CPA区神经鞘瘤周围颅神经的术前超选弥散张量追踪辨认

发布时间：2018-01-22 06:50

本文关键词： 前庭神经鞘瘤弥散张量示踪图面神经蜗神经三叉神经鞘瘤弥散张量追踪图像面听神经三叉神经外展神经　出处：《首都医科大学》2015年博士论文　论文类型：学位论文

【摘要】：背景前庭神经鞘瘤（Vestibular schwannoma, VS）手术的目的就是在消灭肿瘤的同时，保护好患者的面、听神经功能。在大听神经瘤中，由于神经位置、走行的不确定性，以及神经在形态学上较正常神经常发生较大的偏差，使在术中达到这一目标挑战重重。在之前的研究中，有人在术前用面神经的弥散张量示踪图像（Diffusion tensor tractography, DTT）来预测面神经的位置。本研究将在这一技术的基础上，引入“超选”这一概念，来研究DTT用于术前判断面神经，蜗神经和三叉神经的有效性。方法本研究共纳入2013年11月至2014年5月间就诊于首都医科大学宣武医院的23位患者，肿瘤大小从汉诺威分级T3b到T4b不等。在3.0T的MRI上，采集受试者的弥散张量成像（Diffusion tensor image, DTI）以及增强的稳态构成干扰序列（Contrasted constructive interference in steady state, CISS+C），将其导入Brainlab iPlan3.03导航工作站，在术前对患者的颅神经进行DTT重建，预测其相对于肿瘤的位置，然后在术中对这一结果进行验证。结果在21位患者（91.30%）中，DTT描述的面神经位置同术中情况吻合。这其中包括2例面神经从肿瘤与囊变之间穿过的病例以及3例发生面神经膜变的病例。此外，在4位有术前有效听力的患者中，DTT技术在术前成功辨认出了肿瘤周围除面神经和三叉神经以外的神经，其中，2例明确为蜗神经，另外2例无法判定具体的神经功能。在1位患者中，DTT在术前识别出了从肿瘤中间穿过的神经纤维，而该纤维的存在在术中得到了验证。结论超选DTT可以有效预测复杂情况下的面神经，包括膜变的面神经、从囊变与瘤实质之间穿过的面神经；还可以有效识别蜗神经以及被肿瘤包绕的神经纤维结构，有助于提升听神经瘤手术的安全性。背景三叉神经鞘瘤（Trigeminal schwannoma）为第二大颅内神经鞘瘤，，手术相关的颅神经功能缺损在三叉神经鞘瘤手术中是普遍存在的现象。由于肿瘤可以起源于三叉神经节及节前和节后的鞘膜，导致瘤周颅神经位置差别较大。而较低的发病率使既往研究难以通过大宗病例来揭示颅神经的排列，手术医师在术前对神经位置的预判难以充分。近年来，DTT被用来在术前寻找听神经瘤周围的面听神经，但未见DTT用于三叉神经鞘瘤的相关报道。方法本研究共纳入2014年1月至2014年11间就诊于首都医科大学宣武医院的3位患者，肿瘤均主要位于CPA区。在3.0T的MRI上，采集受试者的弥散张量成像（Diffusion tensor image, DTI）以及增强的稳态构成干扰序列（Contrastedconstructive interference in steady state, CISS+C），将其导入Brainlab iPlan3.03导航工作站，在术前对患者的颅神经进行DTT重建，预测其相对于肿瘤的位置，然后在术中对这一结果进行验证。结果在术中，3位患者的V-VIII对颅神经在三叉神经鞘瘤周围排列差异较大。而在3位患者V-VIII对颅神经的DTT结果中，除病例3的展神经外，其余神经的排列同术中情况完全吻合，各种变异均被DTT准确描述。结论超选DTT可以通过对V-VIII对颅神经的重建，有效预测三叉神经鞘瘤周围多变的颅神经排列方式，为术者在术前提供一个神经排列的可靠印象，从而有助于三叉神经鞘瘤周围颅神经的保留。
[Abstract]:Background : The purpose of the surgery is to protect the patient ' s face and listen to the neurological function while the tumor is eliminated . In the large acoustic neuroma , the position of the facial nerve is predicted due to the nerve position , the uncertainty of walking , and the more normal nerve in morphology . In the previous study , the concept of " hyperselective " was introduced to study the effectiveness of DTT for the determination of facial nerve , cochlear nerve and trigeminal nerve before operation . Methods This study was included in 23 patients at the Xuanwu Hospital of Capital Medical University between November 2013 and May 2014 . The size of tumor ranged from Han ' s to T4b . On MRI of 3.0 T , diffusion tensor imaging ( DTI ) and enhanced steady state constitutive interference sequence ( CISS + C ) were collected , which was introduced into Brainlab iPlan3 . 03 navigation workstation . After operation , the cranial nerves of the patients were reconstructed to predict their position relative to the tumor , and then the results were validated during the procedure . Results In 21 patients ( 91.30 % ) , the position of facial nerve described by DTT was consistent with that in the operation . This included 2 cases of facial nerve passing between tumor and capsule and 3 cases of facial nerve film change . In addition , DTT technique successfully identified the nerves except facial nerve and trigeminal nerve in 4 patients with preoperative effective hearing . In one patient , DTT identified nerve fibers passing through the middle of the tumor before operation , and the presence of the fiber was verified during operation . Conclusion The super - selected DTT can effectively predict the facial nerve in complex cases , including facial nerve of the membrane , the facial nerve passing between the cystic degeneration and the tumor parenchyma , and can effectively identify the cochlear nerve and the nerve fiber structure surrounded by the tumor . It can help to improve the safety of the acoustic neuroma . BACKGROUND To the present study , it is difficult to reveal cranial nerves in patients with trigeminal neurilemmoma due to the fact that tumor can originate from trigeminal ganglion and preganglionic and ganglionic sheath , and the lower incidence makes it difficult to reveal cranial nerve arrangement through large cases . In recent years , DTT has been used to find the acoustic nerve around the acoustic neuroma before surgery , but no DTT is used in the related report of trigeminal neurilemmoma . Methods This study was included in three patients from January 2014 to November 2014 at the Xuanwu Hospital of Capital Medical University . The tumor was mainly located in CPA area . On MRI of 3.0 T , the diffusion tensor imaging ( DTI ) and enhanced steady state constitutive interference sequence ( CISS + C ) were collected , which was introduced into Brainlab iPlan3 . 03 navigation workstation . After operation , the cranial nerves of the patients were reconstructed to predict their position relative to the tumor , and then the results were verified during operation . Results Among the 3 patients , V - VIII was significantly different around the trigeminal neurilemmoma . In the 3 patients with V - VIII , except for the abducens of the case 3 , the arrangement of the remaining nerves was completely consistent with that in the operation . All the variations were accurately described by DTT . Conclusion The super - selective DTT can be used to reconstruct the cranial nerves around the trigeminal neurilemmoma by the reconstruction of V - VIII to the cranial nerves , and provide a reliable impression of the nerve arrangement before the operation , thus contributing to the retention of the cranial nerves around the trigeminal neurilemmoma .

【学位授予单位】：首都医科大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R739.4

【共引文献】