复发性颅咽管瘤的手术治疗

目的　探讨复发性颅咽管瘤的手术治疗方法。方法　回顾性分析 4 0例复发性颅咽管瘤患者的临床资料。其中男 2 4例 ,女 16例 ,平均年龄 35 1岁。主要临床表现 :视力减退 2 5例 ,头痛9例 ,视野缺损 2例 ,闭经 2例 ,性欲减退 1例 ,多饮多尿 1例。平均复发时间 2 9年。 32例为手术后肿瘤残留复发 ,8例为手术肿瘤全切除后复发。肿瘤位于鞍上 19例 ,鞍上 鞍下 9例 ,鞍下 5例 ,第三脑室者 7例。囊性肿瘤 2 1例 ,实性 19例。钙化者 2 7例 ,其中大块样钙化 ( >2cm)者 5例。有脑积水者 12例。手术采用翼点入路 33例 ,额下入路 5例 ,纵裂经胼胝体入路 2例。结果　经翼点入路 33例中 ,2 2例全切除 ,近全切除 9例 ,大部切除 2例。额下入路 5例 ,4例全切除 ,1例近全切除。纵裂胼胝体前部入路 2例中 1例肿瘤全切除 ,1例近全切除。术中垂体柄保留 8例 ,术中断裂 9例 ,术中未见垂体柄 2 3例。术后多饮多尿 17例 ,下丘脑功能低下 12例 ,术后 35d因下丘脑功能低下死亡 1例。随访 3个月～ 3年 ,2 2例患者正常生活和工作 ,11例患者可做轻工作或生活自理 ,6例患者生活需要照顾。结论　虽然复发性颅咽管瘤与周围下丘脑结构有不同程度的粘连 ,但是多数复发性颅咽管瘤患者手术治疗仍可达到良好的效果     

颅咽管瘤显微外科手术62例分析

目的 探讨颅咽管瘤显微外科手术的临床效果. 方法 应用显微外科手术切除颅咽管瘤62例,其中翼点入路19例、额下入路25例、经胼胝体入路11例、经蝶入路7例,根据临床、影像学术后随访结果分析临床效果.结果 手术全切除37例,垂体柄完全保留19例,肿瘤复发1例,死亡1例;手术部分切除25例,垂体柄完全保留24例,肿瘤复发5例,死亡1例. 结论 应用显微外科手术,选择合理的手术入路,可以改善肿瘤全切除率、垂体柄的保留率,减少复发率以及并发症的发生.     

经眶上翼点入路显微手术切除巨大鞍区肿瘤

目的 总结经眶上翼点入路显微手术切巨大鞍区肿瘤的经验。方法 经上翼点入路显微手术切除巨大鞍区肿瘤18例,其中垂体腺瘤7例,颅咽管瘤8例,生殖细胞瘤、脑膜瘤、成熟性畸胎瘤各1例。结果 肿瘤全切除12例,次全切除6例。术后随访4－23个月,恢复良好12例,生活自理3例,生活需人照顾2例,死亡1例。结论 眶上翼点入路能很好地显露鞍区 肿瘤及其周围结构,显微手术是安全切除肿瘤、保护下丘脑功能的关键。     

颅咽管瘤显微手术中垂体柄辨认和保留的研究

目的 探讨颅咽管瘤术中垂体柄辨认和保留的重要性.方法回顾显微外科手术治疗颅咽管瘤69例的临床资料,对肿瘤的临床表现、内分泌学和影像学特点、肿瘤切除程度、术中垂体柄的辨认和保留情况、术后随访进行系统分析.结果 肿瘤全切除50例(72.5%),次全切除13例(18.8%),部分切除6例(8.7%);术中能发现和辨认出垂体柄57例(82.6%),垂体柄完整保留41例(59.4%),部分保留9例(13.0%),垂体柄保留率为72.5%.结论 结合术前影像、肿瘤分型、垂体柄的特征,颅咽管瘤术中垂体柄能够辨认和得到保留,对术后远期生活质量提高具有重要意义.     

经眶-额-颞入路显微手术切除颅咽管瘤

目的 总结经眶-额-颞入路显微手术切除颅咽管瘤的经验,探索肿瘤全切除的手术技巧。方法 采用经眶-额-颞入路显微手术切除颅咽管瘤18例。肿瘤位于鞍上7例、鞍上-第三脑室6例、鞍上-鞍内4例、第三脑室1例。12例肿瘤有钙化、13例囊性变、5例完全实质性。术中根据肿瘤的生长方向,分别从不同的间隙切除肿瘤。结果 肿瘤全切除14例,次全切除2例,部分切除2例。术后17例患者获随访,随访时间8～41个月。肿瘤全切除的14例未见肿瘤复发;次全切除和部分切除的3例于术后1个月内行辅助放疗,在随访期间肿瘤未见明显增大。Karnofsky预后评分(KPS)80～90分12例,60～70分5例,50分1例,无一例死亡。结论 经眶-额-颞入路能清楚地显露鞍区颅咽管瘤及其周围结构,减少对脑组织的牵拉和无效脑暴露。显微手术技巧是安全切除肿瘤、避免穿通动脉损伤和保护下丘脑功能的重要保障,也是手术成败的关键。     

颅咽管瘤全切除术

目的 探索手术全切除颅咽管瘤的有效方法。方法 ３０例颅咽管瘤患者,肿瘤位于鞍上者１７例,进入第三脑内者１１例,鞍上鞍内者２例。肿瘤钙化１８例,肿瘤完全囊性变者５例,部分囊性变得１７例,完全实性者８例;肿瘤直径２．０－６．０ｃｍ,平均３．３４ｃｍ。均在全麻下翼点入路,术中根据肿瘤位置,从视交叉前间隙,视神经外侧间隙和颈内动外侧间隙切除术肿瘤。术中除注意第三脑室底神经结构保护外,应防止从颈内动脉、后交     

经蝶窦入路显微手术切除小儿颅咽管瘤

目的 探讨经蝶窦入路切除小儿颅咽管瘤的手术技巧及适应证。方法 10例接受了11次经蝶窦手术,10次采用唇下－鼻中隔－蝶窦入路,1次采用鼻外侧－筛窦－蝶窦入路,在X线透视监测及显微放大10－15倍下切除肿瘤,对未能全切除病例术后加后放疗1个疗程。结果 无死亡、 无严重并发症,全切除4例,次全切除4例,部分切除2例,其中1例残瘤病例再次经蝶窦手术获得全切除。随访3个月－9年,肿瘤消失5例,残瘤静止4例,1例复发。结论 小儿颅咽管瘤局限于鞍内或伴蝶窦扩大的鞍内 －鞍上型可经蝶窦手术,但钙化明显的肿瘤经该入路难以获得令人满意的切除。     

内镜辅助眶上锁孔入路切除颅咽管瘤手术方法及术后护理对策

目的:总结内镜辅助眶上锁孔入路显微手术切除颅咽管瘤方法及术后护理对策.方法:采用眶上锁孔入路,内镜辅助显微技术切除颅咽管瘤11例.其中鞍内-鞍上型2例,鞍上-视定叉周围-脑室外型8例,脑室内-外型1例.结果:术后复查MRI,肿瘤全切除8例,次全切除3例,残余瘤体给予放疗,无手术死亡.随访3个月-2.3年,肿瘤复发1例.颅咽管瘤术前原有症状均有明显不同程度的好转.结论:内镜辅助眶上锁孔入路能清楚显露颅咽管瘤与周围结构的关系,提高了显微手术的精细度与安全性,及时有效的术后护理,提高了疾病的治愈率,防止并发症的发生.     

颅咽管瘤的手术治疗和复发因素分析

目的探讨颅咽管瘤的手术策略和治疗效果以及影响肿瘤复发的因素。方法回顾性分析我经手术治疗的375例颅咽管瘤病人的临床资料,分析和评价不同类型的颅咽管瘤的手术方式、治疗效果和复发情况。结果 375例颅咽管瘤病人中,鞍上型218例,鞍内型43例,三脑室内114例。手术入路选择:经典开颅翼点或额下入路288例,经鼻蝶入路46例,经纵裂胼胝体前入路23例,经皮层脑室入路17例,联合入路1例。经术中观察和术后影像学证实全切272例,次全切103例。术后病人症状改善356例,效果不佳19例,其中死亡5例。结论颅咽管瘤应根据生长方式和特点选择个体化的手术治疗方式。在保护垂体-下丘脑功能基础上的肿瘤的全切仍然是降低复发获得良好预后的关键。     

经蝶入路显微外科切除颅咽管瘤适应证选择与操作要点

有关颅咽管瘤的手术一直是神经外科医师最感困惑的问题。本文报道经蝶显微手术切除颅咽管瘤18例,均经CT或MRI扫描确诊。本入路适用起源于鞍底或向鞍上扩展的肿物。手术采取经唇下-鼻中隔-蝶窦入路或经鼻前庭-鼻中隔-蝶窦入路两种方式行肿瘤切除术。9例肿瘤获得全切除,4例次全切除,其余5例为部分切除,术后无死亡。15例获长期(平均3.1年)随访,有12例(80.0％)恢复良好,3例影像学检查提示肿瘤复发,需行再次手术,放疗或放射外科治疗。文中对颅咽管瘤手术适应证选择及操作要点进行了讨论。     

Operative outcomes and adjuvant treatment of purely third ventricle craniopharyngioma after a transcallosal approach

We reviewed four surgical cases of purely third ventricle craniopharyngioma, focusing on surgical outcomes and adjuvant treatments. From 2002 to 2008, we performed surgical treatments, via a transcallosal transforaminal approach, on four patients. All were males, with a median age of 42 (36-45) years. Most patients complained of headaches, while two (50%) patients presented with visual disturbances, and one (25%) presented with an endocrinological disturbance. Patients' follow-up periods ranged from 1.6 to 8.6 years. We totally removed the tumor in each of the four patients. The tumors originated in the infundibulum of the third ventricular floor. The pituitary stalk was anatomically preserved. The histopathological findings showed the adamantinomatous type of craniopharyngioma in all patients. Postoperatively, two patients who had experienced visual disturbances showed improvement, and there was no aggravation. Two patients had intact pituitary functioning, while two needed complete hormone replacement. The patients experienced no surgery-related complications. Two patients experienced recurrences 4.5 and 1.6 years later. One patient received gamma knife surgery for the recurred lesion, which controlled the lesion well. Purely third ventricle craniopharyngioma showed good visual and endocrinological outcomes after surgery. Gamma knife surgery could be of help in the event of a recurred lesion.     

Extended transsphenoidal surgery for suprasellar craniopharyngiomas: infrachiasmatic radical resection combined with or without a suprachiasmatic trans-lamina terminalis approach

BACKGROUND: An extended transsphenoidal approach allowed for direct midline exposure of the parasellar structures such as the hypothalamic-pituitary axis and the third ventricle. To evaluate the capability of this approach for removal of suprasellar craniopharyngiomas, surgical outcomes were retrospectively analyzed. METHODS: During a 9-year period, 20 consecutive patients with suprasellar craniopharyngioma underwent transsphenoidal tumor resection. The average follow-up period was 55 months. No patient had a purely intrasellar tumor, 9 had prechiasmatic tumors, 9 had retrochiasmatic tumors, and 2 had purely intraventricular tumors. RESULTS: Total resection was achieved in 86% of operations. Even in mostly intraventricular cases, a transsphenoidal trans-lamina terminalis approach afforded complete resection. Visual improvement and preservation of the pituitary stalk were achieved in 84% and 95% of cases, respectively. New postoperative deterioration of pituitary function occurred in about 65% of cases, and no patient resolved their preoperative hormonal disturbance after surgery. The overall percentage of patients with diabetes insipidus increased to 61% postoperatively from 11% preoperatively. Nonendocrinologic surgical complications were observed: worsening of vision in 3 patients, hyperphagia in 3 patients, short-term memory loss in 2 patients, and cerebrospinal fluid leakage in 3 patients. Recurrence after total resection occurred in 2 (11%) patients with retrochiasmatic tumors. CONCLUSIONS: Reasonable surgical results in this study suggest that the extended transsphenoidal approach is safe and effective for removal of craniopharyngiomas. Although preservation of the pituitary stalk can be achieved in a high percentage of patients, postoperative endocrinopathy still remains as a significant problem after radical removal of the craniopharyngioma.     

Radical intracapsular removal of acoustic neurinomas. Long-term follow-up review of 11 patients

Historically, the neurosurgical treatment of large acoustic neurinomas has developed with two principal goals: complete tumor removal and preservation of facial nerve function. A recent goal for small tumors is the preservation of hearing. Out of a personal series of 124 acoustic neurinomas treated over the past 35 years, the senior author has undertaken a radical intracapsular approach in 12 patients with large tumors (greater than 3 cm in diameter). Surgical indications for intracapsular removal included advanced age (five cases), the patient's wish to avoid any risk of facial paralysis (six cases), contralateral facial palsy (one case), and contralateral deafness (one case). Eleven of these 12 patients were available for follow-up review. Tumor recurrence developed in two patients (18%) at 2 and 3 years postoperatively; there were no late recurrences. Four patients died of unrelated causes, 10 to 19 years after surgery. The remaining five patients have survived a mean of 12 years since surgery without recurrence (range 3 to 22 years). Facial function was preserved in nine patients (82%). The results suggest that radical intracapsular removal may be the procedure of choice under certain circumstances and may offer an alternative to focused high-energy radiation.     

Postoperative intracranial seeding of craniopharyngioma. Three case reports and a review of the literature

Metastasis of craniopharyngioma is uncommon. Only 10 cases have been reported in the literature. In this report, we describe 3 patients who presented metastases following operative treatment of suprasellar craniopharyngioma. All 3 patients (ages: 32, 11, and 9 years) underwent radical excision of a supradiaphragmatic, retrochiasmatic craniopharyngioma by the right frontopterional approach. Resection was considered as total in all cases. All patients required hormone replacement therapy. Local recurrence was observed in only one case. Metastasis occurred along the surgical route in all three patients. The interval between surgery and metastasis was 5 and 3 years in the first two cases. The third patient presented two metastases: one in the temporal space at 3 years and another in the frontal space at 10 years. Repeat surgery was performed in 2 patients. The first case involved a lesion located in the right frontal space, and the second involved local recurrence and metastasis along the surgical route. The third patient was treated by puncture and radiation therapy for the temporal lesion and surveillance for the frontal lesions. No recurrence has been observed at 2 and 7 years after re-operation. Although rare, metastasis of craniopharyngioma has been reported up to 21 years after resection of the primary tumor. Metastasis often occurs along the surgical route, as in our 3 cases, but spreading to distant locations via cerebrospinal fluid has been observed. Regular follow-up is necessary, even after supposedly total resection.     

Eyelid approach to the anterior cranial base

Skull base approaches play a fundamental role in modern neurosurgery by reducing surgical morbidity. Increasing experience has allowed surgeons to perform minimally invasive approaches without straying from the premises of skull base surgery. The eyelid approach has evolved from the orbitopterional osteotomy into a more effective and targeted approach to disease of the anterior cranial fossa. In this technique, after an incision is made on the supratarsal fold, the orbicularis oculi muscle is incised, and a myocutaneous flap composed of the elements of the anterior lamella is elevated. Subperiosteal dissection is used to expose the superior and lateral walls of the orbit, the superior and lateral orbital rim, and the frontosphenoidal suture. A MacCarty bur hole is drilled, and a frontal osteotomy is fashioned medial to the supraorbital notch and extending through the orbital roof back toward the orbital half of the MacCarty bur hole, exposing the frontobasal brain. A conventional microsurgical technique is used to treat tumors and aneurysms of the anterior cranial fossa under the operative microscope. Five patients were treated for unruptured aneurysms of the anterior circulation (3 anterior communicating artery aneurysms, 1 ophthalmic artery aneurysm, and 1 posterior communicating artery aneurysm) using the eyelid approach. The mean aneurysm size was 5 mm, and all aneurysms were approached from the right side. Three tumors in the anterior fossa (2 suprasellar pituitary adenomas and 1 craniopharyngioma) were also excised using this approach. There was no surgical morbidity. Three months after surgery all patients presented excellent cosmetic results. The eyelid approach may be considered as an effective, cosmetically beneficial, and minimally invasive skull base approach to selected aneurysms and tumors of the anterior circulation.     

Far-lateral approach to intradural lesions of the foramen magnum without resection of the occipital condyle

OBJECT: The goal of this study was to determine whether drilling out the occipital condyle facilitates surgery via the far-lateral approach by comparing data from 10 clinical cases with that from studies of eight cadaver heads. METHODS: During the last 6 years at Louisiana State University Health Sciences Center-Shreveport, 10 patients underwent surgery via the far-lateral approach to the foramen magnum. Six of these patients harbored anterior foramen magnum meningiomas, one patient a dermoid cyst, two patients vertebral artery (VA) aneurysms, and an additional patient suffered from rheumatoid disease of the craniocervical junction. The surgical approach consisted of retromastoid craniectomy and C-1 laminectomy. The seven tumors and the pannus of rheumatoid disease were completely excised, and the two aneurysms were clipped without drilling the occipital condyle. In one patient a chronic subdural hematoma was found 3 months after surgery, but no patient displayed any complication associated with surgery. It is significant that in no patient was a cerebrospinal fluid leak present. All patients experienced improved neurological function postoperatively. To compare surgical visibility, eight cadaveric specimens (16 sides) were studied, including delineation of the VA and its segments around the craniocervical junction. Increase in visibility as a function of fractional removal of the occipital condyle was quantified by measuring the degrees of visibility gained by removing one third and one half of the occipital condyle. Removal of one third of the occipital condyle produced a mean increase of 15.9 degrees visibility, and removal of one half produced a mean increase of 19.9 degrees. CONCLUSIONS: On the basis of their findings the authors conclude that removal of the occipital condyle is not necessary for the safe and complete resection of anterior intradural foramen magnum tumors.     

Surgical management of the recurrence and regrowth of craniopharyngiomas

OBJECT: The authors performed a retrospective analysis of a consecutive series of craniopharyngiomas and their recurrences, which were managed with surgery alone. METHODS: In the past 20 years, 37 consecutive patients with craniopharyngiomas underwent surgery without adjuvant radiotherapy. During that period there was a consistent strategy that surgical management was the first choice of treatment whenever possible. Of these 37 patients, 11 experienced tumor recurrence (29.7%) during the mean follow-up period of 11.1 years. Of these 11 patients, seven experienced recurrence after neuroimaging-confirmed total removal, and four patients experienced recurrence after partial or incomplete removal. In these 11 patients, surgical removal was performed 17 times. Using a proper surgical approach (mainly a basal interhemispheric approach) and meticulous microsurgical techniques, total removal of the recurrent tumor was achieved in nine surgeries (52.9). The mortality and morbidity rates associated with these 17 surgeries were 0% and 9.1%, respectively. In most cases, visual function was preserved or improved and intellectual performance was also preserved. CONCLUSIONS: Recurrence of craniopharyngioma can be safely managed by using meticulous contemporary microsurgical techniques without additional radiotherapy. The role of surgery and adjuvant radiotherapy for craniopharyngiomas may vary in the future, depending on innovations in treatment and technology. Nevertheless, surgery can be still a major therapeutic option in the management of recurrent craniopharyngiomas.