幕下-小脑上入路切除松果体瘤的并发症

目的探讨经幕下-小脑上入路(Krause's approach)切除松果体瘤的有关并发症.方法总结2个医院近10年来采用经幕下-小脑上入路切除松果体肿瘤病例共24例,归纳其术后出现的并发症.结果与手术有关的主要并发症有:颅内积气5例,硬膜下积液3例,Parinaud综合征3例,大脑后动脉损伤1例,术后脑膜脑室炎3例.结论幕下-小脑上入路手术的并发症较多,手术过程中对大脑各重要结构的保护是预防并发症的关键.     

直窦解剖变异对松果体区幕下小脑上入路手术的影响

目的评估直窦解剖变异对幕下小脑上入路治疗松果体区病变手术的影响。方法选取200例检查结果为阴性的头颅MRI影像学资料,在正中矢状面T1WI上对直窦的长度、倾斜度、与胼胝体压部的关系进行测量和分析。结果直窦平均长(51±5.3)mm;直窦与硬腭水平的夹角为49.6°±7.2°;与胼胝体压部的位置关系可分为低角度型(24.5%),常见型(69.5%),高角度型(6.0%)。结论直窦的解剖变异较大。术前应用MRI了解直窦的倾斜度,明确手术路径与松果体区病变的空间位置关系,对手术具有重要的指导意义。     

枕下经小脑幕入路松果体区肿瘤切除术后脑积水的处理

目的 总结枕下经小脑幕入路松果体区肿瘤切除术后产生脑积水的原因及处理经验.方法 对11例术后脑积水病人的临床资料进行总结分析.8例脑积水出现在术后2周以内,定为早期脑积水,其中7例进行脑室外引流,引流时间5～8 d;3例脑积水出现在术后2周以上的放疗期间,定为迟发性脑积水,均行脑室镜下第三脑室底造瘘术.结果 松果体区肿瘤术后脑积水病人占同期松果体区肿瘤手术的16.2%.7例经脑室外引流治疗的早期脑积水病人恢复良好,拔除外引流管后无需内引流;1例未行脑室外引流者死亡.3例迟发性脑积水病人症状均缓解,继续放疗,完成计划的照射剂量.结论 松果体区肿瘤术后脑积水是常见并发症.早期脑积水的主要原因系静脉损伤性脑肿胀,多为暂时性;迟发性脑积水系局部黏连所致,需手术治疗.     

神经内镜经幕下小脑上治疗松果体区肿瘤15例

目的 总结神经内镜经幕下小脑上手术入路治疗松果体区肿瘤的相关经验。方法 分析解放军第960医院2017年1月—2020年12月收治的15例患者,均由神经内镜经幕下小脑上治疗松果体区肿瘤。结果 通过神经内镜抵近、多方向观察,精细操作,15例的肿瘤均手术全切,其中6例术中快速病理显示生殖细胞瘤,术中在神经内镜下全切肿瘤,后期转肿瘤科继续治疗。其中13例术前合并不同程度脑积水,术后均缓解,后期均未行脑室腹腔分流术。15例术后半年随访,预后均良好。结论 松果体区肿瘤在神经内镜下经幕下小脑上手术入路,经自然通道,能避免不必要损伤,通过内镜手术治疗既能解决脑积水问题,又能安全有效切除肿瘤,减少手术并发症发生。     

Own experience in surgical treatment of the pineal region and midbrain tumors via the infratentorial approach

Nine cases of tumours located in the pineal and midbrain region in adults operated on between November 1998 and July 2002 in Dept. of Neurosurgery, Central Military Hospital in Warsaw are reported. The patients (2 men and 7 women) were aged from 27 and 69 years (mean age 43.6 years). Their main initial symptoms were caused by hydrocephalus. The histopathological examination revealed anaplastic pinealoma in 2 cases, and pineocytoma, pineal cyst, mesencephalic glial cyst, protoplasmatic astrocytoma, epidermoid cyst, unclear glial scar, and papillary ependymoma in single cases. Five patients had been treated, usually elsewhere, with shunt implantation prior to the surgery. Occipito-suboccipital osteoplastic craniotomy was performed in each case and tumours were totally removed microsurgically via the infratentorial epicerebellar approach. In one case a part of the glial periaqueductal tumour was resected additionally via the fourth ventricle and aqueduct in one stage. Postoperative haematomas in the third and fourth ventricle were found in 2 cases. Main complaints after the surgery included transient diplopia. All the patients improved significantly and resumed their previous life activities. Follow-up ranged from 3 to 44 months. Three patients with pineal tumours and one with a small postoperative ependymoma recurrence were irradiated after the surgery. One patient had been irradiated prior to surgery. Very good results of the surgical treatment of tumours in this area suggest that such patients should be referred earlier to one stage surgical management, as the procedure is easier to perform and shunt implantation may be avoided.     

极外侧小脑上天幕下入路的显微解剖研究

目的探讨极外侧小脑上天幕下入路的手术方法及该入路可暴露的解剖范围。方法对10具动静脉灌注的头颅湿标本于导航辅助下模拟极外侧小脑上天幕下入路显微手术,观测手术全程及术野暴露范围。结果极外侧小脑上天幕下入路可以充分暴露天幕切迹侧方区域、环池、中脑背外侧、滑车神经及伴行的小脑上动脉、大脑后动脉（P2、P3段）、脉络膜后内侧动脉及后方的四叠体池外侧方,切开天幕可以显露海马旁回后部;轮廓化乙状窦和横窦有利于对脑干外侧及对应天幕切迹侧后区域的暴露。结论极外侧小脑上天幕下入路适合于脑干背外侧及与之相对应的天幕切迹区域病变手术。     

Surgical treatment of pineal and tectal tumors from the subtentorial and supracerebellar approach

The results of operative treatment of pineal and tectal tumours by infratentorial, supracerebellar approach were presented. There were 15 patients with pineal and 2 with tectal tumours. Clinical symptoms of the disease were as follows: signs of intracranial hypertension, tectal lesion, impairment of gait and hypoacusis. Diagnostic procedure included CT, MRI, and panangiography investigation. Application of infratentorial, supracerebellar approach enabled total resection of tumours in 14 patients (82.3%) and subtotal in 2 patients (11.8%) In 1 patient we managed to do only diagnostic biopsy (5.9%). This approach makes possible removal of pineal and tectal tumours growing in the midline toward the anterior part of III ventricle and also posterior fossa. The advantage of this approach is fact that the operation takes place below the vein of Galen. Drooping by gravity cerebellum creates enough places for microsurgical operation. During control investigation 13 patients (76%) had no announce any complaints and were without neurological disorders.     

A young and booming approach: the extreme lateral supracerebellar infratentorial approach

Surgical accesses to lesions of the posterolateral pontomesencephalic junction (PMJ) region and the posterolateral tentorial gap remain a challenge in the field of neurosurgery. Since the first report of application of the extreme lateral supracerebellar infratentorial (ELSI) approach in resecting the PMJ lesions in 2000, a few articles concerning the ELSI approach have been published. The present review mainly provided an intimate introduction of the ELSI approach, and evaluated it in facets of patient position, skin incision, craniectomy, draining veins, retraction against the cerebellum, exposure limits, patient healing, as well as advantages and limitations compared with other approaches. The ELSI approach is proposed to be a very young and promising approach to access the lesions of posterolateral PMJ region and the posterolateral tentorial gap. Besides, it has several advantages such as having a shorter surgical pathway, causing less surgical complications, laborsaving, etc. Still, more studies are needed to improve this approach.     

枕部经小脑幕入路切除松果体区肿瘤

作者采用枕部经小脑幕入路对24例松果体区肿瘤进行了手术切除,其中全切除11例;次全切除9例;部分切除4例.24例中.21例症状改善,2例恶化,1例死亡.作者认为,此入路的优点有:①深静脉系统保持在直视下,不易损伤;②供应肿瘤的动脉分支可以早期得以控制;③视野开阔,尤其适用于肿瘤较大.向侧方和(或)脑室内生长者;④可同时进行侧脑率-脑池的分流手术.根据我们的经验.术前伴有脑积水的松果体区肿瘤不论肿瘤是良性还是恶性.也不管肿瘤是否全切除,中脑导水管在术后短期内似乎都不能再通.因此我们认为,对这些病人在切除(即使是全切除)肿瘤后都应同期或分期作分流手术.     

Lateral-paramedian infratentorial approach in lateral decubitus for pineal tumours

All classical operative approaches for pineal tumours have important disadvantages. A lateral-paramedian infratentorial approach in lateral decubitus is proposed. It has the advantage that one can reach the pineal region by way of a shorter distance and over a lower situated part of the upper cerebellar surface. Lifting of the transverse sinus becomes unnecessary. The venous vessels can be saved and there is no risk for air embolism or pneumocephalus.     

一种改良的天幕下小脑上手术入路

目的介绍一种改进的天幕下小脑上入路的术式。方法改良的部分包括病人的体位和骨皮瓣的切口。结果采用此入路进行16例松果体区的肿瘤手术,其中松果体胶质瘤2例,胆脂瘤3例,小脑山坡血管母细胞瘤2例,生殖细胞瘤3例,皮样囊肿2例,小脑幕顶脑膜瘤1例,畸胎瘤1例,Galen静脉性动脉瘤1例,蛛网膜囊肿1例。手术进行顺利。结论与其他经典术式相比,此改良术式具有体位摆放简单,操作轻松,关颅时可做到解剖学复位等优点。     

Poppen入路切除松果体区肿瘤手术间隙的临床研究

目的讨论改良Poppen入路切除松果体区肿瘤时手术间隙的应用。方法16例松果体区肿瘤均采用改良Poppen入路显微手术，观察分析16例肿瘤的松果体区的深静脉引流及各静脉间隙，特别是基底静脉的发育情况，统计各静脉间隙的使用情况。结果术中联合第3、4间隙切除肿瘤最多采用，15例达到镜下全切除。结论松果体区肿瘤采用改良Poppen入路切除优点较多。     

改良Poppen入路及神经导航辅助下切除松果体区肿瘤

目的探讨利用改良的Poppen入路及神经导航引导下切除松果体区肿瘤的实用性和临床疗效。方法回顾性分析2003年2月～2008年10月15例松果体区肿瘤临床资料。全部病人均在神经导航辅助下经改良的Poppen入路行肿瘤切除,手术策略是最大限度切除肿瘤,解除脑脊液循环梗阻,保护好肿瘤周围重要结构。结果肿瘤全切13例,次全切除2例。1例术后出现交通性脑积水,行脑室-腹腔分流术好转。病理结果：胶质瘤7例、脑膜瘤4例、生殖细胞瘤2例、畸胎瘤2例。术后随访3个月～2年,13例恢复良好,2例遗留部分视力、视野损害。结论改良Poppen入路的优点是路径短,减少对枕叶的牵拉,切开小脑幕后大多可获得较好的肿瘤显露,以最大程度切除肿瘤。神经导航能够引导术者行枕角穿刺和进入手术区,减少副损伤,同时对判定肿瘤切除程度具有较大帮助。     

正中幕下小脑上入路的解剖研究及其临床意义

目的研究正中幕下小脑上入路的解剖,为临床手术提供形态学依据。方法用硅胶对30具尸头标本进行灌注,模拟正中幕下小脑上入路手术,观察其暴露范围及暴露内容;然后将脑组织从颅腔内游离出来,并测量该入路的相关数据。结果正中幕下小脑上入路的暴露范围以松果体为中心,上至大脑大静脉和横窦,下至下丘水平,两侧以小脑幕缘为边界;可充分显露大脑大静脉复合体及其属支、大脑后动脉P3段主干、脉络膜后内侧动脉、松果体、四叠体板和海马旁回后部等结构。结论正中幕下小脑上入路适合松果体区、第三脑室后部以及小脑蚓部等区域病变手术。     

Far lateral supracerebellar infratentorial approach for the treatment of upper brainstem gliomas: clinical experience with pediatric patients

Objective Surgical exposure of intrinsic lesions located lateral to the brainstem still represents a challenging task. The aim of this study was to assess the feasibility of the extracerebral far lateral supracerebellar infratentorial (FLSI) approach for the treatment of gliomas located in the upper brainstem in the pediatric population.Methods and results Between 1992 and 2002, seven patients (mean age 8.7 years) with tumors of glial origin (WHO I–IV) located mainly in the pontomesencephalic region were operated with the FLSI approach in a sitting position. Satisfactory extent of resection without additional morbidity was achieved.Conclusion In a carefully selected pediatric patient population, the FLSI approach proved to be a feasible and effective surgical route for the treatment of upper brainstem gliomas.     

经额胼胝体-穹隆间入路切除儿童松果体区肿瘤

目的 研究和探索切除儿童松果体区肿瘤的手术入路。方法 经额胼胝体-穹隆间入路切除儿童松果体区肿瘤45例。结果 肿瘤全切除34例，近全切除8例，大部切除3例，无手术昏迷死亡。结论 经额胼胝体-穹隆间入路是切除松果体区肿瘤的最佳入路之一，直视下操作，按生理间隙进入，肿瘤全切率高，术后合并症少。     

松果体区肿瘤的手术治疗

目的:旨在进一步提高松果体区肿瘤的手术疗效。方法与结果:回顾性研究23例松果体区肿瘤的治疗情况,本组2例根据影像学特征考虑为生殖细胞瘤,给予脑室-腹腔分流术-放射治疗,结果肿瘤消失,余21例均经枕切开天幕入路显微手术治疗。其小4例同时行脑脊液(CSF)分流术,无手术死亡。术后计算机体层摄影(CT)复查证实肿瘤全切除5例,次全切除9例,大部或部分切除7例。结论:松果体区肿瘤手术难度及危险性大,手术前应参照CT或磁共振成像(MRI)等影像资料。针对肿瘤的具体部位及毗邻等情况,选用适当的治疗方法和合理的手术入路,强调经枕切开天幕入路的优越性、指出显微技术、麻醉方法的改进以及必要的放射治疗可以提高此病的治疗效果。     

应用改良Poppen入路切除儿童松果体区肿瘤的手术体会

目的 探讨直切口小骨窗斜行切开小脑幕技术切除儿童松果体区肿瘤的效果.方法 总结2008年1月至2011年10月环湖医院收治9例应用改进Poppen入路手术的松果体区肿瘤患儿.统计肿瘤全切除率、并发症发牛率和开关颅时间.结果 肿瘤显微镜下全切除率为77.8％,桥静脉损伤率为11.1％,一过性同向性偏盲发生率为22.2％,开关颅时间平均(25.4±4.4) min.全切除病例脑积水缓解率100％,1例取活检后行第三脑室底造瘘术,无脑室-腹腔分流病例,无手术死亡病例.结论 改进Poppen入路为松果体区肿瘤切除手术提供了充足的视野和操作空间,使手术安全性更高,并发症发生率更低.     

伽玛刀治疗松果体区肿瘤

目的 探索伽玛刀治疗松果体区肿瘤的具体方法，进一步提高其疗效。方法 使用伽玛刀治疗松果体区肿瘤42例，肿瘤边缘剂量10-15Gy，平均14.1Gy，中心剂量24-37.5Gy，平均30.2Gy。随访4个月-3年。结果 肿瘤消失19例，明显缩小13例，缩小7例，肿瘤不变3例，均无特殊并发症。结论 伽玛刀是治疗松果体区肿瘤的一种安全有效的方法，对有明显梗阻性脑积水，可先行脑脊液分流术再行伽玛刀治疗。     

经胼胝体-穹窿间切除第三脑室松果体区肿瘤

目的 探讨经胼胝体-透明隔-穹窿间入路显微手术切除第三脑室松果体区肿瘤的方法及疗效,并对相应的显微解剖学基础加以讨论.方法 经胼胝体-透明隔-穹窿间入路显微手术切除第三脑室松果体区肿瘤16例.结果 术前1例先行脑室-腹腔分流术、1例行神经内镜第三脑室底终板造瘘术.16例在手术显微镜下肿瘤全切除9例,次全切除4例,大部切除3例.5例在处理完肿瘤后做终板造瘘术.结论 经胼胝体-透明隔-穹窿间入路手术切除第三脑室松果体区肿瘤系通过胚胎组织残留的透明隔间隙进入第三脑室,损伤少,肿瘤全切除、次全切除率高,术后并发症少.