听神经瘤显微手术中岩静脉的保护

目的探讨显微手术切除听神经瘤时岩静脉保护的方法和临床意义。方法显微手术治疗听神经瘤147例,术中先行肿瘤内减压,再逐步分离肿瘤周边结构。岩静脉143例保护良好;4例术中被切断行电凝处理。结果 143例患者术后未发生小脑出血性梗塞。4例电凝处理岩静脉,其中1例发生一过性广泛性小脑水肿,随访18个月能生活自理,但仍有走路步态不稳,3例出现小脑出血性梗塞并水肿,其中1例死亡;2例经后颅窝减压后恢复良好,其中1例随访3 3个月无明显神经功能障碍,1例随访1 2个月尚有走一字路不稳。结论在听神经瘤显微手术中应保护好岩静脉,一旦损伤需在手术后密切观察病情变化,做好再次后颅窝减压手术的准备。     

听神经鞘瘤的显微外科治疗

目的：探讨显微手术切除小脑脑桥角区听神经鞘瘤（AN）的治疗效果。方法：对经CT或MRI证实,位于小脑脑桥角区的425例AN,采用显微手术切除,术后评估治疗效果,分别比较术前,术后的面神经和听神经功能。结果：肿瘤全切率88．71％（377例）;次全切除率8．24％（35例）,部分切除率3．09（13例）;术后死亡率1．41％（6例）,对382例平均随访4．3年,其中293例恢复良好,64例恢复较好,25例恢复较差,后者中有12例肿瘤复发（再次手术治疗后治愈）。结论：采用显微外科技术切除小脑脑桥角区听神经鞘瘤是一种安全,有效的方法。     

听神经瘤的显微手术治疗

目的探讨听神经瘤的显微手术治疗。方法对60例听神经瘤患者采用枕下乙状窦后入路和经迷路入路行显微手术治疗,肿瘤最大径6.2 cm×6.0 cm,骨窗3 cm×3 cm~5 cm×5 cm,术中注意肿瘤与蛛网膜的边界,并沿该边界分离并切除肿瘤,锐性分离面神经;磨开内听道,神经内镜辅助下切除内听道内肿瘤。注意保护重要血管、后组颅神经及脑干。结果肿瘤全切除57例,次全切除3例。面神经解剖保留率83.3%,手术死亡1例。术后1周面神经功能House-Brackmann分级:Ⅳ级31例,Ⅲ级19例,Ⅱ级9例,Ⅰ级1例。随访1年,肿瘤均无复发。结论显微外科技术能有效切除肿瘤,大大提高了面神经保全率,具有微创特点,减少了并发症。     

听神经瘤的听力保护

影像学的进步,使症状轻微的听神经瘤(acoustic neuroma,AN)可以早期发现,其治疗已进入功能保全时代。AN术后的听力保护或丧失是多因素的,依赖于内听动脉、内耳结构和蜗神经的完整及功能正常。复习文献,听力保护率在6％～80％,主要原因是病例选择和听力评价标准不同。     

有关中颅窝入路的岩骨解剖

中颅窝入路切除听神经瘤在20世纪初就已提出,长期以来,尽管手术显微镜的出现使这一术式成为可能,但由于颞骨上份表面缺乏明显的标志,入路困难,因此中颅窝入路切除听神经瘤一直是耳外科学最困难的术式之一。听神经瘤手术的理想目标是完全切除肿     

眶内肿瘤手术入路的显微外科解剖

目的 为眶内肿瘤手术入路提供显微解剖学资料。方法 模拟眶颧颞入路的手术操作，暴露眼眶的上壁及外侧壁，采用不同的手术入路，在手术显微镜下对5具（10侧）福尔马林固定动脉灌注以红色胶乳的成人带颈头颅标本的眼眶内结构及其相互关系进行解剖学观察与测量。结果 ①经眼眶上壁的上内侧入路可以暴露从球后到视神经管的整段神经的上、内侧区；②上中央入路仅能够暴露眶内视神经的中1/3段的上面；③上外侧入路对眶尖深部外侧区的暴露效果与眼眶外侧壁的外上方入路基本相同，但前者能兼顾眶上裂与海绵窦的暴露，而后者则不能；④经眼眶外侧壁的外下方入路可以暴露眶内视神经的外、下侧区。结论 对于眶内肿瘤应根据病变在眶内的具体部位选择相应的手术入路。     

颅颈交界区的显微外科解剖研究

目的　研究颅颈交界区的显微外科解剖 ,评价寰椎横突 (TPA)在颅颈交界区病变手术中的定位意义。方法　成人头颈标本 10例 ,男 8例 ,女 2例 ,红色乳胶灌注颈总动脉和椎动脉。手术显微镜下 (× 3～× 2 0 )逐层显露颅颈交界区结构 ,明确不同解剖结构与TPA的位置关系。结果　颅颈交界区所有重要的解剖结构均可以TPA为参照标志予以明确。二腹肌后腹位于其浅层。TPA的后方为枕下三角 ,枕下三角内有椎动脉、椎静脉丛和C1神经通过。头侧直肌起始于TPA的上表面 ,止于枕骨颈静脉突的下表面 ,可作为确定颅外颈静脉孔、茎乳孔的解剖标志。茎突位于TPA的前方 ,颈内静脉、迷走神经、副神经、舌下神经穿行于茎突与TPA之间 ,颈内动脉位于颈内静脉的前内侧。结论　TPA是颅颈交界区病变手术的重要外科解剖标志 ,利用这一标志有助于明确此区域重要的解剖结构 ,避免术中不必要的损伤     

大型听神经瘤的显微手术技巧及面神经保护

目的探讨大型听神经瘤的显微手术技巧、效果及术中面神经的保护。方法回顾性分析解放军总医院耳鼻咽喉头颈外科2010年1月~2010年12月收治的采用显微外科手术治疗30例大型听神经瘤患者的临床资料。其中男性18例,女性12例;年龄19～71岁,平均39.6±4.2岁;病程3个月～2年。主要临床表现为桥小脑角综合征和颅内压增高征,首发症状表现为耳鸣、听力下降12例,头痛、恶心、呕吐10例,行走不稳4例,面部麻木7例,三叉神经痛2例,面瘫6例。30例术中均行面神经监测,显微镜下切除肿瘤,术毕刺激面神经的脑干端对术后面神经功能进行预测。结果本组30例大型听神经瘤全切除28例,次全切除1例,部分切除1例。术中面神经完整保留29例(96.67%),无死亡病例。肿瘤切除后,面神经刺激阈值的大小与术后面神经功能存在明显的相关性。刺激阈值越小,术后面神经功能越好。结论熟练地采用显微外科技术选择合适的手术入路可明显提高肿瘤的全切除率和面神经的解剖及功能保留率。手术入路的正确选择,娴熟的显微外科操作技术,术中应用面神经监测技术,能有效地保护桥小脑角周围的重要结构及面神经功能,并可预测术后面神经功能。     

听神经瘤手术中面神经的保护和修复

目的 探讨听神经瘤手术治疗中面神经的保护和修复的方法.方法 回顾性分析2004年1月至2006年12月我科收治137例听神经瘤的临床资料,其中肿瘤直径≥4.0 cm的40例中(29.20%),39例采用扩大迷路径路切除肿瘤,1例耳囊径路切除;肿瘤直径2.6～4.0 cm的64例(46.72%)中,经扩大迷路径路切除肿瘤57例,乙状窦后径路切除肿瘤7例;肿瘤直径1～2.5 cm的30例中(21.90%),经扩大迷路径路切除肿瘤19例,乙状窦后径路切除肿瘤11例,肿瘤直径<1 cm的3例(2.19%)均经颅中窝径路切除肿瘤.术中均采用面神经监测.结果 听神经瘤拿切除135例(98.54%),近全切除2例(1.46%);面神经解剖保留110例(80.3%),断离27例,全部为桥小脑角段,其中15例采取面-舌下神经吻合,6例腓肠神经移植面神经桥接吻合,6例因缺损长、术中兼有后组颅神经损伤,而未能修复.术后1周面神经功能达到H-B分级Ⅰ-Ⅱ级84例(61.3%,84/137),Ⅲ-Ⅳ级38例(27.7%,38/137),Ⅴ-Ⅵ级15例(10.95%,15/137).术后6～12月面神经功能Ⅰ-Ⅱ级84例(61.3%,84/137),其中肿瘤≥4.0 cm(5/40),肿瘤2.6～4.0cm者46例(71.86%,46/64);肿瘤1～2.5 cm者30例(100%,30/30);肿瘤<1 cm者3例(100%,3/3);Ⅲ-Ⅳ级者47例(34.31%,47/137),其中,肿瘤≥4.0 cm 29例,肿瘤2.6～4.0cta18例;Ⅴ-Ⅵ级者6例(4.35%,6/137):肿瘤均≥4.0 cm.结论 听神经瘤手术中面神经的保护与肿瘤的大小、面神经的走行、术前放疗、手术径路及术者的操作技巧等相关,术中采用持续面神经监测,可提高面神经的解剖保留,继而提高面神经功能保存率.面神经的修复应视面神经断离的部位、距离及后组颅神经的损伤情况来选择修复方法.     

囊性听神经瘤的显微手术策略与临床分析

目的探讨囊性听神经瘤的临床特点及其显微外科手术的治疗方法。 方法回顾性分析2013年1月~2017年12月华中科技大学同济医学院附属同济医院神经外科收治的囊性听神经瘤69例。所有囊性听神经瘤均行手术治疗,采用枕下乙状窦后入路。结果肿瘤全切61例（88.4%）,次全切除6例（8.7%）,部分切除2例（2.9%）;面神经解剖保留率为64例（92.7%）。术后2周采用面神经功能House Brackmann分级,其中Ⅰ Ⅱ级47例（68.1%）,Ⅲ Ⅳ级16例（23.2%）,Ⅴ Ⅵ级6例（8.7%）;术后后组脑神经功能障碍4例（5.8%）,术后实用听力保留患者4例（5.8%）。结论囊性听神经瘤应尽量早期积极手术,在充分保护面神经功能的前提下,力争全切肿瘤。同时术者丰富的显微外科技术,以及超声刀、激光刀、电生理监测等重要工具的应用,是保障囊性听神经瘤手术效果和保全神经功能的关键因素。     

Hearing preservation in acoustic neuroma surgery

Hearing conservation in acoustic tumour surgery remains controversial. There have been few previous reports in the British literature. The senior author has managed 24 patients by retrosigmoid surgery with the intention of preserving hearing during the last 9 years. The clinical features, surgical technique and results are discussed with respect to pre-operative selection criteria, and post-operative quality of hearing. Hearing preservation has been achieved in 11 (78.6%) of 14 patients with small or intracanalicular tumours and a mean minimum auditory threshold of 35 dB and 70% speech discrimination, the majority (81.8%) above the 50 dB/50% level. Tumour filling the fundus of the internal auditory canal was found to be a significant adverse prognostic factor as regards successful hearing preservation. Tumour excision was complete in all patients. Nearly 90% of patients had normal facial function, and the remaining 10% grade II function. Associated morbidity was minimal. It is suggested that the potential for hearing conservation should be considered as a factor in the management of patients with small acoustic neuromas.     

经岩骨入路面神经的显微解剖学研究

目的为经岩骨入路保护面神经提供显微解剖学资料.方法手术显微镜下对10具(20侧)福尔马林固定的成人头颈部标本模拟经岩骨入路的手术操作,观测管段面神经的解剖及其与重要结构的关系.结果管段面神经分3段迷路段长(3.2±0.9)mm,上下方向管径(1.1±0.2)mm;鼓室段长(11.7±1.5)mm,水平方向管径(1.4±0.1)mm,两段成角71.0°±11.7°;垂直段长(13.9±1.8)mm,前后方向管径(1.6±0.2)mm,与水平段成角106.6°±7.7°.管段面神经的解剖标志①锥隆起是上膝部的标志,锥隆起与茎乳孔连线为垂直段的标志线;②面神经裂孔是膝状神经节的标志;③垂直段距离海伦嵴(15.0±1.3)mm.结论熟悉管段面神经的解剖特点和标志,有利于手术中保护面神经.     

肌电图监护下大型听神经瘤的显微手术及面神经保留

目的 介绍经枕下-乙状窦后入路大型听神经瘤显微手术切除及面神经保留技巧。方法对32例大型听神经瘤在面肌肌电图监护下行显微手术切除。结果所有32例病人均行肿瘤全切，面神经解剖保留率为96．88％。根据House-Brackmann面神经功能分级标准，面神经功能保留率术后6个月为Ⅱ级52．38％、Ⅲ级42．86％、Ⅳ级4．76％；术后1年为Ⅱ级66．67％、Ⅲ级28．57％、Ⅳ级4．76％。结论对大型听神经瘤，在面肌肌电图监护下通过显微手术技术，可以全切肿瘤同时保留面神经解剖的完整。     

Acuteness of preoperative factors to predict hearing preservation in acoustic neuroma surgery

OBJECTIVES: To determine in patients with acoustic neuromas the predictive factors of hearing preservation according to clinical, radiological, and electrophysiological parameters and to evaluate, for each of these predictive factors, the percentage of patients with preserved hearing. STUDY DESIGN: The study involved 107 candidates for hearing preservation attempt. Mean age was 49.7 +/- 11.4 years. Quantitative and qualitative parameters were prospectively studied. Quantitative parameters were age, duration of functional complaints, hearing loss assessed by pure tone and speech audiometry, and auditory brainstem responses (ABRs). Qualitative parameters (expressed in percentage of presence) were sex, functional complaints, vestibular deficit revealed by vestibular testings, well-shaped ABRs, wave I, III, or V of ABRs, and transient evoked otoacoustic emissions (TEOAEs). METHODS: Patients were divided into two groups according to whether their hearing was preserved (52.3%) or not preserved (47.7%). First, quantitative and qualitative factors were compared between both groups to identify predictive factors. Second, all patients were considered together and the percentage of hearing preservation was determined according to the presence of each predictive factor. RESULTS: The results confirmed the predictive value of classic parameters such as preoperative hearing level, radiological data, and trace of ABRs. They also emphasized the predictive role of other parameters such as short duration of hearing loss, presence of wave III in ABRs, and presence of TEOAEs. CONCLUSIONS: The size of the tumor and the preoperative hearing levels are longstanding predictive factors of hearing preservation in acoustic neuroma surgery, and candidates for hearing preservation are therefore now selected according to these factors. This study added more recent predictive factors and, among the 10 factors identified as predictive, the most relevant to hearing preservation were the presence of TEOAEs (69.7%), short duration of hearing loss (66.7%), and presence of wave III in ABRs (66.7%).     

Experiences at the Timone Hospital,Marseille in acoustic neuroma surgery

Summary The authors report their experiences after operating on 279 patients with unilateral acoustic neuromas between 1976 and 1988, with 258 cases managed by the translabyrinthine approach and 21 cases by the middle fossa approach. The authors emphasize the necessity for total removal in order to avoid recurrences.Presented at the First European Congress of Oto-Rhino-Laryngology and Cervico-Facial Surgery, Paris, 26–29 September 1988     

Hearing preservation in acoustic neuroma surgery: the impact of different patient selection criteria

OBJECTIVES/HYPOTHESIS: The aim of the present study was to assess whether applying the various selection criteria for hearing preservation surgery on the same group of patients with acoustic neuroma leads to significantly different numbers of patients being considered suitable for this kind of surgery. STUDY DESIGN: We used different selection criteria for hearing conservation surgery based on a range of studies in the published literature. We applied these criteria to a consecutive group of patients presenting to our unit with acoustic neuroma. We then calculated the numbers of patients deemed suitable for hearing preservation surgery as a function of these different selection criteria. METHODS: Studies with published selection criteria, total numbers of patients, and numbers of patients suitable for hearing preservation surgery were found in the literature. These selection criteria were applied to our patient data. A chi2 statistical analysis was used to assess whether applying different selection criteria to the same group of patients (the subjects of the present study) resulted in different numbers of patients suitable for hearing preservation surgery. RESULTS: The numbers of patients suitable for hearing preservation showed wide variation, ranging from 8 (10%) to 45 (56%) patients (of the total number of 80 patients in the present study). The chi2 statistical analysis revealed that the various selection criteria did have an effect on the numbers of patients suitable for hearing preservation surgery, and the statistical significance reached the level of P<.001. CONCLUSIONS: Different selection criteria lead to significantly different numbers of patients being considered suitable for hearing preservation surgery. Consensus and agreed selection criteria would help set patient expectations, refine candidate selection, and facilitate the comparison of outcomes across centers.     

颞下经岩尖-小脑幕入路手术的显微解剖研究

目的 为颞下经岩骨入路手术处理斜坡及脑干腹侧病灶提供解剖学资料。方法 模拟颞下经岩尖—小脑幕入路的手术操作,在手术显微镜下对20侧(10具)福尔马林固定的国人成年带颈头颅标本进行解剖,并观测各主要解剖结构的相互关系。结果 颞下硬脑膜外经前内侧的三叉神经压迹、外侧的岩浅大神经沟及岩上窦所形成的三角区磨削岩骨尖。其周围结构的测量结果为:上半规管垂直于岩骨嵴,位于弓状隆起下方,耳蜗位于内听道前方、岩骨颈内动脉膝后方,内听道位于上半规管与岩浅大神经夹角中央。20侧中有2侧面神经膝裸露,耳蜗至膝状神经节的距离约为3.30 mm±0.79 mm,耳蜗距颈内动脉膝约2.48 mm±1.14 mm,内听道距岩斜缝约16.03 mm±1.94 mm,颈内动脉水平段距岩上窦约10.73 mm±2.00 mm。结论 颞下经岩尖—小脑幕入路能增加岩斜坡及脑干腹侧的显露,但显露范围有限,且需一定程度的颞叶牵拉。同时可能因为不熟悉解剖而误伤耳蜗、颈内动脉及第Ⅶ脑神经、第Ⅷ脑神经,选择应用时应审慎考虑。     

翼点入路对大脑前动脉的显微应用解剖

目的：探讨经翼点入路大脑前动脉及其穿通支的显微解剖及其临床应用，方法：对10具（20侧）红色乳胶颈内动脉和推动脉灌注头颈部标本的大脑前动脉及其穿通支在手术显微镜下解剖观测。结果：大脑前动脉A1段变异多，右侧A1发育不全多见，A1外径左侧大于右侧。A2左右走行和前后走行各约占一半，大脑前动脉穿通支大多数由A1上壁、内上壁发出并向后、上方行走。A1近端3－5mm,中1／3区域穿通支少。结论：A1变异多，这可能与前交通动脉瘤形成有关；在大脑前动脉下壁、外侧壁解剖或在A1近端3－5mm、中1／3区域临时夹闭A1可减少A1穿通支的损伤。