巨大实性高血运听神经瘤的外科治疗
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摘要
目的探讨和总结巨大实性高血运听神经瘤的临床显微手术技巧,以期提高手术疗效。方法回顾性分析2008年8月～2016年8月手术的21例巨大实性高血运听神经瘤患者临床资料,探讨手术操作技巧,总结肿瘤切除程度、术后面瘫情况及其余并发症。结果 21例患者均采用枕下乙状窦后入路,肿瘤最大径62 mm,最小直径40 mm;肿瘤全切6例,近全切除15例。无一例死亡。术后面神经功能H-B 1级7例,2级7例,3级5利,4级2例;共济运动障碍者2例。术后2年以上随访H-B 2级患者有3例恢复至1级。结论合理控制出血是切除巨大实性高血运听神经瘤的关键步骤,内听道后壁的精细打磨、面神经扇形扩张平面的确认与保护是保留面神经功能的重要步骤。
Objective To investigate and summarize the microsurgical technique for giant solid hypervascular acoustic neuroma so as to improve the surgical effect.Methods Clinical data of 21 patients who underwent removal of giant solid hypervascular acoustic neuroma from Aug. 2008 to Aug. 2016 were analyzed retrospectively. The analyzed data included surgical technique, extent of tumor resection, postoperative complications such as facial paralysis and long-term follow-up results.Results A retrosigmoid approach was adopted in all the 21 cases. The maximal tumor diameter was 62 mm and the minimal diameter was 40 mm. Total resection was achieved in 6 cases and subtotal resection in 15. No case died. According to House-Brackmann(H-B) classification of facial nerve function, the facial nerve function was grade 1 in 7 cases, grade 2 in 7, grade 3 in 5, and grade 4 in 2. And 2 patients had postoperative ataxia. After 2 years of follow-up, 3 patients with H-B grade 2 recovered to grade 1.Conclusion Reasonable control of hemorrhage is the key for resection of giant solid hypervascular acoustic neuroma. Fine polishing of the posterior wall of the internal auditory canal, identification and protection of the fan-shaped expansion plane of the facial nerve are important for the preservation of facial nerve function.
Objective To investigate and summarize the microsurgical technique for giant solid hypervascular acoustic neuroma so as to improve the surgical effect.Methods Clinical data of 21 patients who underwent removal of giant solid hypervascular acoustic neuroma from Aug. 2008 to Aug. 2016 were analyzed retrospectively. The analyzed data included surgical technique, extent of tumor resection, postoperative complications such as facial paralysis and long-term follow-up results.Results A retrosigmoid approach was adopted in all the 21 cases. The maximal tumor diameter was 62 mm and the minimal diameter was 40 mm. Total resection was achieved in 6 cases and subtotal resection in 15. No case died. According to House-Brackmann(H-B) classification of facial nerve function, the facial nerve function was grade 1 in 7 cases, grade 2 in 7, grade 3 in 5, and grade 4 in 2. And 2 patients had postoperative ataxia. After 2 years of follow-up, 3 patients with H-B grade 2 recovered to grade 1.Conclusion Reasonable control of hemorrhage is the key for resection of giant solid hypervascular acoustic neuroma. Fine polishing of the posterior wall of the internal auditory canal, identification and protection of the fan-shaped expansion plane of the facial nerve are important for the preservation of facial nerve function.
引文
[1] 张明山,张宏伟,谷春雨,等.青年高血供听神经瘤手术技巧的探讨[J].中国微侵袭神经外科杂志,2016,21(2):57-59. Zhang MS, Zhang HW, Gu CY, et al. Analysis of surgical skills for hypervascular acoustic neuroma in young adults[J]. Chinese Journal of Minimally Invasive Neurosurgery, 2016,21(2):57-59.
[2] Bonneville F, Cattin F, Czorny A, et al. Hypervascular intracisternal acoustic neuroma[J].J Neuroradiol,2002,29(2):128-131.
[3] Yamakami I, Kobayashi E, Iwadate Y, et al. Hypervascular vestibular schwannomas[J].Surg Neurol,2002,57(2):105-112.
[4] LeMay DR, Sun JK, Fishback D, et al. Hypervascular acoustic neuroma[J].Neurol Res,1998,20(8):748-750.
[5] Dunn IF, Bi WL, Erkmen K, et al. Medial acoustic neuromas: clinical and surgical implications[J].J Neurosurg,2014, 120(5):1095-1104.
[6] Boublata L, Belahreche M, Ouchtati R, et al. Facial nerve function and quality of resection in large and giant vestibular schwannomas surgery operated by retrosigmoid transmeatal approach in semi-sitting position with intraoperative facial nerve monitoring[J].World Neurosurg,2017,103:231-240.
[7] Sato Y, Mizutani T, Shimizu K, et al. Retrosigmoid intradural suprameatal-inframeatal approach for complete surgical removal of a giant recurrent vestibular schwannoma with severe petrous bone involvement: technical case report[J].World Neurosurg,2018,110:93-98.
[8] Turel MK, D’Souza WP, Chacko AG, et al. Giant vestibular schwannomas: surgical nuances influencing outcome in 179 patients[J].Neurol India, 2016,64 (3):478-484.
[9] Sorour M, Sayama C, Couldwell WT. Posterior reversible encephalopathy syndrome after surgical resection of a giant vestibular schwannoma: case report and literature review[J].J Neurol Surg A Cent Eur Neurosurg,2016,77(3):274-279.
[10] Mura J, Cuevas JL, Rojas-Zalazar D, et al. Vestibular schwannomas: surgical treatment of 67 cases in 10 years[J].Neurocirugia(Astur),2015,26(6):261-267.
[11] Samprón N, Altuna X, Armendáriz M, et al. Treatment of giant acoustic neuromas[J].Neurocirugia (Astur),2014,25(6):247-260.
[12] Mehrotra N, Behari S, Pal L, et al. Giant vestibular schwannomas: focusing on the differences between the solid and the cystic variants[J].Br J Neurosurg,2008,22(4): 550-556.
[2] Bonneville F, Cattin F, Czorny A, et al. Hypervascular intracisternal acoustic neuroma[J].J Neuroradiol,2002,29(2):128-131.
[3] Yamakami I, Kobayashi E, Iwadate Y, et al. Hypervascular vestibular schwannomas[J].Surg Neurol,2002,57(2):105-112.
[4] LeMay DR, Sun JK, Fishback D, et al. Hypervascular acoustic neuroma[J].Neurol Res,1998,20(8):748-750.
[5] Dunn IF, Bi WL, Erkmen K, et al. Medial acoustic neuromas: clinical and surgical implications[J].J Neurosurg,2014, 120(5):1095-1104.
[6] Boublata L, Belahreche M, Ouchtati R, et al. Facial nerve function and quality of resection in large and giant vestibular schwannomas surgery operated by retrosigmoid transmeatal approach in semi-sitting position with intraoperative facial nerve monitoring[J].World Neurosurg,2017,103:231-240.
[7] Sato Y, Mizutani T, Shimizu K, et al. Retrosigmoid intradural suprameatal-inframeatal approach for complete surgical removal of a giant recurrent vestibular schwannoma with severe petrous bone involvement: technical case report[J].World Neurosurg,2018,110:93-98.
[8] Turel MK, D’Souza WP, Chacko AG, et al. Giant vestibular schwannomas: surgical nuances influencing outcome in 179 patients[J].Neurol India, 2016,64 (3):478-484.
[9] Sorour M, Sayama C, Couldwell WT. Posterior reversible encephalopathy syndrome after surgical resection of a giant vestibular schwannoma: case report and literature review[J].J Neurol Surg A Cent Eur Neurosurg,2016,77(3):274-279.
[10] Mura J, Cuevas JL, Rojas-Zalazar D, et al. Vestibular schwannomas: surgical treatment of 67 cases in 10 years[J].Neurocirugia(Astur),2015,26(6):261-267.
[11] Samprón N, Altuna X, Armendáriz M, et al. Treatment of giant acoustic neuromas[J].Neurocirugia (Astur),2014,25(6):247-260.
[12] Mehrotra N, Behari S, Pal L, et al. Giant vestibular schwannomas: focusing on the differences between the solid and the cystic variants[J].Br J Neurosurg,2008,22(4): 550-556.