内镜辅助眶上锁孔入路切除鞍上区肿瘤

目的 探讨内镜辅助眶上锁孔入路切除鞍上区肿瘤的显微手术技术,以最大限度地切除肿瘤,减少手术创伤。方法 16例鞍上区肿瘤患者依据手术前影像学检查结果,制订个体化手术方案,采用眉部皮肤切口,在眶上行直径2cm左右开颅,应用内镜辅助的显微手术技术切除病变。结果 16例患者经眶上锁孔入路技术获肿瘤全部切除,无手术并发症发生。结论 眶上锁孔入路可明显减少手术创伤、提供鞍上区足够的手术空间,有利于肿瘤的全切除。     

神经内镜辅助眶上锁孔入路治疗巨大嗅沟脑膜瘤

目的探讨神经内镜辅助眶上锁孔入路治疗巨大嗅沟脑膜瘤的手术效果及手术技巧。方法采用内镜辅助、眶上锁孔入路（显微手术）治疗12例巨大（≥7cm）嗅沟脑膜瘤。结果肿瘤全切除9例（SimpsonⅠ级切除5例，Ⅱ级切除4例），次全切除（SimpsonⅢ级切除）3例。无手术死亡。10例随访3个月～2年，平均14个月。9例恢复正常生活，1例生活能自理。NRI随访9例，肿瘤无复发。结论利用神经内镜辅助及显微外科技术，采用眶上锁孔入路、对肿瘤进行分块切除治疗巨大嗅沟脑膜瘤，手术创伤小，疗效满意。     

鞍结节脑膜瘤的手术入路选择及显微手术切除

目的 报道鞍结节脑膜瘤手术治疗的入路选择及显微手术的临床效果。方法回顾分析鞍结节脑膜瘤29例的临床资料，29例鞍结节脑膜瘤分别经额下、翼点或额下翼点联合入路，采用显微手术方法切除肿瘤。结果29例均采用显微手术治疗，全切除27例，大部分切除2例，无死亡。28例术后视力得到满意的恢复。结论选择正确的手术入路和采用显微手术治疗鞍结节脑膜瘤，可明显提高临床疗效。     

翼点入路切除鞍结节脑膜瘤

鞍结节脑膜瘤多指起源于鞍结节的脑膜瘤,也包括起源于前床突、视交叉沟及鞍隔等部位的脑膜瘤,约占颅内脑膜瘤的5％～10％［1］。因肿瘤位于颅底中线部,位置深在,与视神经、视交叉、下丘脑、颈内动脉及海绵窦等重要结构毗邻,完全切除肿瘤及神经功能保护难度大［2］。2010年1月～2014年6月,我院采用翼点入路和显微神经外科技术切除鞍结节脑膜瘤46例,疗效满意,现报告如下。     

翼点入路显微手术切除巨大型鞍结节脑膜瘤

目的总结经翼点入路显微手术切除巨大鞍结节脑膜瘤的经验. 方法 2000年2月～2004年11月我院应用显微外科技术,治疗巨大鞍结节脑膜瘤18例.偏侧生长的肿瘤选择翼点入路,先处理肿瘤基底减少血供,再充分利用鞍区脑池及肿瘤与周围结构之间的蛛网膜界面,在保护好重要结构的前提下最大限度地切除肿瘤. 结果全切除16例(88.9%),次全切除2例(11.1%),无一例手术死亡.14例随访3个月～4年,平均2.5年,肿瘤无复发. 结论翼点入路可对中颅窝、鞍区病变进行良好暴露,提高巨大型鞍结节脑膜瘤全切除率.     

眶上锁孔入路内窥镜辅助切除鞍上蔓延性垂体瘤及锁孔修复

目的 探索眶上入路、内窥镜辅助微创手术治疗鞍上蔓延性垂体瘤及锁孔修复的方法与技巧。方法 2001年2月～2003年3月，对9例鞍上蔓延性垂体瘤患者行眶上锁孔入路、显微镜下切除直视肿瘤部分，再辅用神经内窥镜经1、2间隙切除残余肿瘤。小骨瓣复位后用一枚钛钉固定。结果 常规显微镜下切除肿瘤后，经神经内窥镜探查时发现7例仍有不同程度的残瘤，辅用内镜进一步切除，6例全切除，3例次全切除。术后1周7例视力改善，2例无变化，无手术致残及死亡。6例随访6～22个月，半年后生活完全自理，恢复正常工作，视力提高0．3～0．5，3例激素恢复正常。6例复查MRI显示鞍区结构恢复良好，无肿瘤复发。骨窗修复稳固，且无切口并发症。结论 眶上锁孔人路可提供足够的颅内外操作空间；内窥镜辅助微创术提高了肿瘤的全切率及成功率，且有利于神经功能保护和减少并发症。用钛钉固定小骨瓣安全可靠，骨窗修复良好。     

眶上微骨窗入路显微手术切除鞍上脑膜瘤

目的 介绍经眶上微骨窗入路切除鞍上脑膜瘤的显微外科技术和经验.方法 经眉内小切口5例,经翼点入路16例,采用眶上约3.5 cm×2.5 cm小骨窗开颅,显微外科技术切除鞍上脑膜瘤21例,肿瘤最大径2.8～6.2 cm,回顾分析其临床资料.结果 所有肿瘤显露良好,Simpson Ⅰ级切除5例,Simpson Ⅱ级切除15例,Simpson Ⅲ级切除1例.无手术死亡及严重并发症,术前视力障碍患者术后均有不同程度改善.术后随访6个月至5年,平均3.8年,影像学上肿瘤残留1例.结论 眶上微骨窗入路可替代传统额下或翼点入路切除鞍上脑膜瘤并具有手术创伤小、术后恢复快等优点.     

鞍结节脑膜瘤的手术治疗

鞍结节脑膜瘤是少见的良性肿瘤，全切除可获治愈，但周边毗邻解剖结构复杂，手术空间狭小，手术难度大。因此选择合适的手术入路将肿瘤全切除至关重要。     

翼点入路治疗鞍区脑膜瘤

目的 探讨显微手术治疗鞍区脑膜瘤的方法。方法 回顾性分析了23例鞍区脑膜瘤的临床表现、诊断和显微外科治疗结果，采用经翼点入路显微外科治疗。结果 全切17例，大部切除6例。随访1个月～6年，平均19.1个月，22例恢复良好，随访期间3例复发。结论 选择合适的手术入路，应用显微外科技术，是鞍区脑膜瘤全切并取得良好效果的关键。     

鞍结节脑膜瘤的显微外科手术治疗

目的探讨和评价鞍结节脑膜瘤的临床和影像学特点,以及显微外科技术和手术效果.方法回顾性分析本院1985年至2002年手术治疗的鞍结节脑膜瘤41例,分析其临床和影像学表现的特点.根据CT和MR的表现,将其分为大、中、小3型,采用4种不同的手术入路,比较全切除率、手术结果和并发症发生情况.结果鞍结节脑膜瘤的临床特点是早期出现单侧和双侧视力下降,视野改变不典型.MRI特点为明亮均一的增强,肿瘤中心在鞍上,伴基底硬膜尾征,蝶鞍不扩大.肿瘤的全切除率与肿瘤大小有关,中、小型肿瘤全切除率较高.眶上匙孔入路、翼点入路和眶颧入路显露满意和手术效果好,明显优于单侧额下入路.结论鞍结节脑膜瘤早期出现视力下降,以中、小型肿瘤为主.大多数鞍结节脑膜瘤可以完全及安全地切除,小、中型肿瘤宜采用眶上匙孔入路,中、大型肿瘤宜采用翼点侧裂入路,大型肿瘤宜采用眶颧入路切除肿瘤.     

Transcranial Transsphenoidal Approach for Tuberculum Sellae Meningiomas

Summary  Objective. A series of 21 patients with tuberculum sellae meningioma who received surgical treatment is reported.  Patients and Methods. All 9 females and 12 males (mean age 49 years) presented visual disturbances of varying degrees in either one or both eyes. Eighteen of the tumours were less than 3 cm in size, and 3 were larger. Tumour resection of uniform surgical technique was performed in all cases. Following a bicoronal scalp incision, bifrontal craniotomy combined with removal of the orbital rim bilaterally was performed. The frontal dura was opened bilaterally, and the most anterior portion of the superior sagittal sinus was transected. Bifrontal retraction and arachnoid dissection along the proximal olfactory tracts brought the tumour into view. Additional dissection of the interhemispheric fissure extended the operative field to the anterior communicating artery. The anterior skull base was drilled out to resect the basal part of the tumour. In all cases, the optic canal and sphenoid sinus, and additionally in some cases the ethmoid sinus were opened. The tumour uniformly extended inferomedially to the optic nerve, and direct visualization of this portion of the tumour was possible with our approach. The opened paranasal sinuses were reconstructed with adipose tissue harvested from the patient's abdomen and the pericranial flap.  Results. In all patients, total or almost total resection of the tumour was accomplished. Postoperatively, visual function was improved in 11 patients, was unchanged in 8, and worsened in 2. There were no operative deaths. Cerebrospinal fluid leakage was occurred in two patients but could be conservatively managed. In a mean 3-year follow-up, tumour recurrence was observed in only one patient who presented a malignant histology.  Conclusions. We are confident that our surgical approach has great clinical value in surgical resection of tuberculum sellae meningioma. The good accessibility to a tumour extending inferomedially to the optic nerve should, in particular, be stressed.     

Endoscopic Resection of Tuberculum Sellae Meningiomas

Objective To evaluate the results of endoscopic transnasal resection of tuberculum sellae meningiomas (TSMs) as compared with transcranial approaches.Design We retrospectively analyzed five patients who underwent endoscopic endonasal resection of TSM and performed a comprehensive review of articles published between 2000 and 2012 describing the operative treatment of TSMs.Results Gross total resection (GTR) was achieved in four patients (80%). Transient diabetes insipidus occurred in three patients (60%). Preoperative visual field deficit resolved in all patients. Cerebrospinal fluid (CSF) leak occurred in one patient. Analysis of published studies included 1,026 transcranial and 144 transnasal cases. GTR was achieved in 85% of transcranial and 72% of transnasal cases. Visual field deficit improved in 65% of transcranial and 82% of transnasal cases. Rate of diabetes insipidus and CSF leak was higher in the transnasal series. Rate of GTR and visual improvement was higher in endoscopic endonasal as compared with microsurgical transnasal series.Conclusion The literature supports transsphenoidal surgery for the resection of TSMs with significant optic nerve compromise and limited lateral extension. This approach may have an equivalent if not superior outcome over transcranial surgery in visual outcome. CSF leaks are still a challenge but may improve with the use of vascularized nasoseptal flaps.     

Meningiomas of the Tuberculum and Diaphragma Sellae

Introduction Although tuberculum sellae (TS) and diaphragma sellae (DS) meningiomas have different anatomical origins, they are frequently discussed as a single entity. Here we review the radiologic and intraoperative findings of TS and DS meningiomas and propose a radiologic classification.Methods We retrospectively reviewed 10 consecutive TS and DS meningiomas. Data regarding clinical presentation, preoperative imaging, and intraoperative findings were analyzed. Three sellar dimensions were measured on magnetic resonance imaging (MRI): the tuberculum-sellar floor interval (TSFI), the planum-tuberculum interval (PTI), and the total height.Results Three distinct anatomical patterns were recognized: exclusively tubercular meningiomas (type A) were accompanied by elongation of the TSFI and, more significantly, of the PTI; combined TS and DS meningiomas (type B) were associated with relative elongation of both the PTI and TSFI; and the sole exclusively DS meningioma (type C) was associated with elongation of neither PTI nor TSFI.Conclusion Suprasellar meningiomas can be classified as tubercular, combined, or diaphragmatic based on preoperative MRI. Exclusively tubercular meningiomas (type A) require only a supradiaphragmatic approach. Tumor involvement of the sellar diaphragm (type B or C) requires resection of the diaphragm and thus a combined infra- and supradiaphragmatic approach.     

Tuberculum Sellae Meningiomas: Surgical Technique,Visual Outcome,and Prognostic Factors in 51 Cases

Complete tumor resection with preservation or improvement of visual function is the goal of tuberculum sellae meningioma (TSM) treatment. The authors retrospectively reviewed 51 patients treated surgically for TSM between 2003 and 2010, with special attention to surgical technique, visual outcomes, and prognostic factors for treatment outcome.All patients were operated via the lateral subfrontal approach. The cohort mean age and Karnofsky performance status (KPS) on admission was 57.1 ± 13.6 and 84.3 ± 11.7, respectively. The most common presenting sign was visual impairment. The mean tumor size was 29.4 ± 10.7 mm. In 45 of the patients (88.2%), gross total resection was achieved. Improvement and/or preservation of visual acuity and visual field were achieved in 95.9% and 85.3%, respectively. Visual functions on admission were found to be the strongest predictors for postoperative improvement in visual outcome, followed by better KPS on admission, smaller tumor size, and young age. Postoperative neurological complications included cerebrospinal fluid (CSF) leak, meningitis, and postoperative seizures.TSM can be safely operated on through the lateral subfrontal approach. A high percentage of complete tumor resection and excellent visual outcomes are achieved using this technique. Surgical treatment in the early stage of the disease may result in a better visual outcome.     

神经内镜辅助锁孔手术治疗颅内动脉瘤

目的 探讨神经内镜辅助下的锁孔手术治疗颅内动脉瘤的手术效果。方法 对14例颅内动脉瘤行动脉瘤夹闭术。经眉弓或翼点锁孔开颅，手术显微镜下初步暴露动脉瘤，置入神经内镜，观察动脉瘤颈及其周围结构的局部解剖，动脉瘤夹夹闭，再次置入神经内镜了解夹闭情况。结果 14例患者均无手术并发症，未出现新的神经系统症状与体征，全部恢复良好出院。结论 应用神经内镜辅助下的锁孔手术治疗颅内动脉瘤，可充分暴露动脉瘤及周围结构的局部解剖结构，手术创伤小，手术时间缩短，手术效果明显提高。     

Transsphenoidal-Transtuberculum Sellae Approach for Supradiaphragmatic Tumours: Technical Note

Summary  The Classic transsphenoidal approach may not afford sufficient exposure for a supradiaphragmatic tumour adjacent to the pituitary stalk. Various transcranial approaches have been utilized to access such a lesion with adequate results. This report describes a less invasive technique, termed “transsphenoidal-transtuberculum sellae approach”. This modified transsphenoidal approach requires a bone ablation of the tuberculum sellae, the limbus sphenoidalis, and a portion of the planum sphenoidale, in addition to an opening of the anterior floor of the sella turcica. The dura mater on the tuberculum sellae and the pituitary fossa is sectioned with a bilateral obliteration of the anterior intercavernous sinus. The anterior pituitary gland is not necessarily resected. The optic chiasm, optic nerves, pituitary stalk, and tuber cinereum can be directly observed, making it possible to safely dissect a lesion from these structures. Utilizing this approach, we have removed 14 supradiaphragmatic tumours without complications and dealt with other lesions such as optic nerve injuries or cerebrospinal fluid rhinorrhea, leaving pituitary function intact. The transsphenoidal-transtuberculum sellae approach for accessing small supradiaphragmatic tumours is a useful procedure requiring only a minor modification of the classic transsphenoidal technique.     

超早期小翼点切口锁孔经侧裂-岛叶入路显微手术治疗高血压基底节区脑出血的临床研究

目的探讨高血压脑出血新的手术方法及疗效。方法对12例高血压基底节区脑出血病人在超早期内（≤6h）采用小翼点切口锁孔经侧裂-岛叶入路显微手术治疗。结果手术12例中死亡1例，存活11例。术后因二次出血再手术1例，颅内感染1例。术后随访3～6个月，依据GOS评分，优7例，良3例，中1例。结论超早期小翼点切口锁孔经侧裂-岛叶入路显微手术治疗高血压基底节区脑出血，手术疗效好，为治疗高血压脑出血开辟新的途径。     

Current Status of Endoscopic Endonasal Surgery for Skull Base Meningiomas: Review of the Literature

Endoscopic endonasal approach (EEA) is expected to be ideal for the paramedian ventral skull base meningiomas, allowing wide access to the ventral skull base regions and realizing early devascularization of the tumor without retraction of the brain. We searched clinical reports of EEA for skull base meningiomas, written in English language, published before October 2014, using the PubMed literature search on the website. Skull base meningiomas are subdivided by the site of occurrence, olfactory groove (8 articles including 80 cases), tuberculum sellae (14 articles, 153 cases), cavernous sinus (2 articles, 8 cases), petroclival region (4 articles, 10 cases), and craniofacial region (2 articles, 5 cases), and the surgical outcomes of EEA were analyzed. In anterior skull base regions, EEA contributed to effective improvement of the symptoms in small and round-shaped meningiomas, but 25% of the patients had postoperative cerebrospinal fluid rhinorrhea. In cavernous sinus and petroclival regions, successful surgical removal largely depended on tumor consistency, and the extent of the surgical resection proportionally increased the risks of serious complications. Thus, judicious endoscopic resection with adjuvant radiotherapy or radiosurgery remains to be the most reasonable treatment option. To decrease the risks of surgical complications, the surgeons must master the closure techniques of dural defect and meticulous microsurgical procedure under endoscopic vision. Further progress will depend on the progresses of surgical technique in neurosurgeons engaging this potentially “minimally invasive” surgery.