经菱形窝切除脑干海绵状血管瘤

目的探讨28例经菱形窝入路切除的脑干海绵状血管瘤的适应证、手术技巧及术中注意点。方法术中采取坐位,枕下正中开颅,广泛打开小脑延髓裂;在脑干表面有色素沉淀或膨隆处,或在B超、导航引导、术中颅神经监护下切开脑干,病变暴露后清除血肿,然后切除病变,保留含铁血黄素沉淀的胶质组织。结果28例中有21例位于桥脑;术中发现脑干表面有含铁血黄素沉淀21例,其中脑干表面膨隆9例;所有病变位于脑干背侧;随访期间:症状和体征较术前改善的19例,保持术前水平的5例,加重、出现新的颅神经症状、或其他神经功能障碍(共济失调、运动障碍、感觉障碍)共4例。MRI随访未见病变残留或复发。结论经菱形窝入路主要适于桥脑部、且位于背侧的海绵状血管瘤;脑干表面的含铁血黄素沉淀和(或)膨隆是脑干的安全进入区,术中结合神经电生理监测、B超以及导航是手术成功的关键;术中尽可能全切病变,但保留含铁血黄素沉淀的胶质组织。

The resection of brain-stem cavernoma via trans-rhomboid fossa approach

Objective To explore the surgical indication, technique of trans- rhomboid fossa approach, twenty-eight brain-stem cavernomas ( data from Department of Neurosurgery, Marburg University Hospital, Marburg, 35033, Germany) were retrospectively reviewed. Methods All the patients were in sitting position, with midline suboccipital craniotomy and widely opening the cerebellomedullary fissure. Then, the safety entry zone was chosen according to the hemosiderin or bulging of the surface of the brain-stem, or by the guide of B ultrasound, navigation, monitoring of cranial nerves. After exposure the lesions, the hematoma was evacuated, then removed the cavernoma, remaining the hemosiderin gliomatic tissue. Results Most of the twenty-eight brain-stem cavernomas were located in pons (21 cases). There was hemosiderin on the surface of brain-stem in 21 cases, among of them; nine cases exhibited bulging of the brain-stem. All the lesions were situated on the dorsal of the brain-stem. Nineteen cases were improved in symptom and signs, comparing to the pre-operation, 5 cases remaining unchanged, during the follow-up. On the other hand, 4 cases presented new cranial nerve symptoms, or other neural dysfunction including ataxia, disturbance of movement and sense. No remaining lesion or recurrence was found in the MRI scan. Conclusion The trans-rhomoid fossa approach was used in the brain-stem cavernoma, locating in the pons and on the dorsal surface. The safety entry zone was selected by the hemosiderin or bulging of the surface of the brain-stem. The use of B ultrasound, navigation, monitoring of cranial nerves was the critical factor on the successful outcome. The lesions were totally removed as soon as possible, however, remaining the hemosiderin gliomatic tissue.