颞下乙状窦前入路岩斜区肿瘤切除 (附5例报告)

岩斜区肿瘤位置深在 ,手术入路受到岩锥阻挡 ,周围结构毗邻重要 ,此区肿瘤切除手术难度大 ,肿瘤残留率及致残率均较高。传统的乙状窦后入路 (枕下入路 )和颞下入路在处理肿瘤时因岩锥阻挡及手术径路过深造成显露、操作上的困难。颅底外科经验和技术的发展使经岩后 (乙状窦前 )入路成为传统入路的重要替代和选择之一。我科于 2 0 0 1年 2月至2 0 0 1年 5月 ,采用乙状窦前入路岩斜区肿瘤切除术切除肿瘤 5例 ,现报告如下。1　临床资料1.1　一般资料 :本组 5例 ,男 3例 ,女 2例 ,年龄 2 8～ 45岁 ,平均 37岁。临床表现头痛 1例 ,病灶侧面神经周…     

乙状窦前入路切除岩斜区脑膜瘤

目的 探索岩斜区脑膜瘤的手术入路及手术方式,并评价其疗效.方法 采用乙状窦前入路,应用显微神经外科技术,将岩斜区脑膜瘤分块行全切或部分切除.结果 9例病例中肿瘤全切6例,占66.6%;次全切除2例,占22.2%;大部分切除1例,占11.2%.无手术死亡病例,术后7例随访,平均20个月.6例正常生活,1例生活自理.MRI随访5例,未见肿瘤复发或再生长.结论 采用乙状窦前入路、应用显微神经外科技术治疗岩斜区脑膜瘤,能提高该病治愈率,减少并发症.     

颞下-乙状窦后联合锁孔入路显微手术治疗岩斜区脑膜瘤

目的：探讨应用颞下-乙状窦后联合锁孔入路显微手术切除岩斜区脑膜瘤的方法和经验,以及岩斜区脑膜瘤的微侵袭手术入路和方法,提高肿瘤的全部切除率与术后疗效。方法：回顾性分析经颞下-乙状窦后联合锁孔入路治疗的21例岩斜区脑膜瘤的临床资料,总结联合锁孔手术的方法和技巧,并对肿瘤切除程度和手术前后功能状态评分（Karnofsky performance score,KPS）进行分析,其中在神经导航引导下手术9例,在神经电生理监测下进行的手术12例。结果：肿瘤全部切除(Simpson Ⅰ、Ⅱ级)18例(85.7%,18/21),次(近)切除(SimpsonⅢ级)3例(14.3%, 3/21),术后三维CT显露锁孔骨瓣复位良好,术后病理均证实为脑膜瘤。术后新增颅神经功能障碍或原有神经功能障碍加重5例(23.8%),其中短暂性滑车神经3例、外展神经1例、三叉神经运动支麻痹1例。出现外展神经麻痹的1例,同时伴有听力障碍加重。术后3个月随访时,11例KPS同术前,7例术后改善,3例加重。KPS平均评分77.14±23.12,与术前比较差异无统计学意义（P>0.05）。术后随访半年,恢复良好者19例（KPS≥70）,恢复一般2例（KPS＜70）。术后随访3~29个月,无肿瘤复发或进展。结论：颞下-乙状窦后联合锁孔入路是简便、安全、微创、理想的切除岩斜区脑膜瘤的手术入路,掌握手术技巧和术中注意事项,有利于提高肿瘤的全部切除率和术后疗效。     

改良经岩骨乙状窦前入路显微外科治疗岩斜区肿瘤

目的探讨岩斜区肿瘤经改良岩骨乙状窦前入路显微外科治疗的手术特征及并发症。方法回顾性分析经显微手术治疗的9例岩斜区肿瘤,对肿瘤临床和影像学特征、手术入路、手术切除技巧及术后常见并发症的处理进行研究。结果肿瘤全切除7例,近全切除1例,大部切除1例。术后一过性失语1例,脑水肿2例,周围性面瘫1例,脑脊液耳漏1例,腰穿引流后好转。无死亡病例。结论改良经岩骨乙状窦前入路可充分暴露岩斜区肿瘤及其周围结构,是岩斜区肿瘤的较佳手术入路。     

经颞下-乙状窦前入路切除巨大岩斜脑膜瘤

目的 :岩斜型脑膜瘤的手术切除相当困难 ,本文对经颞下 -乙状窦前入路切除该区肿瘤作一评价。　 方法 :回顾分析我院 1994年 11月～ 1996年 1月经颞下 -乙状窦前入路切除的巨大岩斜型脑膜瘤 5例。　 结果 :5例患者中 ,全切除 3例 ,其中 2例恢复良好 ,1例术后偏瘫和多脑神经麻痹 ;因肿瘤与脑干不能分开而行肿瘤次全切除和部分切除各 1例 ,其中 1例遗留永久性动眼神经麻痹 ,另 1例术后长期昏迷。　 结论 :经颞下 -乙状窦前入路切除该区肿瘤具有以下优点 :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。肿瘤不能全切除和患者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及侵犯了软脑膜 ,使肿瘤与脑干间失去蛛网膜界面     

乙状窦前人路治疗岩斜区肿瘤9例报告

对9例岩斜区肿瘤患者采用经乙状窦前入路的手术治疗。结果6例肿瘤全切除，2例次全切除，1例大部分切除。术后症状改善6例。提示乙状窦前入路能最大限度地暴露乙状窦前空间，充分暴露岩斜区肿瘤。是岩斜区肿瘤的首选手术入路。     

岩斜区脑膜瘤显微手术入路的改良及疗效

目的探讨改良经岩骨乙状窦前入路显微手术切除岩斜区脑膜瘤的疗效及手术技巧.方法采用改良经岩骨乙状窦前入路显微外科切除岩斜区脑膜瘤11例并对其临床资料进行回顾性分析.结果肿瘤全切除8例,次全切除1例,大部切除2例.本组无死亡病例,术后昏迷 1 例,新出现暂时性颅神经障碍3例,无脑脊液漏发生.结论改良经岩骨乙状窦前入路简便、安全,可充分显露岩斜区,有利于提高肿瘤切除程度和术后疗效,是岩斜区脑膜瘤手术治疗的较佳入路,但对术者的手术技巧和经验要求较高.     

岩斜区脑膜瘤显微手术入路的改良及疗效

目的探讨改良经岩骨乙状窦前入路显微手术切除岩斜区脑膜瘤的疗效及手术技巧.方法采用改良经岩骨乙状窦前入路显微外科切除岩斜区脑膜瘤11例并对其临床资料进行回顾性分析.结果肿瘤全切除8例,次全切除1例,大部切除2例.本组无死亡病例,术后昏迷 1 例,新出现暂时性颅神经障碍3例,无脑脊液漏发生.结论改良经岩骨乙状窦前入路简便、安全,可充分显露岩斜区,有利于提高肿瘤切除程度和术后疗效,是岩斜区脑膜瘤手术治疗的较佳入路,但对术者的手术技巧和经验要求较高.     

乙状窦前入路治疗岩斜区肿瘤9例报告

对9例岩斜区肿瘤患者采用经乙状窦前入路的手术治疗。结果6例肿瘤全切除,2例次全切除,1例大部分切除。术后症状改善6例。提示乙状窦前入路能最大限度地暴露乙状窦前空间,充分暴露岩斜区肿瘤,是岩斜区肿瘤的首选手术入路。     

乙状窦前入路治疗岩骨斜坡区病变

经岩骨入路切除岩骨斜坡区 (下称岩斜区 )肿瘤已有近百年历史。 190 4年Ｆｒａｅｎｋｅｌ[1 ] 首次报道了枕下 -经迷路入路切除听神经瘤 ,1977年Ｈａｋｕｂｕ[2 ] 据此改为经岩骨 -经小脑幕入路做斜坡脑膜瘤全切除术 ,术中保留迷路。 1988年ＡｌＭｅｆｔｙ等在应用小脑幕上下联合入路切除岩斜区脑膜瘤时提出了乙状窦前入路到达岩斜区。目前 ,乙状窦前迷路后小脑幕上下联合入路已公认为到达岩斜区的最佳入路。1　辅助检查乙状窦前入路标志是乙状窦前打开硬膜 ,保留迷路及耳蜗[3 ] 。因此 ,相关的辅助检查对病变的诊断和指导手术是十分必要的…     

PARAPETROSAL PRESIGMOID APPROACH FOR PETROCLIVAL TUMORS

Petroclivaltumorsrepresentmoredifficultto radicalresection.Thesetumorsarelocateddeepat skullbase,usuallywithabundantbloodsupplyand broadattachmenttothepetrous,clivus,andtentori um.Sometimesthetumorinvadesintothecavernous sinusandthevitalperforatingarteries,cranial nerves,andthebrainstemareinvolved[1].Inthepastdecade,withtheadventofskullbase surgeryconcept,moreandmoresurgeonsreported successfulcasesofpetroclivaltumorremoved.Over all,therehasbeenadecreaseinpostoperativemor talityandmorbidity.Se…     

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.

     

侵入海绵窦的岩斜脑膜瘤的手术治疗

目的 探讨侵入海绵窦的岩斜脑膜瘤的临床特点、手术策略、手术技巧和治疗效果.方法　回顾性分析2004年4月至2009年3月南昌大学第一附属医院临床资料完整的15例侵入海绵窦的岩斜脑膜瘤病例,总结其临床特点.本组均采用经乙状窦前入路,手术策略为全切除岩斜区肿瘤,对侵入海绵窦内的肿瘤行次全切除,术后辅以γ刀治疗.分析手术后颅神经功能和病人生存状况.结果头痛头晕、外展麻痹和面部麻木为本病的主要症状.手术近全切除肿瘤13例,切除≥90%2例.12例残余肿瘤术后行γ刀治疗.无手术死亡,术后无新增颅神经损害6例,出现动眼神经麻痹6例,面部麻木7例,外展功能障碍4例,面瘫7例.随访6～59个月(平均38.6个月),12例恢复正常工作和生活,2例生活自理,1例生活需他人照顾.13例无肿瘤复发,2例残余肿瘤增大者中1例经γ刀治疗肿瘤生长得到控制.眼球运动和上睑下垂均完全恢复,面瘫基本恢复,面部麻木5例部分缓解,外展功能障碍无明显改善.结论对侵人海绵窦的岩斜脑膜瘤应采用合理的手术策略,尽可能减少手术引起的神经损害,有利于提高病人的生存质量.     

Keyhole approach surgery for petroclival meningioma

Background In China, the feasibility of keyhole approach in surgical treatment of petroclival meningioma has not been well evaluated. This report summarized our experience in 25 patients with petroclival meningioma who had been treated with keyhole approach surgery. Methods From July 2000 to July 2005, 25 patients with petroclival meningioma were subjected to resection via subtemporal, retrosigmoid or combined keyhole approaches. 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 2 to 7 cm （mean, 4.5 cm）. Gross total resection （GTR） was achieved in 14 patients, giving a GTR rate of 56%. Subtotal resection （STR） was carried out in 8 patients and partial resection in 3. Thirteen patients kept normal neurological status, whereas others suffered from cranial nerve deficits （Ⅶ, Ⅶ, Ⅲ and lower CN）. One patient died in the postoperative period. Conclusions Keyhole approach surgery, especially the combined keyhole approach is suitable for the treatment of petroclival meningioma. It provides easy and quick access to the supra- and infratentorial juxta-clival region without drilling of the petrous bone. Complications related to the approach can be minimized.     

岩斜区肿瘤显微外科治疗手术入路选择（附17例报告）

目的：探讨岩斜区肿瘤外科治疗手术入路选择。方法：回顾性分析我院自1997年至2000年6月显微外科手术治疗的17例岩斜区肿瘤。12例肿瘤直径大于4cm。采用6种手术入路：颞下-小脑幕;天幕上下联合;颞下-乙状窦前;枕下乳突后;枕下远外侧;额眶颧入路。结果：肿瘤全切除12例（71%）,术后恢复良好者11例（65%）,术后新增颅神经损害6例（35%）。结论：选择和掌握适合的颅底手术入路,采用显微外科技术入路,采用显微外科技术切除岩斜区肿瘤可取得满意效果。     

颞下经小脑幕岩骨嵴入路切除岩斜区脑膜瘤的显微外科治疗

目的:探讨显微外科条件下以颞下经小脑幕岩骨嵴入路切除岩斜区脑膜瘤的临床疗效。方法:回顾性分析23例岩斜区脑膜瘤病人的临床资料,手术入路均选择颞下经小脑幕岩骨嵴入路,其中7例联合幕下乙状窦后入路。结果:对术后肿瘤切除程度根据Simpson分级:Ⅰ^Ⅱ级切除12例;Ⅲ级切除3例;Ⅳ级切除8例。术后出现昏迷2例;面神经功能小于Ⅲ级7例;眼球运动障碍11例;听力障碍2例;肢体肌力下降3例;颅内感染2例;死亡1例。15例随访6Ⅱ级切除12例;Ⅲ级切除3例;Ⅳ级切除8例。术后出现昏迷2例;面神经功能小于Ⅲ级7例;眼球运动障碍11例;听力障碍2例;肢体肌力下降3例;颅内感染2例;死亡1例。15例随访6³0个月,术前症状及术后并发症大部分不同程度改善,随访期内10例无肿瘤复发及残余肿瘤进展,5例肿瘤明显复发再次手术。结论:颞下经小脑幕岩骨嵴入路是岩斜区脑膜瘤手术治疗的重要方式,具有暴露满意、手术创伤小的优点。联合幕下乙状窦后入路可进一步增大幕下的暴露范围。对于无法全切的SimpsonⅢ级以上肿瘤,术后可辅助γ刀放射治疗抑制残余肿瘤进展,降低复发率。