经胼胝体-穹窿间入路显微手术切除颅咽管瘤

目的探讨经胼胝体-穹窿间入路显微切除颅咽管瘤的临床效果。方法经胼胝体-穹窿间入路切除颅咽管瘤21例。结果在手术显微镜下全切除10例，近全切除8例，大部分切除3例，无死亡病例。结论应用显微外科技术该入路可以切除第三脑室内颅咽管瘤，术野显露清楚，不易造成穹窿、丘脑、大脑内静脉、丘纹静脉的损伤，减少了术后并发症的发生。     

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.     

颅咽管瘤的临床病理因素与显微外科手术疗效关系分析

目的 探讨颅咽管瘤的临床病理因素与显微外科手术后疗效关系、为手术治疗及预后判断提供理论依据.方法 回顾总结2001年9月至2007年9月施行显微外科手术切除颅咽管瘤78例的临床资料,对其病理组织应用HE染色进行病理分型,并确认肿瘤是否具有侵袭性;根据肿瘤的切除程度、病理类型、肿瘤侵袭性与术后复发、死亡等进行对比分析. 结果 釉质型颅咽管瘤与鳞状乳头状颅咽管瘤两组术后复发率、死亡率比较,差异无统计学意义(P＞0.05);侵袭性颅咽管瘤与非侵袭性颅咽管瘤两组全切术后死亡率比较,差异有统计学意义(P＜0.05),两组全切术后复发率比较,差异无统计学意义(P＞0.05);完全切除、近全切除、部分切除三组术后复发率比较,差异有统计学意义(P＜0.05),三组术后死亡比较,差异无统计学意义(P＞0.05). 结论 影响颅咽管瘤复发的主要因素是切除程度,而与病理类型无关;侵袭性颅咽管瘤只存在于釉质型颅咽管瘤中,全切术后死亡与肿瘤侵袭性有关.     

脑室内外型颅咽管瘤的显微外科手术

三脑室内外型颅咽管瘤较少见，治疗困难。十年来采用显微外科手术共１２例，经大脑纵裂入路，全切除肿瘤５例，次全切除４例，部分切除３例。手术死亡２例；长期随访，全切和次全切除的病例组均未见肿瘤复发，认为经纵裂－终板入路手术应为首选方法。     

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。     

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.     

改良翼点入路行颅咽管瘤全切除术应用的体会

目的探索手术根治颅咽管瘤的方法。方法5例颅咽管瘤病人，年龄17～23岁，平均20岁；以视力障碍起病1例，月经紊乱或闭经3例，头痛1例。CT及MRI：肿瘤位于鞍上者4例，凸入三脑室内者1例，肿瘤钙化者4例，囊性3例，完全实性2例。均为初次手术。全部病人均在全麻下经改良翼点入路采用显微外科技术手术，根据肿瘤位置，从交叉间隙及颈内动脉和视神经间隙均切除肿瘤。结果5例手术病人肿瘤均全部切除，术后观察1～2年均参加日常工作。结论经改良翼点入路，采用显微外科技术对鞍上和三脑室内各种类型的肿瘤绝大多数能够全部切除，并发症少，愈后良好。     

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。     

显微手术治疗颅咽管瘤19例

目的 报道颅咽管瘤显微手术的入路选择及手术疗效。方法 回顾分析近28个月来收治的19例颅咽管瘤患者的临床材料及治疗方法和结果。开颅手术13例，其中全切除7例，次全切除4例，部分切除2例，经蝶手术6例，其中次全切除4例，部分切除2例。结果 手术后死亡1例，动眼神经麻痹1例。结论 采用合理的手术入路，显微手术能有效治疗颅咽管瘤。     

Intrinsic third ventricular craniopharyngiomas: report on six cases and a review of the literature

BACKGROUND: Craniopharyngiomas constitute 2 to 4% of intracranial neoplasms. However, the purely intraventricular variety are rare. Their magnetic resonance imaging (MRI) characteristically shows an intact third ventricular floor, a patent suprasellar cistern, an intact pituitary stalk, and the absence of sellar abnormalities. METHODS: Between 1994 and June 2002, 6 patients with purely intraventricular craniopharyngioma were surgically managed. There were 4 cystic and 2 solid lesions. The surgical approaches utilized included a frontal, parasagittal, transcallosal approach with the third ventricle being accessed using either the transforaminal or subchoroidal approach (n = 3); pterional, transsylvian (n = 1), and bifrontal interhemispheric (n = 2) approaches in which the third ventricle was accessed via the lamina terminalis. A ventriculoperitoneal shunt was required for one of the 3 patients with hydrocephalus. RESULTS: Total excision was performed in 3 patients with cystic craniopharyngioma, while a small residual lesion was left adherent to the third ventricular floor in the others. There was one perioperative mortality because of septicemia. Two patients required thyroxine supplementation. Two patients developed transient and one other patient a sustained diabetes insipidus. The 2 patients with solid tumors received radiotherapy for the residual lesions. At follow up ranging from 8 to 36 months, neither tumor recurrence nor regrowth was observed in any of the patients. The symptoms of raised intracranial pressure, hypothalamic dysfunction or visual field defects had resolved. CONCLUSIONS: Intraventricular craniopharyngiomas occur in an older population and present mainly with raised intracranial pressure. Visual and endocrinologic imbalances are much less in these lesions compared to the suprasellar craniopharyngiomas. They mainly attach to the third ventricular floor. The surgical approaches to the third ventricle, along with radiotherapy and hormone supplementation, were successful in the management of these rare tumors.     

第四脑室肿瘤的显微外科治疗

目的探讨第四脑室肿瘤手术入路和显微手术技巧,以提高第四脑室肿瘤的手术疗效。方法84例第四脑室肿瘤患者,行显微镜下切除肿瘤、后颅窝骨瓣成形及复位术。其中,61例采用正中孔-小脑蚓部入路,19例采用小脑延髓裂入路,4例取正中孔-小脑蚓部与小脑延髓裂联合入路。术前行侧脑室外引流4例,术中行侧脑室-枕大池分流3例,术后行侧脑室外引流术1例。结果本组全切除肿瘤63例(75.0%),次全切除21例(25.0%),无手术死亡病例。术后并发症:上消化道出血6例,小脑缄默症2例,四脑室血肿1例,脑积水1例,颅神经功能障碍1例。随访82例,平均38.4个月,死亡9例。结论术前正确判断肿瘤性质及其基底部所在位置,选择适宜的手术入路,熟练应用显微外科技术,是手术成功治疗的第四脑室肿瘤关键。     

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.     

Ectopic recurrence of craniopharyngioma after an interhemispheric transcallosal approach: case report

OBJECTIVE AND IMPORTANCE: Ectopic recurrence of a craniopharyngioma is a rare postoperative complication. We present a case of a craniopharyngioma that ectopically recurred along the tract of a previous surgical route. CLINICAL PRESENTATION: A 73-year-old female patient presented 8 years earlier with a suprasellar craniopharyngioma. She underwent a right frontal craniotomy, with an interhemispheric transcallosal approach, for total microsurgical resection of the tumor. No postoperative radiotherapy was administered. Four years after surgery, magnetic resonance imaging studies revealed a well-circumscribed, heterogeneously enhancing, parasagittal mass with significant vasogenic edema in the right frontal lobe. Enlargement of the lesion was noted in subsequent radiological evaluations until 8 years after surgery, when the patient experienced a significant decline in neurocognitive status and the mass was surgically resected. INTERVENTION: Gross total resection of a histologically confirmed craniopharyngioma was achieved. CONCLUSION: To our knowledge, only eight previous case reports described the ectopic recurrence of a craniopharyngioma. Transplantation of tumor cells along the tract of a previous surgical route in six cases and dissemination in cerebrospinal fluid in two cases are presumed to be the primary mechanisms by which these ectopic recurrences occurred. The results of our literature review led us to conclude that total surgical resection, combined with careful inspection and irrigation of the surgical field, is the optimal treatment for preventing ectopic recurrences. Furthermore, it is recommended that, after primary craniopharyngioma resection, patients undergo long-term clinical and radiological follow-up monitoring for the rare development of an ectopically recurring tumor.     

Tumor-third ventricular relationships in supradiaphragmatic craniopharyngiomas: correlation of morphological, magnetic resonance imaging, and operative findings

OBJECTIVE: To disclose the relationships of primarily supradiaphragmatic craniopharyngiomas with the third ventricular floor (3rdVF) by means of preoperative magnetic resonance imaging (MRI) and thus to select the surgical approach avoiding the hypothalamic structures. METHODS: MRI findings in 76 consecutive patients with craniopharyngiomas operated on between June 1991 and December 2002 were interpreted on the basis of the results of the authors' own previous microanatomic studies. The assumed tumor-3rdVF relationships were then correlated with the operative findings. MRI features characteristic for different topographical relationships were analyzed in 44 patients (18 children, 26 adults) with exclusively supradiaphragmatic tumors. RESULTS: In 14 of 15 patients with the tumor located below the 3rdVF (suprasellar extraventricular craniopharyngioma), the anterior communicating artery was displaced upward and indirectly indicated the position of the chiasm between the prechiasmatic and the retrochiasmatic tumor portions. Hydrocephalus was absent in 14 patients, including those with giant tumors. The anterior part of the third ventricular cavity was found in front of the level of the foramina of Monro in 6 patients. All 28 tumors growing partially inside and partially outside the third ventricular cavity (intraventricular and extraventricular craniopharyngioma) were retrochiasmatic. They caused severe or moderate hydrocephalus in 20 patients and mild hydrocephalus in 2. One purely intraventricular tumor caused severe hydrocephalus. CONCLUSION: The position of the optic chiasm and the size of the lateral ventricles on preoperative MRI enable us to determine the position of the 3rdVF or its remnants in relation to the supradiaphragmatic craniopharyngiomas and to select the proper surgical approach allowing exposure of the tumor while avoiding the hypothalamic structures.     

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     

Neuroendoscopic treatment of cystic craniopharyngioma in the third ventricle.

The third ventricle is a relatively uncommon location for craniopharyngiomas. Generally, craniotomy has been considered the procedure of choice in such cases. We describe a girl in whom a cystic third ventricular craniopharyngioma was successfully treated by evacuation of the cyst contents via a flexible neuroendoscope and precise placement of an Ommaya reservoir catheter within the tumor.     

Total removal of craniopharyngiomas. Approaches and long-term results in 144 patients

The clinical features, perioperative course, and postoperative outcomes of 144 patients who underwent microsurgical resection of craniopharyngioma were reviewed. Overall, 90% of the tumors were completely resected and 7% recurred. Evaluation of those patients who underwent primary resection revealed much better results. The operative techniques and approaches are reviewed in detail. The results of this series suggest that primary total removal of craniopharyngiomas yields the best long-term outcome for the patient. Experience has shown that the larger the tumor the greater will be the damage, both preoperatively and intraoperatively, to vital intracranial structures. Consequently, early diagnosis, at a stage when the tumor is still small, improves the chances of accomplishing complete removal and of achieving good operative results. The early diagnosis of craniopharyngioma, before it can produce devastating neurological defects, continues to be the principal goal of our medical and pediatric colleagues.     

改良翼点入路颅咽管瘤的显微外科治疗

目的 探讨改良翼点入路显微手术治疗颅咽管瘤(craniopharyngioma,CP)的临床效果.方法 回顾性总结采用改良翼点入路显微手术切除颅咽管瘤41例.术前准备主要是进行激素的替代疗法和癫痫的预防.手术采用改良翼点入路,术后观察患者的神志、血压、出入水量、尿量、尿比重、电解质及CT、MRI等指标,及时防治尿崩症和电解质紊乱等并发症,预防癫痫和激素水平低下.结果 手术全切除33例,次全切除5例,部分切除3例,无手术死亡.术后随访2～19个月,可正常参加生活、学习、工作正常者32例,生活需要帮助者9例,次全切除及部分切除的8例中3例于术后6～12个月复发.结论 采用改良翼点入路并结合积极有效的围手术期处理可以降低下丘脑损伤的发生率和提高肿瘤的切除率,获得良好的疗效.     

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.