虚拟现实技术在上矢状窦旁脑膜瘤患者围手术期的应用

发布时间：2018-05-31 08:49

本文选题：上矢状窦旁脑膜瘤 + 侧支循环　；参考：《福建医科大学》2014年硕士论文

【摘要】：目的 1.通过VR技术了解窦旁脑膜瘤颅内静脉直径及数目的变化，推测上矢状窦旁脑膜瘤患者静脉循环代偿通路的建立，为上矢状窦旁脑膜瘤术中静脉保护、降低复发率及并发症提供指导。 2.探讨术前应用3D CE-MRV及VR技术评估上矢状窦旁脑膜瘤的临床意义,并总结上矢状窦旁脑膜瘤手术治疗的经验及教训。资料和方法 ①收集福建医科大学福总临床学院在2011年10月～2014年3月收治的48例拟行手术的上矢状窦旁脑膜瘤患者，视为肿瘤组；及无颅内静脉病变的三叉神经痛和面肌痉挛患者20例，视为对照组；所有患者均行3D CE-MRV；②将影像学资料导入VR工作站重建相关解剖，评估侧支循环、肿瘤位置及侵袭程度；③在3D视角下测量SSS两侧皮质静脉的直径、数目及SSV、VT、VL、GCV、ISS、StS、TS、SS等静脉直径；④对比肿瘤组与对照组之间，不同侧支循环、肿瘤位置及侵袭程度与对照组之间静脉直径及数目的差异；⑤对48例已行上矢状窦旁脑膜瘤切除的患者进行随访，并收集围手术期静脉处理方法及预后相关因素；⑥整体分析本组资料的并发症、手术死亡率及复发率，并根据不同静脉窦处理方案分析各静脉窦处理组相关的临床资料。结果 ①48例PSM一般情况 7例PSM位于上矢状窦前1/3段，31例位于SSS中1/3段，10例位于SSS后1/3段；静脉窦侵袭分级1-2级24例，3-4级及5-6级各有12例；未形成侧支循环23例，1级侧支循环9例，侧支循环3级16例。 ②PSM与对照组颅内静脉直径及数目的比较 PSM组与正常对照组仅SSS后1/3段直径存在统计学差异(P＜0.05)，分别(2.07±0.84)mm和(2.64±0.97)mm；其余各颅内静脉直径及数目均无统计学差异(p＞0.05)； ③不同位置的PSM与对照组颅内静脉直径及数目的比较 SSS前1/3段组与正常对照组间，颅内各静脉直径和数目无统计学差异(P＞0.05)；SSS中1/3段组中，仅SSS后1/3段桥静脉和VL直径较对照组数值小，分别为(2.11±0.79)mm[对照组(2.64±0.97)mm]、(2.16±0.35)mm[对照组(2.41±0.35)mm]，，差异具有统计学意义(P＜0.05)；SSS后1/3组中，SSS后1/3段桥静脉数目、TS直径较正常对照组数值小，分别为(1.60±0.70)[对照组(2.80±1.58)]、(4.54±1.26)mm[对照组(5.70±0.90)mm]，SSV直径较对照组数值大，为(2.90±0.57)mm[对照组(2.32±0.45)mm]，差异均具有统计学意义(P＜0.05)；SSS中1/3组较SSS后1/3段组的SSS后1/3段桥静脉数目多(P＜0.05)，分别为(2.59±1.30)支、(1.60±0.70)支。 ④不同侵袭程度的PSM与对照组颅内静脉直径及数目的比较将48例PSM按照不同侵袭程度分为1-2级组、3-4级组和5-6级组；1-2级组与正常对照组间，颅内各静脉直径和数目无统计学差异(P＞0.05)；3-4级组与正常对照组间，仅SSS前1/3段桥静脉数目较正常组小，为(3.00±1.41)支[对照组(4.60±1.70)支]，差异具有统计学意义(P＜0.05)；5-6级组中，SSS后1/3段桥静脉、TS直径较正常对照组数值小，分别为(1.53±1.14)mm[对照组(2.64±0.97)mm]、(4.16±1.10)mm[对照组(5.70±0.90)mm]，差异均具有统计学意义(P＜0.05)；两两比较三组之间静脉直径及数目，三组各静脉数值均无统计学差异(P＞0.05)。 ⑤不同侧支循环的PSM与对照组颅内静脉直径及数目的比较将48例PSM按照不同侧支循环分级分为0级组、1级组和3级组；0级组与正常对照组间，颅内各静脉直径和数目无统计学差异(P＞0.05)；1级组与正常对照组间，仅VL、TS较对照组小，分别为(2.06±0.21)mm[对照组(2.41±0.35)mm]、(4.71±1.19)mm[对照组(5.70±0.90)mm]，差异具有统计学意义(P＜0.05)；3级组中，TS直径较正常对照组数值小，分别为(4.42±1.08)mm[对照组(5.70±0.90)mm]，SSV直径较对照组大，为(2.83±0.58)mm[对照组(2.32±0.45)mm]，差异均具有统计学意义(P＜0.05)；两两比较三组之间静脉直径及数目，三组各静脉数值均无统计学差异(P＞0.05)。 ⑥48例脑膜瘤围手术期及随访情况 48例拟行手术治疗的上矢状窦旁脑膜瘤患者，术后失访4例，随访时间2-46个月；纳入44例，其中男17例，女27例，年龄27~85岁,44例PSM中，Simpson分级I/II切除为41例(93.18%)，侧支循环3级为16例(36.36%)，手术后新增神经功能障碍或原症状恶化9例，永久性神经功能障碍6例(13.64%)。3例患者术后出现静脉窦血栓形成(6.82%)，2例好转出院；死亡1例(2.27%)。复发1例(2.27%)。 ⑦不同静脉窦处理方案PSM预后情况 44例上矢状窦旁脑膜瘤根据术前侵袭程度及侧支循环分级，共9例术中SSS采取离断，预后不良率33.33%；3例术中开放SSS，切除肿瘤后，修补或直接缝合SSS，预后不良1例(33.33%)；32例术中采取电凝上矢状窦壁，2例预后不佳(6.25%)；三者之间采用Fisher精确概率法计算，三者之间预后不良无统计学差别(P＞0.05)。对3种不同静脉窦处理方法预后不良影响因素分析，各组均未见统计学差异(P＞0.05)。结论 1.PSM侵袭静脉窦主要引起SSS后1/3段BrV直径及数目的改变，特别是在肿瘤位于SSS后1/3段时，其对SSS后1/3段BrV影响最大。 2. PSM侵袭SSS后导致VL、SSS桥静脉数目、直径的减少，SSV直径的增加。 3. PSM侵袭SSS后可能导致VL、TS、SSS桥静脉引流减少，颅内静脉血流主要通过SSV引流，汇入蝶顶静脉窦和海绵窦，最终引流出颅。 4.术前对侧支循环、侵袭程度及肿瘤位置进行分级评估，了解PSM患者静脉循环状态，有助于指导手术方式选择，改善患者预后。 5.联合使用VR技术及3D CE-MRV术前评估颅内静脉循环状态及肿瘤周围结构，有助于选择适宜的手术术式，减少静脉损伤，改善患者预后。
[Abstract]:objective
1. the changes in the intracranial venous diameter and number of paranantral meningiomas were detected by VR technique, and the establishment of the compensatory pathway in the upper sagittal meningioma was expected to provide guidance for the protection of the vein in the superior sagittal paranantral meningioma and the reduction of the recurrence rate and complications.
2. to explore the clinical significance of preoperative 3D CE-MRV and VR techniques in the evaluation of superior parasagittal meningiomas, and to summarize the experience and lessons of surgical treatment for parasagittal meningiomas.
Information and methods
(1) 48 cases of superior sagittal paranasal meningioma who were treated from October 2011 to March 2014 at the General Clinical College of Fujian Medical University were treated as tumor group, and 20 cases of trigeminal neuralgia and hemifacial spasm without intracranial venous disease were treated as control group; all patients were treated with 3D CE-MRV; 2. The imaging data were introduced into VR The workstation reconstruction related anatomy, evaluation of collateral circulation, tumor location and invasion degree; (3) measuring the diameter of the cortical veins in both sides of SSS, the number and the diameter of SSV, VT, VL, GCV, ISS, StS, TS, SS and other venous diameters in the 3D perspective; (4) compare the circulation of different side branches, tumor location and invasion between the tumor group and the control group and the venous diameter between the control group and the control group. The differences in the number of patients were followed up in 48 patients who had been excised by the superior sagittal meningioma, and the perioperative venous treatment and prognosis related factors were collected. 6. The overall analysis of the complications of the data, the mortality and recurrence rate of the operation, and the analysis of the related clinical trials in the different venous sinus treatment groups according to the different venous sinus treatments. Information.
Result
The general situation of 48 cases of PSM
7 cases of PSM were located in the 1/3 segment of the superior sagittal sinus, 31 in 1/3 segment in SSS, 10 in 1/3 segment of SSS, 24 in grade 1-2 in venous sinus invasion, 12 in Grade 5-6, and 23 in no collateral circulation, 9 in 1 collateral circulation, and 3 in collateral circulation 3.
Comparison of diameter and number of intracranial veins between PSM and control group
The diameter of 1/3 segment in group PSM and normal control group was statistically different (P < 0.05) (P < 0.05), respectively (2.07 + 0.84) mm and (2.64 + 0.97) mm, and the other intracranial venous diameters and numbers were not statistically different (P > 0.05).
Comparison of the diameter and number of intracranial veins in different locations of PSM and control group
There was no significant difference in the diameter and number of intracranial veins between the pre SSS 1/3 group and the normal control group (P > 0.05), and in the 1/3 group of SSS, the diameter of the bridge vein and VL in the 1/3 segment was smaller than that of the control group, which was (2.11 + 0.79) mm[control group (2.64 + 0.97) mm], (2.16 + 0.35) mm[control group (2.41 + 0.35) mm], the difference was statistically significant (0.05 In group 1/3 after SSS, the number of bridge veins of 1/3 segment after SSS was smaller than that of normal control group, which was (1.60 + 0.70) [control group (2.80 + 1.58)], (4.54 + 1.26) mm[control group (5.70 + 0.90) mm], SSV diameter was larger than that of control group, and (2.90 + 0.57) mm[pairs (2.32 + 0.45) mm], the difference was statistically significant (P < < < < < < < < P <). Compared with SSS, there were more 1/3 segment bridging veins after 1/3 in group SSS (P < 0.05), respectively (2.59 + 1.30) and (1.60 + 0.70).
(4) comparison of the diameter and number of intracranial veins between PSM with different invasiveness and control group.
48 cases of PSM were divided into 1-2 grade group, 3-4 class group and 5-6 grade group according to different invasion degree. There was no statistical difference between the diameter and number of intracranial veins between the 1-2 group and the normal control group (P > 0.05). The number of the 3-4 group and the normal control group was smaller than the normal group, which was (3 + 1.41) Branch [4.60 + 1-2], and the difference has the difference. There were statistical significance (P < 0.05); in the 5-6 grade group, the 1/3 segment of the bridge vein after SSS was smaller than that of the normal control group, respectively (1.53 + 1.14) mm[control group (2.64 + 0.97) mm], (4.16 + 1.10) mm[control group (5.70 + 0.90) mm], the difference was statistically significant (P < 0.05), 22 compared the diameter and number of venous between three groups, and the number of various veins among the three groups. There was no statistical difference between the values (P > 0.05).
Comparison of diameter and number of intracranial veins between PSM with different collateral circulation and control group
48 cases of PSM were divided into 0 grade group, 1 grade group and 3 grade group according to different collateral circulation. There was no statistical difference between the diameter and number of intracranial veins between the 0 group and the normal control group (P > 0.05), the 1 group and the normal control group, only VL and TS were smaller than the control group, respectively (2.06 + 0.21) mm[control group (2.41 + 0.35) mm], (4.71 + 1.19) mm[control group (4.71 + 1.19) mm[control group (4.71 + 1.19) (4.71) mm[control group (4.71 + 1.19) (4.71 + 1.19) mm[control group (4.71 + 1.19) (4.71 + 1.19) mm[control group (4.71 + 1.19) (4.71 + 1.19) mm[control group .90) mm], the difference was statistically significant (P < 0.05); in the 3 grade group, the diameter of TS was smaller than that of the normal control group, respectively (4.42 + 1.08) mm[control group (5.70 + 0.90) mm], SSV diameter larger than the control group, (2.83 + 0.58) mm[control group (2.32 + 0.45) mm], and the difference was statistically significant (P < 0.05); 22 compared the diameter and number of venous between three groups of three groups. There was no significant difference in the number of veins between the three groups (P > 0.05).
The perioperative period and follow-up of 48 cases of meningioma
48 cases of superior sagittal paranus meningioma were treated with surgical treatment, and 4 cases were lost and followed up for 2-46 months. 44 cases were included in 17 men, 27 women, age 27~85 years, 44 PSM, 41 cases (93.18%) with Simpson grading I/II resection, and 3 level of collateral circulation in 16 (36.36%). There were 6 cases (13.64%) of sexual nerve dysfunction (.3). Venous sinus thrombosis (6.82%) occurred after operation, 2 cases recovered and discharged, 1 cases died (2.27%), 1 cases recurred (2.27%).
The prognosis of PSM with different venous sinus treatment
44 cases of superior sagittal paranasal meningioma were classified according to the degree of preoperative invasion and collateral circulation, and 9 cases of SSS were disconnected during operation, and the rate of poor prognosis was 33.33%. 3 cases opened SSS during operation, after resection of the tumor, repair or direct suture of SSS, and 1 cases (33.33%) with poor prognosis; 32 cases were treated with electrocoagulation on sagittal sinus wall and 2 cases with poor prognosis (6.25%); three were used among three. There was no statistically significant difference in prognosis between the three cases (P > 0.05) by the Fisher precision probability method (P > 0.05). There was no statistically significant difference in the prognostic factors of 3 different venous sinus treatments (P > 0.05).
conclusion
1.PSM invasion of venous sinus mainly caused changes in the diameter and number of 1/3 segment BrV after SSS, especially when the tumor was located at 1/3 segment after SSS, which had the greatest effect on 1/3 BrV after SSS.
2. PSM invasion of SSS resulted in a decrease in the number of VL, SSS bridging veins, and an increase in the diameter of SSV.
3. PSM invasion of SSS may lead to the decrease of VL, TS, SSS bridge venous drainage. The intracranial venous blood flow is mainly through SSV drainage, into the sphenoid antrum and cavernous sinus, and eventually drainage of the cranium.
4. to evaluate the collateral circulation, the degree of invasion and the location of the tumor before operation. To understand the venous circulation of PSM patients, it is helpful to guide the selection of surgical methods and improve the prognosis of the patients.
5. the combined use of VR technology and 3D CE-MRV preoperative assessment of intracranial venous circulation and the surrounding structure of the tumor can help to select appropriate surgical procedures, reduce venous injury and improve the prognosis of the patients.
【学位授予单位】：福建医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R739.45

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