岩静脉在桥脑小脑角肿瘤显微手术中的临床意义

目的探讨岩静脉在桥脑小脑角肿瘤显微手术中的临床意义。方法以2004年12月至2006年3月进行的桥脑小脑角肿瘤显微手术33例为观察对象，其中2例手术中岩静脉撕裂被电凝处理，31例保护良好。结果31例岩静脉保护好的手术后没有发生小脑出血性梗塞，2例电凝处理岩静脉的术后都发生小脑出血性梗塞并水肿，其中1例死亡，1例恢复良好。结论岩静脉在桥脑小脑角显微手术中应尽可能保护良好，若被处理则需在手术后做好再次后颅窝减压手术的准备。     

脑干肿瘤的显微手术治疗体会

目的 :总结 1 0例脑干肿瘤进行 1 0次显微手术的经验。方法 :根据肿瘤生长部位及方向不同选择不同的入路。肿瘤位于延脑突向IV脑室者取后颅窝枕下中线开颅 ,切开小脑蚓部 ;突向桥小脑角者选择单侧乳突后入路 ,切除部分小脑。手术在显微镜下直视瘤内小块切除。结果 :8例获得较好的疗效。随访 5个月～ 2年半。 3例恢复工作、学习 ,2例生活自理 ,3例需人照料 ,恢复过程良好 ,术后死亡 2例。结论 :脑干肿瘤积极手术治疗是获得良好疗效的关键 ,MRI是脑干肿瘤首选的检查方法。术后并发症防治至关重要。     

大型听神经瘤的手术治疗和显微手术技巧

目的探讨大型听神经瘤与毗邻神经、血管的关系，并对全切肿瘤的显微外科技巧进行讨论。方法回顾性分析经显微外科手术治疗的大型听神经瘤63例，对听神经瘤的供血来源、与颅神经及重要血管结构的解剖关系、肿瘤全切除的手术技巧进行分析。结果63例听神经瘤均有小脑前下动脉分支参与供血；术中发现面神经绝大多数位于肿瘤的前方（占84．1％），其中面神经位于听神经瘤前上方13例，正前方31例，前下方9例。术中面神经解剖保留51例（81％），肿瘤全切53例（84．1％）。结论掌握听神经的显微解剖特征和手术技巧对全切除听神经瘤和颅神经功能保护具有重要的意义。     

幕下小脑上锁孔入路显微手术切除松果体区肿瘤

目的探讨幕下小脑上锁孔入路显微手术切除松果体区肿瘤的可行性和安全性。方法依据术前神经影像学检查结果,制定个体化手术方案．采用经幕下小脑上锁孔入路,显微手术切除病变7例。骨窗大小约2．0 cm×2．5 cm,上缘达横窦和窦汇下缘。结果7例中,胚生殖细胞瘤2例；松果体细胞瘤2例；松果体母细胞瘤1例；胶质瘤1例；胆脂瘤1例。术后均行MRI检查,肿瘤全切除6例,1例次全切除。并发术后小脑肿胀、脑积水1例,再次行手术减压；1例术后出现一过性缄默及凝视；无死亡、感染及术后出血病例。近期随访效果良好。结论应用幕下小脑上锁孔入路显微手术切除松果体区肿瘤不仅可取得满意的切除率,而且手术创伤小、疗效好。     

第四脑室肿瘤的显微手术治疗

目的探讨第四脑室肿瘤的显微手术方法. 方法 2000年1月～2003年6月我院对29例第四脑室肿瘤采用显微手术治疗,5例因肿瘤侵犯上蚓,瘤体接近皮层部采用小脑蚓部入路,余24例均经小脑延髓裂入路,显微手术切除肿瘤. 结果肿瘤全切除23例,次全切除6例.术后并发症:上消化道出血2例,小脑缄默征1例,第四脑室血肿1例,远隔部位硬膜外血肿1例,呼吸不规则1例.19例随访3～12个月,平均5.5月,肿瘤无复发. 结论术前正确判断肿瘤性质及其基底部所在位置,选择适当的手术入路,熟练掌握第四脑室的显微解剖是手术成功的关键.     

三维个体化数字解剖技术在脑桥小脑角肿瘤显微手术中的应用

目的 总结桥小脑角肿瘤21例患者,借助三维个体化数字解剖技术行乙状窦后入路显微手术的临床经验,评价该技术在处理桥小脑角肿瘤的应用价值. 方法 2011年1月至2011年11月共收治桥小脑角肿瘤21例,术前行薄层CTA扫描,数据经3Dview软件重建局部结构,根据解剖标志物设计个体化骨窗范围,术中根据三维个体化解剖模型制作骨瓣及制定显微手术方案行乙状窦后入路显微手术. 结果 所有病例骨瓣均一次成型并复位,无入路相关并发症,术野暴露良好,复位的骨瓣在随访中愈合良好.术后随访3～12个月,均行CT及MRI检查,无1例出现脑脊液漏或皮下积液,无1例出现手术入路相关并发症.术后CT检查均显示骨瓣无移位,并且骨瓣生长良好,三维重建更直观显示颅骨固定及愈合情况. 结论 根据三维个体化解剖技术施行桥小脑角肿瘤的显微手术,能减少术后相关并发症发生.     

经乙状窦后入路显微手术治疗继发性三叉神经痛37例

目的探讨经乙状窦后入路显微手术治疗桥小脑角占位性病变引起的继发性三叉神经痛的疗效。方法回顾分析我院2000年10月～2006年7月37例继发性三叉神经痛的临床资料，其中胆脂瘤18例，脑膜瘤8例，听神经瘤6例，三叉神经鞘瘤5例，均经乙状窦后入路显微手术切除肿瘤。结果肿瘤全切23例，次全切除10例，部分切除4例。35例疼痛症状消失（32例立即消失，3例术后2个月消失），随访3个月～5年无复发；2例无效。发生暂时性面瘫6例，面部麻木6例，无颅内感染及脑脊液漏。结论经乙状窦后入路显微手术是治疗继发性三叉神经痛安全有效的方法。     

脑干肿瘤的显微手术治疗

目的：总结１５例脑干肿瘤进行１６次显微手术的经验。方法：根据肿瘤生长部位及方向不同选择不同的入路。肿瘤位于延脑突向ＩＶ脑室取后颅窝枕下中线开颅，切开小脑蚓部；突向桥小脑血者选择单侧乳突后入路，切除部分小脑。手术在显微镜下直视瘤内分小块切除。结果：１０例获得较好的疗效。随访５个月至２年半。３例恢复工作、学习，３例生活自理，４例需人照料，恢复过程良好。结论：选择手术入路是成功的关键，ＭＲＩ是脑干肿瘤首     

无牵拉技术在听神经瘤切除术的应用及术中面听神经保护策略

正对于听神经瘤的手术治疗,无论其大小,保护面听神经的功能应放在首位[1-4]。无牵开器切除听神经瘤技术可减轻小脑水肿等术后并发症,有利于面听神经保护。采用无牵拉(无牵开器)切除听神经瘤,即原则上不使用脑压板牵开脑组织,术中使用器械(如吸引器、双极与弹簧剪等)进行动态牵拉,暴露肿瘤的同时进行切除。使用脑压板牵拉小脑的传统听神经瘤暴露技术,因其存在固定、静态的牵拉,可能导致接触面脑组织长时间受压产生局部缺血、梗塞,术后水肿明显[5-6];     

听神经瘤膜性结构与坐位显微手术的关系

听神经瘤是源于前庭神经的良性肿瘤,绝大多数肿瘤位于桥小脑角附近。对于临床症状明显,随访中肿瘤逐渐增大,压迫周围脑组织的听神经瘤,目前最好的治疗方式是手术治疗。由于桥小脑角神经、血管丰富,如何完整切除肿瘤又避免对周围脑组织、神经、血管损伤是手术治疗的关键。随着对听神经瘤周围膜性结构的深入研究,我们认为,了解听神经瘤周围膜性结构的组成及其与肿瘤的关系,利用其膜性结构在手术中的特点,通过一定技巧保护所有术中膜样组织,可能是既能尽量完整切除肿瘤组织,又避免对肿瘤周围组织造成伤害导致术后神经功能缺失的重要环节,利用听神经瘤膜性组织可能是切除听神经瘤的重要方式。     

Postoperative radiographic findings following acoustic neuroma removal

This paper assesses the radiographic findings seen on early postoperative CT following acoustic neuroma resection. CT head scans were routinely obtained from 86 patients within 24 hours of tumor resection via a translabyrinthine or retrosigmoid approach. Repeat CT scans were performed in those patients with abnormal clinical symptoms. The abnormalities seen on postoperative CT included cerebellar hematoma (nine patients), cerebral and/or cerebellar infarction (six patients), CSF leak at the incision (two patients), subdural hematoma (two patients), hydrocephalus (one patient), and residual acoustic neuroma (two patients). An unexpected CT finding was ipsilateral temporal lobe lucency, suggesting venous edema, ischemia, and/or infarction in 16% (14/86) of patients. Overall, the clinical complication rate was 8%, and subclinical CT abnormalities were seen in 17% of patients. Temporal lobe venous edema, ischemia, or infarction is a complication of translabyrinthine resection of acoustic neuroma and is thought to be due to obstruction of an inferior temporal lobe draining vein. Some cases may be related to intraoperative interruption of the superior petrosal sinus or petrosal vein, and/or coagulation of the sigmoid sinus dural margins, interruption of an inferior temporal vein, or venous hypotension. Care in dealing with the superior petrosal and sigmoid sinuses at surgery is needed.     

Postoperative Radiographic Findings Following Acoustic Neuroma Removal

This paper assesses the radiographic findings seen on early postoperative CT following acoustic neuroma resection. CT head scans were routinely obtained from 86 patients within 24 hours of tumor resection via a translabyrinthine or retrosigmoid approach. Repeat CT scans were performed in those patients with abnormal clinical symptoms. The abnormalities seen on postoperative CT included cerebellar hematoma (nine patients), cerebral and/or cerebellar infarction (six patients), CSF leak at the incision (two patients), subdural hematoma (two patients), hydrocephalus (one patient), and residual acoustic neuroma (two patients). An unexpected CT finding was ipsilateral temporal lobe lucency, suggesting venous edema, ischemia, and/or infarction in 16% (14/86) of patients. Overall, the clinical complication rate was 8%, and subclinical CT abnormalities were seen in 17% of patients. Temporal lobe venous edema, ischemia, or infarction is a complication of translabyrinthine resection of acoustic neuroma and is thought to be due to obstruction of an inferior temporal lobe draining vein. Some cases may be related to intraoperative interruption of the superior petrosal sinus or petrosal vein, and/or coagulation of the sigmoid sinus dural margins, interruption of an inferior temporal vein, or venous hypotension. Care in dealing with the superior petrosal and sigmoid sinuses at surgery is needed.     

Surgical exposure in retrosigmoid approach: do we need cerebellar retractors?

BACKGROUND: The aim of this study was to present our technique of posterior fossa surgery and to evaluate whether cerebellar retractors are needed. METHODS: Since March 1989, more than 500 surgeries were performed through retrosigmoid approach, and our surgical technique was described. The data were evaluated whether or not cerebellar retractors were used in the operations. RESULTS: The surgeries were vestibular neurectomy, acoustic neuroma removal, and neurovascular decompression in 351, 135, and 14 patients, respectively. Cerebellar retractors have not been used in vestibular neurectomies and in most acoustic neuroma surgeries. The cerebellar retractors have been used in all of the neurovascular decompression surgeries where better exposure of the root entry zones of the cranial nerves is needed, and intracranial endoscopy is applied for further exposure and decompression of the vascular loop. CONCLUSION: There is no need for cerebellar retractors when adequate conditions such as patient positioning, adequate anesthesia techniques, and surgical manipulations are applied in posterior fossa approach except for neurovascular decompression and some of the acoustic neuroma surgeries.     

Microsurgical anatomy of acoustic neuroma. 2002

This article reviews the microsurgical anatomy important to preserving the involved cranial nerves and adjacent neural and vascular structures during acoustic neuroma removal. These anatomic considerations are divided into sections dealing with the relationships at the lateral end of the tumor in the meatus and those on the medial end of the tumor at the brain stem. The anatomy of the region offers the opportunity for three approaches to the tumor in the meatus and cerebellopontine angle. One is directed through the middle cranial fossa and the roof of the meatus. Another is directed throught the labyrinth and posterior surface of the temporal bone. The third is directed through the posterior cranial fossa and posterior meatel lip. The anatomy presented by all three approaches is reviewed in this article.     

Superior petrosal vein in trigeminal neuralgia

During microvascular decompression procedure for trigeminal neuralgia, surgical attention is mainly focused at the neurovascular conflict at trigeminal root entry zone. However, many major complications of this surgery are often related to venous structures in the posterior fossa, including the venous sinuses and the superior petrosal vein(s). The author reviews surgical anatomy of the superior petrosal vein, highlights important surgical steps related to its microsurgical dissection and discusses avoidance of complications, as well as their management during microvascular decompressive surgery in this region. The discussion is mainly focused on the surgical anatomy of the superior petrosal vein along with its significance during surgery and not on the neurovascular relationships of the trigeminal nerve or aetio-pathogenesis of trigeminal neuralgia.     

Extradural neuromas at the petrous apex: report of two cases

OBJECTIVE AND IMPORTANCE: Two rare cases of middle cranial fossa neuroma located in the epidural space at the petrous apex are reported. CLINICAL PRESENTATION: Two women, aged 58 and 49 years, were admitted to our hospital with diagnoses of cavernous sinus tumor. Analysis of preoperative computed tomography scans showed bone erosion of the petrous apex, and magnetic resonance imaging demonstrated the presence of an extradural mass located along the course of the petrous internal carotid artery in both patients. INTERVENTION: The tumor was completely removed in one patient and partially removed in the other by use of the epidural middle cranial fossa transpetrosal approach. In both patients, histological examination of tumor specimens revealed neuroma. CONCLUSION: Because surgical exploration revealed that these epidural tumors adhered tightly to the internal carotid artery, and because they had no relationship to the trigeminal nerve, facial nerve, or proximal greater superficial petrosal nerve, in our opinion, these tumors originated from the distal portion of the greater superficial petrosal nerve or the deep petrosal nerve. These neuromas were mainly found in a site under the cavernous sinus at the petrous apex, a location not previously reported.     

Anatomical variation of superior petrosal vein and its management during surgery for cerebellopontine angle meningiomas

No systematic study is yet available that focuses on the surgical anatomy of the superior petrosal vein and its significance during surgery for cerebellopontine angle meningiomas. The aim of the present study was to examine the variation of the superior petrosal vein via the retrosigmoid suboccipital approach in relation to the tumor attachment of cerebellopontine angle meningiomas as well as postoperative complications related to venous occlusion. Forty-three patients with cerebellopontine angle meningiomas were analyzed retrospectively. Based on the operative findings, the tumors were classified into four subtypes: the petroclival type, tentorial type, anterior petrous type, and posterior petrous type. According to a previous anatomical report, the superior petrosal veins were divided into three groups: Type I which emptied into the superior petrosal sinus above and lateral to the internal acoustic meatus, Type II which emptied between the lateral limit of the trigeminal nerve at Meckel’s cave and the medial limit of the facial nerve at the internal acoustic meatus, and Type III which emptied into the superior petrosal sinus above and medial to Meckel’s cave. In both the petroclival and anterior petrous types, the most common vein was Type III which is the ideal vein for a retrosigmoid approach. In contrast, the Type II vein which is at high risk of being sacrificed during a suprameatal approach procedure was most frequent in posterior petrous type, in which the superior petrosal vein was not largely an obstacle. Intraoperative sacrificing of veins was associated with a significantly higher rate of venous-related phenomena, while venous complications occurred even in cases where the superior petrosal vein was absent or compressed by the tumor. The variation in the superior petrosal vein appeared to differ among the tumor attachment subtypes, which could permit a satisfactory surgical exposure without dividing the superior petrosal vein. In cases where the superior petrosal vein was previously occluded, other bridging veins could correspond with implications for the crucial venous drainage system, and should thus be identified and protected whenever possible.     

Transpetrous spread of acoustic neuroma into the middle cranial fossa: report of two cases

We report two patients with acoustic neuromas which spread upwards through the petrous temporal bone into the middle fossa as well as medially through the porus acousticus into the posterior fossa. There appear to be no previous reports of such transpetrous spread of an acoustic neuroma.     

听神经瘤显微手术面神经损伤的预防

目的总结与分析听神经瘤显微手术中预防面神经损伤的方法。方法经MRI和（或）CT检查确诊的大型听神经瘤（≥4．0cm）180例（72％）及中型听神经瘤（2．4～4．0cm）70例（28％）。均采用经患侧枕下乙状窦后入路保留面神经的显微手术。注意三大解剖关系：骨性解剖、蛛网膜解剖、神经与血管的解剖。肿瘤囊内减压后,确认面神经的起始位置、面神经与肿瘤的关系、面神经变形与扭曲、面神经分离的方法、面神经的断裂端-端吻合。随访6个月～1年。结果肿瘤全切除240例（96．0％）;次全切除10例（4．0％）,其中死亡1例（0．4％）。面神经功能评定：Ⅰ级214例（85．6％）;Ⅱ级25例（10．0％）;Ⅲ级5例（2．1％）;Ⅳ级5例（2．1％）。结论术中注意典型的解剖位置,正确的手术入路和显微手术技术可达到较高的肿瘤全切除率,提高面神经的功能保全率。