桥小脑角区肿瘤的CT诊断

目的 探讨桥小脑角区肿瘤的CT表现及特征，提高对桥小脑角区肿瘤的定位诊断水平。方法 回顾性分析47例我院经手术及病理证实的桥小脑角区肿瘤患者的临床资料及CT表现。结果 47例中其中听神经瘤26例。脑膜瘤7例，三叉神经瘤6例，胆脂瘤2例，蛛网膜囊肿2例，血管母细胞瘤2例，动脉瘤，胶质瘤及转移瘤各1例。桥小脑角区肿瘤中95.7%为脑外病变，4.3%为脑内病变。听神经瘤、脑膜瘤，三叉神经瘤为桥小脑角区常见的肿瘤，该区肿瘤大部分有特征性CT表现，术前定位，定性准确率为89.4%和72.3%。结论 桥小脑角区肿瘤有特定的好发部位，CT对该区肿瘤的诊断和鉴别诊断有重要价值。     

桥小脑角肿瘤的手术治疗（附50例报告）

目的探讨桥小脑角区肿瘤手术方法及并发症防治。方法回顾性分析经外科手术切除桥小脑角区肿瘤50例临床资料。结果本组50例,全切除35例,次全切除12例,部分切除3例。无死亡病例,轻度面瘫15例,听力下降5例。结论熟练的手术技术及合适的手术入路是保证桥小脑角区肿瘤全切除的重要因素。术中保证清晰的解剖结构及层次,减少周围神经及小脑的牵拉,对预防脑干损伤,减少术后并发症非常关键。     

桥小脑角区肿瘤的MRI诊断

目的:总结桥小脑角区肿瘤的MRI表现,提高对桥小脑角区肿瘤的诊断水平。方法:回顾性分析65例经手术、病理证实的桥小脑角区肿瘤的MRI资料。结果:听神经瘤26例,脑膜瘤14例,胆脂瘤12例,三叉神经瘤8例,蛛网膜囊肿2例,脑干胶质瘤2例,颅咽管瘤1例。桥小脑角区肿瘤中最多见的是听神经瘤(40%)和脑膜瘤(21.5%)。结论:MRI可清晰显示桥小脑角区肿瘤的不同特点,对桥小脑角区肿瘤的诊断和鉴别诊断具有重要价值。     

大型桥脑小脑角肿瘤三种手术入路对比

５７例桥小及角肿瘤病人，分别采用单纯幕下入路，颞下小脑幕入路和颞下乳突后改良人路进行肿瘤切除，对比分析显示颞下乳突后改良人路对切除桥脑小脑角肿瘤有较好效果，全切除率高，术后面神经损害及并发症少。     

桥小脑角区肿瘤的MRI诊断

目的分析桥小脑角区不同肿瘤的MRI表现,探讨其MRI诊断价值。方法收集手术后病理证实的桥小脑角区肿瘤27例,分析不同肿瘤的MRI表现。结果桥小脑角区肿瘤在MR上具有不同表现,能够准确地进行定位诊断,并能作出较为准确的定性诊断。结论MRI对于桥小脑角区肿瘤的诊断具有重要价值。     

桥小脑角区肿瘤的MRI诊断

目的分析桥小脑角区不同肿瘤的MRI表现,探讨其MRI诊断价值。方法收集手术后病理证实的桥小脑角区肿瘤27例,分析不同肿瘤的MRI表现。结果桥小脑角区肿瘤在MRI上具有不同表现,能够准确地进行定位诊断,并能作出较为准确的定性诊断。结论MRI对于桥小脑角区肿瘤的诊断具有重要价值。     

桥小脑角区肿瘤患者术后呼吸道管理

对桥小脑角区肿瘤切除术后，常见并发症的呼吸道监护措施进行了总结。将47例桥小脑角区肿瘤患者，依据术后后组颅神经、脑干损伤及水肿引起的不同呼吸道并发症而采取相应的监护措施。47例患者无误吸发生，肺部感染4例。桥小脑角区肿瘤切除由于后组颅神经、脑干损伤所引起的呼吸道并发症，只要护理措施得当是可以预防的，其对病人的预后起至关重要的作用。     

桥小脑角肿瘤切除术中神经电生理监测的应用及配合

<正>随着显微外科的快速发展及手术技术的日益成熟,桥小脑角肿瘤手术的目的已从降低死亡率转变为全切除肿瘤情况下保全面听神经功能,提高患者生活质量。我院2006年8月开始对桥小脑角肿瘤切除实行术中面神经、三叉神经的神经电生理监测,以尽可能保全神经解剖,降低术后患者面瘫的发生率。本文总结了10例桥小脑肿瘤显微切除手术的应用及护理,现报道如下。     

桥小脑角区肿瘤的MRI诊断

目的 分析桥小脑角区不同肿瘤的MRI表现.探讨其MRI诊断价值.方法 收集手术后病理证实的桥小脑角区肿瘤27例.分析不同肿瘤的M RI表现.结果 桥小脑角区肿瘤在M RI上具有不同表现,能够准确地进行定位诊断,并能作出较为准确的定性诊断.结论 M RI对于桥小脑角区肿瘤的诊断具有重要价值.     

桥小脑角肿瘤45例手术探讨

目的探讨桥小脑角区肿瘤显微手术方法及并发症防治。方法回顾性分析经显微外科手术切除桥小脑角区肿瘤45例的临床资料。结果本组45例,全切除36例,次全切除8例,部分切除1例。无死亡病例,轻度面瘫10例,听力下降4例。结论合适的手术入路和严格细致的显微外科操作是保证桥小脑角区肿瘤全切除的重要因素,并能有效地保护桥小脑角周围的重要结构及其功能。     

桥脑角区肿瘤的显微外科手术治疗

目的：提高显微外科手术切除小脑桥脑角区肿瘤的技巧,减少手术并发症,予病人术后良好的生存质量。方法：分析１９９４～１９９８年我科经显微外科手术切除小脑桥脑角区肿瘤４２例的经验。结果：全切除３１例（７３．８％）,次全切６例（１４．２％）,面神经保留２１例（５０％）,死亡例（４．７％）。结论：应用显微外科技术是改善小脑桥脑角区肿瘤手术效果,减少手术并发症的关键。     

动眼神经损伤及再生的动物模型研究

目的 研究健康SD大鼠动眼神经颅内段的显微解剖特征，建立大鼠动眼神经损伤及再生研究的动物模型，为相关实验提供造模方法。方法 选用健康雄性SD大鼠30只，经右侧颞底入路，显微手术解剖、暴露动眼神经海绵窦段或海绵窦后段，行动眼神经切断并通过动眼神经功能测定，研究手术入路和应用解剖以及降低动物死亡率和减少并发症的方法。结果 显微镜下可见动眼神经在岩尖部紧邻三叉神经半月节内侧进入海绵窦。在中颅底，动眼神经、外展神经和三叉神经位于海绵窦硬膜下方。动眼神经在海绵窦内位于三叉神经眼支内侧，其内下方是外展神经。全部实验步骤均能被SD大鼠耐受，所有存活鼠术后均生存良好，无感染和角膜溃疡等并发症，除动眼神经损伤所致的瞳孔完全散大和眼球运动障碍之外，无其它神经功能障碍征象。结论 应用该方法建立的鼠动眼神经损伤及再生的动物模型，可方便、安全地暴露鼠颅内段动眼神经，以备各种实验干预，动物死亡率低，并发症少，并可应用于三叉神经、外展神经和视神经等颅神经再生的实验研究。     

Subtemporal transpetrosal apex approach: study on its use in large and giant petroclival meningiomas

Background  The subtemporal transtentoral approach has been reported for nearly two decades; however it was not well used due to some limitations in dealing with large and giant petroclival meningiomas. The clinical outcome and merit of the modified subtemporal transpetrosal apex approach in large and giant petroclival meningiomas, as well as the choices, the improvements and the therapy strategies of the microsurgical approach in such patients were evaluated in this study.

Methods  Totally 25 cases of large and giant petroclival meningiomas undergone the modified subtemporal transpetrosal apex approach between April 2004 and January 2010 were enrolled in this study. The choice and improvement of the approach, the basis of anatomy and related research, the effect of accessory equipment, the exposure of tumor and the changes of neurofunction pre- and post-operation were all reviewed retrospectively. The operation outcomes and complications in this approach were also compared with those in the transpetrous presigmoid approach done in 14 cases in the same period.

Results  All 25 cases underwent the modified subtemporal transpetrosal apex approach under electrophysiologic monitoring of cranial nerves and brain stem function. Trochlear nerve was partly wrapped in 14 cases, totally wrapped but can be explored in the initial segment of the cerebellum tentorium in 8 cases, totally wrapped and could not be seen until tumor was partly removed in 3 cases. The cerebellum tentorium was cut along the temporal bone from the anterior part of the apex to the mastoid part of superior petrous sinus in 6 cases, from the posterior part of the apex to the mastoid part of superior petrous sinus in 19 cases. Gross tumor resection was accomplished in 17 (68%) patients, subtotal resection in 7 (28%) patients, and partial resection in 1 (4%) patient. The most common postoperative complication was new neurological deficits or aggravations of preexisting deficit (64%). Follow-up ranged from 3 to 69 months. Compared with the transpetrous presigmoid approach done in 14 cases in the same period, the modified subtemporal transpetrosal apex approach showed obvious advantages such as simplicity in manipulating, microinvasiveness, less time-consuming, less complication, higher rate of tumor resection though the rates of gross tumor resection might be of no significant difference.

Conclusions  Modified subtemporal transpetrosal apex approach has obvious advantages compared with the transpetrous presigmoid approach. Some complications need to be solved by practice and modification of the approach as well as the accumulation of the experiences.

     

部分肌松下多组颅神经监护在小脑桥脑角区肿瘤切除术患者中的应用

目的 评价全身麻醉下小脑桥脑角区肿瘤切除术患者中,在部分肌松条件下多组颅神经监护的效率.方法 70例择期行小脑桥脑角区肿瘤显微手术患者,随机分为两组,一组术中只进行面神经监护(FN组,n=35),另一组则除了面神经外,尚监护三叉神经、舌咽神经或副神经、舌下神经(MN组,n=35).两组均根据监护结果调整手术操作,患者颅神经监护期间均采用TOF肌松临测,连续输注维库溴铵维持TOF值为3.术前和术后第8天评价所监护神经支配的肌肉功能.结果 术中两组患者在TOF=3的部分肌松条件下均能得到清晰可辨的肌电图波形.FN组和MN组术后面神经功能恶化(从H-B Ⅰ～Ⅱ级至Ⅲ～Ⅳ级)的均增加4例,另外FN组新增1例舌咽神经损伤,而MN组新增1例舌下神经损伤.结论 全麻下在部分肌松条件下进行术中多组颅神经监护是可行的,但在小脑桥脑角区肿瘤显微手术中多组神经联合面神经监护似乎并不增加术后短期颅神经的保护效率.     

Anatomic structural study of cerebellopontine angle via endoscope

Background  Minimally invasive surgery in skull base relying on searching for possible anatomic basis for endoscopic technology is controversial. The objective of this study was to observe the spatial relationships between main blood vessels and nerves in the cerebellopontine angle area and provide anatomic basis for lateral and posterior skull base minimally invasive surgery via endoscopic retrosigmoid keyhole approach.
Methods  This study was conducted on thirty dried adult skulls to measure the spatial relationships among the surface bony marks of posterior cranial fossa, and to locate the most appropriate drilling area for retrosigmoid keyhole approach. In addition, we used 10 formaldehyde-fixed adult cadaver specimens for simulating endoscopic retrosigmoid approach to determine the visible scope.
Results  The midpoint between the mastoid tip and the asterion was the best drilling point for retrosigmoid approach. A hole centered on this point with the 2.0 cm in diameter was suitable for exposing the related structures in the cerebellopontine angle. Retrosigmoid keyhole approach can decrease the pressure on the cerebellum and expose the related structures effectively which include facial nerve, vestibulocochlear nerve, trigeminal nerve, glossopharyngeal nerve, vagus nerve, accessory nerve, hypoglossal nerve, anterior inferior cerebellar artery, posterior inferior cerebellar artery and labyrinthine artery, etc.
Conclusions  Exact location on endoscope retrosigmoid approach can avoid dragging cerebellum during the minimally invasive surgery. The application of retrosigmoid keyhole approach will extend the application of endoscopic technology.

     

面神经颅内段的显微外科解剖学研究

目的探讨面神经颅内段的显微解剖,为临床手术提供解剖学参数.方法应用10%甲醛充分固定的成人尸头标本10例20侧;漂白干颅骨10例20侧.结合侧方手术入路对面神经及其毗邻结构进行测量和拍照.结果面神经颅内段分为五段,即脑桥小脑角段、内耳道段、迷路段、鼓室段和乳突段.脑桥小脑角段和内耳道段与位听神经伴行;迷路段最短最细,约3.8mm±0.7mm长;鼓室段与骨迷路和中耳关系密切;乳突段长约15.5mm±1.9mm,经茎乳孔出颅.结论枕下乙状窦后入路中可利用第四脑室脉络丛定位面神经脑干端;经岩前人路中可利用弓状隆起和岩浅大神经定位面神经内耳道段和迷路段部分鼓室段骨壁缺如,面神经直接裸露在岩骨表面;外半规管至二腹肌嵴前端是面神经乳突段的标志线.     

幕下小脑上外侧入路内镜解剖学研究

目的探讨幕下小脑上外侧入路内镜下的解剖特点。方法在10具尸体头上用内镜模拟手术,观察入路中主要神经、血管等解剖标志的分支、变异情况和周围毗邻关系。结果通过幕下小脑上外侧入路可以顺利进入脑桥小脑角上部,清晰地观察三叉神经及其责任血管。利用不同角度内镜,可扩展对脑桥小脑角立体结构的暴露,特别利于查明手术显微镜难以观察的部位。结论幕下小脑上远外侧锁孔入路具有解剖学的可行性。可达到对岩静脉、三叉神经根、小脑上动脉的清晰显露。     

诱发电位、肌电图在桥小脑角区肿瘤术中的应用及临床意义

目的通过研究脑干听觉诱发电位（BAEP）及面部肌肉肌电图（EMG）在桥小脑角区肿瘤显微切除手术中的监测变化,对手术操作提前预警,以最大限度地避免损伤重要结构。方法2009年12月～2010年12月对16例桥小脑角区肿瘤患者,应用双侧BAEP和同侧EMG连续实时监护,根据监测结果对可造成脑干和受累的颅神经功能障碍的操作进行提前预警,观察手术操作对它们的影响。结果桥小脑角区肿瘤术中脑干及其周围手术操作均可以引起BAEP改变,BAEPV波波幅降低,V波峰潜伏期（PL）、I—V及Ⅲ～V波峰间期（IPL）明显延长。术中自发EMG会有不同程度的变化,表现为突发的、多相的高幅电位改变。结论BAEP的V波PL延长和波幅下降以及I－V、Ⅲ－V波峰间期延长是桥小脑角区肿瘤术中敏感的电生理指标,对其进行监护,可避免术中脑干功能障碍;通过EMG的监测,准确判断颅神经的位置及走行,最大程度避免颅神经的损伤,降低手术伤残率。     

颅鼻眶联合入路切除筛窦恶性肿瘤

目的总结经颅鼻眶入路治疗筛窦恶性肿瘤的临床经验。方法回顾性分析39例经颅鼻眶入路手术切除侵犯前颅凹及眼眶的筛窦恶性肿瘤的临床资料。39例中男29例,女10例,年龄20～65岁,平均42岁;肿瘤类型包括嗅母细胞瘤10例、腺癌8例、鳞癌7例、乳头状瘤6例、肉瘤4例、未分化癌3例、基底细胞癌1例。38例肿瘤侵犯前颅凹,其中31例侵犯眼眶、5例侵犯翼腭窝、3例侵犯中颅凹及海绵窦。临床表现包括鼻堵、鼻溢、鼻衄、鼻部肿物,突眼、视力下降,面部麻木,意识障碍等。结果肿瘤全切除32例（其中包括9例完整摘除）,近全切除7例。术后一过性脑脊液鼻漏5例,无颅内及切口感染。随访到27例（77．1％）,随访时间为3个月至7年,平均3年6个月。肿瘤局部复发8例,肺部转移1例。术后1个月至6年死亡4例。结论经颅鼻眶入路充分显露侵犯前颅凹及眼眶部的筛窦肿瘤,且能完整切除肿瘤,手术安全,并发症少。     

Removal of vestibular schwannoma and facial nerve preservation using small suboccipital retrosigmoid craniotomy

Background  Vestibular schwannoma, the commonest form of intracranial schwannoma, arises from the Schwann cells investing the vestibular nerve. At present, the surgery for vestibular schwannoma remains one of the most complicated operations demanding for surgical skills in neurosurgery. And the trend of minimal invasion should also be the major influence on the management of patients with vestibular schwannomas. We summarized the microsurgical removal experience in a recent series of vestibular schwannomas and presented the operative technique and cranial nerve preservation in order to improve the rates of total tumor removal and facial nerve preservation. 
Methods  A retrospective analysis was performed in 145 patients over a 7-year period who suffered from vestibular schwannomas that had been microsurgically removed by suboccipital retrosigmoid transmeatus approach with small craniotomy. CT thinner scans revealed the tumor size in the internal auditory meatus and the relationship of the posterior wall of the internal acoustic meatus to the bone labyrinths preoperatively. Brain stem evoked potential was monitored intraoperatively. The posterior wall of the internal acoustic meatus was designedly drilled off. Patient records and operative reports, including data from the electrophysiological monitoring, follow-up audiometric examinations, and neuroradiological findings were analyzed. 
Results  Total tumor resection was achieved in 140 cases (96.6%) and subtotal resection in 5 cases. The anatomical integrity of the facial nerve was preserved in 91.0% (132/145) of the cases. Intracranial end-to-end anastomosis of the facial nerve was performed in 7 cases. Functional preservation of the facial nerve was achieved in 115 patients (Grade I and Grade II, 79.3%). No patient died in this series. Preservation of nerves and vessels were as important as tumor removal during the operation. CT thinner scan could show the relationship between the posterior wall of the internal acoustic meatus and bone labyrinths, that is helpful for a safe drilling of the posterior wall of the internal acoustic meatus.
Conclusions  The goal of every surgery should be the preservation of function of all cranial nerves. Using the retrosigmoid approach with small craniotomy is possible even for large schwannomas. Knowing the microanatomy of the cerebellopontine angle and internal auditory meatus, intraoperating neurophysiological monitoring of the facial nerve function, and the microsurgical techniques of the surgeons are all important factors for improving total tumor removal and preserving facial nerve function.