垂体ACTH腺瘤的诊断和治疗(附29例报告)

目的 分析和探讨垂体ACTH腺瘤的诊断和治疗。方法 对我科收治的29例垂体ACTH腺瘤患者的临床特点和治疗效果进行了回顾性分析。结果 垂体ACTH微腺瘤的诊断较为困难，有库欣氏综合征表现的患者，辅以血清ACTH、地塞米松抑制试验等并结合影像学资料方可确诊，经蝶手术切除肿瘤复发率仅为6．9％。结论 垂体ACTH腺瘤的诊断须依靠临床表现、实验室检查和影像学检查等。经蝶手术切除肿瘤是治疗垂体ACTH腺瘤的首选方法。     

非分泌性垂体腺瘤的显微外科手术策略

目的 探讨非分泌性垂体腺瘤治疗的显微外科手术策略。方法 回顾分析经手术证实的236例非分泌性垂体腺瘤的临床资料，采取四种显微手术策略：经蝶手术202例（85．59％），开颅手术15例（6．36％），经蝶＋开颅手术11例（4．66％），分次经蝶手术8例（3.39％）。结果 显微手术全切除171例（72．46％），次全切除65例（27．64％）。无同手术期严重并发症，视力视野改进占88．02%。甲状腺功能恢复正常占38．98％，血清催乳素水平恢复正常占70．63％。免疫组化研究提示促性腺激素细胞腺瘤占52．54％，裸细胞腺瘤占25．00％，大嗜酸粒细胞腺瘤占14．41％，静态促肾上腺皮质激素腺瘤占8．05％。结论 对于非分泌性垂体腺瘤，根据个性化的原则，采取不同的显微外科手术策略．可以取得满意的疗效。     

经蝶辅助内窥镜切除大型垂体腺瘤

目的：介绍和评价1993年至2002年内经蝶入路显微外科辅助内窥镜切除138例大型垂体腺瘤的手术操作技术及经验。方法：138例大型垂体腺瘤，男性66例，女性72例。手术采用经蝶显微外科辅助内窥镜。结果：本组全切肿瘤109例，占78.9％。结论：经蝶显微手术仍是一种较为实用手术，显微外科辅助内窥镜可提高大型垂体腺瘤的全切率。     

儿童和青春期垂体腺瘤（附23例报告）

报道１９８０年至１９９２年收治的儿童和青春期垂体腺瘤２３例，占同期全部垂体腺瘤的３．２％。其中２０例为激素分泌型垂体腺瘤，３例为无功能垂体腺瘤。除４例经额开颅外，其余均经蝶显微外科手术治疗，手术疗效与成人病例相似。讨论了儿童和青春期垂体腺瘤病人的临床特点、治疗方法的选择和手术技术。     

经蝶手术对男性青壮年垂体泌乳素腺瘤患者性腺功能的影响（附70例分析）

目的：探讨经蝶垂体泌乳素腺瘤切除手术对男性青壮年患者性腺功能的影响。方法：回顾性分析复旦大学附属华山医院神经外科2005年10月至2007年11月接受经蝶手术的70例男性青壮年（18-45岁）垂体泌乳素腺瘤（平均年龄36．4岁）患者的年龄和性别分布情况、发病特点、肿瘤分型、治疗与预后等情况。确诊主要依靠血泌乳素与MRI及术后病理检查;随访其术后内分泌指标及MRI以及患者的性功能恢复情况。结果：70例男性患者中垂体大腺瘤者56例,肿瘤具有侵袭性者28／70例（40％）;患者治愈率为55．7％（39／70）,未愈为44．3％（31／70）;患者性功能恢复正常者16／70例（22．9％）,部分改善者23／70例（32．9％）,无改善者31／70例（44．3％）。结论：在男性青壮年垂体泌乳素瘤患者中,大腺瘤所占比例较高,巨大型及侵袭性大腺瘤的比例也较高。男性垂体微腺瘤患者手术后性功能恢复良好,巨大型及侵袭性垂体腺瘤患者手术后性功能恢复不佳。     

儿童和青春期垂体腺瘤的诊断和治疗

儿章和青春期垂体腺瘤多数指16或18岁以前经手术证实的病例。全面评估内分泌、影像学改变是诊断的关键、治疗的基础。儿童和青春期PRL腺瘤与成人PRL腺瘤在对溴隐停有效性方面相同。甲介型或气化不良的经窦并不是经蝶手术的禁忌症。关于Cushing’s病的治疗，首选经蝶手术，治愈率可达80％～98％．放射治疗应严格掌握适应症，尽可能减少延迟性的垂体功能低下的发生。术后可以发生各种垂体和下丘脑功能障碍，长期、正规的随访具有特别重要的意义。     

高龄非分泌性垂体腺瘤的经蝶手术治疗

目的评价高龄非分泌性垂体腺瘤患者经蝶手术的疗效和安全性。方法回顾分析经手术证实的17例年龄在70岁以上垂体腺瘤患者。术前的平均症状期为1．8年，视交叉症状14例。术前内分泌检查提示生长激素(GH)缺乏占70．6％．甲状腺功能低下占35．3％，肾上腺功能低下占47．1％，性腺功能减退和高催乳素血症分别占76．5％和52．9％。肿瘤直径19～52mm．包括3例局限性和14例侵袭性垂体腺瘤。结果显微镜下肿瘤全切12例，次全切除5例。无围手术期严重并发症，视力视野改进占78．6％。GH均未恢复，甲状腺功能恢复正常占33．3％，血清催乳素(PRL)水平恢复正常占66．7％。免疫组化研究提示促性腺激素细胞腺瘤占52．9％，裸细胞腺瘤占23．5％，大嗜酸粒细胞腺瘤占11．8％，静态促肾上腺皮质激素(ACTH)腺瘤占11．8％。结论在高龄垂体腺瘤中，经蝶手术是一种安全的治疗方法，创伤小，耐受性好，并发症少。     

读者·作者·编者

我有幸拜读了贵刊刊发的北京协和医院王任直教授的文章《扩大经蝶入路切除巨大或侵袭性生长的垂体腺瘤》(2004年第20卷第6期)。文章详细描述了通过扩大经蝶入路成功切除向蝶窦前方、侧方、后方侵袭生长的垂体腺瘤，全切除率达到92％(12／13)，且无明显手术并发症。尤其是通过经蝶向侧方切除海绵窦内肿瘤，手术难度非常大，     

大型和巨大型垂体腺瘤经蝶显微外科治疗的疗效及处理策略

目的 探讨大型和巨大型垂体腺瘤手术入路的选择和处理策略。方法 回顾性总结1985—2001年收治的302例大型和巨大型垂体腺瘤临床资料和经蝶手术切除的疗效。结果 显微镜下全切除188例(62．3％)，次全切除68例，部分和大部分切除46例。手术并发症多为一过性，死亡5例(1、66％)。术后动态随诊CT(MRI)173例，无肿瘤残余92例(53．2％)。随诊期(平均22．5个月)视力、视野改善190例(95．5％)，激素分泌性垂体腺瘤相应激素水平大部分正常或不同程度下降。结论 绝大部分本类型肿瘤均可首选经蝶手术切除。术后定期随诊，如残余肿瘤明显或再生长、复发，根据具体情况经颅或再次经蝶手术和(或)辅以放疗和溴隐亭等药物治疗。     

影响巨大垂体腺瘤手术疗效的几个问题探讨

目的 介绍56例巨大垂体腺瘤显微外科手术治疗经验，探讨影响手术疗效的几个问题。方法 回顾性分析56例巨大垂体腺瘤病人的临床资料。据肿瘤的生长方向及部位分为四型，据此分别采用经蝶、经额下、额下经蝶、扩大经蝶、扩大额下硬膜外、额下一翼点等10种入路进行显微手术。重点介绍手术入路的选择及注意事项。结果 56例巨大垂体腺瘤全切29例，近全切20例，大部分切除7例，无死亡。结论 依据巨大垂体腺瘤的不同位置及生长方向选择适当的手术入路、掌握手术时机以及术后辅以放疗是提高手术疗效的重要手段。     

Primary intrasellar schwannoma

Intracranial schwannomas commonly arise from the eighth cranial nerve in the cerebellopontine angle. Schwannoma arising in the sella and extending into the suprasellar region is very rare and is easily mistaken for pituitary adenoma. To our knowledge, there have been only 12 previous reports. We present a patient with primary intrasellar schwannoma that clinically and radiologically resembled a pituitary adenoma (PA). Intra-operative findings differed from a PA, as the tumour had a firmer consistency. Gross total excision of the lesion was done via a transethmosphenoidal approach. Post-operatively the patient improved in visual acuity and visual fields. We have reviewed the literature and described the characteristics of such lesions.     

Suprasellar and intrasellar paragangliomas

Neoplasms of the sellar region are entities with a large differential diagnosis. Although paraganglionic cells have not been demonstrated in the pituitary or adjacent structures, the existence of sellar region paragangliomas is well-documented. To elucidate, in this area the nature of these unusual tumors is relatively difficult. Clinical history, physical examination, radiographic investigation as well as intraoperative gross observation are the same as those of sellar meningioma or pituitary adenoma. Immunohistochemistry, using neuroendocrine markers and electron microscopy are the two definitive diagnostic methods to differentiate among these entities. The clinical management, the possible pathogenesis of the tumor, the importance of immunohistochemistry in making the diagnosis and the clinical outcome of these patients are discussed.     

Transsphenoidal removal of intrasellar pilocytic astrocytoma

A 26-year-old man with a sellar pilocytic astrocytoma had a recurrent non-enhancing mass located in the sellar/suprasellar region visible on MRI. Due to tumor progression and worsening vision, the mass was completely resected through a transsphenoidal approach. Postoperatively, the patient’s vision improved and imaging showed complete removal of the tumor and optic pathway decompression. Pilocytic astrocytomas originating in suprasellar structures can intrude into the sella, and should be included in the differential diagnosis of intrasellar tumors. The transsphenoidal approach can be effective for resecting such tumors.     

Isolated intrasellar tuberculoma mimicking pituitary adenoma.

A 37-year-old woman presenting with galactorrhea and menstrual irregularity due to an intrasellar lesion of the pituitary gland underwent transsphenoidal surgery for histopathological diagnosis and removal of the lesion. Histological findings were consistent with a tuberculoma. The post-operative course was satisfactory with resolution of galactorrhea and improved ovulatory cycle. The patient was successfully treated with a combination of surgical resection and anti-tuberculous therapy for one year, which resulted in hormonal and tuberculosis control. This patient appears unique regarding the location of the lesion and the dramatic response to surgical treatment. Although differential diagnosis of inflammatory pathologies of the intrasellar region presents difficulties, this patient demonstrates that tuberculoma should be considered.     

Hypopituitarism resulting from an intrasellar carotid aneurysm

We report a 74 year old lady who presented with an exceedingly rare combination of an internal carotid artery aneurysm which was almost entirely intrasellar and associated with hypopituitarism but no neurological deficits. Such a lesion could be misdiagnosed as a pituitary tumour with serious consequences, if surgery is attempted without prior carotid angiography.     

Transsphenoidal surgery of intrasellar and perichiasmatic tumors--personal experience

Microsurgical transsphenoidal approach has been for decades an established standard surgical treatment of pituitary adenomas. Actually it offers a safe and rapid midline access to the sellar region with a minimal risk of injury to vascular vessels, the optic chiasm or nerves and the brain. Major limitations of this approach are due to the narrow and deep operating field, with the related possible complications of the pituitary insufficiency and the cerebrospinal fluid rhinorrhea. In this paper the authors present their own experience with transsphenoidal surgery they performed in over 1500 cases during the past 28 years. The history and evolution of the microsurgery are described, including the operative technique, indications and counter-indications, as well as relative advantages and disadvantages of the transsphenoidal approach. Moreover, current modifications of the neurosurgical technique (extended transsphenoidal approaches) and their application in the treatment of non-glandular perichiasmatic tumors are outlined and discussed.     

荧屏监视下经鼻蝶窦穿刺治疗鞍内囊性肿瘤

目的探讨鞍内囊性肿瘤的微创疗法及其效果、优缺点及适应证。方法对14例鞍内囊性肿瘤(11例颅咽管瘤,2例复发性垂体腺瘤,1例性质不明)病人在X-线监视下和神经导航监测下进行经鼻蝶窦穿刺抽吸术。结果本组均获得满意疗效,术中、术后未出现严重并发症,术后辅以放疗,经3个月～7年随访,2例症状复发,再次穿刺治疗后好转。结论经鼻蝶窦穿刺治疗鞍内囊性肿瘤操作简便,快捷,创伤小,并发症少,经济,可多次施行。     

Hormone disorders caused by intrasellar persistent trigeminal artery

Persistent trigeminal artery is a relatively frequent type of intracranial arterial developmental anomalies. The diagnostic tools for demonstration previously consisted of carotid angiography, later CT and DSA and nowadays MR and MRA. The practical benefit of the diagnosis is to avoid any hazard at the operation of associated hypophysis adenomas and aneurysms and could also give a possible explanation for apparent hormonal abnormalities. The authors support the latter possibility with a case report.