经额侧脑室联合翼点入路显微切除第三脑室颅咽管瘤

目的探讨经额侧脑室联合翼点入路显微切除鞍上突入第三脑室的内外型颅咽管瘤的手术适应证、疗效及并发症的防治。方法18例第三脑室内外型颅咽管瘤首先采用经额皮质造瘘,侧脑室室间孔入路切除侧脑室、第三脑室内肿瘤,然后应用翼点入路切除鞍上及鞍旁残余肿瘤。结果肿瘤全切除15例,次全切除3例。患者术后视力改善率75．0％（24／32）,视野改善率76．5％（26／34）;术后16例患者出现不同程度尿崩,3例出现癫痫症状。结论对脑室内外型颅咽管瘤,经额皮质造瘘侧脑室室间孔入路联合翼点入路,充分暴露第三脑室底部、下丘脑、鞍区各脑池及其穿通血管等结构,可提高肿瘤的全切率,减少手术并发症。     

经额下—第三脑室联合入路切除巨大垂体腺瘤与颅咽管瘤24例报告

目的 介绍经额下-第三脑室联合入路切除巨大垂体腺瘤及颅咽管瘤的途径、体会及疗效。方法 额部开颅,先经侧脑室-室间孔达第三脑室,切除第三脑室肿瘤,此时因侧脑室及第三脑室已经开放,颅内压明显降低,可以很容易地抬起额叶,显露并切除鞍上及鞍内肿瘤。结果 4例全切除,20例次全切除,无死亡病例。24例术前均有不同程度视觉障碍,其中10例在住院期间视力视野已有改善,8例术后出现尿崩,经治疗1～2周好转。结论 当垂体瘤或颅咽管瘤长入第三脑室时,经额下-第三脑室入路是较理想的手术入路。     

经胼胝体-穹隆间入路切除突入第三脑室内颅咽管瘤

目的 探讨切除鞍上突入第三脑室内颅咽管瘤的显微手术人路及疗效.方法 经胼胝体-穹隆间入路显微手术切除46例突入第三脑室内的颅咽管瘤.结果 肿瘤全切33例,近全切10例,部分切除3例;随访46例,随访时间3个月-15年,其中39例术后恢复正常工作和生活,8例术后复发.结论 经胼胝体-穹隆间入路切除第三脑室颅咽管瘤疗效显著.此入路能最大限度地保护正常脑组织,并在明显提高肿瘤全切率的同时做到较少的术后并发症.     

29例大型颅咽管瘤的显微外科治疗

目的探讨手术切除大型颅咽管瘤的有效方法。方法对29例经显微手术切除的大型颅咽管瘤患者的临床资料进行回顾性分析,肿瘤位于鞍上者15例,进入第三脑室者8例,位于鞍上鞍内者6例。有明显钙化18例,无明显钙化11例。囊性肿瘤24例,实质性肿瘤5例。经右翼点入路手术切除23例,经纵裂-胼胝体入路手术切除6例。结果肿瘤全切27例,次全切2例;死亡2例。所有患者术后均有不同程度的一过性尿崩症,水电解质紊乱27例,动眼神经麻痹5例。27例平均随访3年,复发3例,余能正常生活学习。结论翼点入路是鞍区大型颅咽管瘤手术的首选入路,绝大多数患者可达到肿瘤全切和良好预后。     

颅咽管瘤手术入路的选择及术后并发症的防治

目的 探讨颅咽管瘤的手术入路选择及并发症防治措施.方法 对32例颅咽管瘤患者选用不同的手术入路,其中经翼点和改良翼点入路16例,胼胝体-透明隔间隙-穹隆间入路4例,前纵裂-终板联合额下入路12例.结果 肿瘤全切除25例,次全切除7例.术后死亡1例.主要并发症:尿崩症15例,电解质紊乱24例.结论 对颅咽管瘤患者选择合适的手术入路,有利于在直视下显露并全切除肿瘤;熟悉鞍区的解剖关系并重视术中对下丘脑的保护,是降低术后并发症的重要环节.     

小骨窗前纵裂入路显微手术切除巨大颅咽管瘤(17例报告)

目的评价小骨窗前纵裂入路在颅咽管瘤手术中的应用价值及并发症。方法经小骨窗前纵裂入路切除巨大颅咽管瘤17例,对手术技术及结果进行总结。结果本组全切除15例、近全切除2例,无手术死亡病例。由于术中直视下处理肿瘤在垂体漏斗部位的粘连,可较好保护垂体柄、下丘脑结构及局部穿支血管,13例患者超过2年的随访未见肿瘤复发及再生长。结论经小骨窗前纵裂入路可直视下处理肿瘤鞍内、鞍上及三脑室前部分,是鞍上生长位置较高的大型颅咽管瘤安全有效的手术入路之一。     

前纵裂入路显微手术切除鞍上脑室内外型颅咽管瘤

目的 探讨前纵裂入路在鞍上脑室内外型颅咽管瘤显微手术切除中的应用,并比较与其他手术入路的优缺点.方法 回顾性分析22例采用前纵裂入路显微手术切除鞍上脑室内外型大型颅咽管瘤患者,分析手术技巧及术后效果.结果 肿瘤全切20例,次全切除2例,无手术死亡病例.术后发生电解质紊乱15例,尿量增多17例,2-7周后好转,术后1周内视力好转15例.随访6-60个月,肿瘤复发2例,均为12个月内复发.结论 前纵裂入路可直视下处理肿瘤在垂体漏斗部位的粘连,是鞍上脑室内外型颅咽管瘤较好的手术入路.     

经额底纵裂入路切除颅咽管瘤的临床分析

目的探讨经额底纵裂入路切除颅咽管瘤的手术方法和疗效。方法回顾性分析2008-01-2015-02我院收治的经额底纵裂入路切除的颅咽管瘤临床资料。评价该手术入路及显微操作的优缺点。结果术中肿瘤全切41例;次全切除8例,保留垂柄(完全或部分保留)31例,因肿瘤完全侵蚀垂体柄将其与肿瘤一并切除14例,4例术中为见垂体柄。术后并发症主要为尿崩、电解质紊乱及体温调节紊乱。结论经额底纵裂入路切除鞍上颅咽管瘤具有操作空间大、安全性好、视角佳等优点,可作为切除鞍上颅咽管瘤的有效入路。     

经鼻蝶入路切除鞍区斜坡肿瘤

目的:探讨经鼻蝶入路切除鞍区斜坡肿瘤的优缺点。方法:经鼻蝶显微手术。结果:对118例鞍区斜坡肿瘤采用鼻蝶入路手术切除,效果满意,107例垂体腺瘤行全切或次全切除。3例囊性颅咽管瘤行永久性引流,6例脊索瘤行次全切除。结论:合理应用本手术入路,对某些颅底肿瘤的切除是一有效的途径。     

颅咽管瘤侵袭第三脑室的方式对手术切除的影响

目的 探讨大型颅咽管瘤与第三脑室的关系在肿瘤切除手术中的意义. 方法 南方医科大学南方医院神经外科白1997年1月至2003年1月共采用手术治疗大型颅咽管瘤患者72例.根据肿瘤的影像学表现及手术所见对其进行分类,每一类肿瘤根据大小及其与第三腩室底的关系分为3级,根据术中判断和术后CT和(或)MPd增强扫描结果确定颅咽管瘤手术切除程度,分析肿瘤分级与手术切除程度的关系. 结果颅咽管瘤总体上可以分为第三脑室内型(本组7例)和第三脑室累及型(本组65例)两大类;手术切除程度在不同分级肿瘤间总体分布位置不同,差异有统计学意义(P<0.05). 结论 明确大型颅咽管瘤与第三脑室底及下丘腩结构间的关系对提高大型颅咽管瘤手术疗效有重要意义.     

Fronto-basal interhemispheric approach for craniopharyngiomas extending outside the suprasellar cistern

Objective The aim of the present study was to establish the usefulness of the fronto-basal approach with a relatively small craniotomy window for the removal of tumors protruding from the sellar–suprasellar region to the third and basal cistern.Method Forty-two patients who were surgically treated for craniopharyngiomas extending outside the sellar–suprasellar region were evaluated. All the patients were operated on by the fronto-basal interhemispheric approach, and the average follow-up period was 5 years.Results Gross total resection of the lesion was achieved in 30 cases. Eight patients underwent subtotal resection and four patients underwent partial removal due to recurrence after previous surgeries with or without radiotherapy. In the immediate postoperative period, major complications, including impairment of the cranial nerves, were observed in two cases. One patient exhibited transient memory disturbance due to infarction of the perforator; after 3 months, this symptom was ameliorated. Three of the patients died during follow-up; however, 6 of the 30 undergoing gross total removal and 10 of the 12 patients undergoing subtotal or partial removal suffered regrowth. Ultimately, a total of 12 patients underwent re-operation with the same approach or combined with the orbito-zygomatic approach.Conclusion In our experience, the fronto-basal interhemispheric approach, even through a small craniotomy window, is a valid choice for the removal of craniopharyngiomas extending outside the sellar–suprasellar region. Using this approach, tumors can be removed without significant sequelae related to surgical technique due to easy preservation of the pituitary stalk, hypothalamic structures, and perforators. This approach offers a safe and minimally invasive means of treating craniopharyngiomas.     

导航引导下内镜扩大经鼻蝶窦入路切除鞍上区和第三脑室内颅咽管瘤

目的 探讨导航引导下完全内镜扩大经鼻蝶窦入路切除位于鞍上区和第三脑室内颅咽管瘤的可行性和有效性.方法 采用内镜扩大经鼻蝶窦入路、术中导航引导下切除3例位于鞍上区和第三脑室内的颅咽管瘤.结果 3例颅咽管瘤全切,手术效果好.术后随访10-14个月,患者生活正常,需要激素替代治疗.结论 内镜扩大经鼻蝶窦入路可以安全有效地切除位于鞍上区、第三脑室内的颅咽管瘤,这种手术方式不需要牵拉脑组织,并能完全暴露视交叉后、下方区域,在直视下操作,有利于对下丘脑、垂体柄及其他重要结构的保护.对于选择性的颅咽管瘤病例,内镜扩大经鼻蝶窦入路是切除肿瘤的一种新型微创手术入路.神经导航可以验证解剖标记点,引导手术方向,增加手术安全性.

Abstract：

Objective To investigate the feasibility and efficacy of image -guided extended endoscopic endonasal transsphenoidal approach(EEETA) for the removal of craniopharyngiomas in the suprasellar region and third ventricle. Method A pure EEETA with image -guided system was used. Three patients with a craniopharyngioma involving the suprasellar region and third ventricle were treated. Results Total craniopharyngioma removal was achieved in three cases. All the patients recovered uneventfully. The follow - up study was carried out for 10 to 14 months with good outcomes. Compensatory endocrine substitution therapy was needed in all of them. Conclusions The EEETA for removal of craniopharyngiomas in the suprasellar region and third ventricle is feasible and effective. It has the advantages of no needing for brain retraction,offering panoramic view of retrochiasmatic and infrachiasmatic regions,manipulating under direct vision and protecting hypothalamus,pituitary stalk and other vital structures. The EEETA is a novel and minimally invasive approach for selected cases of craniopharyngioma. Neuronavigation plays an important role in identifying anatomic landmarks,guiding surgical direction and increasing safety of the operations.     

Trans-lamina terminalis approach for third ventricle and suprasellar tumours

Background

The trans-lamina terminalis (TLT) approach to the suprasellar region and third ventricle is complex, with risks of visual and hormonal deficits. However, the postoperative deficits might not be directly related to opening of the lamina terminalis but to the close relationship of tumours with vital neural and vascular structures. The analysis of results using this approach was the objective of this study.

Material and methods

The TLT approach was used in 29 patients (18 craniopharyngiomas, 5 astrocytomas, 5 germinomas and 1 ganglioglioma). The extent of tumour removal, mortality and morbidity (especially visual or hormonal deficits) were studied.

Results

Complete tumour removal was achieved in 15 patients, subtotal extensive removal (more than 90%) in 9 cases and partial removal in 5 cases. Panhypopituitarism developed in 22 patients. Total tumour removal was associated with the development of endocrinological disturbances. There was worsening or the onset of new visual field defects in 4 cases. Postoperative endocrine and visual deficits were in the range generally described regarding surgery for tumours in this region.

Conclusion

The TLT approach allows for extensive removal of third ventricle and suprasellar tumours, without increased risks of visual and hormonal deficits, compared to those described regarding surgery for lesions in this region.     

经额底纵裂终板入路切除鞍后、鞍上区及第三脑室前部肿瘤

目的总结经额底纵裂终板入路切除鞍后、鞍上区及第三脑室前部肿瘤的治疗经验。方法回顾性分析32例鞍后、鞍上区及第三脑室前部肿瘤病人的临床资料,其中颅咽管瘤28例,生殖细胞瘤1例,垂体瘤3例。均经额底纵裂终板入路切除肿瘤。结果肿瘤全切除21例,次全切除6例,大部分切除5例;双侧嗅神经均保留29例,垂体柄保留24例。随访30例,时间2个月～2年,仅2例肿瘤大部分切除病人复发再次手术。结论经额底纵裂终板入路适合于切除向鞍后、鞍上区及第三脑室前部生长的肿瘤,术野显露充分,便于保留下丘脑、垂体柄等重要结构,肿瘤全切率高,并发症少,疗效好。     

显微手术切除治疗颅咽管瘤

目的 探讨颅咽管瘤显微手术切除的方法和入路。方法 45例经显微手术切除的颅咽管瘤中,囊性者34例(有钙化者26例),实质性11例;肿瘤直径2cm或以下者5例,2.1～4.0cm29例,4.1～6.0cm 6例,>6.0cm者5例。4例三脑室内肿瘤经胼胝体前入路,经胼胝体-翼点联合入路2例,39例经右翼点入路切除肿瘤。结果 经术中观察和影像学资料证实,全切除41例,次全切除2例,大部切除2例,随访2月～4年,参加工作或学习者38例,需生活照顾者5例,死亡2例,均系实质性肿瘤。结论早期诊断的颅咽管瘤显微手术全切除,效果理想;巨大、实质性肿瘤且伴有糖尿病者手术危险性很大。翼点入路是鞍区颅咽管瘤显微手术切除的最佳入路。     

CT观察脑挫裂伤时第三脑室及基底池形态改变的临床意义

目的探讨脑挫裂伤时第三脑室及基底池影像学征象改变的临床意义。方法对126例脑挫裂伤患者影像学资料进行回顾分析。根据首次CT扫描第三脑室和基底池形态改变分为4组,Ⅰ组(33例):第三脑室和基底池形态正常;Ⅱ组(31例):第三脑室呈条形或基底池轻度受压;Ⅲ组(32例):第三脑室呈线形和基底池明显受压;Ⅳ组(30例):第三脑室和基底池均消失。观察第三脑室及基底池改变与GCS评分、治疗方案及预后的关系。结果第三脑室和基底池形态与GCS评分、治疗方案密切相关,第三脑室和基底池形态改变越明显,恢复越差,病死率越高,各组间比较差异有显著性意义(P<0.01)。结论第三脑室和基底池形态的改变与脑挫裂伤预后密切相关,是判断预后的有效指标。     

Premio Sixto Obrador 2013. Modelo topográfico de 3 ejes para el tratamiento quirúrgico de los craneofaringiomas. Parte II: Evidencias anatómicas y neurorradiológicas que definen el modelo de clasificación de 3 ejes y su utilidad para predecir el riesgo quirúrgico individual

Introduction and objectivesThis study evaluates the pathological and magnetic resonance imaging evidence to define the precise topographical relationships of craniopharyngiomas and to classify these lesions according to the risks of hypothalamic injury associated with their removal.Material and methodsAn extensive, systematic analysis of the topographical classification models used in the surgical series of craniopharyngiomas reported in the literature (n = 145 series, 4,588 craniopharyngiomas) was performed. Topographical relationships of well-described operated craniopharyngiomas (n = 224 cases) and of non-operated cases reported in autopsies (n = 201 cases) were also analysed. Finally, preoperative and postoperative magnetic resonance imaging studies displayed in craniopharyngiomas reports (n = 130) were compared to develop a triple-axis model for the topographical classification of these lesions with qualitative information regarding the associated risk of hypothalamic injury.ResultsThe 2 major variables with prognostic value to define the topography of a craniopharyngioma are its position relative to the sellar diaphragm and its degree of invasion of the third ventricle floor. A multivariate diagnostic model including 5 variables –patient age, presence of hydrocephalus and/or psychiatric symptoms, the relative position of the hypothalamus and the mammillary body angle– makes it possible to differentiate suprasellar craniopharyngiomas displacing the third ventricle upwards (pseudointraventricular craniopharyngiomas) from either strictly intraventricular craniopharyngiomas or lesions developing primarily within the third ventricle floor (infundibulo-tuberal or not strictly intraventricular craniopharyngiomas).ConclusionsA triple-axis topographical model for craniopharyngiomas that includes the degree of hypothalamus invasion is useful in planning the surgical approach and degree of resection. Infundibulo-tuberal craniopharyngiomas represent 42% of all cases. These lesions typically show tight, circumferential adhesion to the third ventricle floor, with their removal being associated with a 50% risk of hypothalamic injury. The endoscopically-assisted extended transsphenoidal approach provides a proper view to assess the degree and extension of craniopharyngioma adherence to the hypothalamus.