内侧型蝶骨嵴脑膜瘤的显微外科治疗及伽玛刀治疗
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摘要
目的:探讨显微外科手术和伽玛刀治疗内侧型蝶骨嵴脑膜瘤的有效性.方法:回顾性分析39例内侧型蝶骨嵴脑膜瘤的临床病例资料,采用翼点或改良翼点入路者30例,额下入路者5例,额颞眶颧入路者4例,复发的5例及未全切的8例患者接受伽玛刀治疗.结果:肿瘤全切(SimpsonⅠ级及SimpsonⅡ级)率为69.2%(27/39),次全切(SimpsonⅢ级)率为20.5%(8/39),部分切除(SimpsonⅣ级)率为10.3%(4/39).复发6例,其中5例接受伽玛刀治疗,控制率为60%(3例),SimpsonⅢ级+Ⅳ级切除12例,其中8例患者接受伽玛刀治疗,肿瘤控制率为75%(6例).随访4个月～8年,平均45个月,预后优良32例,一般4例,差3例,死亡1例.术前视力视野障碍的21例患者有7例术后视力明显改善,9例无明显变化,5例恶化,术前偏瘫或偏侧感觉障碍的7例患者中6例术后有改善,1例加重,术前动眼神经麻痹的6例患者有1例改善,2例无明显变化,3例恶化.术后新出现动眼神经麻痹的患者6例,意识障碍3例,出现对侧肢体偏瘫1例,语言功能障碍1例,精神异常1例,嗅觉丧失1例.结论:内侧型蝶骨嵴脑膜瘤能否全切与肿瘤的位置、大小、质地、瘤周水肿程度、与海绵窦、颈内动脉等的关系有关;术中CUSA与等离子刀的应用,可提高肿瘤全切率;伽玛刀是处理肿瘤术后残余或复发的安全有效措施.
Objective:To explore the effectiveness of microsurgery and Gamma knife radiosurgery for medial sphenoid ridge meningioma. Methods: 39 cases of medial sphenoid ridge meningioma, admitted into our department from March 2008 to December 2015 and undergoing operations, were retrospectively analyzed.30 cases were operated via pterional approach or improved pterional approach, 5 cases via subfrontal approach, 4 cases via frontotemporal-orbitozygomatic approach(FTOZA). Five cases with recurrence and 8 cases of incomplete resection and were treated with Gamma knife radiosurgery. Results: In this study, total resection(Simpson Grade Ⅰ or Ⅱ) was achieved in 69.2%(27/39); subtotal resection(Simpson Grade Ⅲ) in 20.5%(8/39); partial resection(Simpson Grade Ⅳ) in 10.3%(4/39). In 6 cases of recurrence, 5 cases received Gamma knife radiosurgery and the control rate was 60%(3 cases). In 12 cases of subtotal and partial resection(Simpson Grade Ⅲ and Ⅳ), 8 cases received Gamma knife radiosurgery and the control rate was 75%(6 cases). After follow up for 6 months to 8 years(mean 45 months), the prognosis was excellent in 32 cases, general in 4 cases and poor in 3 cases, and one patient died. In 21 patients with visual field disorder before operation, 7 had marked improvement in visual acuity after operation, 9 showed no obvious change and 5 got worse. In 7 patients with preoperative hemiplegia and hemidysesthesia, 6 were improved and 1 aggravated postoperatively. In 6 patients with preoperative oculomotor nerve palsy, 1 patient was significantly improved, 2 had no apparent change and 3 worsened postoperatively. After operation, there were 6 new cases of oculomotor nerve palsy, 3 of conscious disturbance, 1 of contralateral hemiplegia, 1 of language dysfunction, 1 of mental disorder and 1 of anosphrasia. Conclusion:Whether performing total resection of medial sphenoid ridge meningioma depends on the position, size, texture and surrounding edema degree of tumor and the relationship of tumor with cavernous sinus and internal carotid artery. The application of CUSA and plasma knife can improve total resection rate of tumor. Gamma knife radiosurgery is a safe and effective method for treating tumor residue and recurrence after operation.
Objective:To explore the effectiveness of microsurgery and Gamma knife radiosurgery for medial sphenoid ridge meningioma. Methods: 39 cases of medial sphenoid ridge meningioma, admitted into our department from March 2008 to December 2015 and undergoing operations, were retrospectively analyzed.30 cases were operated via pterional approach or improved pterional approach, 5 cases via subfrontal approach, 4 cases via frontotemporal-orbitozygomatic approach(FTOZA). Five cases with recurrence and 8 cases of incomplete resection and were treated with Gamma knife radiosurgery. Results: In this study, total resection(Simpson Grade Ⅰ or Ⅱ) was achieved in 69.2%(27/39); subtotal resection(Simpson Grade Ⅲ) in 20.5%(8/39); partial resection(Simpson Grade Ⅳ) in 10.3%(4/39). In 6 cases of recurrence, 5 cases received Gamma knife radiosurgery and the control rate was 60%(3 cases). In 12 cases of subtotal and partial resection(Simpson Grade Ⅲ and Ⅳ), 8 cases received Gamma knife radiosurgery and the control rate was 75%(6 cases). After follow up for 6 months to 8 years(mean 45 months), the prognosis was excellent in 32 cases, general in 4 cases and poor in 3 cases, and one patient died. In 21 patients with visual field disorder before operation, 7 had marked improvement in visual acuity after operation, 9 showed no obvious change and 5 got worse. In 7 patients with preoperative hemiplegia and hemidysesthesia, 6 were improved and 1 aggravated postoperatively. In 6 patients with preoperative oculomotor nerve palsy, 1 patient was significantly improved, 2 had no apparent change and 3 worsened postoperatively. After operation, there were 6 new cases of oculomotor nerve palsy, 3 of conscious disturbance, 1 of contralateral hemiplegia, 1 of language dysfunction, 1 of mental disorder and 1 of anosphrasia. Conclusion:Whether performing total resection of medial sphenoid ridge meningioma depends on the position, size, texture and surrounding edema degree of tumor and the relationship of tumor with cavernous sinus and internal carotid artery. The application of CUSA and plasma knife can improve total resection rate of tumor. Gamma knife radiosurgery is a safe and effective method for treating tumor residue and recurrence after operation.
引文
[1] 杨树源,只达石.神经外科学[M].北京:人民卫生出版社,2008:544. YANG S Y, ZHI D S. Neurosurgery[M]. Beijing:People’s Medical Publishing House, 2008: 544.
[2] FARHOUD A, ABOUL-ENEIN H. Microsurgical treatment of medial sphenoid wing meningioma: strategy and results[J].Neurosurgery,2010,20(4):263-267.
[3] MARINIELLO G, MAIURI F, STRIANESE D. et al. Spheno-orbital meningiomas: surgical approaches and outcome according to the intraorbital tumor extent[J]. Zentrallbl Neurochir, 2008, 69(4): 175-181.
[4] CUSHING H, EISENHARDT L. Meningiomas: Their classification,regional behavior,life history, and surgical end results[J].Springfield, Charles C Thomas, 1938,42(2):448.
[5] CLAUS E B,BONDY M L,SCHILDKRAUT J M,et al.Epidemiology of intracranial meningioma[J]. Neurosurgery, 2005, 57(6):1088-1095.
[6] NAKAMURA M,ROSER F, JACOBS C, et al. Medial sphenoid wing meningiomas:clinical outcome and recurrence rate[J].Neurosurgery, 2006,58(4):626-639.
[7] 孙红卫, 宋来君, 张志强, 等. 内侧型蝶骨嵴脑膜瘤分型及治疗[J]. 中华神经外科杂志, 2006, 22(7):396-398. SUN H W, SUN L J, ZHANG Z Q, et al. Classification and treatment of sphenoid ridge meningiomas[J]. Chin J Neurosury, 2006, 22(7):396-398.
[8] 李仲森,傅先明,费小瑞,等. 蝶骨嵴内侧脑膜瘤围手术期的处理要点[J]. 中国微侵袭神经外科杂志,2015,20(6):256-258. LI Z S, FU X M, FEI X R, et al.Perioperative treatment of the medial sphenoid ridge meningioma[J].Chin J Minim Invasive Neurosurg, 2015, 20(6):256-258.
[9] DAY J D. Cranial base surgical techniques for large sphenocavernous meningiomas: technical note[J]. Neurosurgery, 2000,46(3):754-759.
[10] EVANS J J, HWANG Y S, LEE J H. Pre-versus post-anterior clinoidectomy measurements of the optic nerve, internal carotid artery, and optico-carotid triangle: A cadaveric morphometric study[J]. Neurosurgery, 2000,46(4):1018-1023.
[11] LEE J H, JEUN S S, EVANS J, et al. Surgical management of clinoidal meningiomas[J]. Neurosurgery, 2001,48(5):1012-1019.
[12] MARINIELLO G, DE DIVITIIS O, SENECA V, et al. Classical pterional compared to the extended skull base approach for the removal of clinoidal meningiomas[J].Journal of Clinical Neuroscience,2012,19(12):1646-1650.
[13] CHAN R C,THOMPSON G B. Mobidity, mortality, and quality of life following surgery for intracranial meningiomas[J]. J Neurosurg,1984,60(1):52-60.
[14] ATTIA M, UMANSKY F, PALDOR I, et al. Giant anterior clinoidal meningiomas: surgical technique and outcomes[J]. J Neurosurg, 2012,117(4):654-665.
[15] VAN HAVENBERGH T, CARVALHO G,TATAGIBA M, et al. Natural history of petroclival meningiomas[J]. Neurosurgery,2003,52(1):55-62.
[16] ABDEL-AZIZ K M,FROELICH S C,DAGNEW E.Large sphenoid wing meningiomas ivolving the cavernous sinus:conservative surgical strategies for better functional outcomes[J].Neurosurgery,2004,54(6):1375-1384.
[17] SEKHAR L N, PATEL S, CUSIMANO M, et al. Surgical treatment of meningiomas involving the cavernous sinus: evolving ideas based on a ten year experience[J].Acta Neurochir Suppl, 1996,(65):58-62.
[18] GOEL A, GUPTA S, DESAI K. New grading system to predict resectability of anterior clinoid meningiomas[J]. Neurol MedChir (Tokyo), 2000,40(12):610-617.
[19] TOBIAS S, KIM C H, KOSMORSKY G, et al. Management ofsurgical clinoidal meningiomas[J]. Neurosurg Focus, 2003,14(6):e5.
[20] AL-MEFTY O.Clinoid mengioma[J].Neurosurgery,1990,73(6):840-849.
[21] CZERNICKI T, KUNERT P, NOWAK A, et al. Results of surgical treatment of anterior clinoidal meningiomas-our experiences[J]. Neurologia i Neurochirurgia Polska, 2015,49(1):29-35.
[22]HARRIGAN M R.Angiogenic factors in the centnal nervous system[J].Neurosurgery,2003,53(3):639-661.
[23] HUGHES J D, FATTAHI N, VAN GOMPEL J,et al.Higer-resolution magnetic resonance elastography in meningiomas to determine intratumoral consistency[J]. Neurosurgery,2015,77(4):653-659.
[24] SCHEITZACH J, SCHEBESCH K M, BRAWANSKI A, et al. Skull base meningiomas:neurological outcome after microsurgical resection[J].J Neurooncol, 2014,116(2):381-386.
[25] YANG J, MA S C, LIU Y H, et al.Large and giant medial sphenoid wing meningiomas involving vascular structures: clinical features and management experience in 53 patients[J].Chinese Medical Journal,2013,126(23):4470-4476.
[26] RUSSELL S M,BENJAMIN V.Medial sphenoid ridge meningiomas:classification,microsurgicalanatomy,operative nuances,and long-term surgical out come in 35 consecutive patients[J].Neurosurgery,2008,62(1):38-40.
[27] RISI P, USKE A, DE TRIBOLET N. Meningiomas involving the anterior clinoid process[J]. Br J Neurosurg,1994,8(3):295-305.
[28] IWAI Y, YAMANAKA K, ISHIGURO T. Gamma knife radiosurgery for the treatment of cavernous sinus meningiomas[J].Neurosurgery, 2003,52(3):517-524.
[29] LEE J Y, NIRANJAN A, MCINERNEY J, et al. Stereotactic radiosurgery providing long-term tumor control of cavernous sinus meningiomas[J]. J Neurosurg, 2002,97(1):65-72.
[30] TAYLOR B W, MARCUS R B, FRIEDAN W A, et al.The meningioma controversy: postoper ative radiation therapy[J]. Int J Radiat Oncol Biol Phys,1988,15(2):299-304.
[31] 赵继宗.神经外科学[M].北京:人民卫生出版社,2012:716. ZHAO J Z. Neurosurgery[M]. Benjing:People’s Medical Publishing House, 2012:716.
[2] FARHOUD A, ABOUL-ENEIN H. Microsurgical treatment of medial sphenoid wing meningioma: strategy and results[J].Neurosurgery,2010,20(4):263-267.
[3] MARINIELLO G, MAIURI F, STRIANESE D. et al. Spheno-orbital meningiomas: surgical approaches and outcome according to the intraorbital tumor extent[J]. Zentrallbl Neurochir, 2008, 69(4): 175-181.
[4] CUSHING H, EISENHARDT L. Meningiomas: Their classification,regional behavior,life history, and surgical end results[J].Springfield, Charles C Thomas, 1938,42(2):448.
[5] CLAUS E B,BONDY M L,SCHILDKRAUT J M,et al.Epidemiology of intracranial meningioma[J]. Neurosurgery, 2005, 57(6):1088-1095.
[6] NAKAMURA M,ROSER F, JACOBS C, et al. Medial sphenoid wing meningiomas:clinical outcome and recurrence rate[J].Neurosurgery, 2006,58(4):626-639.
[7] 孙红卫, 宋来君, 张志强, 等. 内侧型蝶骨嵴脑膜瘤分型及治疗[J]. 中华神经外科杂志, 2006, 22(7):396-398. SUN H W, SUN L J, ZHANG Z Q, et al. Classification and treatment of sphenoid ridge meningiomas[J]. Chin J Neurosury, 2006, 22(7):396-398.
[8] 李仲森,傅先明,费小瑞,等. 蝶骨嵴内侧脑膜瘤围手术期的处理要点[J]. 中国微侵袭神经外科杂志,2015,20(6):256-258. LI Z S, FU X M, FEI X R, et al.Perioperative treatment of the medial sphenoid ridge meningioma[J].Chin J Minim Invasive Neurosurg, 2015, 20(6):256-258.
[9] DAY J D. Cranial base surgical techniques for large sphenocavernous meningiomas: technical note[J]. Neurosurgery, 2000,46(3):754-759.
[10] EVANS J J, HWANG Y S, LEE J H. Pre-versus post-anterior clinoidectomy measurements of the optic nerve, internal carotid artery, and optico-carotid triangle: A cadaveric morphometric study[J]. Neurosurgery, 2000,46(4):1018-1023.
[11] LEE J H, JEUN S S, EVANS J, et al. Surgical management of clinoidal meningiomas[J]. Neurosurgery, 2001,48(5):1012-1019.
[12] MARINIELLO G, DE DIVITIIS O, SENECA V, et al. Classical pterional compared to the extended skull base approach for the removal of clinoidal meningiomas[J].Journal of Clinical Neuroscience,2012,19(12):1646-1650.
[13] CHAN R C,THOMPSON G B. Mobidity, mortality, and quality of life following surgery for intracranial meningiomas[J]. J Neurosurg,1984,60(1):52-60.
[14] ATTIA M, UMANSKY F, PALDOR I, et al. Giant anterior clinoidal meningiomas: surgical technique and outcomes[J]. J Neurosurg, 2012,117(4):654-665.
[15] VAN HAVENBERGH T, CARVALHO G,TATAGIBA M, et al. Natural history of petroclival meningiomas[J]. Neurosurgery,2003,52(1):55-62.
[16] ABDEL-AZIZ K M,FROELICH S C,DAGNEW E.Large sphenoid wing meningiomas ivolving the cavernous sinus:conservative surgical strategies for better functional outcomes[J].Neurosurgery,2004,54(6):1375-1384.
[17] SEKHAR L N, PATEL S, CUSIMANO M, et al. Surgical treatment of meningiomas involving the cavernous sinus: evolving ideas based on a ten year experience[J].Acta Neurochir Suppl, 1996,(65):58-62.
[18] GOEL A, GUPTA S, DESAI K. New grading system to predict resectability of anterior clinoid meningiomas[J]. Neurol MedChir (Tokyo), 2000,40(12):610-617.
[19] TOBIAS S, KIM C H, KOSMORSKY G, et al. Management ofsurgical clinoidal meningiomas[J]. Neurosurg Focus, 2003,14(6):e5.
[20] AL-MEFTY O.Clinoid mengioma[J].Neurosurgery,1990,73(6):840-849.
[21] CZERNICKI T, KUNERT P, NOWAK A, et al. Results of surgical treatment of anterior clinoidal meningiomas-our experiences[J]. Neurologia i Neurochirurgia Polska, 2015,49(1):29-35.
[22]HARRIGAN M R.Angiogenic factors in the centnal nervous system[J].Neurosurgery,2003,53(3):639-661.
[23] HUGHES J D, FATTAHI N, VAN GOMPEL J,et al.Higer-resolution magnetic resonance elastography in meningiomas to determine intratumoral consistency[J]. Neurosurgery,2015,77(4):653-659.
[24] SCHEITZACH J, SCHEBESCH K M, BRAWANSKI A, et al. Skull base meningiomas:neurological outcome after microsurgical resection[J].J Neurooncol, 2014,116(2):381-386.
[25] YANG J, MA S C, LIU Y H, et al.Large and giant medial sphenoid wing meningiomas involving vascular structures: clinical features and management experience in 53 patients[J].Chinese Medical Journal,2013,126(23):4470-4476.
[26] RUSSELL S M,BENJAMIN V.Medial sphenoid ridge meningiomas:classification,microsurgicalanatomy,operative nuances,and long-term surgical out come in 35 consecutive patients[J].Neurosurgery,2008,62(1):38-40.
[27] RISI P, USKE A, DE TRIBOLET N. Meningiomas involving the anterior clinoid process[J]. Br J Neurosurg,1994,8(3):295-305.
[28] IWAI Y, YAMANAKA K, ISHIGURO T. Gamma knife radiosurgery for the treatment of cavernous sinus meningiomas[J].Neurosurgery, 2003,52(3):517-524.
[29] LEE J Y, NIRANJAN A, MCINERNEY J, et al. Stereotactic radiosurgery providing long-term tumor control of cavernous sinus meningiomas[J]. J Neurosurg, 2002,97(1):65-72.
[30] TAYLOR B W, MARCUS R B, FRIEDAN W A, et al.The meningioma controversy: postoper ative radiation therapy[J]. Int J Radiat Oncol Biol Phys,1988,15(2):299-304.
[31] 赵继宗.神经外科学[M].北京:人民卫生出版社,2012:716. ZHAO J Z. Neurosurgery[M]. Benjing:People’s Medical Publishing House, 2012:716.