核磁共振与内镜检查在带血管蒂鼻中隔黏骨膜瓣颅底重建术后管理中的意义

目的:探讨核磁共振(MR)与内镜检查在带血管蒂鼻中隔黏骨膜瓣颅底修复术后管理中的意义。方法:回顾性分析8例应用带血管蒂的鼻中隔黏骨膜瓣内镜下修复颅底硬膜缺损的资料。其中7例术后(术后5～7d)和近期随访(术后3～7个月)MR和内镜检查资料完整,1例因金属植入物而行CT和内镜检查。2种检查方法配合应用,掌握与颅底重建成败相关的信息,包括术后颅内及颅底修复局部、组织瓣供区和鼻腔鼻窦黏膜术后转归状况,以掌握愈合规律,提高重建成功率。结果:MR结合内镜检查可以准确获取带血管蒂鼻中隔瓣重建颅底术后颅内和修复局部的关键信息。MR可以排除术后常见的颅内并发症如颅内血肿、脑水肿或气颅,显示颅底缺损的位置及大致范围,提示组织瓣的位置及其与硬膜缺损边缘之间的重叠覆盖状态,定位术后脑脊液漏口。在术后和近期随访加强MR中,中隔瓣在颅底大致呈"C"形,7例中隔瓣均匀强化明显,提示血供佳。术后内镜检查证明7例中隔瓣无缺血坏死。6例组织瓣同颅底骨质愈合佳,1例内镜检查发现MR提示的脑脊液漏口并处理。中隔瓣在术后有一定程度的水肿和充血,近期随访时消失,组织瓣有缩小、变薄的征象,1例行CT和内镜检查者,中隔瓣发生坏死,因内衬人工硬膜完好,颅底一期愈合。内镜随访鼻腔鼻窦黏膜水肿在术后近期随访时明显减轻或消失,中隔瓣供区处裸露的中隔软骨在2个月左右被黏膜覆盖。结论:MR结合内镜检查可获取血管化中隔瓣重建颅底术后颅内外关键信息。排除术后并发症,掌握与修复成败密切相关的信息如组织瓣位置,血供及缺损处愈合情况,定位术后脑脊液漏的位置等,为及时处理并发症提供准确信息。所得结果可以提高外科和放射科医师对中隔瓣修复颅底缺损术后康复过程的认识,提高对修复失败情况的辨识和处理能力。

The role of MR and endoscopy in postoperative management of skull base reconstruction by vascular pedicle septal flap

Objective:To explore the significance of MR and endoscopy in the postoperative management of skull base reconstruction with a vascular pedicle nasoseptal mucoperiosteal flap.Method:The immediate,and delayed postoperative MR imaging scans and endoscopic data of 8 patients who underwent endonasal endoscopic reconstruction of skull base dural defects with a vascular pedicle nasoseptal mucoperiosteal flap were retrospectively studied.Among the 8 patients,7 cases have integrated immediate,delayed postoperative MR and synchronous endoscopic data which were harvest at the first week and at a 3-to 7-month interval respectively.One case was followed up by CT and endoscopy.The intracranial parenchymal changes,local situation of skull base defect site,the septal flap,healing of flap donor site and the transition of nasosinus mucosa were fully evaluated to explore the healing process and to improve the success rate of the reconstruction.Result:We can obtain the key postoperative information of intracranial and the skull base reconstruction site with MR and endoscopy.The MR can exclude the intracranial complications such as postoperative intracranial hematoma,cerebral edema,or pneumocephalus,and clearly show the location and extent of skull base defects,the position of the flap,the overlapping manner between the dural defect margin and the flap and the postoperative cerebrospinal fistula.In immediate and postoperative follow-up with MR,the septal flap had homogeneous enhanced image with a roughly "C" figure under the skull base,indicating stable blood supplement.The synchronous endoscopic examination also proved the survival of the septal flaps in 7 cases,the cerebrospinal fluid leakage in 1 case.One case flap necrosis.The septal flaps presented edema and congested in the immediate postoperative endoscopy,and returned to normal in the delayed examination.The non-vascular materials such as gelatin sponge and fat tissue had the different characteristics signal.Nasal mucosal edema and sinus ventilation continually recovered during the follow up and the exposed septal cartilage on the donor site resurfaced by mucosa in 2 months.Conclusion:MR and endoscopy could provide the critical postoperative information about the vascular pedicle septal flap reconstruction.MR combined with endoscopy not only could rule out the complications,but also could gain the information such as the position,blood supply and healing of the flap,at the same time detected the cerebrospinal fluid leakage to provide accurate information for the secondary stage reconstruction.The information got from MR and endoscopy were important for the surgeon and the radiologist to recognize the flap and to evaluate for variations that may suggest potential flap failure.