海绵窦非脑膜瘤性肿瘤的显微外科治疗

目的探讨海绵窦非脑膜瘤性肿瘤的鉴别诊断和手术疗效。方法回顾性分析了67例海绵窦区非脑膜瘤性肿瘤的临床表现、诊断与鉴别诊断、手术方式和疗效。67例患者中男32例,女35例,平均年龄(41±16)岁。主要临床表现有:颅神经症状47例(70.1%),内分泌症状11例(16.4%),眼痛9例(13.6%),突眼7例(10.6%),肢体乏力5例(7.5%),头痛、头昏、嗜睡、颞叶癫痫各4例(6.0%),鼻衄1例(1.5%)。所有患者术前均行CT或MRI检查,26例患者术前行数字减影血管造影检查及球囊阻塞试验。所有患者均行手术治疗。手术采用眶-颧-翼点开颅,其中以硬膜下入路手术者20例,硬膜外入路手术者33例,硬膜外与硬膜下入路相结合手术者14例。结果通过硬膜下入路手术者全切8例,次全切除者7例,大部切除者5例,分别占此组病例的40%、35%、25%。通过硬膜外手术者肿瘤全切除27例,次全切除1例,大部切除5例,分别占此组病例的81.8%、3.0%、15.2%。硬膜外与硬膜下入路相结合者(主要为侵袭性垂体瘤与哑铃型三叉神经鞘瘤)14例,其中全切除10例(71.4%),次全切除4例(28.6%)。术后随访6个月至10年,原有的神经系统症状有所恢复者39例(58.2%)。加重或新出现的神经系统症状主要为三叉神经麻痹16例(23.8%)、动眼神经麻痹13例(19.4%)及外展神经麻痹9例(13.4%)。结论根据不同的肿瘤类型及肿瘤的生长方式,选择扩大中颅底硬膜外入路,或结合硬膜下入路,可在最大限度切除肿瘤的同时,保护颅神经的功能,获得良好的手术效果。

Microsurgical treatment of nonmeningeal tumors of the cavernous sinus

OBJECTIVE: To analyze the differential diagnosis of and effectiveness of surgical treatment on nonmeningeal tumors of cavernous sinus. METHODS: The clinical data, including clinical manifestations, diagnosis and differential diagnosis, operative procedure, and treatment results of 67 cases of nonmeningeal tumors of cavernous sinus, 32 males and 35 females, aged 41 +/- 16, who underwent microsurgical treatment were analyzed respectively. RESULTS: The main clinical presentation included cranial nerve paralysis (47 cases, 70.1%), neuroendocrine symptoms (11 cases, 16.4%), eye pain (9 cases, 13.6%), proptosis (7 cases, 10.6%), limb weakness (5 cases, 7.5%), headache, dizziness, lethargy, and temporal lobe epilepsy (4 cases each), and epistaxis (1 case). All patients had CT and/or MRI scanning before operation. Twenty-six patients had DSA examination and balloon occlusion test (BOT). All patients underwent orbito-zygomatico-pterional craniotomy. Twenty cases were operated on via intradural approach, 33 cases via epidural approach, and 14 cases via epidural/intradural combination approach most of which suffered from invasive pituitary adenoma and dumbbell type trigeminal neurinoma. Pathological examination revealed that hemangioma (24 cases), trigeminal schwannoma (18 cases), and invasive pituitary adenomas (11 cases) comprised the majority of tumors; the remaining tumor types were chordoma, chondroma, chondromyosarcoma, chondrofibroma, dermoid tumor, malignant nerve sheath tumor, metastatic tumor, and lymphoma. In the intradural approach group, total tumor removal was achieved in 8 cases (40%), and 7 (35%) cases and 5 (25%) cases had subtotal and partial resection respectively. In the epidural approach group, 27 cases (81.8%) had total tumor removal, while 1 case (3.0%) had subtotal and 5 cases had partial excision of the tumor. In the epiduro-transdural approach group 10 cases (71.4%) achieved total resection and 4 cases (28.6%) had subtotal resection. Postoperative follow-up lasting 6 months to 10 years showed that the pre-operative central nervous system symptoms recovered in 39 cases (58.2%). The aggressive or new symptoms mainly included paralysis of oculomotor nerve (13 cases, 19.4%), trigeminal nerve (9 cases, 13.4%), and abduct nerve (9 cases, 13.4%). CONCLUSION: Depending on pathologic type and growth pattern of the tumor, extended middle skull base epidural or epidural-transdural approach is selected. Such techniques can offer satisfactory outcome, protecting the cranial nerve functions and removing the tumor to the maximum extent.