颅内蛛网膜囊肿的手术治疗（附36例病例分析）
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摘要
本文通过对近年来发表的相关文献进行复习,对颅内蛛网膜囊肿的定义、病因、病理、发病机制、自然转归、临床表现、辅助检查、诊断治疗及术后并发症等方面进行综述,着重探讨手术适应症的选择及不同手术方式的比较。收集吉林大学中日联谊医院神经外科2000年1月至2010年12月收治的36例行手术治疗的颅内蛛网膜囊肿患者的临床资料。采用病例回顾性分析的方法结合国内外相关文献进行综合分析,以探讨颅内蛛网膜囊肿的手术适应症和手术方式,总结手术技巧,以提高手术成功率,降低术后复发率。得出结论如下:(1)颅内蛛网膜囊肿作为一种颅内非肿瘤性良性占位性病变,近年来随着先进影像学技术广泛的应用于临床及人们自我保健意识的不断增强,其发病率和行外科手术治疗的比例有增多的趋势。(2)对于颅内蛛网膜的手术适应症目前并没有统一的标准,是否行手术治疗应从蛛网膜囊肿的类型、囊肿体积是否进行性增长、脑组织等重要结构受压情况及患者的临床症状和体征有无进行性加重等几方面综合考虑。处于发育阶段的儿童颅内蛛网膜囊肿患者应相对积极的行手术治疗。(3)颅内蛛网膜囊肿手术方式的选择应根据囊肿的部位、疾病的特殊性、术者手术操作的熟练程度等因素综合考虑。显微囊肿切除+脑池沟通术相比囊肿—腹腔分流术在手术疗效、术后并发症及囊肿复发率等几方面有明显优势,尤其在对颅内蛛网膜囊肿合并癫痫患者的手术治疗上应作为首选术式。希望通过本文能够加深临床工作者对颅内蛛网膜囊肿的诊断及治疗方面的认识。对于不同类型、不同部位颅内蛛网膜囊肿最佳手术方式的选择仍是今后神经外科工作者继续探索的重要课题。
Objective:
To investigate the clinical characteristics, surgical indications and surgical methods of intracranial arachnoid cysts. Summary of surgical techniques can improve the success rate and lower recurrence rate.
Method:
In our hospital from January 2000 to December 2010, we collect 36 cases with intracranial arachnoid cysts of surgical treatment, whose general information, clinical manifestations, imaging data, treatment and curative effects are analyzed retrospectively. In 10 cases with microscopic cyst excision plus cistern communication surgery, we resect the cyst wall tissue firstly,and then we communicate between cyst cavity and subarachnoid space, cisterns or ventricles, including 3 cases with epilepsy (2 cases do epilepsy foci resection, a case does bipolar coagulation electrocoagulation of subcortical surgery). Other 26 cases do cyst-peritoneal shunt, most of which choose low-pressure shunt equipment with non-anti-siphon.
Results:
All patients are successful during operation, who have not severe complications after surgery. In 10 cases with microscopic cyst excision plus cistern communication surgery, their original symptoms were improved more or less, including 3 cases with epilepsy no longer having seizures. All of 10 cases have no recurrence. In 26 cases with cyst-peritoneal shunt, 22 cases’original symptoms are disappeared or improved after surgery (accounting for 84.6%), 4 cases’original symptoms have no significant changes (accounting for 15.4%). In 8 cases with epilepsy of 26 cases with cyst-peritoneal shunt, 2 cases’the original symptoms are disappeared, 4 cases’the original symptoms are improved, 2 cases have no significant changes. 3 cases with cyst-peritoneal shunt recurred after surgery, recurrence rate is about 11.5%.
Conclusion:
1. Intracranial arachnoid cyst is a kind of intracranial non-neoplastic benign lesion. In recent years, with the advanced imaging technology used in clinical widely and people’s growing awareness of self-care, it’s morbidity and the proportion of surgerial treatment cases have an increasing trend.
2. The surgical indication of intracranial arachnoid have no uniform standard currently. We should decide whether doing operation for a patient, according to the type of arachnoid cyst, whether having a growth of cysts’volume, important brain structures’damage, clinical symptoms and other aspects. In the developmental stages of children, surgical treatment should be active relatively .
3. The choice of surgical approach of intracranial arachnoid cysts should be based on cyst location, the special nature of disease, surgical proficiency and other factors considered. Microscopic cyst excision plus cistern communication surgery has more obvious advantages than cyst-peritoneal shunt in results of operations, postoperative complications, recurrence rate of cysts and other aspects. When the patient is intracranial arachnoid cyst with epilepsy, the first surgical treatment should be microscopic cyst excision plus cistern communication surgery.
Objective:
To investigate the clinical characteristics, surgical indications and surgical methods of intracranial arachnoid cysts. Summary of surgical techniques can improve the success rate and lower recurrence rate.
Method:
In our hospital from January 2000 to December 2010, we collect 36 cases with intracranial arachnoid cysts of surgical treatment, whose general information, clinical manifestations, imaging data, treatment and curative effects are analyzed retrospectively. In 10 cases with microscopic cyst excision plus cistern communication surgery, we resect the cyst wall tissue firstly,and then we communicate between cyst cavity and subarachnoid space, cisterns or ventricles, including 3 cases with epilepsy (2 cases do epilepsy foci resection, a case does bipolar coagulation electrocoagulation of subcortical surgery). Other 26 cases do cyst-peritoneal shunt, most of which choose low-pressure shunt equipment with non-anti-siphon.
Results:
All patients are successful during operation, who have not severe complications after surgery. In 10 cases with microscopic cyst excision plus cistern communication surgery, their original symptoms were improved more or less, including 3 cases with epilepsy no longer having seizures. All of 10 cases have no recurrence. In 26 cases with cyst-peritoneal shunt, 22 cases’original symptoms are disappeared or improved after surgery (accounting for 84.6%), 4 cases’original symptoms have no significant changes (accounting for 15.4%). In 8 cases with epilepsy of 26 cases with cyst-peritoneal shunt, 2 cases’the original symptoms are disappeared, 4 cases’the original symptoms are improved, 2 cases have no significant changes. 3 cases with cyst-peritoneal shunt recurred after surgery, recurrence rate is about 11.5%.
Conclusion:
1. Intracranial arachnoid cyst is a kind of intracranial non-neoplastic benign lesion. In recent years, with the advanced imaging technology used in clinical widely and people’s growing awareness of self-care, it’s morbidity and the proportion of surgerial treatment cases have an increasing trend.
2. The surgical indication of intracranial arachnoid have no uniform standard currently. We should decide whether doing operation for a patient, according to the type of arachnoid cyst, whether having a growth of cysts’volume, important brain structures’damage, clinical symptoms and other aspects. In the developmental stages of children, surgical treatment should be active relatively .
3. The choice of surgical approach of intracranial arachnoid cysts should be based on cyst location, the special nature of disease, surgical proficiency and other factors considered. Microscopic cyst excision plus cistern communication surgery has more obvious advantages than cyst-peritoneal shunt in results of operations, postoperative complications, recurrence rate of cysts and other aspects. When the patient is intracranial arachnoid cyst with epilepsy, the first surgical treatment should be microscopic cyst excision plus cistern communication surgery.
引文
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[2] Cincu R, Agrawal A, Eiras J. Intracranial arachnoid cysts: current concepts and treatment alternatives[J]. Clin Neurol Neurosurg, 2007, 109(16): 837-843.
[3] Cokluk C, Senel A, Celik F, et al.Spontaneous disappearance of two asymptomatic arachnoid cysts in two different location[J] . Minim Invasive Neurosury, 2003, 46: 110.
[4] Celabert-Conzalez M, Femandez-Villa J, Cutrin-Prieto J, at al. Arachnoid cyst rupture with subdural hygroma: report of three cases and literature review[J] .Childs Nerv Syst, 2002, 18, 18: 609.
[5] De K, Berry K, Denniston S. Haemorrhage into an arachnoid cyst: a serious complication of minor head trauma[J]. Emerg Med J, 2002, 19: 365.
[6]翟广,冯承宣,冯祖荫,等.蛛网膜囊肿相关的慢性硬膜下血肿6例诊治[J].第四军医大学学报, 2005, 26(22) :2090.
[7] Parcsh CS, Kraub J, Hofmann E, at al. Arachnoid cysts associated with subdural hematomas and hygromas: Analysis of 16 cases, longterm follow-up, and review of the literature[J]. Neurosurgery, 1997, 40(3): 483-490.
[8] Gundersen H, Helland CA, Raeder MB, et al. Visual attention in patients with intracranial arachnoid[J]. Neurol, 2007, 254(1): 60-66.
[9] Mazurkiewicz-Beldzinska M, Dilling-Ostroska E. Presentation of intracranial arachnoid cysts in children: correlation between localization and clinical symptoms[J]. Med Sci Monit, 2002, 8(6): 462-465.
[10]刘琨,陈成雨,刘运振,等.颅内蛛网膜囊肿所致精神障碍24例临床分析[J].中国神经精神疾病杂志, 2002, 28(4): 294-295.
[11]王东海,李新钢,徐淑军,等.颅内蛛网膜囊肿的CTC诊断及临床意义[J].实用放射学杂志, 2006, 22(8): 912-914.
[12] Mcbride LA, Winston KR, Freeman JE, at al. Cystoventricular shunting of intracranial arachnoid cysts[J]. Pediatr Neurosurg, 2003, 39(6): 323-329.
[13]李新钢,王东海,徐淑军,等.非交通性蛛网膜囊肿的诊断与神经内镜治疗[J].中华神经外科杂志, 2005, 21(2): 91-94.
[14] Tamburrini G, Angelo L, Paternoster G, et al. Endoscopic management of intra and paraventricular CSF cysts[J]. Childs Nerv Syst. 2007, 23(12): 645-651.
[15]朱晓黎,沈天真,陈星荣,等. MR相位对比电影法在蛛网膜囊肿诊断中应用价值初探[J],中国医学计算机成像杂志, 2002, 8(1): 9-12.
[16]郝大鹏,徐文坚,解桂花,等.颅内表皮样囊肿和蛛网膜囊肿的DWI鉴别诊断[J].放射学实践, 2006, 21(5): 484-486.
[17] Boutarbouch M, Abdessamad EI, Rifi L. Managament of intracranial arachnoid cysts[J]. Clin Neurol Neurosurg, 2008, 110(2): 1-7.
[18] Wester K, Helland CA. How often do chronic extra-cerebral haematomas occur in patients with intracranial arachnoid cysts?[J]. Neurol Neurosurg Psychiatry. 2007, 9(2): 116-118.
[19] Gelabert GM. Intracranial arachnoid cysts[J]. Rev Neurol, 2004, 39(12): 1161-1166.
[20]冯祖荫.颅内蛛网膜囊肿[J].中国实用神经疾病杂志, 2006, 9(1): 107-108.
[21]杨冰,徐启武,于佶,等. 49例颅内蛛网膜囊肿手术治疗临床分析[J].复旦学报(医学版), 2008, 35(2): 296-299.
[22]彭玉平,张喜安,漆松涛,等.神经内镜手术治疗颅内蛛网膜囊肿[J] .中华神经医学杂志, 2005, 4: 585.
[23] Sgouros S, Chapman S. Congenital middle fossa arachnoid cysts may cause global brain ischaemia: a study with 99Tc-Hexamethylprop -eayleneamineo-xime single photon emission computerized tomograghy scans[J]. Pediatr Neurosurg, 2001, 35: 188-194.
[24]王玉玉,刘同华,李刚,等. 36例颅内蛛网膜囊肿的诊断和治疗[J].第三军医大学学报, 2005,27(6): 524-528.
[25]李学元,房宝军,张连群,等.儿童颅内蛛网膜囊肿的治疗探讨[J].中国临床神经外科杂志, 2009, 14(4): 245-247.
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