经蝶入路显微切除大和巨大型垂体腺瘤

目的 探讨大和巨大型垂体腺瘤较理想的手术治疗原则。方法 所有病例采用经唇下蝶窦入路显微镜下肿瘤切除术。结果 30例肿瘤手术全切除26例,4例肿瘤因侵袭入鞍膈上和/或海绵窦内而行大部分切除,其中1例经额术后再二期经鼻蝶入路显微切除鞍内和蝶窦内肿瘤。结论 多数大和巨大垂体腺瘤可选择经鼻蝶入路全切。     

分期手术治疗巨大垂体腺瘤临床研究

目的探讨巨大垂体腺瘤分期手术治疗的方法及临床意义。方法回顾性分析郑州大学第一附属医院行分期手术切除的18例巨大垂体腺瘤患者的临床资料,根据肿瘤的不同形态及生长方式,采用两种分期手术策略:2例Ⅰ期经鼻蝶入路切除蝶窦、鞍内肿瘤,Ⅱ期经额下入路切除鞍上及脑室内肿瘤;16例Ⅰ期经额下入路切除鞍上及脑室内肿瘤,Ⅱ期经鼻蝶入路切除鞍内肿瘤。结果肿瘤全切除13例,次全切3例,大部分切除2例,无死亡病例。术后无严重发症。随访2个月~3a,18例临床症状均不同程度改善,对残留肿瘤的患者行药物或伽马刀治疗,未见肿瘤复发。结论对于巨大垂体腺瘤要根据肿瘤特性和个体化原则,采取不同的手术入路和分期手术策略,能提高肿瘤全切除率,同时术中要注意对垂体柄、下丘脑的保护,以减少术后并发症的发生,降低手术风险,提高治疗效果。     

经颅切除鞍区大型肿瘤手术入路探讨

目的探讨经颅切除鞍区大型肿瘤的手术入路。方法对13例位于鞍内-鞍上轴线上的大型肿瘤采用一侧额下经眶入路手术;11例鞍上巨大型肿瘤和侵袭至鞍区周邻部位的肿瘤经眶-翼点入路切除。结果肿瘤全切除9例,次全切除9例,大部分切除6例。术后死亡1例,余无严重并发症,恢复良好。结论该两种手术入路具有操作简便、显露良好、脑牵拉轻和并发症少等优点,适于鞍区大型肿瘤的经颅手术切除。     

扩大额下硬膜外入路切除巨大侵袭性垂体瘤

目的：报道２０例经扩大额下硬膜外入路切除巨大侵袭性垂体瘤。方法：侵及蝶窦、筛窦和斜坡部位的肿瘤可在直视下完全切除，对于鞍上和鞍旁有巨大瘤体者，加用额下硬膜内入路和颞下硬膜内入路可提高切除率。本文重点介绍该入路的手术方法，注意事项等。结果：本组巨型垂体瘤全切除和次全切除率为９０％，无手术死亡，无严重并发症。结论：采用扩大额下硬膜外入路切除巨大侵袭性垂体瘤，尤其向颅底方向生长者，疗效满意     

经颅显微外科手术治疗鞍区肿瘤（附20例报告）

目的探讨经颅单侧额下入路和翼点入路显微手术切除鞍区肿瘤的疗效。方法对15例位于鞍内、鞍上主要在轴线上的鞍区肿瘤采用一侧额下入路，5例偏轴线生长或巨大型向鞍旁、鞍后侵袭的肿瘤采用经翼点入路手术切除。结果肿瘤全切除10例，次全切除7例，大部分切除3例。术后14例发生短暂尿崩，10例出现低钠血症，1例出现高钠血症，无手术死亡病例。结论经颅额下和翼点入路切除鞍区肿瘤具有操作直观、显露良好、损伤小的优点，结合显微操作技术，可获得满意疗效。     

鞍上生长的巨大垂体肿瘤的手术策略

目的探讨分期手术治疗鞍上生长的巨大垂体肿瘤的临床意义。方法回顾性分析10例鞍上生长的巨大垂体肿瘤病例资料。一期手术均采用神经内镜经鼻蝶窦入路切除肿瘤,依据术后肿瘤残留情况,选择合适的分期手术方法。结果一期手术肿瘤全切除2例,次全切除3例,部分切除、采用分期手术5例。其中残余肿瘤下降至鞍内2例,二期手术采用内镜经鼻蝶窦入路手术;残余肿瘤位于鞍上3例,二期手术采用眉弓眶上锁孔入路显微手术。在5例采用分期手术病例中,肿瘤全切除4例,次全切除1例。术后无脑脊液漏、颅内感染等严重并发症。随访3~60个月,平均26个月,激素替代治疗3~6个月后,垂体功能基本恢复正常。结论对于鞍上生长的巨大垂体肿瘤,选择合理的分期手术方法,采用伽玛刀、药物等综合辅助治疗,可使病人获得良好的治疗效果。     

显微手术治疗垂体腺瘤(附57例分析)

目的总结经不同手术入路显微切除垂体腺瘤的临床经验。方法回顾性分析57例垂体腺瘤的临床资料。本组病人经不同手术入路切除垂体腺瘤。结果经额下入路全切12例,次全切3例,部分切除1例。经翼点入路全切8例,次全切2例。经单鼻孔-蝶窦入路全切23例,次全切6例,部分切除2例。经颅手术全切率为76.9%,经单鼻孔-蝶窦入路全切率为74%。结论微腺瘤与中、小型腺瘤及肿瘤向鞍上垂直生长,无海绵窦浸润及颈内动脉包裹的大腺瘤,经单鼻孔-蝶窦是首选术式。明显向鞍上生长的大腺瘤,若肿瘤明显偏向侧方侵犯海绵窦、颈内动脉、额叶底及鞍背后方者应采用经颅手术,且以翼点入路为佳。     

垂体腺瘤显微手术入路选择探讨

目的探讨垂体腺瘤不同显微手术入路的优缺点,以便临床更合理有效地选用手术治疗方式。方法回顾性分析2000年1月至2008年7月经CT、MRI及内分泌检查确诊的124例垂体腺瘤患者的临床资料。这124例患者均经手术治疗,其中经颅入路手术切除肿瘤29例,经单鼻孔-蝶窦入路手术切除肿瘤91例,4例分期采取了上述两种入路手术切除。结果经颅入路手术全切除肿瘤19例,次全切除和大部分切除肿瘤10例;复发6例,死亡1例。经单鼻孔一蝶窦入路手术全切除肿瘤74例,次全切除和部分切除肿瘤17例;复发2例,无死亡病例。分期手术4例,全切1例,次全切除1例,大部分切除2例。结论经单鼻孔-蝶窦入路手术可作为各类中小型腺瘤和多数大型腺瘤首选的治疗手段;对于大型垂体腺瘤,肿瘤向鞍上和颈内动脉两侧膨胀生长者采用经颅和／或二期经单鼻孔-蝶窦入路手术治疗可有效提高肿瘤切除率,减少手术并发症的发生。     

伴甲介型、鞍前型蝶窦的垂体腺瘤经蝶入路手术治疗研究

目的 探讨伴甲介型、鞍前型蝶窦的垂体腺瘤经蝶人路手术治疗的方法及特点.方法回顾性分析中山大学附属三院神经外科自2004年6月至2009年6月收治的32例经蝶入路手术治疗的伴甲介型、鞍前型蝶窦的垂体腺瘤患者的临床资料,其中伴甲介型蝶窦的垂体腺瘤5例,伴鞍前型蝶窦的垂体腺瘤27例.根据术前CT多平面重建、CT仿真内镜及MRI影像资料,指导术中暴露鞍底,切除肿瘤.结果 未使用定位设备的情况下,术中均能顺利暴露鞍底,切除肿瘤,平均手术时间86min.术后3 d内MRI复查示肿瘤全切除25例,次全切除6例,大部分切除1例.结论 对于伴甲介型、鞍前型蝶窦的垂体腺瘤经蝶入路手术治疗,通过术前详细的影像学检查、术中磨钻及显微镜或内镜的使用,术中能准确辨认及充分暴露鞍底、切除肿瘤.     

鞍区大型肿瘤不同显微手术入路的疗效评估(附82例报道)

目的 探讨和评估大型鞍区肿瘤不同手术入路的疗效. 方法 福建医科大学附属漳州市医院神经外科和上海同济大学附属仁济医院神经外科自2004年1月至2012年1月采用不同的手术入路治疗鞍区大型肿瘤患者82例,其中双额底内侧入路32例,单鼻孔经蝶入路32例,扩大的翼点入路12例、单侧额下外侧入路6例,评估不同入路的结果和预后. 结果 本组肿瘤全切除66例,次全切除16例,其中经双额底内侧入路肿瘤全切除28例(87.5％),次全切4例;单鼻孔经蝶经入路肿瘤全切除26例(81.2％),次全切6例;扩大的翼点入路肿瘤全切除9例(75％),次全切3例;单侧额下外侧入路肿瘤全切除3例(50％),次全切3例.无手术死亡患者. 结论 鞍区大型肿瘤的切除可根据肿瘤类型选用经扩大的翼点入路或双额底内侧入路,单鼻孔经蝶入路主要适用于垂体腺瘤.     

经纵裂蝶窦入路显微外科切除巨大侵袭性垂体腺瘤

目的 研究巨大侵袭性垂体腺瘤的手术入路,探讨肿瘤全切除的方法,以及术后并发症的防治。方法 采用改良冠状开颅,经大脑纵裂、蝶窦入路。结果：施术３０例,肿瘤显微镜下全切除２２例,全切除率达７３％。２７例随访２～３年,２３例恢复正常工作,肿瘤无复发。结论：该手术入路充分显露蝶鞍、蝶窦、鞍旁及鞍后,是切除巨大侵袭性垂体腺瘤的较理想方法。     

Transsphenoidal removal of intrasellar pilocytic astrocytoma

A 26-year-old man with a sellar pilocytic astrocytoma had a recurrent non-enhancing mass located in the sellar/suprasellar region visible on MRI. Due to tumor progression and worsening vision, the mass was completely resected through a transsphenoidal approach. Postoperatively, the patient’s vision improved and imaging showed complete removal of the tumor and optic pathway decompression. Pilocytic astrocytomas originating in suprasellar structures can intrude into the sella, and should be included in the differential diagnosis of intrasellar tumors. The transsphenoidal approach can be effective for resecting such tumors.     

大型垂体腺瘤经颅显微手术切除技术探讨

目的介绍经颅切除大型、巨大型垂体腺瘤的显微操作技术与经验。方法23例病人均取右侧眶．额下入路。充分降低脑张力，先切除囊内肿瘤组织，次环行切除鞍上瘤壁（鞍隔）。避免非直视下切除瘤壁至后床突，以保护垂体柄。鞍内瘤壁予电凝。结果肿瘤全切除9例，次全切除14例。9例出现尿崩，其中8例症状轻微，尿崩于术后1-2周内消失；1例尿崩持续8个月。35／46只眼术后视力好转（75．2％），无1例发生其他严重并发症，无1例死亡。除1例因经济原因提前离院外，余22例出院时一般情况良好，生活自理。结论右侧眶-额入路是大型、巨大型垂体腺瘤手术的理想入路。熟悉鞍区显微解剖，循囊内肿瘤全切、鞍上瘤壁环切、鞍内瘤壁电凝的顺序与方法及娴熟的显微外科操作技术是全切除肿瘤的基础和关键，并能有效降低手术风险，减少并发症。     

Aggressive resection of craniopharyngioma achieved by drilling the tuberculum sellae/planum sphenoidale using a frontal basal interhemispheric approach: A review of 55 cases

ObjectiveThe frontal basal interhemispheric approach (FBIA) is preferable for resection of craniopharyngioma (CP), achieving desirable total resection rates in early reports of lesions located in the suprasellar region to the third ventricle. For tumours that have created a larger obstruction of the tuberculum sellae and planum sphenoidale, aggressive resection in the intrasellar region and medial wall of the cavernous sinus is not feasible compared to improving tumour visualization by drilling the tuberculum sellae and planum sphenoidale. In a report of drilling the sellar tuberculum and sphenoid planum, drilling allowed the direct visualization of tumours invading the intrasellar region and medial wall of the cavernous sinus. Reconstructing the opening of the sellar-sphenoid cavity is achieved by microsuturing a piece of the pericranium/dura around the dural edge of the defective dura of the open sphenoid sinus and sellar cavity to prevent cerebrospinal fluid (CSF) leakage.Patients and methodsThe FBIA with drilling of the tuberculum sellae and planum sphenoidale was performed to remove the tumours that invaded the intrasellar region and cavernous sinus in 55 patients from January 2014 to October 2019 at our institution. The pre- and postoperative pituitary hormone levels and vision were evaluated as effective standards after surgery and compared using paired t-tests. The different rates of CSF leakage between the packing and microsuture groups were compared by χ² test, p < 0.05.ResultsIn all patients with a mean 37-month follow-up (range, 3–2 months), 43 (78.2%) patients returned to their normal life or school independently, 7 (12.7%) patients were able to perform normal activities with minor complaints or effort, and 4 (7.3%) patients could care for themselves or only required occasional assistance. One (1.8%) death occurred, attributed to CSF leak-related meningitis at 5 months after surgery. Postoperative CSF leakage occurred in eight (19.0%) of 42 patients with packed bone wax or pieces of muscle to the sphenoid sinus. Of 13 patients with a piece of the periosteum/dura microsutured around the defective dura of the sellar region and open sphenoid sinus, one (7.7%) of 13 patients experienced CSF leakage in the perioperative period. With statistical analysis, there was a potential risk for postoperative CSF leakage in the bone wax and muscle piece in the open sphenoid sinus, whereas microsuture manoeuvres were effective for avoiding the risk of postoperative CSF leakage (χ² = 8.865, p < 0.005). The microsutures closed the open sphenoid sinus such that it was water-tight. Postoperative visual acuity and the visual field were not affected by the increased intrasellar exposure or the open sphenoid sinus achieved by drilling the tuberculum sellae and planum sphenoidale.ConclusionTuberculum sellae/planum sphenoidale drilling via FBIA is feasible to enhance the direct visualization of CP resection, which expands the intrasellar region with a direct resection of recurrent tumours in the sellar cavity and adhering to the medial wall of the cavernous sinus. The potential risk of a CSF leakage seemed to be mitigated when using water-tight microsutures on a piece of the pericranium/dura around the edge of the defective dura in the sellar region and the open sphenoid sinus cavity.     

Sellar lymphoma mimicking sphenoid infection presenting with cavernous sinus syndrome

Lymphomas can occur throughout the body, but are relatively rare in the sphenoid region. The clinical presentations are atypical, ranging from nasal symptoms, pituitary hormone dysfunction and neurological impairment. We report a 63-year-old female patient who suffered nasal discharge, retro-ocular pain and left lateral gaze palsy for 3 months. Cranial MRI revealed sellar and suprasellar lesions involving the clivus, cavernous sinus and sphenoid sinus. The patient was treated for chronic sphenoid sinusitis. Histopathological review for possible misdiagnosis was arranged owing to treatment failure 1 month later. The final diagnosis was primary large B-cell lymphoma, which was confirmed by immunohistochemical study and systemic survey. The symptoms of sellar lymphoma resemble those of chronic sphenoid sinusitis. MRI and hematoxylin and eosin histological examination can accurately diagnose most cases. Immunohistochemistry assay is recommended in equivocal cases and provides a more detailed tumor classification.     

Spontaneous pneumoventriculogram following radiation of a pituitary adenoma.

Three years after radiation therapy for an intrasellar tumor, a 42-year-old housewife presented with headache, lethargy, and remarkable plain skull roentgenograms, in which dilated lateral and third ventricles were filled with air. Air apparently had entered the cranium through the sphenoid sinus and eroded sellar floor, extending directly through intrasellar remnants of the chromophobe adenoma and into the floor of the third ventricle. Frontal exploration showed an empty sella turcica and no residual tumor. She made an excellent recovery and has done well for 5 years after operative closure of the defect.     

Need for intrasellar packing in sellar reconstruction of transsphenoidal surgery: Less is more?

BACKGROUND: This study investigated patients with pituitary macroadenomas who received transsphenoidal surgery using two different sellar reconstruction methods, to determine the need for intrasellar packing. METHODS: The authors reviewed 53 patients with pituitary macroadenomas at a single institution between January 1999 and November 2002. On tumour removal, the group 1 patients underwent traditional sellar reconstruction (intrasellar and sphenoid sinus packing), while the group 2 patients did not undergo intrasellar packing. RESULTS: The two groups did not differ significantly in terms of complications. There was no mortality; notably, no delayed empty sella syndrome occurred in the group 2 patients. CONCLUSIONS: Simplified reconstruction of the sella floor using only sphenoid bone without intrasellar packing is thought to be safe and effective. This technique obviates the need for a second surgical incision, risk of overpacking, complications associated with packing material and interference on postoperative magnetic resonance imaging.     

鼻窦镜辅助下经单鼻孔入路垂体腺瘤显微手术切除

目的总结鼻窦镜辅助下经单鼻孔入路垂体瘤显微手术切除术的经验及初步体会.方法鼻窦镜辅助下,经单侧鼻腔,严格中线入路打开蝶窦前壁,暴露鞍底.然后在神经显微镜下行垂体瘤切除,最后鼻窦镜下鞍底重建.结果 21例患者中16例一次手术全切除,3例次全切除,1例巨大生长激素(growth hormone, GH)腺瘤大部分切除,后经改良翼点入路二次手术切除,1例巨大催乳素(prolactin, PRL)腺瘤分2次经蝶肿瘤切除,术后患者症状均改善.尿崩2例,分别于术后7 d、15 d停止;脑脊液漏1例,保守治疗2周治愈.结论耳鼻喉科医师解剖熟悉,鼻窦镜下显露鞍底准确充分,神经外科医师显微镜下可克服内镜单手操作的不便,二者结合有利于减少经单鼻孔入路垂体瘤切除的创伤,提高安全性,是一种有效的方法.     

鞍膈脑膜瘤的显微外科治疗

提出开并探讨鞍膈脑膜瘤的诊断、鉴别诊断及其显微外科手术治疗，方法:8年间经手术厦病理证实的鞍膈脑膜瘤10例，其中男性5例，女性5例，平均年龄43岁。根据肿瘤与鞍膈的关系可分为3型，即鞍上型、鞍内型和鞍内鞍上型。10例均采用Yargil切口行显微外科治疗。结果：10例中8例行肿瘤全切除，2例行肿瘤大部分切除，7侧痊愈，2例好转，仅1例死亡。结论：鞍膈脑膜瘤为发生于鞍膈及其附近的肿瘤，肿瘤可向鞍内或鞍上生长，其临床表现为进行性视力下降、而内分泌功能障碍却很少见，计算机体层摄影(CT)及磁其振成像(MRI)检查见鞍内用鞍上有肿块阴影，易误诊为垂体腺瘤，显微外科治疗有益于肿瘤全切除。     

Progressive visual loss because of a suprasellar pneumatocele after trans-sphenoidal resection of a pituitary adenoma.

A 63-year-old man who underwent uneventful trans-sphenoidal resection of a pituitary adenoma with fat packing complained postoperatively of progressive binocular visual acuity loss. Neuroimaging showed a suprasellar pneumatocele compressing the optic chiasm and a communication between the sphenoid sinus and the sella. After a second trans-sphenoidal procedure to remove the air and fully pack the sphenoid sinus, visual acuity recovered dramatically. A rare complication of trans-sphenoidal surgery for pituitary adenoma, suprasellar pneumatocele probably forms through a ball-valve mechanism that results from incomplete packing of the sellar floor. This case highlights the need for effective sphenoid sinus packing and for ophthalmic monitoring after trans-sphenoidal surgery.