脑室内脑膜瘤的诊断与显微手术治疗
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摘要
目的:总结分析脑室内脑膜瘤的流行病学特点,临床表现,影像学表现,诊断及鉴别诊断,显微手术治疗方法,术后并发症,病理学特点以及随访结果,以提高脑室内脑膜瘤的诊断与治疗水平。
方法:回顾性分析山东大学齐鲁医院神经外科1999年7月至2006年12月间收治的32例脑室内脑膜瘤患者的临床资料;所有患者均行过CT检查,13例患者行MRI检查,1例行DSA检查。
结果:脑室内脑膜瘤患者约占同期收治颅内脑膜瘤的4.3%;男性患者10例,女性22例,平均发病年龄41.7岁(21岁～67岁),平均病程18个月。32例中男性患者10例(31.25%)全为侧脑室内脑膜瘤;女性22例(68.75%):侧脑室19例、四脑室3例;最主要的临床症状是头痛(68.8%)。所有患者均在显微镜下进行了肿瘤切除,其中全切除30例(93.75%),次全切除2例(6.25%);无手术死亡病例。术后失语改善1例,偏盲改善2例;轻偏瘫或偏瘫加重5例,不完全性失语或失语加重8例,偏盲或偏盲加重5例,颅内感染1例;术后并发症在出院时基本消失或明显改善。术后6个月获得随访18例,采用KPS(karnofsky performance status)评分:100分1例、90分3例、80分8例、70分5例、60分1例。1例患者于术后9个月复发,经再手术治疗,恢复良好。
结论:①脑室内脑膜瘤发病率低,多见于侧脑室三角区,以中青年女性多见。②脑室内脑膜瘤没有特异性的临床表现,多以颅内压增高为常见,其诊断有赖于影像学检查。③MRI检查可以提供较为准确的三维位置及肿瘤供血情况。④脑室内脑膜瘤的手术切除效果满意,显微外科技术与适当的手术入路和手术技巧是提高肿瘤全切率及降低死残率的保障。
Objective: To improve the diagnosis and treatment of intraventricular meningiomas, the characteristics of epidemiology, clinical manifestation, radiological features, diagnosis and differential diagnosis, surgical skills, postoperative complications, pathological features and final outcome of patients with intraventricular meningiomas are described.
Method: 32 patients with intraventricular meningiomas which were hospitalization and treatment in Department of Neurosurgery, Qilu Hospital of Shandong University between July 1999 and December 2006 were analyzed retrospectively. All the patients were diagnosed by CT (computer tomography), in 13 of them MRI (magnetic resonance imaging) was performed and 1 patient was inspected by DSA (digital subtraction angiography).
Results: Patients with intraventricular meningiomas is about 4.3% of all the intracranial meningiomas. Ten patients were male and 22 female. Mean age was 41.7 years (21～67) and the average duration of presenting symptoms was 18 months. Ten patients of 32 (31.25%) with lateral venticular meningiomas were male, 22 of 32 (68.75%) were female: 19 patients with lateral venticular meningiomas and 3 with meningiomas that were in the fourth ventricle. The most common complaints at presentation were headaches (68.8%). All the meningiomas underwent microsurgery, total resection was achieved in 30 cases (93.75%) and subtotal resection was performed in 2 cases (6.25%). There was no operative mortality. Postoperatively, aphasia is improved in 1 patient and hemiopia improved in 2 cases, hemiparalysis occurred in 5 cases, aphasia in 8, hemiopia in 5, and also one intracranial infection. Postoperative complications were obsolescent or improved when they were discharge. The follow-up was available in 18 patients. They were evaluated with KPS (karnofsky performance status) six months after operation. Twelve cases were above 80 scores and 6 were below. One patient was under reoperation nine months after operation for recurrence of meningioma, and the effectiveness of recovery was satisfactory.
Conclusions: 1. Incidence of intraventricular meningiomas is low, which is ofen located in the trigone of lateral cerebral ventricle and preference with young and middle-aged women. 2. Intraventricular meningiomas have no characteristic clinical manifestation, which is common in intracranial hypertension and diagnosis depends on imageology. 3. Examination by MRI (magnetic resonance imaging) can offer precise three-dimensional localization and blood-supply of tumor. 4. The effectiveness of treatment with microneurosurgery for intraventricular meningiomas is satisfactory. Microsurgical techinique, proper operative approaches together with microsurgical skills are the guarantee for increasing total removal rate of tumors and decreasing mortality and disability rate.
方法:回顾性分析山东大学齐鲁医院神经外科1999年7月至2006年12月间收治的32例脑室内脑膜瘤患者的临床资料;所有患者均行过CT检查,13例患者行MRI检查,1例行DSA检查。
结果:脑室内脑膜瘤患者约占同期收治颅内脑膜瘤的4.3%;男性患者10例,女性22例,平均发病年龄41.7岁(21岁～67岁),平均病程18个月。32例中男性患者10例(31.25%)全为侧脑室内脑膜瘤;女性22例(68.75%):侧脑室19例、四脑室3例;最主要的临床症状是头痛(68.8%)。所有患者均在显微镜下进行了肿瘤切除,其中全切除30例(93.75%),次全切除2例(6.25%);无手术死亡病例。术后失语改善1例,偏盲改善2例;轻偏瘫或偏瘫加重5例,不完全性失语或失语加重8例,偏盲或偏盲加重5例,颅内感染1例;术后并发症在出院时基本消失或明显改善。术后6个月获得随访18例,采用KPS(karnofsky performance status)评分:100分1例、90分3例、80分8例、70分5例、60分1例。1例患者于术后9个月复发,经再手术治疗,恢复良好。
结论:①脑室内脑膜瘤发病率低,多见于侧脑室三角区,以中青年女性多见。②脑室内脑膜瘤没有特异性的临床表现,多以颅内压增高为常见,其诊断有赖于影像学检查。③MRI检查可以提供较为准确的三维位置及肿瘤供血情况。④脑室内脑膜瘤的手术切除效果满意,显微外科技术与适当的手术入路和手术技巧是提高肿瘤全切率及降低死残率的保障。
Objective: To improve the diagnosis and treatment of intraventricular meningiomas, the characteristics of epidemiology, clinical manifestation, radiological features, diagnosis and differential diagnosis, surgical skills, postoperative complications, pathological features and final outcome of patients with intraventricular meningiomas are described.
Method: 32 patients with intraventricular meningiomas which were hospitalization and treatment in Department of Neurosurgery, Qilu Hospital of Shandong University between July 1999 and December 2006 were analyzed retrospectively. All the patients were diagnosed by CT (computer tomography), in 13 of them MRI (magnetic resonance imaging) was performed and 1 patient was inspected by DSA (digital subtraction angiography).
Results: Patients with intraventricular meningiomas is about 4.3% of all the intracranial meningiomas. Ten patients were male and 22 female. Mean age was 41.7 years (21～67) and the average duration of presenting symptoms was 18 months. Ten patients of 32 (31.25%) with lateral venticular meningiomas were male, 22 of 32 (68.75%) were female: 19 patients with lateral venticular meningiomas and 3 with meningiomas that were in the fourth ventricle. The most common complaints at presentation were headaches (68.8%). All the meningiomas underwent microsurgery, total resection was achieved in 30 cases (93.75%) and subtotal resection was performed in 2 cases (6.25%). There was no operative mortality. Postoperatively, aphasia is improved in 1 patient and hemiopia improved in 2 cases, hemiparalysis occurred in 5 cases, aphasia in 8, hemiopia in 5, and also one intracranial infection. Postoperative complications were obsolescent or improved when they were discharge. The follow-up was available in 18 patients. They were evaluated with KPS (karnofsky performance status) six months after operation. Twelve cases were above 80 scores and 6 were below. One patient was under reoperation nine months after operation for recurrence of meningioma, and the effectiveness of recovery was satisfactory.
Conclusions: 1. Incidence of intraventricular meningiomas is low, which is ofen located in the trigone of lateral cerebral ventricle and preference with young and middle-aged women. 2. Intraventricular meningiomas have no characteristic clinical manifestation, which is common in intracranial hypertension and diagnosis depends on imageology. 3. Examination by MRI (magnetic resonance imaging) can offer precise three-dimensional localization and blood-supply of tumor. 4. The effectiveness of treatment with microneurosurgery for intraventricular meningiomas is satisfactory. Microsurgical techinique, proper operative approaches together with microsurgical skills are the guarantee for increasing total removal rate of tumors and decreasing mortality and disability rate.
引文
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[7]Majo's C,Cucurella G,Aguilera C,et al.Intraventricular meningiomas:MR imaging and MR spectroscopic findings in two cases[J].AJNR,1999,20(5):882-885.
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[21]于同刚,戴嘉中,李克.脑膜瘤的MRI表现与组织病理对照研究.实用放射学杂志,2004,20(3):199-202.
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[23]Yamaguchi N,Kawase T,Sagoh M,et al.Prediction of consistency of meningiomas with preoperative magnetic resonance imaging[J].Surg Neurol,1997,48(6):579-583.
[24]Engelhard HH.Progress in the diagnosis and treatment of patients with meningiomas.Part I:diagnostic imaging,preoperative embolization[J].Surg Neurol,2001,55(2):89-101.
[25]Yoneoka Y,Fujii Y,Takahashi H,et al.Pre-Operative histopathological evaluation of meningiomas by 3.0T T_2R MRI[J].Acta Neurochirurgica,2002,144(10):953-957.
[26]Alafaci C,Salpietro FM,Grasso G,et al.Osteoblastic meningioma of the lateral ventricle[J].J Neurosurg,1999,91(12):1058.
[27]Lee EJ,Choi KH,Kang SW,et al.Intraventricular hemorrhage caused by lateral ventricular meningioma:a case report[J].Korean J Radiol,2001,2(2):105-107.
[28]Lang I,Jackson A,Strang FA.Intraventricular hemorrhage caused by intraventricular meningioma:CT appearance[J].AJNR,1995,16(6):1378-1381.
[29]夏晓,余准,吴力源.侧脑室肿瘤的CT和MRI诊断.中华放射学杂志,1996,30(1):41-44.
[30]Bertalanffy A,Roessler K,Koperek O,et al.Intraventricular meningiomas:a report of 16 cases.Neurosurg Rev.2006,29(1):30-35.
[31]Due-Tonnessen B,Helseth E,Skullerud K,et al.Choroid plexus tumors in children and young adults report of 16 consecutive cases.[J].Child's Nerv Syst,2001,17(4-5):252-256.
[32]Schild SE.Benign central neurocytoma:a double misnomer? Cancer.2002,94(1):284-284.
[33]Pendle G,Eustacchio S,Unger F.Radiosurgery as alternative treatment for skull base meningiomas.[J].J Clin Neurosci,2001,8(supp11):12-14.
[34]Aichholzer M,Bertalanffy A,Dietrich W,et al.Gamma knife radiosurgery of skull base meningiomas.[J].Acta Neurochir(wien),2000,142:647-652.
[35]Carella RJ,Raosohoff J,Newall J.Role of radiation therapy in the management of meniagioma.Neurosurgery,1982,10:332-339.
[36]Barharo NM,Gutin PM,Wilson CB,et al.Radiation therapy in the treatment of partially resected meningiomas.Neurosurgery,1987,20(4):525-528.
[37]吴鸿勋,梁军潮,覃子衡,等.颅内肿瘤的伽玛刀治疗.功能性和立体定向神经外科杂志,1997,10(3):47-50.
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[51]Gaab MR,Schroeder HW.Neuroendoscopic approach to intraventrlcular lesions.J Neurosurgery,1998,88(3):496-505.
[52]张懋植,王磊,赵继宗,等.脑沟入路手术切除侧脑室三角区病变(附35例报告).中国微侵袭神经外科杂志,2003,8(2):59-61
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[2]段国升,朱诚.手术学全集神经外科卷[M].北京:人民军医出版社,1994:184-186.
[3]漆松涛,张喜安,彭玉平,等.三脑室脑膜瘤.中华神经外科杂志,2006,22(4):214-216.
[4]王磊,于春江.四脑室内脑膜瘤1例.中国医学影像学杂志,2002,10(1):35
[5]Conforti P,Moraci A,Albanese V,et al.Microsurgical management of suprasellar and intraventricular meningiomas.Neurochirurgia,1991,34(3):85-89.
[6]Nakamura M,Roser F,Bundschuh O,et al.Intraventricular meningiomas:a review of 16 cases with reference to the literature.Surg Neurol,2003,59(6):491-504.
[7]Majo's C,Cucurella G,Aguilera C,et al.Intraventricular meningiomas:MR imaging and MR spectroscopic findings in two cases[J].AJNR,1999,20(5):882-885.
[8]蒋宇钢,张治平,李奇,等.侧脑室脑膜瘤的显微外科治疗.中华显微外科杂志,2001,24(1):16.
[9]Crisculo GR,Symon L.Intraventricular meningioma:a review of 10 cases of the national hospital,Queen Square(1974-1985)with reference to the literature.Acta Neurochir(Wein),1986,83:83-91.
[10]Tsuboi K,Nose T,Maki Y.Meningioma of the fourth ventricle:a case report.Neurosurgery.1983,13(2):163-166.
[11]何理盛,吴承远,等.脑膜瘤,第1版.北京:人民卫生出版社,2003年12月:3-464.
[12]李子孝,戴建平,江涛,等.功能和纤维成像在脑功能区胶质瘤中的应用.中华外科杂志,2006,44:1275-1279.
[13]王忠诚.王忠诚神经外科学,第1版.武汉:湖北科学技术出版社,2005年3月:587-619.
[14]李振平.临床中枢神经解剖学,第1版.北京:科学出版社,2003年8月:246-249.
[15]Mahmood A,Qureslri NH,Malik GM.Intracranial meningiomas:analysis of recurrence after surgical treatment.Acta Neurochir,1994,126(2-4):53-58.
[16]雷万生,谭启富,邬祖良.侧脑室内脑膜瘤八例报道并文献复习.中华神经外科杂志.1993,9(6):344-345.
[17]吴惠恩.CT诊断脑室内肿瘤.中华放射杂志,1987,21(6):325-328.
[18]Buetow MP,Buetow PC,Smirniotopoulos JG.Typical,atypical,and misleading features in meningioma[J].Radiographics,1991,11(6):1087-1106.
[19]Lee EJ,Choi KH,Kang SW,et al.Intraventricular hemorrhage caused by lateral ventricular meningioma:a case report[J].Korean J Radiol,2001,2(2):105-107.
[20]Kloc W,Imielinski,Wasilewski W,et al.Meningiomas of the lateral ventricles of the brain in children[J].Child's Nerv Syst,1998,14(8):350-353.
[21]于同刚,戴嘉中,李克.脑膜瘤的MRI表现与组织病理对照研究.实用放射学杂志,2004,20(3):199-202.
[22]Maiuri F,Iaconetta G,de Divitiis O,et al.Intracranial meningiomas:correlations between MR imaging and histology[J].Eur J Radiol,1997,31(1):69-75.
[23]Yamaguchi N,Kawase T,Sagoh M,et al.Prediction of consistency of meningiomas with preoperative magnetic resonance imaging[J].Surg Neurol,1997,48(6):579-583.
[24]Engelhard HH.Progress in the diagnosis and treatment of patients with meningiomas.Part I:diagnostic imaging,preoperative embolization[J].Surg Neurol,2001,55(2):89-101.
[25]Yoneoka Y,Fujii Y,Takahashi H,et al.Pre-Operative histopathological evaluation of meningiomas by 3.0T T_2R MRI[J].Acta Neurochirurgica,2002,144(10):953-957.
[26]Alafaci C,Salpietro FM,Grasso G,et al.Osteoblastic meningioma of the lateral ventricle[J].J Neurosurg,1999,91(12):1058.
[27]Lee EJ,Choi KH,Kang SW,et al.Intraventricular hemorrhage caused by lateral ventricular meningioma:a case report[J].Korean J Radiol,2001,2(2):105-107.
[28]Lang I,Jackson A,Strang FA.Intraventricular hemorrhage caused by intraventricular meningioma:CT appearance[J].AJNR,1995,16(6):1378-1381.
[29]夏晓,余准,吴力源.侧脑室肿瘤的CT和MRI诊断.中华放射学杂志,1996,30(1):41-44.
[30]Bertalanffy A,Roessler K,Koperek O,et al.Intraventricular meningiomas:a report of 16 cases.Neurosurg Rev.2006,29(1):30-35.
[31]Due-Tonnessen B,Helseth E,Skullerud K,et al.Choroid plexus tumors in children and young adults report of 16 consecutive cases.[J].Child's Nerv Syst,2001,17(4-5):252-256.
[32]Schild SE.Benign central neurocytoma:a double misnomer? Cancer.2002,94(1):284-284.
[33]Pendle G,Eustacchio S,Unger F.Radiosurgery as alternative treatment for skull base meningiomas.[J].J Clin Neurosci,2001,8(supp11):12-14.
[34]Aichholzer M,Bertalanffy A,Dietrich W,et al.Gamma knife radiosurgery of skull base meningiomas.[J].Acta Neurochir(wien),2000,142:647-652.
[35]Carella RJ,Raosohoff J,Newall J.Role of radiation therapy in the management of meniagioma.Neurosurgery,1982,10:332-339.
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