鞍结节脑膜瘤显微手术治疗体会

目的 探讨鞍结节脑膜瘤手术入路选择、手术技巧及临床效果.方法 回顾性分析2000年2月至2006年10月手术治疗的45例鞍结节脑膜瘤的临床资料,14例经单侧额下入路,15例经翼点入路,9例经眶额翼点入路,7例扩大经额入路.结果 肿瘤全切除42例,大部分切除3例;术后视力改善33例,无明显变化9例,3例恶化.结论 根据肿瘤大小、部位、生长方式及毗邻关系选择正确的手术入路并结合熟练的显微外科手术操作是全切除肿瘤及获得良好临床疗效的关键.

Abstract：

Objective To study the surgical approaches, operative techniques and curative effects of tuberculum sellae meningiomas. Method Retrospective analysis was made on 45 cases of tuberculum sellae meningiomas operated with a variety of surgical approaches. In 14 patients,the tumors were removed through unilateral subfrontal approach, 15 through pterional approach,9 through fronto - orbital craniotomy and 7 through extended frontal approach. Results Of the 45 cases, tumor was totally removed in 42 cases, subtotally removed in 3. Postoperatively, the eyesight was improved in 33 cases, unchanged in 9 cases, and worse in 3 cases. Conclusions The surgical approach for tuberculum sellae meningioma should be chosen according to the size, location, growth pattern and adjacent relation of tumor. The microsurgical skill is the key for total removal of tumor and good curative effect.     

Chiari畸形的临床诊断和显微手术治疗体会

目的 探讨Chiari畸形的诊断及显微外科处理方法.方法 回顾性分析50例Chiari畸形的临床资料,其中合并脊髓空洞30例,齿状突型颅底陷入3例.结果 50例术后平均随访35个月,按Tator疗效标准:优36例(72%);良12例(24%);差2例(4%).有效率96%.空洞缩小21例,消失7例.结论 有限的后颅窝减压及枕大池重建是治疗Chiari畸形的有效方法;合并齿状突型颅底陷入应先行口咽入路齿状突磨除术或许为较好的选择.

Abstract：

Objective To study the diagnosis and the microsurgical treatment for Chiari malformation(CM).Methods The clinical data of 50 cases of Chiari malformation were analyzed retrospectively,30 cases were combinated with syringomyelia,3 with cranial basal invagination referred to dens of axis.Results 50 cases were followed up for an average 35 months.According to Tator's standard,the curative effect was excellent in 36,good in 12 and bad in 2 patients.The effective rate was 96%.The cavities in spinal cords reduced in 21 cases,disappeared in 7.Conclusion Limited posterior fossa decompression with reconstruction of cistern magna is a effective method for treatment of CM;CM with cranial basilar invagination referred to dens of axis treated firefly by anterior decompression of odontoidectomy via oral approach may be an optimal selection.     

经额叶侧脑室脉络膜裂入路丘脑胶质瘤切除术

目的 研究经额叶侧脑室脉络膜裂入路切除丘脑胶质瘤的手术方法.方法 采用经额叶侧脑室脉络膜裂入路切除丘脑胶质瘤20例,在冠状缝前约1.5 cm、冠状缝后不超过1 cm内分离额上沟并切除部分额中回,进入侧脑室体部.根据丘脑肿瘤主体与脉络膜裂的关系,4例在脉络膜裂的内侧纵形进入第三脑室,切除突出于第三脑室的丘脑肿瘤;16例在脉络膜裂的外侧切除丘脑肿瘤.结果 1例肿瘤切除范围小于50%,余19例切除范围大于90%;病理结果:胶质瘤Ⅱ级3例,Ⅲ级9例,Ⅳ级8例.围手术期死亡1例.随访无癫痫发生,GOS评分:良好16例,重残1例,死亡2例.结论 丘脑胶质瘤的手术仍存在较大的困难,采用经额叶侧脑室脉络膜裂入路切除丘脑胶质瘤,取得较理想的效果.

Abstract：

Objective To evaluate the effect of surgical treatment of thalamic gliomas via transcortico -ventriculo -choroidal approach. Methods 20 cases of thalamic gliomas were included in this group. The part of middle frontal gyrus was removed to get to the lateral ventricule and from there, according to the direction of the tumor encroaching and relationship with choroidal fissure, the tumor was removed directly or through the third ventricle. Results Partial resection ( less than 50% ) was performed in 1 case. Subtotal resection (more than 90% ) was performed in 19 cases. 3 tumors were low -grade gliomas, 17 high - grade. There were two postoperative death. During follow - up period, 16 cases lived in good neurological condition, one severe condition who needed help completely. Another case died of glioblastoma multiforme. Conclusions Transcortico - ventriculo - choroidal approach is safe and effective for getting a good view in the surgical treatment of thalamic glioma.     

Expression of angiogenic factors in cerebral arteriovenous malformations

BACKGROUND： In the process of vascularization, vascular endothelial growth factor （VEGF）, angiopoietin-2 and Tie2 are involved in the migration, differentiation and proliferation of vascular endothelial cells, and stimulate the rapid angiogenesis; Tiel and angiopoietin-1 play important roles in facilitating the formation of vascular lumen and maintaining the integrity of vascular wall. Thus the distributions and expressions may be associated with the occurrence of cerebral arteriovenous malformation. OBJECTIVE： To observe the biological effects of angiogenic factors in the occurrence and development of cerebral arteriovenous malformation. DESIGN： An observational comparative experiment. SETTINGS： Department of Neurosurgery, General Hospital of Shenyang Military Area Command of Chinese PLA; Department of Neurosurgery, General Hospital of Tianjin Medical University. PARTICIPANTS： Fresh samples of complete cerebral arteriovenous malformations resected in 47 patients were collected from the Department of Neurosurgery, General Hospital of Tianjin Medical University from August 1999 to May 2001, including 22 males and 25 females, the mean age was 34.5 years. Informed consents were obtained from all the patients or their relatives. The initial symptom was hemorrhage in 28 cases. All the patients were classified according to the clinical imaging data and Spetzler-Martin grading standard, including 11 cases of grade Ⅰ, 17 cases of grade Ⅱ, 11 cases of grade Ⅲ, and 8 cases of grade Ⅳ - Ⅴ. Normal brain tissues resected by decompression due to trauma were taken from 8 patients as controls, including 5 males and 3 females, aging 12 - 65 years. METHODS： ① The expressions of VEGF, Tie receptors, angiopoietin-1, angiopoietin-2, proto-oncogene c-myc and proliferating cell nuclear antigen（PCNA） in the samples of cerebral arteriovenous malformation were detected with immunohistochemical method. Under light microscope, the positively stained rat-anti-human factor Ⅷ-related antigens （specific marker of vascular endothelial cells） were counted, then the immuno-positive cells of the other antibodies in the visual field of neighboring section which was in ＂mirror＂ relation were counted, and the percentage of the latter to the former was considered as the labeling index of positive cells. The immunostaining intensity was classified negative （ - ）： no positive cells; positive （＋）： number of positive cells 〈 20%; moderately positive （＋＋）： number of positive cells 20% - 50%; strongly positive （＋＋＋）： number of positive cells 〉 50%. ② The differences of the enumeration data were compared with chi-squam test, and the correlation were analyzed with the linear correlation analysis. MAIN OUTCOME MEASURES： Expressions and distributions of VEGF, Tie 1 and Tie2 receptors, angiopoietin-1, angiopoietin-2, PCNA and c-myc in the samples of cerebral arteriovenons malformation and normal brain tissue. RESULTS： ① Expressions of angiogenic factors in the control group and cerebral arteriovenons malformation groups of each grade： The positive rates of VEGF, Tie2, angiopoietin-2, c-myc and PCNA expressions in the control group were significantly different from those in the cerebral arteriovenous malformation groups of each grade （ x^2=21.09 - 34.23, P 〈 0.05）, whereas the positive rates of Tiel and angiopoietin-1 expressions were close （ x^2=3.43 - 3.869, P 〉 0.05）. ② Expressions of angiogenic factors in hemorrhage group and non-hemorrhage group： The expressions of VEGF, angiopoietin-2 and PCNA in the hemorrhage group were significantly lower than those in the non-hemorrhage group （ x^2= 16.22 - 26.56, P 〈 0.05）. There ware no obvious differences in the expressions of Tiel and angiopoietin-1 expressions between the hemorrhage group and non-hemorrhage group （ x^2=3.22 - 3.78, P 〉 0.05）.The VEGF was positively correlated with the expressions of c-myc and PCNA （r = 0.728, 0.916, P 〈 0.05）. CONCLUSION： ①The expressions of angiogenic factors and related receptors may be involved in the process of cerebral arteriovenous malformation, and had important correlation the its clinical grading. ② Angiogenic factors may induce the expression of endothelial cell c-myc in cerebral arteriovenous malformation, and then interfere the cell proliferation and apoptosis.     

Surgical strategy for cerebral arteriovenous malformation with acute hemorrhage

BACKGROUND: Presently, there have been craniocerebral operation, interventional embolization, stereotactic radiotherapy and other methods in treating cerebral arteriovenous malformation (AVM). However, the standard of different therapeutic regimens of cerebral AVM at the acute stage of hemorrhage has not been completely identified. OBJECTIVE: To observe the clinical characteristics and therapeutic effects of AVM at the acute stage of hemorrhage in patients, and to analyze corresponding therapeutic strategies. DESIGN: Non-randomized clinical observation. SETTING: Department of Neurosurgery, Foshan First People's Hospital, Sun Yat-sen University. PARTICIPANTS: Forty-six patients with cerebral AVM complicated by hemorrhage admitted to Department of Neurosurgery, Foshan First People's Hospital between January 1999 and December 2006, were involved in this study. All the patients were confirmed as cerebral AVM complicated by hemorrhage by brain angiography or/and postoperational pathology. The involved patients, 32 males and 14 females, averaged 25 years old, ranging from 6 to 62 years. Informed consents of therapeutic items were obtained from the relatives of all the patients. METHODS: ①On admission, skull CT and brain angiography were conducted in the involved subjects. ②The therapeutic method was confirmed according to the consciousness, hematoma region, hematoma volume, imageological results following comprehensive analysis. DSA examination was permitted to identify the size and position of abnormal vessel mass, and the distribution of feeding artery and draining vein. Craniocerebral operation was carried out as early as possible in patients with severe or progressive conscious disturbance, in which most of hematoma with obvious occupied effect or cerebral hernia was located in lobe of brain. The primary thing was to clean intracerebral hematoma for in time decompression. According to different situations, corresponding therapeutic measures were used for resecting abnormal vessel mass, and the treatments of patients were observed. ③The therapeutic effects were assessed following Glasgow outcome scale(GOS) at 3 months after hemorrhage. MAIN OUTCOME MEASURES: ① The examination results of skull CT and brain angiography of patients on admission. ② Treatment of patients. ③ GOS results at 3 months after hemorrhage. RESULTS: Forty-six patients were involved, and all of them participated in the final analysis. ① Examination results of skull CT and brain angiography: Bleeding part: frontal lobe in 7 cases, parietal lobe 15, temporal lobe 19, occipital lobe 3, cerebellar hemisphere 2, and hemorrhage rupturing into ventricle 10. Haematoma volume: small volume of hematoma （< 20 mL）in 4 cases, moderate volume of hematoma （20–50 mL）14 , large volume of hematoma （50–80 mL）21, great volume of hematoma (> 80 mL) 7; Abnormal vessel mass: Among 17 patients undergoing aortocranial angiography, abnormal vessel mass was found in 16 patients, including cortex 13 patients, basal ganglia and thalamencephalon(deep part) 2 patients , and posterior cranial fossa 1 patient. The size of abnormal vessel mass: small (< 3 cm) 4 patients, moderate (3–6 cm) 9 patients, and large (> 6 cm) 3 patients. The type of feeding artery: perforating branch blood-supply 1 patient, cortical branch blood supply 13 patients, mixed branch blood supply 2 patients. The type of draining vein: cortical draining (superficial part) 10 patients, deep part draining 2 patients, and mixed draining 4 patients. ② Treatment condition: Among 17 patients undergoing brain angiography followed by craniocerebral operation, hematoma was removed and AVM was completely resected in 12 patients, hematoma was removed and AVM was partially resected in 3 patients, and only hematoma was resected in 2 patients; Among 24 patients undergoing emergent craniocerebral operation, hematoma was removed and AVM was completely resected in 5 patients, hematoma was removed and AVM was partially resected in 9 patients, and only hematoma was resected in 10 patients; Expectant treatment was carried out in the early stage in 5 patients. When disease condition was stable, AVM resection was separately or complicatedly conducted in 13 patients, embolization in 4 patients, and γ- radiotherapy in 5 patients. ③GOS: 5 patients died in postoperative complications, and among the other patients, 19 had moderate or had not functional impairment, 13 had moderate disability, 6 had severe disability, 2 were vegetative state, and 2 died. ④ Post-operative re-examination of brain angiography: Among 16 patients undergoing AVM, vessel mass disappeared in 9 patients. CONCLUSION: Good therapeutic effects can be obtained by choosing proper therapeutic regimen according to clinical and imageological characteristics of patients with arteriovenous malformation complicated by hemorrhage at the acute stage.     

经翼点-眶顶入路切除颅眶沟通肿瘤

目的 探讨经翼点-眶顶入路切除颅眶沟通肿瘤的手术方法和治疗效果.方法 回顾性分析自2004年至2009年收治的13例颅眶沟通肿瘤患者的临床资料,采取经翼点-眶顶入路的手术方式切除肿瘤.结果 在13例患者中,肿瘤全切10例,大部或部分切除3例.经组织病理学检查证实良性肿瘤9例,恶性肿瘤4例.最常见的肿瘤类型为脑膜瘤,本组6例.所有患者的临床症状在术后均有不同程度的改善,无手术死亡及严重并发症.结论 经翼点-眶顶入路切除颅眶沟通肿瘤,操作简便、易于暴露、手术创伤小.术中应注意保护球后重要组织,并根据需要进行眶顶修补或重建.

Abstract：

Objective To investigate the procedure via pterional -orbital approach for cranioorbital communicating tumors.Method 13 patients with cranio -orbital communicating tumors were retrospectively analyzed.Pterional approach was adopted for the operations with resection of orbital roof, and the surgical advantages and cautions were concerned.Results In 13 patients, 10 cases undertook total removal, and 3 cases undertook subtotal or partial removal of tumors.9 cases were benign, and 4 cases were malignant tumors.Pathological results showed that 6 cases were meningioma which was the most common type.Patient's follow - up ranged from 3 to 52 months, which showed that no operative death and severe complications were revealed.The most common complication was injury of extraocular muscles, which occurred in 4 patients.Conclusions Resection of cranio - orbital tumors via pterional - orbital approach provided facilities for exposing tumors and showed less operative damages.Protecting important tissues in postglobal region and reconstructing orbital roof will result in less postoperative complications.     

经耳前颧弓硬膜外入路切除海绵窦肿瘤60例分析

目的 总结回顾2002年至2009年经治的海绵窦病变60例的临床特点、手术人路及手术效果.方法 神经鞘瘤18例,海绵状血管瘤23例,皮样囊肿9例,脑膜瘤4例,脊索瘤3例,垂体瘤3例.均经耳前颧弓硬膜外入路切除.结果 神经鞘瘤18均全切,海绵状血管瘤23例,全切18例,5例有残留.皮样囊肿9例全切,脑膜瘤4例,全切3例,次全切1例.脊索瘤3例,结合经鼻蝶窦入路手术,均达到了全切.垂体瘤3例全切.结论 经耳前颧弓硬膜外入路切除海绵窦病变是一个理想的手术入路,可以充分显露病变,减少对脑组织的牵拉,也可以明确Ⅲ～Ⅵ脑神经和颈内动脉的位置,减少神经和血管损伤的概率.对与动脉或神经粘连无法彻底切除的病变可以辅以立体定向放射治疗.

Abstract：

Objective To review our experience of microsurgery for 60 cavernous sinus tumors from 2002 to 2009.The clinical features,surgical techniques and outcome of cavernous sinus tumor in 60 cases were investigated retrospectively.Methods The patients included 23 hemangiomas,18 shwannomas,9 dermoid cysts,4 meningiomas,3 chordomas,3 pituitary adenomas.AIl the tumors were removed with subtomperal preauricular extradural approach.Results The tumors were removed satisfactorily.The shwannomas were totally removed. The hemangiomas were totally removed in 18,near-totally removed in 5 cases.Nine dermoid cysts were removed totally.For the 4 meningiomas,3 were removed completely,neartotallv removed in 1 cases.The 3 Chordomas were resected near-totally and achieved a completely removal with combined approach.Conclusion The subtomperal preauricular extradural approach is a rational choice.It can reveal the cranial nerve branches and artery at an early stage so that cranial nerves Ⅲ～Ⅵ and internal carotid artery can be preserved during operation.The tumor exposure is ideal and brain traction and contusion are slightly.The adjunctive radiotherapy is demanded for residual tumors adhering to nerves and arteries severely.     

枕大孔区肿瘤的分型及手术入路选择

目的 探讨枕大孔区肿瘤的分型及手术入路.方法 回顾性分析显微手术治疗的43例枕骨大孔区肿瘤,根据肿瘤位置分为:Ⅰ型(背侧)和Ⅱ型(腹侧),Ⅰ型又分为Ⅰ a(髓外)、Ⅰ b(髓内)、Ⅰ c(髓内外)三型,Ⅱ型又分为Ⅱa(髓外)和Ⅱb(髓内)两型.对于17例Ⅰ型患者选择后正中入路,26例Ⅱ型患者选择远外侧入路.结果 全切肿瘤35例(81%),无手术死亡,随访期内无肿瘤复发.临床症状改善32例;保持原有症状3例;加重8例,包括出现新的脑神经症状、肢体运动障碍和呼吸困难.结论 枕大孔区肿瘤的术前分型有助于手术入路的选择和判断手术效果,Ⅰ型多选择后正中入路,Ⅱ型选择远外侧入路.

Abstract：

Objective To explore the classification and surgical approach of magnum foramen tumor.Method A retrospective analysis was performed for 43 surgically treated patients with tumors involving the foramen magnum.According to the site of the tumor,the classification was divided to:Type Ⅰ ,located at dorsal, Ⅰ a extra - medullary, Ⅰ b intra - medullary, Ⅰ cintra - and extramedullary; Type Ⅱ,located at ventral, Ⅱ a extramedullary, Ⅱ b intramedullary.The midline approach was used in the Type Ⅰ (17cases), while the lateral or far- lateral approach for the Type Ⅱ (26 cases).Results Total excision was performed in 35(81% ).There were no mortality and no recurrence during the follow -up period.Thirtytwo patients had improvement in their neurological status, 3 cases unchanged.There were 8 cases aggravation,including newly cranial nerve deficits, hemiplegia, dyspnoea.Conclusions The preoperative classification was useful for the selection of surgical approach and evaluation of surgical outcome.The midline approach was apt to Type Ⅰ , while the lateral or far - lateral approach for the Type Ⅱ.     

微血管多普勒监测下手术治疗大脑后动脉动脉瘤

目的 总结2006年1月至2009年12月我科收治的10例大脑后动脉动脉瘤的临床特征、手术入路和手术技巧.方法 10例中P1段3例,P2段5例,P3段2例.P1段动脉瘤采用颞下+翼点联合入路,P2、P3段动脉瘤采用颞下入路.在微血管多普勒监测下7例行动脉瘤颈夹闭术,2例行血管塑形动脉瘤夹闭术,1例行动脉瘤孤立术.其中3例巨大动脉瘤行动脉瘤切除术.结果 10例患者中6例恢复良好,2例术后出现动眼神经麻痹,1例出现同向偏盲,1例出现轻偏瘫,经治疗后均恢复正常.术前1例存在动眼神经麻痹和1例存在同向偏盲者手术后3个月恢复.结论 显微外科手术是治疗大脑后动脉瘤的主要方法,经颞下入路暴露充分,是一种安全、简便的入路.微血管多普勒在动脉瘤夹闭术中是一种直接、有效和便捷的监测方法,对提高手术治疗效果具有重要价值.

Abstract：

Objective To summarize the clinical features of intracranial aneurysms of posterior cerebral artery (PCA), and the surgical approaches and operative skills to treat them. Method The aneurysms arose from the P1 segment in 3 patients, the P2 segment in 5 patients and the P3 segment in 2 patients. Aneurysms on P1 segment were surgically treated via subtemporal associated pterional approach. Aneurysms on P2 and P3 segment were surgically treated via subtemporal approach. 7 aneurysms were successfully treated by clipping the aneurysmal neck,2 aneurysms were shaped and 1 aneurysm was isolated. 3 giant aneurysms were resected. Microvascular Doppler was conducted to examine the blood flow of aneurysms and parent arteries. Results 6 of 10 patients had postoperative good recovery. Temporal oculomotor palsy occurred in 2 patients, syntropic hemiablepsia occurred in 1 patients,light hemiplegia in 1 patient. All these patients were recovery with treatment. 1 oculomotor palsy and 1 syntropic hemiablepsia preoperation recovered postoperation after three months. Conclusions The microsurgery is one of the major methods for treating aneurysm of PCA. The subtemporal approach in treating aneurysm of PCA is simple,safe and good exposure. Microvascular doppler is a feasible, safe, and very reliable technique in aneurysm surgery.     

手术治疗大脑前动脉远端动脉瘤(附九例报告)

目的 探讨大脑前动脉远端动脉瘤(DACAA)的诊断和显微外科手术治疗.方法 回顾分析2007年10月至2010年3月显微手术治疗DACAA 9例.术前Hunt-Hess分级0级1例,Ⅰ级2例,Ⅱ级4例,Ⅲ级1例,Ⅳ级1例.结果 9例DACAA经额纵裂入路成功夹闭动脉瘤11个,动脉瘤直径在3～30 mm之间,其中囊性动脉瘤9个,梭形动脉瘤1个,巨大动脉瘤1个;位于A2段2个,A3段8个,胼周动脉末梢段1个.2例为多发动脉瘤,1例合并动静脉畸形.1例梭形动脉瘤患者术后出现对侧肢体偏瘫,余治疗效果满意,无手术死亡,亦无其他并发症.按照GOS预后评分,8例恢复良好,1例重残.结论 通过术前3D-CTA和DSA等影像学诊断和准确手术定位,经额纵裂入路显微手术夹闭DACAA效果满意.

Abstract：

Objective To report the clinical diagnosis and microsurgical treatment of ruptured distal anterior cerebral artery aneurysm(DACAA)patients treated over the last 3 years.Methods 9 consecutive cases of ruptured DACAA operated from October 2007 to March 2010 were reviewed and followed up.Methods 11 aneurysms were clipped through interhemispheric approach microsurgery in 9 cases with ruptured DACAA.The diameter of 11 aneurysms was between 3-30 mm.Of which 9 cases were saccular aneurysms,1 case was fusiform aneurysm and 1 case was giant aneurysm.There were 2 aneurysm located at A2 segment of the ACA,8 located at A3 and 1 located at distal pericallosal artery.So there were 2 cases with multiple aneurysms and 1 case combined with AVM.The clinical outcomes of these patients evaluated by Glasgow Outcome Scale were:Except 1 case of fusiform DACAA presented hemiplegic paralysis after the surgery,all 8 cases discharged without deficit and no mortality in the group.Conclusion Depending on precise understanding of angiography imaging and location of 3D- CTA and DSA,interhemispheric approach is a safe method to clip the DACAA.     

脑干海绵状血管瘤的显微外科治疗(附10例报告)

目的分析脑干海绵状血管瘤的显微外科治疗方法和预后。方法显微手术切除脑干海绵状血管瘤10例,病灶位于桥脑8例,延髓2例。6例桥脑、延髓背侧的海绵状血管瘤,采用枕下正中经四脑室底入路切除; 4例桥脑外侧和腹外侧的海绵状血管瘤,采用枕下乙状窦后入路切除。结果病灶均镜下全切除,病理证实为海绵状血管瘤。4例患者术后症状明显改善,5例患者出现不同程度并发症,在1周至3个月内恢复,1例患者术后因肺内感染死亡。患者术后随访3-58个月,复查MRI均未发现病灶复发,无其他并发症出现。结论在正确选择适应证的前提下,脑干海绵状血管瘤的显微外科治疗效果良好。     

颞下经小脑幕入路切除脑桥海绵状血管畸形

目的总结颞下经小脑幕入路切除脑桥海绵状血管畸形的治疗经验。方法回顾性分析23例脑桥海绵状血管畸形病人的临床资料,采用颞下经小脑幕入路手术切除病灶。采用常规马蹄形切口15例,耳前弧形切口8例。结果全切除21例,近全切除2例,无手术死亡。术前面瘫、眼肌协同性运动障碍完全恢复,无新出现的面瘫,术后出现一过性语言障碍5例。GOS评分:恢复良好21例,重度病残2例。结论颞下经小脑幕入路能够充分显露并切除脑桥海绵状血管畸形,同时可避免出现面瘫等严重并发症。     

小脑血管畸形显微手术治疗的临床分析

目的探讨小脑血管畸形的临床特点及手术治疗方法与疗效。方法回顾性分析72例小脑血管畸形病人的临床资料．采用乙状窦后入路或枕下后正中入路进行手术。结果72例病人均手术全切病灶。术后病理结果：动静脉畸形（AVM）67例,海绵状血管瘤（CM）3例,静脉畸形（VM）2例。术后GOS评分：5分64例,4分4例,3分1例,2分1例,1分2例。随访4个月～13年,恢复良好64例,轻残4例,重残1例,植物生存状态1例,死亡2例。无复发病例。术前GCS评分≥8分的AVM病人,其术后GOS评分较GCS评分〈8分者高（P〈0．05）。结论小脑血管畸形应尽早行手术切除治疗,术中采用合适的手术入路、适当的手术技巧,可取得良好的手术效果。AVM病人术前GCS评分≥8分的病人恢复好,〈8分病人恢复较差。     

显微手术切除脑干海绵状血管瘤

目的 探讨显微手术切除腩十海绵状血管瘤的时机、方法和预后.方法 回顾性分析显微手术切除及病理证实的10例脑干内海绵状血管瘤的临床资料.所有病例均行CT及MRI检查.海绵状血管瘤位丁中脑1例、桥脑7例、延髓2例.采用颞下入路切除中脑海绵状血管瘤1例;乙状窦后入路切除桥腑海绵状血管瘤3例;枕下中线经第四脑室入路切除延髓海绵状血管瘤2例、桥脑海绵状血管瘤4例.采用GOS分级对于术结果进行评估.结果 显微镜下将肿瘤全切,无手术死亡.10例患者均获得随访,随访时间3-48个月(平均18.5个月).术后3个月GOS分级:Ⅴ级5例,Ⅳ级5例;术后1年GOS分级:Ⅴ级8例,Ⅳ级2例.无再出血者.结论 显微外科手术是治疗脑干内海绵状血管瘤的有效方法,远期效果满意.     

脑干海绵状血管瘤手术入路选择

目的探讨脑干海绵状血管瘤手术适应证和手术入路的选择。方法回顾分析70例手术治疗的脑干海绵状血管瘤，其中位于：中脑15例、中脑-桥脑交界8例、桥脑34例、桥脑-延髓交界5例、延髓8例。我们共采用8种手术入路：经菱形窝27例、颞下或颞-枕入路14例、远外侧经髁7例、外侧小脑上幕下7例、中线小脑上幕下8例、枕经天幕4例、乳突后2例，以及眶颧1例。结果本组病例的年出血率为2．9％（77／2364），占同期颅内海绵状血管瘤的44％（70／159）；97％的病例手术选择在亚急性或慢性期、且所有患者均有颅神经症状和（或）运动功能障碍、感觉障碍、共济失调（包括失平衡）。中脑病变手术入路选择以中线小脑上（46．7％，7／15）、颞下或颞-枕（26．7％，4／15）为主；桥脑病变多选择菱形窝（58．8％，20／34）、颞下或颞-枕（23．5％，8／34）；而病变位于延髓者以远外侧经髁（62．5％，5／8）和菱形窝入路（37．5％，3／8）为主。结论脑干海绵状血管瘤表现为进行性神经功能缺失、具有占位效应、接近脑干表面者可考虑手术治疗；个体化地选择手术入路、术中神经电生理监测以及直接的电刺激是手术成功的关键。     

脑干海绵状血管瘤的显微外科治疗(附8例分析)

目的 评价显微手术切除脑干海绵状血管瘤的可行性与预后.方法 回顾性分析我科2000年3月～2006年10月间采用显微手术切除的8例脑干海绵状血管瘤病人的临床资料;结合文献复习,探讨脑干海绵状血管瘤的影像学特点、手术指征与方法.结果 8例均为单发病变.除1例术后3个月MRI显示仍有病变残余和再次少量出血外,其余7例经术中镜下观察和术后随访MRI证实为全切除.无手术死亡.术后早期神经功能障碍改善3例,同术前2例,加重3例.随访10～49个月,1例仍未恢复至术前状态,余病例均未见复发.结论 合理掌握手术指征,采用显微手术切除脑干海绵状血管瘤,可获得满意疗效.     

海绵状血管畸形伴静脉畸形的诊治

目的研究海绵状血管畸形(CM)伴静脉畸形的诊治。方法回顾性分析39例经手术治疗的CM病人的临床资料,术中观察和判断是否伴随静脉畸形,并将病例分为伴静脉畸形组和不伴静脉畸形组,分析两组病人的资料,对CM伴静脉畸形的诊断和外科处理策略提出建议。结果术中显微镜下发现伴静脉畸形14例,术前MRI增强扫描检出伴静脉畸形12例,DSA检出伴静脉畸形1例,MRA未检出伴静脉畸形。伴静脉畸形组和不伴静脉畸形组病灶大小、病变部位、首发症状和预后差异均无统计学意义(P0.05),表明静脉畸形可能是CM病变的一个组成部分。但伴静脉畸形组因术中切断静脉畸形而出现严重脑肿胀2例,其中1例死亡。结论 MRI增强扫描应列为CM的术前常规检查;伴静脉畸形的病例应在设计手术入路时,尽量避开静脉畸形血管,并在术中加以保护。     

Surgical treatment of brainstem gliomas and other tumors in adults

BACKGROUND AND PURPOSE: After the introduction of MR imaging to the diagnostics of brainstem tumors and after the introduction of microsurgical procedures to their treatment, the successful treatment, particularly of focal and exophytic forms of these tumors has begun all over the world. The objective of this paper is to establish indications for surgical treatment of gliomas and other tumors of brainstem, to determine surgical approaches and to establish the outcome. MATERIAL AND METHODS: Within the last 6 years, 12 patients with focal and exophytic tumors of the brainstem in adults were operated on. 5 tumors were located in the midbrain, 4 in the pons, 2 in the medulla oblongata and 1 was a cervicomedullary one. With one exception, all tumors were approached via the posterior fossa. Results: The total removal was performed in 75% and a subtotal one in 25% of cases. A serious complication in 2 patients was bilateral ptosis after the removal of midbrain tumors. This lesion gradually regressed. A similar dangerous complication is impaired swallowing and coughing reflex loss which, by exposing the patient to the risk of aspiration pneumonia, occurred in 2 patients. One of these patients died after the operation. CONCLUSIONS: Patients with focal and exophytic forms of the brainstem tumors in MR imaging are qualified for surgical treatment. Immediate results of the treatment depend on the localization and size of the neoplasm. A precise operative approach, use of the neurophysiological examination and postoperative care at the Intensive Care Unit are essential conditions to obtain good results of the operative treatment.     

脑干海绵状血管瘤的显微外科治疗:46例报告

目的探讨脑干海绵状血管瘤显微手术治疗的指征和技巧,以及手术入路的选择和术中注意事项。方法回顾性分析作者近十年期间经显微手术治疗的46例脑干海绵状血管瘤的临床资料。中脑海绵状血管瘤8例,间脑-中脑交界处1例,中脑-桥脑交界处2例,桥脑海绵状血管瘤29例,延髓海绵状血管瘤4例,桥脑-延髓交界处2例。采用神经电生理监测引导手术,5例术中采用神经导航定位。结果肿瘤全切45例,1例次全切。术中见19例伴有明显的静脉畸形,予以保护。神经功能障碍改善22例,无明显变化21例,术后症状改善和稳定率为93.5%(43/46)。术后症状加重3例,出现复视、面瘫和肢体活动障碍加重各1例。2例经随访神经功能已恢复至术前状态,仍有1例患者未恢复至术前状态。随访3～58个月,肿瘤全切的43例,42未见肿瘤增大,均未见脑干海绵状血管瘤再出血,1例复发行伽玛刀治疗。无手术死亡。结论正确选择手术指征和个体化选择手术入路、术中神经电生理监测以及采用显微外科技术可安全和有效地切除肿瘤。     

前颞下"锁孔"入路显微手术的临床应用

目的以"锁孔"微创的理念,改良常规颞下入路,以减少手术损伤.方法采用耳前方颧弓向上直切口4 cm,铣开2.0～2.5 cm左右直径骨窗,经颞下行海绵窦、脑干、岩斜区部位病灶的手术治疗13例.结果6例岩斜区脑膜瘤全切除4例,次全切1例,大部切除1例;脑干转移癌、颞底胶质瘤各1例均全切除,海绵窦脑膜瘤、脑桥胶质瘤各1例次全切除,脑桥病灶出血1例予AVM切除、血肿清除,海绵窦内血栓1例子全切除,大脑后动脉瘤1例予夹闭.1例术后出现脑脊液耳漏,经原入路修补后痊愈.2例岩斜区脑膜瘤切除术后遗有轻度偏瘫.结论颞下"锁孔"入路可满足岩斜区、脑桥腹、侧方及海绵窦区的手术要求,是一种行之有效的微创手术入路.