大，直视下操作，可切除第三脑室前、中、后各部位肿瘤，肿瘤全切除率高，并发症少。     

小脑幕切迹脑膜瘤的显微外科治疗

目的:通过对2 0例小脑幕切迹脑膜瘤显微外科治疗的分析,探讨小脑幕切迹脑膜瘤的显微手术治疗方法。方法:总结2 0例小脑幕切迹脑膜瘤的临床表现、神经影像学特征及显微手术方法和术后处理,肿瘤的体积从3×3×3cm到5×6×7cm。结果:肿瘤切除程度按Simpson分级:Ⅰ、Ⅱ级(根治性全切除) 13例,Ⅲ级6例,Ⅳ级1例。本组术后无死亡,术后脑积水行V -P分流1例,一过性象限盲1例。随访2～6年,无复发。结论:枕下幕上入路及幕下小脑上入路是小脑幕切迹脑膜瘤最常采用的手术入路,该入路对小脑幕切迹区域暴露充分,距离近,手术并发症少。手术者良好的显微外科技术、经验和对小脑幕切迹区域显微解剖的了解,是成功切除该区域肿瘤的关键。     

第三脑室肿瘤的显微手术治疗

目的 探讨切除第三脑室肿瘤的手术入路和显微手术技巧。方法 23例采取显微直视手术，2例采取显微直视手术加神经内镜辅助手术，1例第三脑室囊性病变的采取神经内镜切除术。结果 在手术显微镜下全切除12例，次全切除10例，部分切除4例。结论 显微手术为首选治疗方案，第三脑室内囊性病变可用神经内镜治疗。术中注意保护第三脑室周围结构，可减少术后并发症的发生。     

桥小脑角大型脑膜瘤的显微手术治疗

目的探讨桥小脑角大型及巨大型脑膜瘤手术入路及显微手术切除方法方法回顾分析经显微手术治疗的28例桥小脑角大型及巨大型脑膜瘤：其中19例采用枕下乙状窦后入路，3例采用颞枕开颅乙状窦前入路，4例采用颞枕开颅颞下小脑幕入路，2例采用颞枕开颅与幕上、下联合入路：结果肿瘤全切除(SimpsonⅠ、Ⅱ级)22例，全切除率为78．6％。全组无手术死亡。术后症状改善者20例，症状基本同术前5例。26例随访6个月至4年，生活自理者23例(88．5%)，复发2例(7．7％)。结论合理选择手术入路，术中应用显微技术妥善处理和保护血管、神经、脑干等，能较理想地切除肿瘤和提高患者生存质量。     

Analysis of single-staged resection of a fourth ventricular tumor via a combined infratentorial-supracerebellar and telovelar approach: Case report and review of the literature

INTRODUCTIONThe authors explore a combined infratentorial-supracerebellar and telovelar approach in an adult, while avoiding vermian-splitting methods for a large, midline, fourth-ventricular tumor, unapproachable though a single traditional route. Experience with a combined surgical approach for pediatric patients has been published, but the authors believe that describing this combined method in an adult will provide a preliminary experience for further exploration of this approach in other adult patients.PRESENTATION OF CASEThe authors present a review of the literature along with the case of a 60-year-old man with slight ataxia who presented with a 1-month history of gait difficulty and memory lapse. His MRI of the brain showed mild hydrocephalus and a large tumor of the fourth ventricle. Surgical removal through a suboccipital craniotomy was attempted, and part of the tumor overlying the tectum and the superior cerebellar velum was removed without difficulty. However, despite inferior retraction of the vermis, which allowed further resection of the tumor from the fourth ventricle, residual tumor in the caudal surgical resection cavity was present. Partial transection of the vermis was considered, but avoided because of potential neurological deficits. Instead, the authors redirected their approach and exposed the residual tumor by transecting the inferior medullary velum and removed additional tumor while avoiding the floor of the fourth ventricle. The infratentorial-supracerebellar and telovelar approach resulted in total gross resection of the tumor.DISCUSSIONFor patients with large midline tumors that arise from the superior vermis or the quadrigeminal plate and fill the upper third of the fourth ventricular space, this combined approach may offer a unique possibility of safe tumor removal.CONCLUSIONThis case demonstrates the benefit of a combined approach for a select group of patients.     

高位颈段椎管内神经鞘瘤显微手术治疗59例

目的 探讨高位颈段神经鞘瘤显微手术技巧和疗效.方法从2004年1月至2007年12月,对59例均采用后正中入路显微手术治疗,采用德国产Laika显微镜下切除肿瘤,较大肿瘤不能完整切除时,用分块切除或囊内切除,术后常规颈托限制颈部活动,55例术后随访6个月～2年.结果 痊愈54例,症状改善5例,无死亡.55例随访6个月～2年,4例失访.35例术后3～12个月MR检查未见肿瘤残存或复发,42例术后6个月颈椎正侧位及张口位片检查未见脊柱骨性结构变形,脊柱稳定性好.结论 高位颈段神经鞘瘤一旦确诊,就应该及早显微手术治疗.手术安全、效果良好.

Abstract：

Objective To explore surgical techniques and curative effects of microsurgical treatment for neurilemmoma in upper cervical spinal canal. Methods From Jan. 2004 to Nov. 2007, 59 cases of schwannoma was resected through microoperation, the operation was conducted through a posteromedial approach, using German Laika microscope resection of the tumor, large tumors cannot complete resection,block or sac, resection postoperative neck activity conventional neck restrictions, with following observation of 6 months-2 years. Results A complete recovery was achieved in 54 cases, an improvement of symptoms was achieved in 5 cases, no death was encountered. Follow-up observations were carried out in 55 cases from 3 months-2 years (6.5 ± 1.5 months). MRI examinations 3-12 months after operation in 35 cases found no residual or recurrent tumor. X-ray radiography under anteroposterior, lateral, and open-mouth view 6 months after operation in 42 cases showed no spinal deformation and good vertebral stability. Conclusions As long as neurilemmoma in upper cervical spinal canal are diagnosed, a microsurgical treatment should be given as early as possible. Appropriate selection of surgical approach, skillful microsurgical techniques in accordance with pathological types of lesions, and principles of minimal invasion are critical for the operation safety.     

侧脑室内肿瘤的显微外科治疗

目的 探讨侧脑室内肿瘤的临床特点及显微手术方式,旨在提高对该疾病的认识及手术疗效.方法 65例侧脑室内肿瘤,男39例,女26例,首发症状主要是头痛、呕吐(48例);分别经皮层-脑室前入路(34例)、皮层-脑室后入路(20例)和胼胝体前部入路(11例)采用显微外科技术切除;回顾分析其临床特点、手术方式、病理诊断及术后并发症.结果 手术全切54例,大部分切除11例.术后病理诊断以室管膜瘤及星形细胞瘤最常见.术后并发症:术后发热26例;术后脑积水9例;脑室内积血或血肿形成7例,其中2例因出现意识障碍后行开颅血肿清除术;术后癫痫7例;术后出现意识障碍4例,均治疗后好转;伤口感染3例.手术死亡3例,其中2例系继发术后癫痫出现呼吸衰竭死亡.结论 早期发现侧脑室内肿瘤、周密的手术方案和精细的显微操作以及正确的术后处理是提高显微手术治疗侧脑室内肿瘤全切率、减少术后并发症和死亡率的关键.     

颈段椎管内肿瘤的显微手术治疗

目的 报道颈段椎管内肿瘤显微手术的临床疗效. 方法 颈段椎管内肿瘤32例,均采用后正中入路显微手术,术后22例进行颈椎稳定性重建.结果 肿瘤全切26例,占81.25%,肿瘤大部分切除6例(包括3例星形细胞瘤,3例包裹并紧密粘连椎动脉的哑铃形神经鞘瘤),占18.75%.按George的方法 评估,恢复良好23例(71.88%),症状改善6例(18.75%),无明显改善3例(9.38%),无手术死亡.30例随访3个月～3年.26例术后3个月MR检查未见肿瘤残存或复发,1例神经鞘瘤维持术后大小未增大,3例星形细胞瘤复发.术后X线检查其中4例出现颈椎不稳,26例稳定性良好. 结论 早期显微手术是颈段椎管内肿瘤的关键治疗手段,术后重建椎管的稳定性对患者的远期恢复意义重大.     

Surgical treatment for choroid plexus tumors in the fourth ventricle: brain stem infiltration hinders total extirpation

The significance of surgery for choroid plexus tumors is well established, but surgical resection of those in the fourth ventricle has not been evaluated. This study reviewed five consecutive patients with choroid plexus tumors in the fourth ventricle treated in our institute between 1996 and 2005, focusing on the factors that hindered total extirpation. Two cases were choroid plexus papillomas, and three cases were choroid plexus carcinomas. Preoperative T2-weighted magnetic resonance imaging showed a diffuse high-intensity lesion in the brain stem in four patients. Infiltration into the fourth ventricle floor was apparent in all five patients during surgery, which hindered total resection of the tumors without neurological deterioration. Intraoperative bleeding was well controlled in all five patients by cauterizing the feeding arteries at the early stage of surgery through the telovelar approach. Performance status was improved in all patients postoperatively. All patients with choroid plexus carcinomas underwent radiation therapy after the surgical removal. No patient suffered tumor progression within the follow-up of 24–129 months (mean 64 months). Total resection of choroid plexus tumors in the fourth ventricle is difficult because of invasion into the fourth ventricle floor. Adjuvant therapy for choroid plexus tumors with brain stem infiltration must be established.     

显微手术切除及椎管固定融合治疗高颈段椎管哑铃型肿瘤

目的探讨显微手术切除高颈段椎管哑铃型肿瘤及椎管固定融合的方法及效果。方法回顾性分析11例高颈段椎管哑铃型肿瘤患者的临床资料,其中ToyamaⅡ型6例,Ⅲ型4例,Ⅴ型1例。均行显微手术切除,其中远外侧入路3例,颈后正中入路8例。同时行椎管固定融合6例。结果本组全切10例,次全切除1例。术后病理学诊断为神经纤维瘤9例,脊膜瘤2例。术后症状明显改善9例,改善2例,无感染及死亡病例。随访10例,平均时间27个月（3个月～3年）,患者的症状和神经功能均有不同程度的改善,无颈椎不稳及后凸畸形。结论高颈段椎管哑铃型肿瘤显微手术切除并椎管固定融合能明显改善症状,安全性好,并发症少。     

Surgical approach to the fourth ventricle cavity through the cerebellomedullary fissure

Lesions of the fourth ventricle represent a challenge to neurosurgeons because of severe deficits that occur following injury to the delicate structures in the ventricle wall and floor. The conventional approach to the fourth ventricle is by splitting the vermis on the suboccipital surface of the cerebellum. In the last 9 years, a series of 21 patients in our clinic underwent microsurgical tumor resection by the unilateral transcerebellomedullary fissure approach. The patients had various pathologies including hemangioblastoma, epidermoid tumor, medulloblastoma, ependymoma, low grade astrocytoma, choroid plexus carcinoma, choroid plexus papilloma, adenocarcinoma in the pons, and cavernoma in the medulla. Total removal was achieved in all but three cases. One death occurred 2 months after surgery due to pulmonary complication. In the follow-up period of 2 months to 5 years, the preoperative symptoms disappeared in all cases except one with a brainstem lesion. By a unilateral transcerebellomedullary fissure approach, it is possible to provide sufficient operative space from aqueduct to obex without splitting the vermis. This approach needs meticulous dissection of the fissure and preservation of the posterior inferior cerebellar artery and its branches.     

侧脑室脑膜瘤的显微外科治疗

目的 研究侧脑室脑膜瘤临床特点及显微外科手术治疗的效果。方法 利用CT、MRI及脑血管造影明确肿瘤的诊断,16例脑室脑膜瘤的采用显微外科手术摘除。结果 本组病例肿瘤全部切除,无手术死亡。结论 CT、MRI是诊断侧 脑室脑膜瘤最可靠的方法,血管造影明确肿瘤的 供血情况,选择合理的手术入路应用显微外科手术可达到肿瘤的全切除。