脑干海绵状血管瘤手术入路选择

目的探讨脑干海绵状血管瘤手术适应证和手术入路的选择。方法回顾分析70例手术治疗的脑干海绵状血管瘤，其中位于：中脑15例、中脑-桥脑交界8例、桥脑34例、桥脑-延髓交界5例、延髓8例。我们共采用8种手术入路：经菱形窝27例、颞下或颞-枕入路14例、远外侧经髁7例、外侧小脑上幕下7例、中线小脑上幕下8例、枕经天幕4例、乳突后2例，以及眶颧1例。结果本组病例的年出血率为2．9％（77／2364），占同期颅内海绵状血管瘤的44％（70／159）；97％的病例手术选择在亚急性或慢性期、且所有患者均有颅神经症状和（或）运动功能障碍、感觉障碍、共济失调（包括失平衡）。中脑病变手术入路选择以中线小脑上（46．7％，7／15）、颞下或颞-枕（26．7％，4／15）为主；桥脑病变多选择菱形窝（58．8％，20／34）、颞下或颞-枕（23．5％，8／34）；而病变位于延髓者以远外侧经髁（62．5％，5／8）和菱形窝入路（37．5％，3／8）为主。结论脑干海绵状血管瘤表现为进行性神经功能缺失、具有占位效应、接近脑干表面者可考虑手术治疗；个体化地选择手术入路、术中神经电生理监测以及直接的电刺激是手术成功的关键。

The choice of surgical approach to the brainstem cavernous malformation

Objective To explore the surgical indication and the approach of brain-stem cavernous malformation, seventy brain-stem cavernous malformations were retrospectively analyzed. Methods Of the seventy brain-stem cavernous malformations, 15 were situated in the mesencephalon, 8 in pontomesencephalic junction, 34 in pons, 5 in pontomedullary junction and 8 in medulla oblongata. All the lesions were approached by trans-rhomboid fossa (27 cases), subtemporal or temporal-suboccipital transtentorial approach (14 cases), far lateral transcondylar (7 cases), lateral supracerebellar infratentorial (7 cases), midline supracerebellar infratentorial (8 cases), occipital transtentorial (3 cases), retrosigmoid (2 cases) and orbitozygomatic approach (1 case).Results The annual hemorrhagic rate of our cases is 2.9% (77/2 364), accounting for 44% of intracranial symptomatic cavernomas (70/159). 97% of all the cases were operated at the subacute or chronic stage; furthermore, all of the cases had cranial nerve deficits and/or motor or sense dysfunction, ataxia (including disequilibrium). The lesions in midbrain were operated by midline supracerebellar infratentorial (46.7%, 7/15), subtemporal or temporal-occipital transtentorial (26.7%, 4/15). While for the lesions in pons, the transrhomoid fossa (58.8%, 20/34) and subtemporal or temporal-occipital transtentorial (23.5%, 8/34) approaches were utilized. The far lateral transcondylar and rhomboid fossa approach were applied to the lesion in medullar oblongata, with the rate of 62.5% (5/8) and 37.5% (3/8) respectively.Conclusion When the patients with brain-stem cavernous malformation exhibited progressive neural function deficits and mass effect, it should be considered as good candidates for surgical therapy. The individual surgical approach, intraoperative neuroelectrophysiological monitoring and the direct electric stimulation are the important prerequisite for satisfactory results.