枕下乙状窦后入路在桥小脑角区脑膜瘤中的应用经验

目的探讨枕下乙状窦后入路在桥小脑角区脑膜瘤手术中的作用。方法通过对我院自2001年12月到2015年12月53例采用枕下乙状窦后入路的桥小脑角区脑膜瘤手术病例进行分析,总结分析肿瘤的影像学特点、临床症状、手术疗效及术后神经功能。结果该组病例肿瘤全切48例,次全切除5例。术后症状和体征完全消失32例,症状较术前减轻7例,颅神经损害症状同术前3例,出现新神经功能障11例。结论枕下乙状窦后入路是处理桥小脑角区病变的经典手术入路,该入路可以获得对桥小脑区神经血管良好的暴露,手术创伤小,患者恢复快,术后并发症少。     

经颞下-乙状窦前入路切除巨大岩斜脑膜瘤

目的：试图通过改进手术入路而改善巨大岩斜脑膜瘤的手术治疗结果。方法：采用经颞下－乙状窦前入路切除５例巨大岩斜脑膜瘤。结果：全切除３例，２例恢复良好，另１例遗留对侧偏瘫和同侧Ⅲ、Ⅴ、Ⅵ脑神经功能障碍；次全切除的１例遗留持久性动眼神经瘫痪；而部分切除的１例则长期昏迷伴对侧偏瘫。结论：此入路的优点有：（１）到达岩斜区最直接，路径最短；（２）手术野开阔，显露良好；（３）可多视角操作；（４）只需很轻的脑牵拉。肿瘤不能全切除和出现严重并发症的主要原因是肿瘤包裹了基底动脉及其分支以及肿瘤破坏了软脑膜使肿瘤与脑干间失去界面。术前的ＭＲＩ检查有助于了解肿瘤侵犯脑干的程度和动脉包裹的情况。     

枕下-乙状窦后入路显微手术切除大型听神经瘤

目的 探讨经枕下-乙状窦后入路显微手术切除大型听神经瘤的临床疗效和意义。方法 采用枕下乙状窦后入路对49例大型（≥4 cm）听神经瘤行显微手术切除,单侧枕下乳突后“S”形皮肤切口,铣刀骨瓣成形,显微镜下行肿瘤囊内逐步切除,最后分离内听道部分,锐性剥离面神经上残存肿瘤。术前及术后分别进行面神经和听神经的功能评估。结果 肿瘤全切除45例（92%）,次全切除4例（8%）,全组无死亡病例。面神经解剖保留42例（86%）,术后2周功能保留36例（73%）;听神经解剖保留7例（14%）,术后2周功能保留3例（6%）。1例手术区血肿再手术清除。37例随访0.5～5年,平均2.8年,肿瘤无复发,均参加正常工作和学习。结论 枕下乙状窦后入路显微手术是切除大型听神经瘤的较好方法,肿瘤的全切率高,死亡率和病残率低,并能有效地保留面、听神经的功能。     

经枕下乙状窦后入路切除桥小脑角脑膜瘤

目的探讨桥小脑角脑膜瘤的临床特点、手术入路及显微手术技巧。方法回顾性分析我院2010年1月~2013年11月间收治的49例桥小脑角脑膜瘤患者的临床资料。所有患者均经枕下乙状窦后入路运用显微技术切除肿瘤。结果肿瘤达SimpsonⅠ级全切除25例(51.0%),Ⅱ级切除17例(34.7%),次全切除7例(14.3%),无手术死亡。随访47例,随访时间平均2.4年(6个月~4年)。37(78.7%)例正常工作,7(14.9%)例能生活自理,3例(6.4%)生活需他人照顾。随访6个月时面听神经功能保留分别为42例(89.4%)与24例(51.1%)。结论枕下乙状窦后入路是切除桥小脑角脑膜瘤非常适宜的入路,术中结合神经电生理监测并合理运用显微技术,能够理想地切除肿瘤和提高患者生存质量。     

枕下乙状窦后-颌下联合入路显微切除颈静脉孔区哑铃型神经鞘瘤

颈静脉孔区哑铃型神经鞘瘤较为罕见，其位置深在，解剖结构复杂，诊断和治疗均比较困难，术后并发症较多。自1999年至2007年我科共收治5例。采用显微神经外科技术，选择枕下乙状窦后一颌下联合入路切除肿瘤，取得良好的效果，报道如下。     

经枕下-乙状窦后入路显微手术切除大型听神经瘤

目的 探讨手术切除大型听神经瘤（LAN）的最佳入径。方法 对术前经CT或MRI证实,且肿瘤位于桥脑小脑角区,直径≥31mm的216例LAN患者,采用枕下-乙状窦后入路显微手术肿瘤切除术;术后评估治疗效果。分析比较术前、后的听神经和面神经功能。结果 肿瘤全切除率79.6%(172例）;次全切除率15.3%(33例）;部分切除率5.1%(11例）;术后病死率1.4%(3例）。听神经解剖保留率为12.5%(27例）。出院时功能保留率为4.2%(A级,9例）;面神经解剖保留率为82.4%（178例）,出院时功能保留率为52.8%(House分级,Ⅰ-Ⅱ级94例）。对187例患者平均随访3.9年,其中128例（68.4%)恢复良好。44例（23.5%)恢复一般,15例（8.0%)恢复较差。在恢复较差患者中有10例（5.4%)肿瘤复发（再次手术治愈）。结论 经枕下-乙状窦后入路显微手术切除大型听神经瘤是一种安全、有效的方法。     

幕上下联合入路切除岩斜区巨大肿瘤

目的:探讨岩斜区巨大肿瘤的手术入路和早期严重并发症的处理。方法:采取幕上下联合入路(颞下经小脑幕及枕下乙状窦后联合入路)对11例岩斜区巨大肿瘤进行手术治疗。结果:10例全切除,1例大部切除,效果满意。结论:有熟悉的解剖知识,采用颞下经小脑幕和枕下乙状窦后联合入路可以切除岩斜区巨大肿瘤。     

幕上下联合锁孔入路显露岩斜区的显微解剖

目的 研究颞下和枕下乙状窦后锁孔入路对岩斜区显露的互补性.方法 尸头上模拟该锁孔入路,颞部骨窗以颧弓根部为中心前后各1.5 cm,高2.5 cm,枕下乙状窦后骨窗直径3 cm,观察显露范围并用导航标记.用带有造影剂的明胶海绵标记适于操作的有效空间,再行CT扫描和三维重建.结果 颞下入路从前外侧到达岩斜区,对颅中窝、鞍旁、幕上桥前池、脚间池下部、环池前部显露佳,切开小脑幕后环池和桥前池下部视野得到扩展,桥小脑角池方向被岩尖遮挡,是显露的死角.枕下乙状窦后入路从后外侧到达岩斜区,对同侧桥小脑角、桥前池、环池后部显露佳,但Meckel's囊开口至海绵窦后部被内听道上结节遮挡,范围小于1 cm3.结论 颞下和枕下锁孔入路的显露空间和角度有互补性,联合运用有利于切除同时累及幕上下,侵犯上斜坡和中下斜坡的岩斜脑膜瘤,尽管对海绵窦后部显露不佳,但范围小,处于放射外科的有效治疗范围之内,达到微创疗效.     

改良乙状窦前经部分骨迷路入路的显微解剖

目的 目的 研究改良乙状窦前经部分骨迷路入路的显微解剖暴露,探讨其对岩斜区的显露及在手术处理该区域病变中的优势. 方法 2012年4月至10月,对15具尸头标本进行手术人路的改良研究,在传统乙状窦前入路的基础上切除部分半规管和岩尖,详细记录岩斜区重要结构的显露情况. 结果 该入路能够提供至岩斜区和海绵窦后部宽大的操作空间,在乙状窦前显露范围(水平方向)为(19.41±1.58) mm,在颞叶下方的显露范围(垂直方向)为(14.18±1.88) mm,斜坡中心凹陷的最大暴露角度为(60.54±6.93)°,手术操作深度(55.87 4.34) mm.椎-基底动脉、小脑前下动脉、小脑上动脉、同侧第Ⅲ～X对和对侧第Ⅵ对脑神经、三叉神经腔、海绵窦后部等均显露良好. 结论 改良乙状窦前经部分骨迷路入路能够获得岩斜区深面和海绵窦后部良好暴露,具有暴露范围大、观察角度多、保留面听神经功能、早期阻断肿瘤的血供等方面的优势.     

显微手术切除岩斜区脑膜瘤32例分析

目的 探讨岩斜脑膜瘤如何根据具体情况给予不同对待。方法 总结32例岩斜区脑膜瘤显微手术方法、结果和术后处理。结果 全切除26例，近全切除6例，肿瘤全切率81．3％。结论 根据术前手术中的策略，选择好手术中入路和运用好显微外科技术可以提高岩斜脑膜瘤的清除率，降低手术病死率。     

Petrosal approach for petroclival meningiomas

Thirteen patients harboring large petroclival meningiomas are reported. The evolution of the petrosal approach is discussed, and modifications for improvement in surgical technique are described. There was no mortality in this series, and total removal was achieved in all but two patients. Morbidity included cranial nerve deficit, pulmonary embolism, and hemiparesis.     

Combined petrosal approach to petroclival meningiomas

OBJECTIVE: To study the use and advantages of combining the posterior petrosal approach with the anterior petrosal approach to petroclival meningiomas. METHODS: Seven cases of petroclival meningiomas operated on via the combined petrosal approach were retrospectively analyzed. The basis on which this approach was selected was assessed, as were its benefits and risks. RESULTS: Gross total resection was achieved in five of the seven patients. No mortality or decrease in Karnofsky performance score was observed at the time of the last follow-up examination. Six of the seven patients had serviceable hearing before the operation. Only one patient lost hearing after the operation, and this hearing loss occurred in only one ear. Before the operation, six patients were House-Brackmann facial nerve function Grade I, and one patient was Grade II to III. At the last follow-up examination, facial nerve function was Grade I in five patients, Grade II in one patient, and Grade V in one patient. Tumors in all patients involved the cavernous sinus, Meckel's cave, petroclival junction, and middle clivus. All patients possessed a large posterior fossa component of tumor measuring an average of 3.6 x 3.5 x 4.2 cm. In four patients, the tumor was attached for the entire width of the clivus to the contralateral petroclival junction. Four patients displayed central brainstem compression. Four patients displayed bony changes at the petrous apex. All patients displayed total or partial encasement of the vertebrobasilar artery and its major branches. CONCLUSION: The combined petrosal approach should be considered for patients who have a large petroclival meningioma and serviceable hearing. This approach enhances petroclival exposure and the degree of tumor resection, especially in the area of the petroclival junction, middle clivus, apical petrous bone, posterior cavernous sinus, and Meckel's cave. The combined petrosal approach also allows better visualization of the contralateral side and the ventral brainstem, which facilitates safe dissection of the tumor from the brainstem, the basilar artery, and the perforators. If a patient has an early draining bridging vein to the tentorial sinus (before it reaches the transverse-sigmoid junction) or a prominent sigmoid sinus and jugular bulb, the combined petrosal approach provides significant working space.     

Presigmoid sinus approach to petroclival meningiomas

Between August 1987 and May 1989 five patients with petroclival meningiomas were operated on at the Neurosurgical Clinic of the Krankenhaus Nordstadt. Hannover, Germany, using an original combined supra- and infratentorial presigmoid sinus approach. There were two men and three women, ranging in age from 34 to 61 years (mean, 48 years; median, 46 years). Follow-up ranged between 1 and 22 months. There was no death. Postoperatively, two patients had no useful hearing, one had a permanent facial palsy (the facial nerve had to be sacrificed intraoperatively due to its involvement with tumor), one had a permanent abducens palsy (the VI nerve was involved with tumor and had to be cut). Temporary lower (IX to XII) cranial nerve palsy was observed in all the patients; temporary VI, in two patients; temporary VII, in two patients, temporary hemiparesis, in one patient, temporary gait ataxia, in three patients; and persistent gait ataxia, in one patient. All patients had total tumor removal as assessed at surgery and with postoperative enhanced computed tomography. Four patients were independent and able to carry on normal activity, and one patient was independent at home but not outside due to severe ataxia 4 months after the operation. The presigmoid sinus avenue to the petroclival region shortens the distance to the clivus, permits a multiangled exposure of this difficult surgical area, minimizes the amount of temporal lobe retraction, preserves the integrity of the transverse sinus, and allows for better preservation of the neurovascular structures. These factors translate into a high percentage of total tumor removal and a low incidence of permanent morbidity.     

岩斜部脑膜瘤的微侵袭治疗

目的探讨微侵袭神经外科技术在岩斜脑膜瘤治疗中的应用。方法采用锁孔技术治疗14例岩斜部脑膜瘤。累及上中斜坡8例，广基或宽基累及上中下斜坡5例，累及中下斜坡1例其中6例同时扩展至鞍旁或海绵窦内，采用枕下乙状窦后锁孔入路6例，颞下锁孔入路2例，幕上下联合入路6例。结果全切除肿瘤8例，次全切除4例，大部切除2例(均为术后复发患者)。术后神经功能完好或未见新增脑神经损伤8例，术后出现轻度面瘫4例，外展功能障碍3例，动眼神经麻痹2例，后组脑神经功能影响1例，均未发生术后脑脊液漏和切口感染经11～19个月随访，轻度面瘫和动眼神经麻痹均有明显改善，但外展功能障碍恢复缓慢。结论针对岩斜部脑膜瘤累及范围，采用单独／联合采用颞下锁孔入路和枕下乙状窦后锁孔入路可有效切除肿瘤，并可减少手术创伤，缩短手术和患者康复时间，减少术后并发症。联合运用微侵袭技术(锁孔入路联合)，术中显微技术与术后放射外科治疗等是今后岩斜部脑膜瘤的治疗方向。     

Surgical resection of large and giant petroclival meningiomas via a modified anterior transpetrous approach

The authors describe a modified anterior transpetrous approach (ATPA) for the surgical resection of 21 cases of petroclival meningiomas (PCMs). Briefly, a curved periauricular skin incision was used. The cerebellar tentorium and the dura on the petrous apex were coagulated and incised to expose the petrous apex bone fully. The drilling of the petrous apex bone was performed subdurally and began internally from the trigeminal impression, not exceeding 1.5 cm laterally, not exceeding 6 mm from the posterior edge of the petrous ridge, and not exceeding 8 mm in depth from the surface of the petrous bone. The tumors were removed totally in 12 (57.1 %) cases, subtotally in 8 (38.1 %) cases, and partially in 1 (4.8 %) case. The transient neurological deficit includes mild oculomotor nerve palsy in three cases, abducens nerve palsy in six cases, language disorder in three cases, and mild hemiplegia in two cases. Facial numbness became worse postoperatively in six patients, and only two patients improved at 6 months after surgery. No death occurred in this series. The modified ATPA is an efficient treatment alterative for large or giant PCMs located at the medial and superior internal acoustic meatus with relatively low risk of complications.     

Combined subtemporal and retrosigmoid keyhole approach for extensive petroclival meningiomas surgery: report of experience with 7 cases.

OBJECTIVE: The resection of petroclival meningiomas offers great challenges to the neurosurgeon. Surgery via a combined subtemporal and retrosigmoid keyhole approach surgery was evaluated for the treatment of extensive petroclival meningiomas on the basis of our experience with 7 cases. METHODS: From July 2002 to July 2005, the resections of 7 petroclival meningiomas, which involved both supra- and infra-tentorial regions, were performed via a combined subtemporal and retrosigmoid keyhole approach. The extent of tumor resection was evaluated by MRI 3 months after surgery, and postoperative complications were investigated. RESULTS: The maximum diameter of tumors ranged from 3.4 to 6.0 cm (mean: 4.4 cm). Gross total resection (GTR) was achieved in 3 cases, giving a GTR rate of 43%. Subtotal resection (STR) was carried out in 4 cases. Neurological status remained intact in one case, while the others presented with cranial nerve deficits (VII, VI, V, III and lower CN). No death was reported during the postoperative period. CONCLUSION: This combined keyhole approach is suitable for the treatment of extensive petroclival meningiomas. It provides easy and quick access to the supra- and infratentorial juxta-clival regions without any petrous bone drilling. Complications related to the approach can be minimized.     

Microsurgical removal of petroclival meningiomas: a report of 33 patients.

This is a report of 33 consecutive cases of petroclival meningioma treated surgically at our institution over the last 10 years; there were 21 women and 12 men between the ages of 27 and 68 (mean age, 52). All patients were assessed by computed tomographic scans including coronal sections and bone algorithm studies; in most cases, digital subtraction angiography and magnetic resonance imaging were also done. The largest tumor diameter was between 2 and 3.5 cm in 14 cases, 3.5 to 6 cm in 15 cases, and over 6 cm in 4 cases. Dural attachment predominantly involved the clivus and apical petrous bone on one side only; in 14 cases, however, the tumor grew over the clivus midline or crossed the tentorial notch. Cranial nerve deficit was extant in all cases and was commensurate with tumor size. Cerebellar signs and somatic motor deficits were present in 60 and 30% of cases, respectively. The surgical approaches used were the retromastoid-retrosigmoid in 23 cases, subtemporal in 5 cases, and combined retromastoid subtemporal presigmoid in the remaining 5. Total removal was achieved in 26 cases (79%); incomplete removal occurred in 7 cases (21%). The extent of tumor removal and operative morbidity were not significantly related to tumor size. Brain stem indentation, arterial and cranial nerve encasement, and epidural invasion were the main factors that prevented total tumor removal and influenced operative morbidity. There was no intraoperative mortality, but three patients (9%) died perioperatively. In the postoperative period, most patients went through momentary neurological deterioration, chiefly due to new cranial nerve deficits. The average follow-up was 4.3 years in 27 patients; of these 17 were unchanged and 10 were improved. Before surgery, only 13 patients were self-sufficient; at long-term follow-up, another 6 had achieved independence. Our experience suggests that, even though real petroclival meningiomas still represent a formidable surgical challenge, such tumors can in most cases be removed completely with low attendant mortality and acceptable morbidity.     

单侧额下入路显微切除大型及巨大型嗅沟脑膜瘤

目的 总结经单侧额下入路显微手术切除大型及巨大型嗅沟脑膜瘤的体会.方法 大型及巨大型嗅沟脑膜瘤患者31例,所有患者均经单侧额下入路开颅,显微手术切除病变.结果 Simpson Ⅰ级切除21例,Ⅱ级切除8例,Ⅲ级切除2例.结论 单侧额下入路显微手术能够用于切除大型及巨大型嗅沟脑膜瘤,与双侧额下入路比较,创伤小,恢复快,术后并发症少,符合微侵袭的理念.