垂体腺瘤显微手术治疗探讨

目的 探讨垂体腺瘤的显微手术治疗方法。方法 PRL瘤14例，GH瘤8例，ACTH瘤5例，多分泌腺瘤10例，无功能瘤13例；经翼点入路48例，2例经右眉上锁孔入路。结果 全切除肿瘤35例，大部分切除9例，部分切除6例。MRI随诊3个月～2年，4例有复发。结论 翼点入路垂体腺瘤切除是治疗垂体腺瘤及复发垂体腺瘤的有效方法。     

显微镜下经单鼻孔蝶窦入路切除垂体腺瘤

目的评价显微镜下经单鼻孔蝶窦入路切除垂体腺瘤的疗效. 方法采用经单鼻孔蝶窦入路行垂体腺瘤切除术20例,其中微腺瘤8例(<10 mm),小腺瘤8例(10～20 mm),中腺瘤3例(20～30 mm),大腺瘤1例(>30 mm);PRL腺瘤9例,GH腺瘤6例,ACTH腺瘤5例. 结果本组20例无并发症,平均随访5(2～10)个月,患者临床症状较术前均有不同程度改善,手术效果良好. 结论经单鼻孔蝶窦入路垂体瘤切除术效果好,术中损伤小,患者痛苦少,术后康复快,没有或较少出现并发症.     

垂体微腺瘤经蝶手术前后的护理

<正> 经唇下鼻蝶入路行鞍内垂体微腺瘤切除术是近年来开展的一种新术式。不需开颅,在显微镜下可选择性切除腺瘤,保全正常垂体组织,术中不必输血,术后不留疤痕,其良好的手术效果及低死亡率已获公认。1 临床资料 我院1988年～1997年施行经蝶手术切除垂体微腺瘤41例,男7例,女34例,年龄20～38岁,其中PRL腺瘤25例,主要表现为闭经、泌乳、不孕等。GH腺瘤14例,临床表现肢端肥大(手、足、颌、鼻、唇),体重增加,月经紊乱,ACTH腺瘤2例,主要表现为顽固性高血压,乏力,体重增加,月经紊乱,脂肪集中在躯干表现为水牛背,全身色素沉着,低血钾等。2 术前护理2.1 心理护理 心理是人脑对客观现实的反映,生活在社会环     

全神经内镜下经鼻蝶入路手术治疗垂体腺瘤72例临床分析

目的 探讨和评价全神经内镜下经鼻蝶入路切除垂体瘤的手术技巧及临床应用价值.方法 2009年1月至2012年3月,完成72例单纯神经内镜经鼻-蝶垂体瘤切除术,回顾性分析患者术前、术后症状及激素水平变化、影像学资料、手术资料、并发症、随访资料等. 结果 72例病例中非功能性腺瘤22例(30.6％),泌乳素腺瘤24例(33.3％),生长激素腺瘤7例(9.7％),促肾上腺皮质激素腺瘤5例(6.9％),促甲状腺激素腺瘤1例(1.4％),多分泌性腺瘤13例(18.1％);肿瘤全切除56例(77.8％),次全切除13例(18.0％),部分切除3例(4.2％);并发脑脊液漏5例,出现短暂性尿崩6例.术后随访3 ～ 24个月,大部分功能性腺瘤术后激素基本恢复正常水平,术后1例视力变差,其余患者症状亦基本恢复正常. 结论 全神经内镜经鼻蝶手术切除垂体腺瘤是一项安全、微创、有效的方法,具有全程直视下切除肿瘤的优点,但系统、专业的训练及相应的设备是必不可少的.     

单鼻孔经蝶显微手术切除垂体瘤的体会

目的探讨单鼻孔经蝶窦入路垂体腺瘤切除术的临床疗效。方法回顾性分析采用经鼻蝶入路显微手术切除的31例垂体腺瘤患者的临床资料,其中微腺瘤10例,大腺瘤15例,巨大腺瘤6例。结果肿瘤全切除22例,大部分切除8例,部分切除1例,手术无死亡病例,术后脑脊液漏3例,垂体功能低下1例,对症处理后均好转出院。结论经单鼻孔蝶窦入路显微手术切除肿瘤彻底、创伤小、并发症较少,是治疗垂体瘤常用的术式。     

经蝶入路显微手术治疗垂体腺瘤22例

目的探讨经蝶入路显微手术治疗垂体腺瘤的价值. 方法回顾性分析我院1990年1月～2001年12月22例经蝶入路显微手术治疗垂体腺瘤的临床资料. 结果肿瘤全切率68.2%(15/22).17例随访1～13年,视力视野障碍均有不同程度改善12例,5例失明均不能恢复. 结论经蝶入路显微手术治疗垂体腺瘤是微创、安全和有效的方法.     

单侧鼻孔经蝶微侵袭垂体腺瘤手术治疗

目的总结单侧鼻孔经蝶入路垂体腺瘤切除术的手术经验及体会。方法对115例垂体腺瘤病人采用经单鼻孔蝶窦入路行显微镜下垂体腺瘤切除手术，其中垂体微腺瘤7例，大腺瘤79例，巨大腺瘤29例(其中累及海绵窦者6例，肿瘤卒中2例)。结果100例肿瘤获全切，目前4例复发，其中3例二次手术，10例大部切除，5例部分切除。所有病人术后内分泌症状均有不同程度改善。术后尿崩症15例，经治疗出院时均恢复正常，1例术后单眼视力较术前明显下降，脑脊液鼻漏2例，术后嗅觉丧失2例。结论此入路有手术距离缩短、损伤小、省时、简单、并发症身等优点。     

神经导航下经鼻蝶垂体腺瘤切除术26例

随着显微神经外科技术的发展,经鼻蝶入路垂体腺瘤已成为治疗垂体腺瘤的常用手术。神经导航系统的应用,可使手术更加准确、安全。2003年6月至2007年7月．笔者对26例垂体腺瘤进行神经导航手术,取得满意疗效。     

内镜经鼻蝶切除伴有蝶窦气化不良的鞍区病变

目的探讨单鼻孔内镜下经鼻蝶切除伴有蝶窦气化不良的鞍区病变的方法。方法 2007年1月～2009年1月,内镜下经鼻蝶切除伴有蝶窦气化不良的15例鞍区病变,其中鞍前型蝶鞍8例,甲介型5例,骨性病变填塞蝶窦2例。结果无手术死亡病例,肿瘤全切12例(80.0%),次全切2例(13.3%),部分切除1例(6.7%)。病理类型包括垂体瘤12例(巨大腺瘤3例,大腺瘤7例,微腺瘤2例),脊索瘤2例,骨纤维结构不良1例。经1～3年随访(平均2.1年),术后复发1例,术后垂体功能低下1例。结论内镜经鼻蝶手术适用于大部分伴有蝶窦气化不良的病例,且效果良好。     

垂体微腺瘤的临床内分泌与病理免疫组化类型相关性分析

目的 探讨垂体微腺瘤临床症状、内分泌检查和病理类型之间的关系,以期更好地指导临床诊断和选择治疗方法.方法 收集2007年1月至2009年6月经手术切除的94例垂体微腺瘤患者的临床资料、内分泌检查结果及病理诊断.按病理免疫组化结果分为免疫组化阳性组和阴性组.运用χ2检验进行数据分析.结果 本组病例中出现内分泌症状86例(91.5%),免疫组化阳性组发生率(85/92,92.4%)较免疫组化阴性组发生率(1/2,50.0%)增高(P＜0.05),内分泌症状与免疫组化结果相符合.激素过多症状与免疫组化结果相一致的占71.7%,其中泌乳素(PRL)阳性出现闭经、溢乳或性功能低下占8 8.9%,生长激素(GH)阳性出现巨人症或肢端肥大症的占28.1%.内分泌检查激素增高与免疫组化结果相一致的占69.0%,其中PRL阳性出现血清PRL增高的占87.7%,GH阳性出现血清GH增高的占21.9%.结论 垂体微腺瘤患者的临床表现及内分泌检查能很好地与病理类型相联系,可以作为功能性垂体微腺瘤临床诊断的主要手段.     

垂体微腺瘤的诊断和治疗探讨

目的 探讨垂体微腺瘤（直径≤５ｍｍ）的诊断和治疗方法。方法 总结经ＣＴ垂体薄层扫描加矢,冠状重建诊断的垂体微腺瘤（直径≤５ｍｍ）２８例,全部采用经口鼻蝶窦入路显微手术切除。随访临床资料和内分泌改变,定期复查ＣＴ。结果 ２８例中病理证实２６例为垂体腺瘤,１例为炎症、１例为增生,诊断率达到９２．８％。汪变的术中定位成ＣＴ立体定位所见的位置完全符合。术后全部病例病情痊愈或好转,无手术死亡和并发症。２２例     

神经导航在经蝶垂体腺瘤手术中的应用

目的 总结神经导航下经蝶手术治疗垂体腺瘤的经验,并讨论其适应证.方法 对2006年1月至2010年12月138例神经导航下经蝶垂体腺瘤手术病例进行回顾性分析.手术适应证包括:既往经蝶手术后复发性垂体腺瘤36例,侵袭型垂体腺瘤45例,位于垂体侧方或深部的微腺瘤45例,蝶窦气化不良4例,颅底异常增厚3例,双侧颈内动脉间距狭窄4例,鼻中隔偏曲1例.结果 复发性垂体腺瘤全切除12例,次全切除9例,术后出现瘤腔血肿2例,脑脊液漏4例,其中3例合并颅内感染,2例合并交通性脑积水,永久性动眼神经麻痹1例,垂体功能低下者3例;治愈9例,缓解8例.侵袭型垂体腺瘤全切除5例,次全切除27例,术后出现脑脊液漏并颅内感染1例,瘤腔血肿1例;治愈2例,缓解22例;侵袭型激素分泌型垂体腺瘤30例均未治愈缓解.微腺瘤45例均为激素分泌型,均全部切除,治愈38例.颈动脉间距狭窄4例和鼻中隔偏曲1例均全切除和治愈.蝶窦气化不良肿瘤全切除2例,次全切除2例,治愈1例.颅底异常增厚肿瘤全切除2例,次全切除1例,治愈1例.结论 神经导航可以使部分经蝶垂体腺瘤切除手术更加准确、安全、有效,在一定程度上扩大了经蝶手术的适应证.

Abstract：

Objectives To summarize the experiences in clinical application of neuronavigation in transsphenoidal microsurgery of specific pituitary adenomas, and to discuss its indications. Methods From January 2006 to December 2010,138 cases of transsphenoidal microsurgery for specific pituitary adenomas under neuronavigation were reviewed. The indications for neuronavigation in transsphenoidal microsurgery includes: recurrent or regrowth of residual pituitary adenomas after former transsphenoidal surgery in 36 cases, invasive pituitary adenomas in 45 cases, extremely laterally or deeply situated microadenomas in 45 cases, poor pneumatization of the sphenoid in 4 cases, skull base anomalies due to osteodysplasia fibrosa in 3 cases, narrow space between bilateral internal carotid arteries in 4 cases, distortion of nasal septum in 1 case. Results In the recurrence group, 12 were totally removed, 9 subtotally removed;postoperative complications included hematoma within the tumor cavity in 2 cases, cerebrospinal fluid (CSF) leakage in 4 cases among which 3 developed intracranial infection and 2 communicating hydrocephalus, oculomotor paralysis in 1 case and hypopituitarysm in 3 cases;9 were cured and 8 remission. In the invasive group, 5 were totally removed, 27 subtotally removed;postoperative complications included hematoma within the tumor cavity in 1 case, CSF leakage and intracranial infection in 1 case;2 were cured and 22 remission. None of the 30 invasive hormone-secreting adenomas were cured or remission. The 45 cases of hormone-secreting microadenomas were all totally removed, among which 38 were cured. Among the poor sphenoid pneumatization group, total and subtotal tumor removal were achieved in 2 cases respectively with only one cured. In the skull base anomaly group, 2 were totally removed and 1 subtotally removed, with only one cured. For the cases with narrow space between bilateral internal carotid arteries and distortion of nasal septum, all were totally removed and cured. Conclusions Transsphenoidal microsurgery under neuronavigation can be applied for pituitary adenomas in above specific indications. It is an accurate, safe and effective approach for specific pituitary adenomas, which can not only expand the indication of transsphenoidal microsurgery for pituitary adenomas, but also reduce the harmful exposure of X-rays for the operating staff.     

Multiple Pituitary Hormone Gradients from Cavernous Sinus Sampling in Patients with Cushing's Disease

Summary  Objective. Cavernous sinus sampling in patients with adrenocorticotropic-hormone (ACTH) secreting pituitary adenomas has been used to identify directly ACTH hypersecretion from the pituitary and to predict the lateralization of a microadenoma. In our previous series, cavernous sinus sampling provided a sufficient central/peripheral (c/p) ratio of ACTH and the correct laterality of the pituitary lesion in all microadenomas situated in the lateral wing. To clarify the diagnostic value of other anterior pituitary hormones in relation to ACTH gradients, we evaluated multiple pituitary hormone gradients between a cavernous sinus and a peripheral vein and between both cavernous sinuses in patients with Cushing's disease.  Methods. Cavernous sinus sampling was done in 11 patients with clinical and biochemical features of ACTH-dependent Cushing's syndrome. In 9, pituitary adenoma was detected during transsphenoidal surgery and histologically confirmed, while 2 others were suspected of having ectopic lesions. Serum ACTH, prolactin (PRL), thyroid stimulating hormone (TSH), growth hormone (GH), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) from catheters in both cavernous sinuses and from a peripheral vein were measured. The c/p ratios of each hormone and the intercavernous gradients were evaluated.  Results. The c/p ratio of ACTH indicated the presense of pituitary lesions in all 9 patients with ACTH-secreting microadenomas. In addition, the intercavernous gradients of ACTH indicated the correct localization of microadenomas in all 6 patients with lateralized lesions. As for other hormones, the c/p ratios of GH, PRL, TSH and LH were significantly high in number 7, 6, 6 and 3 patients, respectively. In contrast, the significant step up of FSH was observed only in one patient. The intercavernous gradients of GH and PRL were significantly high in number 5 and 4 patients, respectively.  Conclusions. The intercavernous gradients of GH and PRL tend to indicate the lateralization of a microadenoma. The measurement of GH and PRL during cavernous sinus sampling may provide additional information, in the lateralization of ACTH-secreting microadenomas.     

Neurosurgical management of acromegaly. Results in 82 patients treated between 1972 and 1977.

A consecutive series of 82 acromegalic patients who underwent transsphenoidal surgery during a 5-year period is presented. Preoperative and postoperative values for human growth hormone (HGH) were available in 80 cases. Microadenomas were present in 18 patients with a mean preoperative HGH value of 25.2 ng/ml, diffuse adenomas in 39 patients with mean of 53.8 ng/ml, and invasive adenomas in 25 with mean of 68.0 ng/ml. There was no operative mortality. The results reflected the classification of the tumors, with apparent cures accomplished in 87.5% of previously untreated patients with microadenoma, all of whom had anterior pituitary function preserved. The percentages of apparent cures in cases of diffuse adenoma (68%) and invasive adenoma (54%) were much less satisfactory. Transsphenoidal microsurgery is capable of achieving good results, particularly in patients with microadenoma.     

Endocrinological evaluation of ACTH-secreting pituitary microadenomas: their location and alpha-melanocyte stimulating hormone immunoreactivity.

It has been hypothesized by Lamberts and coworkers in their analysis of 15 cases that adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas may be derived from either the anterior lobe or the intermediate lobe. The intermediate lobe type of Cushing's disease is thought to be controlled through a hypothalamic pathway and is characterized by hyperprolactinemia; suppressibility of cortisol with bromocriptine, and lower sensitivity to dexamethasone. The authors investigated the validity of this hypothesis in 125 cases of ACTH-secreting pituitary microadenomas by analyzing the endocrine findings, the locations of the microadenomas, and alpha-melanocyte stimulating hormone (alpha-MSH) immunoreactivity in the adenoma cells. No significant differences in the basal hormone levels, cortisol suppressibility with bromocriptine, sensitivity to dexamethasone, and recurrence rate were observed between patients with the microadenoma adjacent to the posterior lobe (considered typical of the intermediate lobe-derived tumor) or those with the microadenoma located in the anterior lobe. The locations of the microadenoma were not correlated with alpha-MSH immunoreactivity in the adenoma cells. No significant differences in endocrine findings were noticed between adenomas positive or negative for alpha-MSH. Thus, Cushing's disease cannot be simply divided into either the anterior lobe type or the intermediate lobe type by endocrinological evaluation as described by Lamberts, et al.     

Ectopic intracavernous sinus adrenocorticotropic hormone-secreting microadenoma: could this be a common cause of failed transsphenoidal surgery in Cushing disease? Case report

Despite diagnostic advances, it remains difficult to identify intrasellar and ectopic parasellar adrenocorticotropic hormone (ACTH)-secreting microadenomas. The authors present the case of a 61-year-old woman with Cushing disease in whom a significant central-to-peripheral and lateralized right-sided ACTH gradient was demonstrated on inferior petrosal sinus sampling; no discernible abnormality was seen on magnetic resonance imaging. She underwent transnasal transsphenoidal surgery. No tumor was found on sellar exploration and a total hypophysectomy was performed, yet her hypercortisolemia persisted. The patient died of cardiac events 17 days postsurgery. Autopsy revealed an isolated, right-sided, intracavernous ACTH-secreting adenoma with no intrasellar communication. This case represents the first failed transsphenoidal surgery for Cushing disease in which there is postmortem confirmation of a suspected intracavernous sinus lesion. It supports the hypothesis that Cushing disease associated with nondiagnostic imaging studies, a strong ACTH gradient on venography, and negative findings on sellar exploration may be caused by an ectopic intracavernous ACTH-secreting adenoma. There are no premortem means of confirming the presence of such lesions, but these tumors could underlie similar cases of failed surgery. Radiation therapy targeting the sella turcica and both cavernous sinuses, possibly supplemented with medical treatment, is suggested for similar patients in whom transsphenoidal hypophysectomy has failed. Adrenalectomy may also be appropriate if a rapid reduction in ACTH is necessary.     

Observations on the pathophysiology of Nelson's syndrome: a report of three cases

Nelson's syndrome is generally regarded as an unusual sequela of primary bilateral adrenalectomy when performed for Cushing's disease. It is classically defined by cutaneous hyperpigmentation, considerably elevated adrenocorticotropic hormone (ACTH) levels, and an enlarged sella turcica. In this report, we present three cases initially treated by transsphenoidal sellar exploration for Cushing's disease. In two of these cases, remission of hypercortisolism did not occur after the initial pituitary exploration. A microadenomectomy was performed in one case and, in the other, no microadenoma was found. In both, Nelson's syndrome occurred after adrenalectomy. A second transsphenoidal operation and radiotherapy were required to control tumor growth. In another case, transsphenoidal adenomectomy of an ACTH-secreting tumor initially led to a remission of hypercortisolism for 4 years, but recurrent Cushing's disease necessitated adrenalectomy, and again Nelson's syndrome occurred. The documentation of a pre-existing ACTH-secreting basophilic pituitary microadenoma before adrenalectomy, as seen in two of our cases, has not been previously reported, and these observations of "non-classical" courses have major implications for the pathophysiology of Nelson's syndrome.     

The Value of Intraoperative Cytology During Transsphenoidal Surgery for ACTH-Secreting Microadenoma

Summary  Background. Microsurgical selective adenomectomy is the best established method available for the treatment of Cushing's disease. However, this surgical method warrants still more efforts to improve the results in minute microadenomas. In this paper the authors evaluate a method of intraoperative cytological investigations during transsphenoidal surgery.  Method. Between January 1997 and September 1999, transsphenoidal surgery was performed in 75 patients with the diagnosis of Cushing's disease. Fifty-one cases of proven microadenomas were reviewed.  Findings. Of 51 cases, 33 tumors were 3 mm or less in diameter, here after called minute adenomas. In 49 of 51 (96.1%) microadenomas, adenoma tissue was identified by intraoperative cytological techniques. Postoperatively, only 35 of 51 ACTH-secreting microadenomas (68.6%) were confirmed by immunostaining methods. This lower percentage was most probably due to the small amount of tissue obtained. Therefore, in 14 cases (including 12 minute adenomas) the presence of the adenoma was only proven by cytological preparation and clinical outcome. The sensitivity of cytological preparations in cases of confirmed Cushing's disease was 100%.  Interpretation. The method described here was particularly well suited for the intraoperative discrimination and documentation of minute adenomas. Cytological preparation appears to be effective in improving the adenoma finding rate and the surgical outcome in cases of Cushing's disease.     

内镜下经单鼻孔-蝶窦切除垂体腺瘤

目的采取经单鼻孔-蝶窦路径于神经内窥镜下摘除垂体腺瘤（pituitary adenoma,PA）,并评价其临床效果。方法本组215例PA,术前对患者作CT或MRI检查,显示肿瘤的大小及与周边结构的关系。均应用经单鼻孔-蝶窦路径、在神经内窥镜辅助下切除肿瘤。结果190例（88．4％）肿瘤获全切除,17例（7．9％）达次全切除,余8例（3．7％）为纤维性肿瘤仅达部分切除。术后死亡2例（0．9％）。对182例进行随访,平均3．5个月,其中165例垂体大腺瘤（pituitary macroadenoma,PMaA）者,150例（90．9％）视力和视野缺损迅速恢复,余15例（9．1％）亦有好转;17例垂体微腺瘤（pituitary microadenoma,PMiA）的内分泌功能障碍逐渐恢复。结论于神经内窥镜下经单鼻孔．蝶窦路径切除PA,是一种安全、有效的微侵袭手术方法。     

解剖标志及神经内镜下经单鼻孔-蝶窦入路治疗脑垂体瘤

目的总结解剖标志及神经内镜下经单鼻孔-蝶窦路径进行垂体瘤切除的手术方法及其疗效。方法回顾分析42例经蝶内镜切除垂体瘤的手术经验。患者行磁共振成像(MRI)或CT扫描检查,显示鞍区肿瘤并压迫视神经与视交叉。均采用经单鼻孔-蝶窦路径、在神经内镜辅助下摘除。结果肿瘤全切除38例,近全切除3例,大部分切除1例。手术无死亡病例。本组随访3~36个月,平均10个月。18例视力下降及缺损者中,16例(88.9%)视力迅速恢复,2例(11.1%)好转。视野缺损14例(77.8%)恢复,4例(22.2%)改善。19例术前异常增高的激素水平术后部分逐渐恢复正常,20例术前内分泌功能紊乱者术后症状缓解。结论解剖定位及神经内镜下经单鼻孔-蝶窦路径切除垂体瘤是一种安全、有效的微侵袭手术方法。