幕上下经岩骨乙状窦前入路切除巨大岩斜部肿瘤

目的 探讨幕上下经岩骨乙状窦前入路切除岩斜部肿瘤手术的技巧及并发症。方法 取颞枕游离骨瓣,分别于迷路前后将乳突及岩骨根部大部切除,但保留骨性半规管、耳蜗及鼓室的完整性;结扎并切断岩上窦,自乙状窦前方抵达岩斜部。结果 ４１例肿瘤包括脑膜瘤２０例,表皮样囊肿２０例,神经鞘瘤１例。手术全切肿瘤３４例,近全切除６例,大部切除１例。术后一过性失语１０例,脑水肿６例。脑干梗塞２例,第Ⅲ、Ⅵ、Ⅶ及后组颅神经损伤     

经岩骨乙状窦前入路的创伤性及并发症

目的探讨经岩骨乙状窦前入路的创伤性及并发症，为岩斜区肿瘤寻求更合理的治疗手段。方法同顾分析28例采用经岩骨乙状窦前入路手术的岩斜区肿瘤病入的临床表现、影像学特征、手术方法和术后处理等。结果肿瘤全切16例，近全切9例，部份切除3例。术后颅神经疵状全缓解5例，症状同术前10例，症状加重10例，昏迷3例。脑脊液耳漏12例。结论经岩骨己状蜜前入路是目前处理岩斜区肿瘤较好的手术入路。但该手术入路创伤性大．并发症较多且严重。     

Operative approach to the frontal skull base: extensive transbasal approach

An operative technique called the extensive transbasal approach is reported with the operative results of 11 cases. This is an operative mode in which en bloc osteotomy of the orbital roofs and frontal sinus is performed after ordinary bifrontal craniotomy. Through this approach, a far wider operative space than that afforded by conventional operative techniques is possible, and reconstruction of the frontal base can be made securely. We consider this approach of major clinical value.     

经眶额颧弓入路切除颅底肿瘤

目的 探讨经眶额颧弓入路切除颅底肿瘤的优越性和适应证。方法 经眶额颧弓入路切除颅底肿瘤１５例,观察术中显露情况及手术效果,并就该入路优越性和适应证进行分析。结果 １５例中,脑膜瘤７例,全切除６例,次全切除１例;颅咽管瘤４例,全切除３例,次全切除１例;三叉神经鞘瘤２例,生殖细胞瘤１例全切除。术后死亡１例。随访至今１１例恢复良好,３例遗留眼外肌麻痹（仍在恢复中）,无肿瘤复发。结论 经眶额颧弓入路切除颅     

Team approach of sinuso-orbital tumors invading the skull base

Summary Two clinical cases of sinuso-orbital tumors invading the skull base are described. The treatment consists of wide resection of the tumor by a combined orbital and intracranial approach in two sessions. Primary reconstruction of the skull base and of the orbital region is performed during the first operation with a free latissimus dorsi myocutaneous flap. The aims of this approach are to obtain integrity of the subdural space and to mask the surgical mutilation.     

经上颌骨翻转入路切除颅底侵入瘤

目的 探讨上颌骨翻转入路手术切除颅底侵入瘤的指征、手术要点及优缺点。方法 自1998年11月－2001年8月,采用上颌骨翻转入路连续切除鼻咽颅底肿瘤27例,对临床资料进行回顾性总结。结果 27例中鼻咽癌6例,鼻咽纤维血管瘤5例,鼻咽囊腺癌5例,神经鞘瘤2例,嗅神经母细胞瘤2例,脊索瘤2例,颞下翼腭窝低分化癌2例,颞下翼腭窝肉瘤2例,上颌窦癌1例。18例曾经1次或多次手术切除肿瘤后复发。侵犯颅内重要结构的17例。全部患者术中显露满意,肿瘤均得到肉眼全切除,无手术死亡,术后无偏瘫等严重并发症。本组患者术后随访2－33个月,平均随访16个月。其中2例分别术后5、8个月死于肿瘤复发;2例于术后7、12个月局部复发;1例于术后11个月出现肺转移,现带瘤生存;其余患者恢复日常生活。结论 采用上颌骨翻转入路切除原发于颅底、翼腭窝的肿瘤及广泛侵犯颅底的其他鼻咽部肿瘤,具有显露充分,手术切除彻底的优点。     

Pediatric skull, skull base, and meningeal tumors.

Calvarial neoplastic and non-neoplastic tumors are routinely encountered by all neurosurgeons. Benign and malignant skull base and meningeal tumors are relatively rare lesions in children. Interdisciplinary approaches to those tumors more frequently encountered in the pediatric population in these locations are discussed. Unique aspects of the diagnosis, treatment, and prognosis for infants and children are discussed.     

Transbasal approach to skull base tumors: evaluation and proposal of classification

A clinical study of the TBA was performed in 22 patients harboring tumors of the skull base. The follow-up ranged from 3 to 89 months (average, 30.5 months). The main complications were intracerebral hematoma, ptosis, and infection. One patient died (4.5%) because of an extradural hematoma. Eight patients died during the follow-up because of tumor complications. Among the survivals, the median of the Karnofsky index was 96.4. Based on this study, we propose a classification for the TBA, according to its extension.     

Substantiation of application of the anterior trans-pyramidal approach in skull base tumors

The microtopographic-anatomic substantiation of anterior transpyramid approaches to the skull base tumors was conducted. The transpyramid approaches introduction in clinical practice had permitted to improve surgical treatment results in patients with the difficult of access skull base tumors. Indications and choice of approach depending on the kind, localization and tumor spread in the skull base in the temporal bone pyramid part were substantiated.     

Surgical treatment of tumors in the anterior skull base using the transbasal approach

Five patients with tumors in the anterior skull base were surgically treated using the transbasal approach, which permits removal of the tumor, repair of the dura mater, and reconstruction of the skull base in a one-stage procedure. By using autologous materials for the bone graft and pedunculated pericranial flap for the reconstruction, the intracranial structures are separated from the air-filled nasal and paranasal cavities. No postoperative complications such as wound infection and leakage of cerebrospinal fluid were encountered. The use of this surgical technique makes it possible to extirpate brain tumors that heretofore have been considered unresectable.     

Surgery for glomus tumors at the skull base

Glomus tumors of the temporal bone frequently involve the skull base. In the present study, 34% of the tumors occurred with cranial nerve palsies and 15% invaded the CNS. The procedure for surgical resection of glomus tumors of the skull base is described. Results of the procedure included successful surgical resection of 80% of the glomus jugulare tumors and of 94% of the glomus tympanicum tumors. Tumor recurrence and persistence occurred only in the patients with CNS invasion.     

Evaluation of combined neurosurgical and trans-facial excision of extensive rhinosinus tumors infiltrating the anterior skull base

Rhino-sinusal tumors are rare, representing approximately 0.3% of all cancers and 3% of tumors of the upper respiratory and digestive tracts. In cases in which the tumor has infiltrated the anterior cranial base, the treatment of choice is a surgical resection by combined neurosurgical and transfacial approach giving the best possible exposition for the excision. The resection is associated with various reconstruction techniques according to the extent of the defect. Sixteen patients with rhino-sinusal tumors extending to the anterior cerebral cavity were operated at the ENT clinic of the CHUV in Lausanne between 1977 and 1997. The transfacial and neurosurgical combined approach is rarely curative (30% 5 years survival rate, 80% local recurrence during follow-up), but is still justified, given that its disabling side-effects are scarce. It offers an acceptable quality of life and prevents complications inherent to the natural development of tumors. Pre- or postoperative radio- and chemotherapy, as well as skull base reconstructions using bone grafts or a micro-anastomosed flap give rise to complications which worsen significantly the overall prognosis and should therefore be avoided as much as possible. Still, this heavy surgery remains indicated, because it prevents the numerous complications of the natural course of the disease and offers an acceptable quality of life with only few side-effects.     

The extended frontal approach to tumors of the anterior, middle, and posterior skull base.

The extended frontal approach is a modification of the transbasal approach of Derome. The addition of a bilateral orbitofrontal or orbitofrontoethmoidal osteotomy improves the exposure of midline lesions of the anterior, middle, and posterior skull base, while minimizing the need for frontal lobe retraction. The authors present a 5-year experience with 49 patients operated on via the extended frontal approach. In seven patients, the extended frontal approach was used alone; in the remaining 42, it was combined with other skull base approaches. Highly malignant tumors were removed en bloc, whereas benign tumors and low-grade malignancies were removed either en bloc or piecemeal. Reconstruction was usually performed using fascia lata, a pericranial flap, and/or autologous fat. A temporalis muscle flap or a distant microvascular free flap was required for some patients. One patient died 1 month postoperatively due to superior mesenteric artery thrombosis. Three patients had postoperative infections, two had cerebrospinal fluid leaks requiring reoperation, and four had brain contusions or hematomas. All but two patients recovered to their preoperative functional level. After an average follow-up period of 26 months (range 6 to 56 months), 64% of patients with benign lesions, 64% of patients with low-grade malignancies, and 44% of patients with high-grade lesions were alive with no evidence of disease.     

Carotid artery vasospasm complicating extensive skull base surgery: cause, prevention, and management

Arterial spasm is rarely encountered in the uncomplicated cervical lymphadenectomy. Intense, often dramatic, vasospasm of the internal carotid artery, however, is not infrequently observed in the removal of skull-base lesions. This myogenic reaction is independent of autonomic innervation, occurs more frequently in younger patients, and appears to be due mainly to longitudinal arterial traction and prolonged arterial contact with fresh blood. A case of severe internal carotid artery spasm, which led to a fatal stroke in a young woman who underwent removal of a large glomus jugulare tumor, is presented to emphasize not only the lethal potential of carotid spasm, but intraoperative changes in the character of the artery which suggest the need for immediate spasmolysis. Perioperative guidelines for the prevention and treatment of arterial spasm--including topical and systemic pharmacotherapy and refined surgical techniques--are outlined on the basis of our subsequent experience.     

Conventional radiation therapy for skull base tumors: an overview

Radiation therapy is an important treatment option for patients with skull base tumors. It has been proven to be effective as primary or adjunctive therapy. Results with conventional radiation treatments have been good to excellent, with limited morbidity. Despite recent advances in neurosurgery and radiation oncology, conventional radiation therapy continues to play a role for some patients. The use of newer technologies such as radiosurgery, three-dimensional conformal therapy, and intensity-modulated radiation therapy should provide equal or better tumor control with decreased morbidity. Future studies should determine the roles of conventional and more innovative radiation approaches.     

Craniofacial resections for tumors involving the base of the skull

Over a 10 year period, 42 patients with tumors involving the base of the skull underwent operation at our institution. Twenty-six patients had tumors involving the anterior fossa and cribriform plate, 3 patients had tumors involving the anterior fossa and orbit, 3 patients had invasion of the middle fossa, 5 patients had invasion of the temporal bone, and 5 patients had invasion of the clivus. A detailed analysis of the 26 patients who underwent craniofacial resection for tumors invading the anterior fossa cribriform plate region has been presented. Histologic studies revealed epithelial tumors in 18 patients, sarcoma in 6 patients, melanoma in one patient, and ossifying fibroma in one patient. The median survival in this group of patients was 60 months. Survival was influenced by histologic diagnosis. Malignant tumors involving the base of the skull can be successfully resected using a craniofacial approach with minimum morbidity and acceptable operative mortality as demonstrated in this experience. Unfavorable prognostic factors included massive intracranial extension, high grade tumor, and previous treatment failure.