大型听神经瘤的手术与病理解剖

目的探讨大型听神经瘤显微手术解剖形态及与毗邻神经、血管结构的解剖关系.方法回顾性分析经显微外科手术的大型听神经瘤63例,对肿瘤的供血来源,与脑神经及血管、重要结构的解剖关系等进行分析.结果肿瘤均由小脑前下动脉分支参与供血,15例小脑上动脉参与肿瘤上极供血,22例小脑后下动脉参与肿瘤下极供血.主要经岩静脉回流至岩上窦,15例同时回流至天幕.面神经位于听神经瘤前方53例(前上方13例,正前方31例,前下方9例),肿瘤上极5例,肿瘤下极4例,肿瘤后方1例,无面神经穿过肿瘤者.结论正确认识听神经瘤病理显微解剖和与毗邻组织结构的解剖关系,对全切除肿瘤和脑神经功能保护具有重要意义.     

面神经电生理监测下切除大型及巨大听神经瘤

目的探讨面神经电生理监测下切除大型及巨大听神经瘤技术。方法回顾分析22例大型及巨大听神经瘤临床资料,在面神经电生理监测下行显微手术切除,术后随访面神经功能。结果肿瘤全切除15例,次全切除7例。面神经自发肌电图在面神经受牵拉、挤压、生理盐水冲洗等操作过程中产生显著放电,刺激肌电图对寻找和辨认面神经具有重要作用。面神经位于肿瘤腹下方7例,腹上方2例,腹侧中部13例。所有病例面神经均解剖保留。术后随访6~42个月,面神经功能(House-Brackmann分级),H-B分级Ⅰ级11例,Ⅱ级5例,Ⅲ级2例,Ⅳ级4例。结论面神经电生理监测辅助显微手术对术中解剖与功能保留面神经具有重要价值。     

大型听神经瘤的显微手术治疗与面神经保护

目的探讨大型听神经瘤的显微手术治疗及面神经的保护。方法54例大型听神经瘤（直径＞3cm）患者,均在面神经及脑干电生理监测下采用枕下乙状窦后入路显微手术切除,术中采用长＂S＂形或直形切口,开枕骨骨瓣直径约4cm,显露横窦和乙状窦,放出枕大池脑脊液,再行显微镜下分离及切除肿瘤,术后对其面神经功能进行随防。结果全切49例（91%）,近全切5例,面神经保留51例,保留率为94%,无死亡病例。结论显微手术与面神经的电生理监测是大型听神经瘤得以全切并保留面神经的关键,扎实的显微解剖知识、娴熟的显微手术技巧及完善的手术中监测是手术成功的保障。     

大型听神经瘤手术中面神经的保护研究

目的探讨大型听神经瘤手术中面神经保护的技术及方法。方法回顾性分析厦门大学附属第一医院神经外科2011年3月—2018年2月,行枕下乙状窦后入路显微手术的48例大型听神经瘤患者的临床资料。对患者的手术效果、术后面神经功能进行观察和随访。结果本组患者中,肿瘤全切者31例(64. 6%),次全切11例(22. 9%),部分切除6例(12. 5%)。术中面神经均获得解剖保留,术后1周面神经功能B-H分级Ⅰ-Ⅱ级者20例(41. 67%)、Ⅲ-Ⅳ级27例(56. 25%)、Ⅴ-Ⅵ级1例(2. 08%);术后3个月时面神经功能B-H分级Ⅰ-Ⅱ级者21例(43. 75%)、Ⅲ-Ⅳ级27例(56. 25%),无Ⅴ-Ⅵ级者。随着患者肿瘤直径的增大,其术后面神经H-B分级越高,功能预后越差(均P 0. 05)。结论精细的显微手术操作、完善的神经电生理监测对术中面神经保护具有重要价值;术前肿瘤体积可作为术后面神经功能预后的预测指标。     

术中面神经监测在听神经瘤术中对面神经的保护意义

目的探讨术中面神经监测在听神经瘤术中对面神经的保护意义,并对解剖保留的面神经的功能进行评价。方法 53例听神经瘤患者在手术时均采用英国Oxford-instrumen公司生产的神经电生理监测仪进行术中面神经监测。全部采用经枕下乙状窦后入路,显微镜下手术切除肿瘤,肿瘤切除后对面神经进行功能评价。结果面神经解剖保留率90.5%,6个月后功能保留率为84.9%。结论术中面神经监测在听神经瘤术中有助于确定面神经的位置,提高面神经的解剖及功能保留率。     

大型听神经瘤显微手术保存面神经功能的治疗体会

目的总结53例大型听神经瘤患者显微切除术后近、远期疗效，探讨手术中、术后如何最大可能的保存面神经功能。方法我们对1995-2005年收治的53例大型听神经瘤患者从切口设计、分离方法、术后管理等多方面采取改进措施，提高治疗质量，术后患者进行6个月至10年以上随访．观察面神经功能恢复的情况。结果53例全部解剖保存了面神经：术后除部分患者不同程度面瘫外无明显其它手术直接并发症；经6个月至10年以上随访，48例患者面神经功能有不同程度的恢复，18例恢复至基本正常。结论即使是大型听神经瘤。只要手术方法适合．术后管理得当，面神经功能保存也是可能的。     

听神经瘤显微手术面神经保护对策

听神经瘤作为颅内常见肿瘤,手术切除是肿瘤治疗的最有效方法.随着神经外科显微技术及手术中神经电生理检测技术的应用,全切肿瘤已不成问题,完整保留面、听神经功能是手术追求的最高要求.选取2010-06-2012-06河南省人民医院神经外科60例听神经瘤患者,采取经枕下乙状窦后入路手术治疗,术中采用分块切除、锐性分离等显微操作,结合肌电图监测保护面神经,取得较好疗效.现报告如下.     

听神经瘤手术中的面神经保护

听神经瘤是颅内常见的肿瘤之一．以其手术复杂性和困难性,被认为是对神经外科医师手术技巧的挑战。显微外科、止血技术和电生理学的发展,为神经外科医师手术技巧的提高奠定了基础。术前对患者评估及术者对显微结构的熟练掌握和术者的经验及电生理监测的应用是面神经功能保留率得以提高的重要因素。术中、术后及时的对面神经予以修复,可以获得一定的面神经支配及功能。     

面神经与听神经瘤局部病理解剖关系的研究

一、临床资料一般资料 :本组男 47例 ,女 65例。年龄 1 4～ 69岁 ,平均 46岁。病史 1个月至 2 0年。左侧 52例 ,右侧60例。首发症状 :耳鸣 51例 ,听力下降 30例 ,发作性头痛 1 3例 ,面部麻木 1 0例 ,面肌抽搐 2例 ,面部疼痛 3例 ,发作性眩晕 2例。体征 :听力丧失 1 5例 ,面瘫 32例 ,后组颅神经功能障碍 2 5例 ,小脑体征 73例 ,视神经乳头水肿 33例。ＭＲＩ显示的肿瘤最大径 :1～ 2ｃｍ2例 ,2～ 3ｃｍ 1 3例 ,3～ 4ｃｍ 36例 ,4～ 5ｃｍ 2 9例 ,5～ 6ｃｍ 2 3例 ,大于 6ｃｍ9例。二、手术方法及结果患者均行乙状窦后入路手术治疗 ,肿瘤全切除…     

大型听神经瘤术中面神经功能的监护和保留

目的：研究在大型听神经瘤手术中,面肌肌电图,脑干听觉诱发电位监护在面神经保留部的作用。方法：对１６例大型听神经瘤患者经枕下入路行显微手术全切除肿瘤,术中同时监测面肌ＥＭＧ,ＢＡＥＰ。结果;肿瘤全切率１００％,无手术死亡,面神经解剖保留率９４％,功能保留良好率８１％。术末刺激强度≤０．４ｍＡ者提示预后良好。     

大型听神经瘤的手术治疗方法

目的探讨在术中神经电生理监测下经枕下-乙状窦后入路显微手术切除大型听神经瘤的方法及效果。方法回顾性分析2013年1月至2015年10月收治的85例大型听神经瘤的临床资料,均在术中神经电生理监测下,采取直切口乙状窦后入路小骨窗显微手术切除肿瘤。结果肿瘤全切除76例(89.4%),次全切除9例(10.6%);术中面神经解剖保留80例(94.1%)。术后即刻、7 d、3个月、6个月、9个月、1年面神经功能分级优良率(H-B分级Ⅰ~Ⅱ级)分别为88.2%、56.0%、41.9%、50.9%、68.6%、86.7%。结论在术中神经电生理监测下显微手术治疗大型听神经瘤,可更好保护面神经功能,提高术后生活质量。     

Recurrence rate,time to progression and facial nerve function in microsurgery of vestibular schwannoma

Abstract

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Objective: Recurrence rate, time to progression, and facial nerve function were analysed by comparing patients with complete and near total tumor removal after suboccipital craniotomy for vestibular schwannoma surgery.

Methods: From 1996 to 2004, 118 patients with vestibular schwannoma were operated with an interdisciplinary approach. Fifty patients fulfilled the inclusion criteria and were included in the study. Progression was defined as an increase of 2 mm in the largest diameter in the magnetic resonance imaging. Preoperative tumor size, facial nerve function estimated using the House-Brackmann score (HBS), time to progression, and recurrence rate were analysed and related to the extent of resection.

Results: In 28 cases (group I), a capsular remnant was left. In 22 cases (group II), tumor removal was complete. In group I, nine patients (32·1%) showed progression. In group II, two patients (9·1%) developed a recurrent tumor, no significance (P = 0·085). In groups I and II, 53·6 and 59·6% had a good function of the facial nerve (HBS I+II), 28·6% in group I and 13·5% in group II had a moderate disturbance (HBS III+IV), and 17·9% in group I and 27·7% in group II had a poor function (HBS V+VI). There was no significant difference between median preoperative tumor size and facial nerve function within patients with HBS III and IV.

Conclusion: Complete tumor removal may be associated with a risk of functional loss, whereas near total tumor removal may be associated with a higher risk of progression.     

枕下-乙状窦后入路切除囊性听神经瘤

目的探讨囊性听神经瘤患者的流行病学、临床表现、治疗和预后。方法回顾性分析2000年1月至2010年6月收治的254例听神经瘤患者,对比研究囊性和实性听神经瘤患者在发病率、性别比例、肿瘤大小、临床表现、术后面听神经功能、术后其他并发症等的差异。结果囊性听神经瘤肿瘤体积更大,术后面听神经保留率更高,中枢感染率较高。结论大型囊性听神经瘤首选显微外科手术,残留肿瘤可采用立体定向放射神经外科处理。     

内听道后壁磨除在前庭神经鞘瘤显微手术治疗中的作用

目的评价内听道后壁磨除对于处理前庭神经鞘瘤内听道内肿瘤的效果。方法回顾性分析自2003年1月至2006年12月,经内听道入路连续显微手术治疗的103例前庭神经鞘瘤。结果术后CT显示部分内听道后壁磨除组从内听道底平均内听道后壁缩短至4.6mm±1.0mm（n=48）;55例内听道后壁广泛磨除组,内听道后壁平均残留1.9mm±0.5mm（从内听道底起）。迷路的解剖位置位于S-F线外侧者52例,位于S-F线上者23例,位于S-F线内侧者28例。术后没有出现与手术有关的永久性并发症,死亡率为0%。结论显微内听道（IAM）后壁磨除在前庭神经鞘瘤切除过程中可提供更好的外科手术入路。     

Management of vestibular schwannomas in young patients—comparison of clinical features and outcome with adult patients

Objects Vestibular schwannomas (VS) in young patients are rare. They are regarded to have different biological characteristics. Our objective is to analyze a series of such patients, with respect to their clinical presentation, treatment, and outcome and to compare the results to a matched series of adult patients. Materials and methods Retrospective analysis of 20 patients under 21 years of age. All patients underwent surgery via the retrosigmoid approach. The analysis included: age, gender, tumor size, clinical, and neurological pre- and postoperative status including cochlear and facial nerve function, and complications. Statistical comparison of the young patient’s data with a series of 200 adult patients previously published by the authors. Conclusions The current study demonstrates that the outcome after surgical management in patients harboring VS does not show any significant difference between young and adult patients.     

Vestibular schwannoma microsurgery with special reference to facial nerve preservation

Objective

To retrospectively study the outcomes of vestibular schwannoma (VS) resection.

Methods

Between January 2003 and December 2006, 103 consecutive patients who had undergone VS resection were included in this study. Medical records, operation summaries, follow-up data, and neuroradiological findings were analyzed. The relationship between tumor size, location, and topography relative to the facial nerve bundles was studied for a mean duration of 16 months (range: 3–39 months).

Results

Complete tumor resection in combination with anatomic preservation of the facial nerve was achieved in 101 (98.1%) cases. The facial nerve was fully preserved in 100% of cases with small or medium tumors and in 37/39 patients with large tumors. Overall, 83.5% of patients had normal or near-normal facial nerve function 3–12 months post-surgically. The mortality rate was 0%.

Conclusions

Even in large VS, preservation of facial nerve function (H-B Grade I or II) should be prioritized over total resection. For tumors >3 cm, the goal of low morbidity and maintenance of normal facial nerve function can be attained with the retrosigmoid transmeatal approach, refined microsurgical technique, and intraoperative facial nerve monitoring.     

伽玛刀治疗听神经瘤中、长期疗效分析

目的总结评价伽玛刀(γ刀)放射外科治疗听神经瘤的中长期效果。方法78例患者平均年龄45.0±17.9岁,男性35例,女性43例;单侧病变74例,双侧4例;20例曾行手术治疗;57例γ刀治疗前存在有用听力;肿瘤容积0.11～27.8ml,平均10.8ml;边缘剂量10～14Gy,平均12.27Gy,中心剂量21～30Gy,平均24.90Gy。结果随访22～96个月,平均58.3±22.9个月;63例(80.8%)肿瘤缩小,12例(15.4%)大小无变化,3例(3.8%)肿瘤增大;47例患者有用听力得到保留,其中13(22.8%)例较术前明显改善;3例(3.8%)出现患侧面瘫;5例(6.4%)出现三叉神经功能部分受损。结论γ刀治疗听神经瘤中、长期疗效分析显示既可控制肿瘤生长又取得较高的神经功能保留率,值得推广。     

Facial nerve palsy after vestibular schwannoma surgery: Dynamic risk-stratification based on continuous EMG-monitoring

ObjectiveA-trains are a pathological pattern in intraoperative EMG-monitoring. Traintime, a parameter calculated by automated EMG-analysis, quantifies A-train activity. Its extent is associated with the degree of postoperative facial nerve palsy. However, false positive results have been observed. A systematic flaw in automated analysis was hypothesized.MethodsFacial nerve EMG-data from 79 patients undergoing vestibular schwannoma surgery were analyzed visually. Automated traintime was compared with these results. The progressive risk for postoperative paresis was calculated with respect to traintime (visual and automated).ResultsAutomated analysis identified a small (1.46%), but highly representative fraction of overall A-train activity: Pearson’s correlation coefficient between both values was 0.944 (p < 0.001). Both were correlated with clinical outcome in a highly significant way (p < 0.001) with Spearman’s Rho 0.592 (automated) and 0.563 (visual). Progressive risk development was visualized as an inverse sigmoid curve with traintime on a logarithmic scale.ConclusionsAutomated traintime is a representative and reliable expression for overall A-train activity. As risk-development is complex, rigid thresholds are problematic.SignificanceIndividual risk for postoperative palsy can be estimated on the basis of the calculated curve presented. This approach is of higher practical value than a rigid (and low) threshold.     

Expression of ErbB-1 and 2 in vestibular schwannomas

ErbB-1 and 2 are receptor tyrosine kinases expressed in malignant tumours. Heterodimers of the ErbB family confer aggressive malignant behaviour, but homodimers are regarded as being less active. Using immunohistochemistry and Western blot techniques we have shown an increased expression of ErbB-2 and no expression of ErbB-1 in vestibular schwannomas (VS). Immunoprecipitation of the ErbB-2 in VS showed less activity when compared to glioblastoma multiforme. These findings implicate a functional role of ErbB-2 in the benign nature of VS and that a rationale for using ErbB targeted therapies in VS may be warranted.