巨大侵袭性泌乳素腺瘤溴隐亭治疗后并发脑脊液漏3例报道并文献复习

目的 探讨巨大侵袭性泌乳素腺瘤溴隐亭治疗后发生脑脊液鼻漏的原因及治疗。方法 回顾性分析2015年3月到2019年12月收治的3例巨大侵袭性泌乳素腺瘤溴隐亭治疗后并发脑脊液鼻漏的临床资料。结果 3例均采用经鼻蝶入路神经内镜下垂体腺瘤部分切除+脑脊液漏修补术,其中2例因广泛颅底缺损术后予以腰大池置管引流。1例术后发生短暂性尿崩,另2例未发生与手术相关的并发症。出院后继续口服溴隐亭治疗,术后随访1~5年,均无脑脊液鼻漏、颅内感染,血清泌乳素水平逐渐降至正常,肿瘤体积明显缩小。结论 溴隐亭治疗巨大侵袭性泌乳素腺瘤有并发脑脊液鼻漏的风险,经鼻蝶入路神经内镜下肿瘤部分切除+脑脊液漏修补术是处理该罕见并发症一种较为有效的方法,既可防止该并发症上升为脑膜炎的风险,又可继续药物治疗。     

发生脑脊液鼻漏的垂体腺瘤经蝶手术治疗

目的　介绍发生脑脊液鼻漏的垂体腺瘤的临床特征和经蝶手术治疗方法。方法　分析１９９１ 年至１９９７ 年北京协和医院经蝶手术治疗的５ 例发生脑脊液鼻漏的垂体腺瘤, 并结合文献加以讨论。结果　５ 例中４ 例为巨大型泌乳素腺瘤, １ 例为部分空泡蝶鞍合并垂体无功能腺瘤, ２ 例以脑脊液鼻漏为首发症状。术后随访半年至６ 年, ３ 例肿瘤全切除, ２ 例次全切除, 脑脊液鼻漏均消失。结论垂体腺瘤自发性脑脊液鼻漏可见于巨大型垂体腺瘤; 也可见于合并部分空泡蝶鞍的垂体腺瘤; 放疗、服溴隐亭治疗可促进垂体腺瘤脑脊液鼻漏的发生。经蝶入路是最适手术入路; 肿瘤切除后严密填塞蝶窦是补漏的主要措施; 术后去枕平卧和腰蛛网膜下腔引流有助于所修补漏口的愈合。     

伽玛刀合并溴隐亭治疗巨大垂体腺瘤12例临床分析

目的观察伽玛刀和溴隐亭联合对巨大垂体腺瘤的治疗作用。方法选择临床直径超过3cm的巨大高泌乳素型垂体腺瘤12例给予溴隐亭和伽玛刀治疗。结果所有患者临床症状均获得不同程度的改善。泌乳素大多降至正常水平,肿瘤体积均获得不同程度的缩小,2例半年后复查CT肿瘤完全消失。所有病例均未出现失明、视力下降等恶性并发症的发生。结论溴隐亭联合伽玛刀治疗巨大泌乳素型垂体腺瘤疗效确切,无明显并发症,优于单纯手术治疗。     

溴隐亭治疗侵袭性巨大泌乳素腺瘤的长期随访结果

目的　观察溴隐亭治疗侵袭性巨大泌乳素腺瘤的长期随访结果。方法　纳入侵袭性巨大泌乳素腺瘤 (IGPs)的标准是:⑴肿瘤直径 4cm以上,侵袭海绵窦或邻近其他结构;⑵血浆PRL>200ng/ml;⑶高泌乳素分泌或占位效应引起的临床症状。符合标准者 20例,其中 6例为术后给以溴隐亭治疗,其余 14例首发溴隐亭治疗。11例配合放疗。结果　所有患者临床症状均得到不同程度改善。在平均随访的 37 3个月内肿瘤体积平均缩小 93 3%, 11例肿瘤在MRI上消失。视力下降者除 1例外其余均获得改善(13 /14)。PRL水平控制正常者 8例,大于 200ng/ml者 7例。服药过程中出现脑脊液漏 1例,行经蝶修补。本组在治疗过程中无肿瘤卒中及耐药现象发生。结论　溴隐亭为侵袭性巨大泌乳素腺瘤的首选治疗,能在较短的时间内有效缩小肿瘤体积和控制PRL水平。部分患者服药后肿瘤消失,另一部分患者肿瘤局限后给以立体定向放射外科治疗,从而避免手术风险和手术费用。溴隐亭对控制PRL和缩小肿瘤体积不是同等敏感的。放疗的选择宜慎重。     

男性巨大垂体泌乳素腺瘤的临床特征及手术治疗

目的 探讨男性巨大垂体泌乳素（PRL）腺瘤的临床特征及手术治疗效果。方法 回顾性分析2018年7月~2019年7月手术治疗的8例男性巨大垂体PRL腺瘤的临床资料。结果 术前血清PRL水平在50.8~9 852 ng/ml,平均3 505.6 ng/ml。肿瘤全切除3例,近全切除4例,大部分切除1例。术后血清PRL恢复正常4例。8例术后症状均有好转。结论 男性巨大垂体PRL腺瘤,可首选溴隐亭治疗,若颅内压增高症状明显,可选择手术治疗。术中尽可能全切除肿瘤,保护正常垂体,术后酌情继续应用溴隐亭治疗或放疗。     

垂体瘤与原发性闭经

目的分析垂体泌乳素腺瘤性原发性闭经的临床特点并评价其治疗效果。方法回顾性分析我院1995～2000年收治的5例垂体泌乳素腺瘤引起的原发性闭经患者的临床资料。结果根据肿瘤类型及生长方向分别行经颅或经蝶入路手术,5例垂体瘤次全切除3例(侵蚀型),全切除2例(局限型)。所有患者视力障碍均明显改善,血清PRL水平有不同程度下降,但只有1例患者在术后辅以溴隐亭治疗时有药物依赖性月经。结论此型垂体泌乳素腺瘤侵袭性强,手术治愈率低,术后辅以溴隐亭治疗可提高疗效,增加治愈机会。     

大型及巨大型垂体腺瘤经蝶手术术后脑脊液鼻漏的危险性因素分析

目的探讨大型及巨大型垂体腺瘤经蝶手术后发生脑脊液鼻漏的相关危险性因素。方法回顾性分析592例大型及巨大型垂体腺瘤病人的临床资料,均采取经蝶手术。结果术后发生脑脊液鼻漏26例。肿瘤大小、再次手术、肿瘤的质地和边缘与术后脑脊液鼻漏的发生相关;肿瘤的侵袭性、术前口服溴隐亭和肿瘤的切除程度与术后脑脊液鼻漏无关。脑脊液鼻漏的首次修补成功率为92.9%。26例脑脊液鼻漏病人中,5例发生脑膜炎;4例出现脑积水,行脑室-腹腔分流术缓解。结论巨大垂体腺瘤、再次手术、腺瘤的表面不光滑和质地韧者可能使发生术后脑脊液鼻漏的风险增加。经蝶手术入路是修补此类脑脊液鼻漏的最佳途径。     

溴隐停影响泌乳素垂体腺瘤质地及肿瘤卒中的相关分析

目的分析溴隐停对泌乳素垂体腺瘤的治疗效果及对肿瘤质地的影响和腺瘤卒中的关系。方法回顾性分析我科自2002年1月至2006年1月行手术切除的具有完整影像学、病理学和随访资料的垂体泌乳素腺瘤93例。并且按照术前是否服用过溴隐停分为两组：溴隐停组（49例）和对照组（44例），进行比较研究。结果术中和术后病理发现溴隐停组的肿瘤体积缩小，组织质地较韧，纤维组织较多；对照组的肿瘤质地较稀软，纤维成分较少。两组具有明显差异（P〈0．01）。另外还发现溴隐停组的腺瘤较易发生卒中（P〈0．01）。结论服用溴隐停可以使泌乳素垂体腺瘤体积变小，质地变韧，泌乳素分泌水平下降，临床症状减轻，但可能是肿瘤卒中的潜在诱发因素。     

囊性垂体泌乳素大腺瘤的治疗

目的探讨囊性垂体泌乳素大腺瘤的治疗方法和临床效果。方法回顾性分析33例囊性垂体泌乳素大腺瘤病人的临床资料。采用经单鼻孔蝶窦入路切除肿瘤,根据术后复查血清泌乳素水平决定是否联合溴隐亭综合治疗。结果全切除26例,次全切7例。术后1周复查,血清泌乳素恢复正常19例,14例未恢复正常,联合口服溴隐亭治疗。14例联合药物治疗病人中,11例泌乳素水平恢复正常,余3例泌乳素水平未恢复正常,但均100 ng/ml,临床症状缓解,未行进一步处理。随访时间6~36个月,平均16个月。术后恢复正常未服药19例病人中,5例复发,采取联合药物治疗后泌乳素水平恢复正常。结论经单鼻孔蝶窦入路切除垂体腺瘤具有安全、简便、微创等优点,可以作为囊性泌乳素大腺瘤的首选治疗方式,如单纯手术无法达到内分泌治愈或术后复发,联合溴隐亭综合治疗是一种较为理想的治疗方案。     

未经治疗垂体腺瘤引起的脑脊液鼻漏

脑脊液鼻漏由未经治疗的垂体腺瘤引起者甚为罕见,作者报告一例患者间歇性脑脊液鼻漏十年,一直被诊断为慢性鼻窦炎,后因并发脑膜炎住院检查,经过一系列检查诊断为垂体腺瘤,感染经扰菌素控制后,作经蝶窦入路手术切除肿瘤,手中发现鞍底已消失,可见有一3厘米直径裂孔,鞍内肿块从中突入蝶窦,脑脊液通过肿块流出,肿块经病理检查确定为垂体腺瘤,全切除肿瘤及多次修补漏口,最后治愈.作者复习了文献,在一组109例脑脊液漏的病因分析中,由于肿瘤,主要是垂体腺瘤所致者,为数不到6%,大多数为外伤性或医源性损伤所致.另一组400例垂体腺瘤中,仅9例并发脑脊液鼻漏,此9例均曾经放疗或手术加放疗.未经治疗的垂体腺瘤引起者极为罕见.Nutkiewicz等认为,强韧的     

侵袭性巨大泌乳素腺瘤的综合治疗（附30例报告）

目的探讨侵袭性巨大泌乳素腺瘤的综合治疗方法及临床治疗效果。方法纳入侵袭性巨大泌乳素腺瘤(IGPs)的标准是:(1)肿瘤直径>4cm;(2)血浆PRL>200ng/ml;(3)高泌乳素分泌或占位效应引起的临床症状。并根据治疗方式的不同分为两组:A组常规的先给以手术治疗,术后给以药物治疗和/(或)放疗,本组18例;B组先给以药物治疗,或配合放疗,必要时再给以手术治疗,本组12例。结果A组失访5例,其余13例在平均随访的42.5个月内肿瘤体积平均缩小76.5%,而B组在随访的23个月内肿瘤体积平均缩小91.3%;肿瘤在MRI上消失A组6例,B组4例;PRL水平控制在200ng/ml以内者A组7例(7/13),B组8例(8/12);A组视力改善者2例(2/13),而B组视力改善者6例(6/12);平均治疗费用A组明显为高。结论对侵袭性巨大泌乳素腺瘤,可先给以药物,能有效地缩小肿瘤体积和控制PRL水平,部分病例可以达到治愈的目的,从而避免手术风险,降低治疗费用。     

侵袭性催乳素腺瘤治疗后海绵窦残留或伴空蝶鞍综合征

目的 探讨侵袭性催乳素(PRL)腺瘤经治疗后海绵窦残留伴空蝶鞍综合征的临床特征和治疗策略.方法 18例侵袭性PRL腺瘤(Knosp分级Ⅲ或Ⅳ级)经治疗后出现海绵窦肿瘤持续残留,首选药物治疗者9例,首选手术治疗结合药物和(或)放疗9例.结果 平均随访55个月,8例PRL水平正常,7例视力改善.14例因鞍内肿瘤吸收遗留空蝶鞍,7例PRL仍升高,其中5例有不同程度的视交叉下疝(P<0.05).PRL水平正常、无临床症状的7例患者采用低剂量溴隐亭治疗达到PRL水平和肿瘤体积的长期控制.结论 PRL腺瘤治疗后海绵窦肿瘤残留伴发空蝶鞍,这一现象应该引起高度重视,尤其对伴有视交叉下疝的病例,长期的密切随访是必需的.无内分泌和压迫症状的海绵窦残留病例可以采用低剂量的药物治疗达到长期的肿瘤控制和内分泌控制.     

Comparative analysis of surgical and medical treatment of macroprolactinoma of different localization

The authors performed comparative analysis of results of primary surgical and medical treatment of 306 patients with macroprolactinoma. The series included 178 male and 128 female patients. The tumor was endosellar in 48 cases, endosuprasellar in 94, invaded skull base in 164. The paper demonstrates that according to dynamics of visual function, neurological and hypopituitary symptoms, and probability of prolactin level normalization, treatment with cabergoline has significant advantages in comparison to surgery. Only surgical treatment of endosellar prolactinomas can compete with conservative treatment. After these operations no postoperative complications were observed, normalization of prolactin level was present in 67% of cases, and these results did not differ from results of medical treatment (71%). In case of extrasellar grown of macroprolactinoma, especially invading skull base, primary medical therapy is preferred.     

Antitumor effect of bromocriptine on estrogen-induced rat prolactinomas: special reference to changes in secretory granules by stereological analysis

Bromocriptine (CB) not only lowers serum prolactin (PRL) levels but also reduces tumor size of human prolactinomas. Gen et al and we have suggested that the size reduction of human prolactinomas by bromocriptine treatment results from the reduction in size of individual tumor cell as well as the reduction in number of tumor cells secondary to cell necrosis. This implies that bromocriptine has a cytosuppressive action and possibly a cytocidal action on human prolactinomas which causes reduction in cell size and cell necrosis, respectively. The mechanism of cytosuppressive action of CB has been investigated by using mostly non-neoplastic pituitary tissues of experimental animals. A decrease in exocytosis of secretory granules and a subsequent accumulation of granules within the cells are suggested to cause the reduction in serum levels of PRL in early stage of CB treatment. However we have reported that in spite of a pronounced reduction of serum PRL levels, the number of exocytosis of the granules in human prolactinomas treated with CB for 2 weeks increased to more than 4 times much as that in the untreated prolactinomas. This is a phenomenon which contradictory to the current hypothesis. The present study is intended to clarify whether the phenomenon we observed is specific for human prolactinomas or common also to the prolactinomas in experimental animals. Seventeen female SD rats were used. They were implanted subcutaneously with a pellet of 20 mg of 17 estradiol-benzoate (20% in cholesterol), and left to grow a pituitary tumor for 10 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)     

Multi-Layer Onlay Graft Using Hydroxyapatite Cement Placement without Cerebrospinal Fluid Diversion for Endoscopic Skull Base Reconstruction

ObjectiveThe skull base reconstruction step, which prevents cerebrospinal fluid (CSF) leakage, is one of the most challenging steps in endoscopic skull base surgery (ESS). The purpose of this study was to assess the outcomes and complications of a reconstruction technique for immediate CSF leakage repair using multiple onlay grafts following ESS. MethodsA total of 230 consecutive patients who underwent skull base reconstruction using multiple onlay grafts with fibrin sealant patch (FSP), hydroxyapatite cement (HAC), and pedicled nasoseptal flap (PNF) for high-flow CSF leakage following ESS at three institutions were enrolled. We retrospectively reviewed the medical and radiological records to analyze the preoperative features and postoperative results. ResultsThe diagnoses included craniopharyngioma (46.8%), meningioma (34.0%), pituitary adenoma (5.3%), chordoma (1.6%), Rathke’s cleft cyst (1.1%) and others (n=21, 11.2%). The trans-planum/tuberculum approach (94.3%) was the most commonly adapted surgical method, followed by the trans-sellar and transclival approaches. The third ventricle was opened in 78 patients (41.5%). Lumbar CSF drainage was not performed postoperatively in any of the patients. Postoperative CSF leakage occurred in four patients (1.7%) due to technical mistakes and were repaired with the same technique. However, postoperative meningitis occurred in 13.5% (n=31) of the patients, but no microorganisms were identified. The median latency to the diagnosis of meningitis was 8 days (range, 2–38). CSF leakage was the unique risk factor for postoperative meningitis (p<0.001). ConclusionThe use of multiple onlay grafts with FSP, HAC, and PNF is a reliable reconstruction technique that provides immediate and complete CSF leakage repair and mucosal grafting on the skull base without the need to harvest autologous tissue or perform postoperative CSF diversion. However, postoperative meningitis should be monitored carefully.     

外伤性颅底骨折所致脑脊液漏的处理及预后因素分析

目的分析影响外伤性颅底骨折所致脑脊液漏愈合的相关因素,以探索外伤性脑脊液漏更好的治疗策略。方法回顾性分析2000年2月至2009年4月期间收治的外伤后颅底骨折所致的脑脊液漏患者的临床资料,收集患者基本信息,入院时GCS评分,脑脊液漏的类型(鼻漏、耳漏)、治疗方式(保守治疗、腰大池引流、手术),有无颅内感染、脑脊液漏预后状况等相关临床资料,采用SPSS软件统计分析可能影响脑脊液漏愈合的相关因素。结果 83例脑脊液漏患者中,男性患者55名,女性患者28名,年龄16~73岁,平均43.8±17.3岁。其中11例患者因颅内合并伤(颅内血肿、神经损伤等)、广泛性颅底骨折、严重的脑脊液漏等行急诊手术治疗,39例患者采用保守治疗脑脊液漏愈合,31例采用腰大池置管引流愈合,2例经保守观察及腰大池引流治疗后仍未治愈行开颅手术修补后愈合。治疗效果满意,无死亡病例,仅1例颅内感染病例。影响脑脊液漏愈合相关因素包括:患者年龄、入院时GCS评分、脑脊液漏的类型。结论多数外伤性脑脊液漏经保守治疗或腰大池置管引流治疗后可愈合,因合并伤需要手术、颅骨广泛性骨折、脑脊液漏严重者需尽早手术治疗。     

Incidence of cerebrospinal fluid leak following petrosectomy and analysis of avoidance techniques

A cerebrospinal fluid (CSF) leak following skull base surgery can lead to meningitis, impaired wound healing, and often requires re-operation and/or CSF diversion. Thirty-two patients underwent a presigmoid, transpetrosal approach to skull base aneurysms and tumors. A vascularized temporalis muscle flap was utilized during the closure of the initial skull base reconstruction in 18 of the 32 patients. A temporary CSF diversion was utilized in 23 of the 32 patients. A permanent shunt was placed in eight patients. One patient developed a postoperative CSF leak from the contralateral ear due to a congenital abnormality in the middle ear. Another patient, who did not have a vascularized temporalis muscle flap reconstruction, developed a postoperative CSF leak in the context of an operation for recurrent tumor and prior radiation treatment. CSF diversion and vascularized temporalis muscle flaps are effective in preventing the development of postoperative CSF leaks following petrosectomy.     

颅前窝内外沟通性肿瘤切除术后的颅底重建

目的总结手术切除颅前窝内外沟通性肿瘤后颅底重建的方法。方法回顾性分析21例颅底肿瘤切除术后的颅底重建经验。对颅底小缺损（〈1.0cm×1.5cm）,行颞肌筋膜修补7例;对颅骨大缺损（≥1.0cm×1.5cm）,采用“四步法”行颅底重建：第一步取自体脂肪填塞肿瘤切除后的残腔;第二步用带血管蒂骨膜瓣覆盖颅底骨缺损,边缘严密缝合于周围硬脑膜;第三步用自体骨或钛板等颅骨修补材料修补骨缺损;第四步取自体筋膜修补硬脑膜;本组14例。结果颅底缺损修补均获得满意效果。术后脑脊液漏1例,经腰穿置管引流后痊愈。术后3个月出现局部感染1例,经抗炎治疗后缓解。无局部脑膨出、脑膜炎等并发症发生。结论“四步法”重建颅底简单易行,能有效预防脑脊液漏、局部脑膨出和脑膜炎等并发症的发生。     

经鼻蝶入路脑脊液漏修补方法进展

随着显微及内镜技术的发展,经鼻蝶入路可用于前颅底外伤、肿瘤、鞍区占位及三脑室、中上斜坡病变的治疗[1].经鼻蝶人路的手术切口更小,术后恢复更好;但其造成的前颅底完整性破坏常导致术后脑脊液(CSF)漏的发生.文献报道经鼻蝶人路手术中CSF漏的发生率在15％-30％[2].前颅底完整性的修补关系到患者的术后恢复;CSF漏作...     

Non-surgical management of cystic prolactinomas

Cystic prolactinomas are considered not amenable to dopamine agonist therapy. We present the results of dopamine agonist therapy in six patients with cystic prolactinomas. The inclusion criteria of patients were: (i) cystic macroadenomas with the cyst occupying more than 50% of the tumour volume; (ii) a serum prolactin value more than 150 ng/mL. All patients were males with a mean age of 35 years. The clinical presentations were erectile dysfunction in 66.6%, visual deficits in 50% and headache in 50% of patients. All patients were treated with bromocriptine only except one who was treated with both bromocriptine and cabergoline. The mean duration of follow up was 57.1 months. At the final follow-up 50% of patients had hormonal cure, 50% had radiological cure and 50% had reduction in the size of the tumour. Hence, it is appropriate to consider dopamine agonist therapy in patients with cystic prolactinomas before considering surgery.