改良额底入路切除鞍结节脑膜瘤的初步研究

发布时间：2018-03-01 22:16

  本文关键词： 改良额底入路 鞍结节脑膜瘤 手术　出处：《泸州医学院》2014年硕士论文　论文类型：学位论文

【摘要】：目的：初步探讨用“改良额底入路方式”来切除鞍结节脑膜瘤的临床效果：如患者术后有无癫痫发作、垂体功能低下、尿崩、额纹消失、颞肌萎缩、嗅神经损伤等，以及肿瘤切除程度，肿瘤复发情况。方法：选择我科2010年12月至2013年12月收治的鞍结节脑膜瘤患者31例，采取“改良额底入路方式”来切除肿瘤。该手术方式术前由磁共振确定肿瘤大小及位置，大致确定额窦大小及体表投影，初步确定骨瓣位置，根据骨瓣位置再确定头皮切口线位置。耳前切口应注意避让面神经及颞浅动脉主干。颅骨钻孔点不选常规的“关键孔”(额颧缝后5mm、上7mm)点，而选取我们采用的“改良额底入路方式”的“美容孔”点。“美容孔”点通常选择在骨瓣外侧边中点以后或者骨瓣后边中点以外的范围内，多选择在该两边的交点处。额窦大者骨瓣适当偏外、上，占位偏鞍区后上者骨瓣前后径适当增大，并尽量靠近中线，以利于术中经纵裂入路，占位横径大者可适当增大骨瓣横径，必要时在矢状窦上颅骨钻孔，跨过矢状窦1至2cm开骨瓣。骨瓣外缘不超过颞肌在额部的附着处，也不超过额颞骨交界的转角处，原则上尽量避让额窦，不能避让者尽量减少打开的范围，但应以充分暴露病变为前提，骨瓣前界尽量低，以能用铣刀铣下为限，如此铣下的骨瓣额底暴露充分，通常不需要再磨除额底颅骨，术中额窦开放用艾利克消毒，用薄层骨蜡封闭窦口。显微镜下切开视神经、颈内动脉和鞍上池蛛网膜，以利于暴露肿瘤。通常从肿瘤侧前方或者正前方前颅底处开始切除肿瘤，向鞍结节方向发展，留出与双侧视神经、颈内动脉的安全距离。待切除部分肿瘤减压及切断肿瘤大部分血供后再小心分离切除神经、血管侧肿瘤，切除肿瘤根部脑膜，磨除受侵犯的颅骨，并行颅底重建。结果：31例患者手术顺利，均康复出院。术后随访1至2年，4例术前有癫痫发作患者，未再有癫痫发作，其余患者无癫痫发作；无垂体功能低下、尿崩病例；无额纹消失病例；无颞肌萎缩患者。有5例患者术侧嗅神经断裂。31例患者术前共有48只眼视力下降，术后有46只眼视力明显改善，有1只眼视力无明显变化，1只眼视力下降。31例患者中，simpsonⅠ级切除25例，其中有1例于术后2年复发；simpsonⅡ级切除5例，其中有1例于术后1.5年时复发，，simpsonⅢ级切除1例，随访2年，残余肿瘤无明显变化。结论：改良额底入路切除鞍结节脑膜瘤具有骨瓣选择灵活，肿瘤暴露充分、切除安全、彻底，并发症少等优点。
[Abstract]:Objective: to explore the clinical effect of "modified frontal approach" for the resection of meningioma of Sellar tubercle, such as epilepsy, hypophysis, collapse of urine, disappearance of frontal stria, atrophy of temporal muscle, injury of olfactory nerve, and so on. Methods: from December 2010 to December 2013, 31 patients with tuberculum sellae meningioma were selected. A modified frontal approach was adopted to remove the tumor. Before operation, the size and location of the tumor were determined by MRI, the size of the frontal sinus and the projection of the body surface were roughly determined, and the position of the bone flap was preliminarily determined. According to the position of bone flap, the position of incision line of scalp should be determined. Attention should be paid to avoiding facial nerve and main trunk of superficial temporal artery in anterior ear incision. And we choose the "beauty hole" point of the "modified frontal approach". The "beauty hole" point is usually selected in the range beyond the midpoint of the lateral edge of the bone flap or beyond the midpoint of the posterior edge of the bone flap. The anterior and posterior diameter of the bone flap of the greater frontal sinus and the posterior region of the Sellar region were increased and as close to the midline as possible, so as to facilitate the translongitudinal fissure approach during the operation. If the transverse diameter of the bone mass is large, the transverse diameter of the bone flap may be increased appropriately, and the bone flap may be drilled into the superior sagittal sinus if necessary, and the bone flap should be opened across the sagittal sinus 1 to 2 cm. The outer edge of the bone flap does not exceed the attachment of the temporal muscle in the frontal part or the corner of the frontotemporal bone junction. In principle, the frontal sinus should be avoided as far as possible, and those who cannot avoid it should minimize the scope of opening, but the premise should be full exposure of the lesion, and the anterior boundary of the bone flap should be as low as possible to the extent that it can be milled with a milling cutter, so that the face bottom of the bone flap can be milled to the full extent. There is usually no need to regrind the skull at the base of the forehead. The frontal sinus is disinfected by Eric during the operation, and the sinus orifice is sealed with a thin layer of bone wax. The optic nerve, the internal carotid artery, and the arachnoid of the suprasellar cistern are cut open under a microscope. Usually from the anterior or anterior cranial base of the tumor, the tumor is removed to the Sellar tubercle, leaving the bilateral optic nerve. The safe distance of the internal carotid artery. After decompression of part of the tumor and cutting off most of the blood supply of the tumor, the nerve is carefully removed, the tumor of the vascular side is removed, the root meninges of the tumor are removed, and the invading skull is removed. Results all 31 cases were successfully operated and discharged from the hospital. 4 patients with epileptic seizures were followed up for 1 to 2 years. There were no epileptic seizures, no seizures, no hypophysis, no urinary avalanche. No frontal stria disappeared, no temporalis atrophy. There were 5 cases of operative olfactory nerve rupture. 31 cases had 48 eyes visual acuity decreased before operation, 46 eyes visual acuity improved obviously after operation. There was no obvious change in visual acuity in 1 eye. Among the 31 cases with visual acuity loss, 25 cases were resected with Simpson 鈪

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