改良的经“外侧裂-岛周”大脑半球切开术研究
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摘要
目的研究改良的经"外侧裂-岛周"大脑半球切开的手术方式及其效果。方法回顾性分析16例行改良的经"外侧裂-岛周"大脑半球切开术患儿的临床资料,总结其效果和并发症,分析注意事项。改良术式的要点:(1)皮肤切口为包绕蝶骨棘的"T"型切口;(2)骨窗范围覆盖外侧裂的全长;(3)根据脑组织萎缩程度确定外侧裂上、下皮质切开的位置及范围;(4)暴露大脑前动脉是充分离断眶额水平纤维和胼胝体的解剖基础。结果改良术式可清晰暴露手术区域,术后影像显示大脑半球纤维离断彻底。手术耗时(切皮到缝皮)为126～189 min,平均(150±13. 3) min,出血量110～450 mL,平均(233±58) mL。术后出现皮下积液者3例,颅内少量渗血2例,均痊愈。结论与经典"U"或"T"型开颅术相比,改良的经"外侧裂-岛周"大脑半球切开术式具有损伤轻、手术时间短、出血少、愈合快、并发症少等优势,值的在临床进一步推广。
Objective To explore an improved surgical method and effect of hemispherotomy via"Sylvian-peri-insular"approach. Methods The clinical data of 16 children underwent sylvian-periinsular approach were analyzed retrospectively,and the pros and cons of the modified operation were summarized. The main points of the new method were as follows. (1) The skin incision was a "T"shaped enclosing the sphenoid ridge region. (2) The scope of craniotomy mainly covered the whole length of the sylvian fissure. (3) The location and scope of the peri-insular window were determined according to the degree of brain atrophy. (4) The exposure of the anterior cerebral artery (ACA) totally was the anatomical basis for the adequate disconnecting the fibers of orbito-frontal lobe and corpus callosum. Results The new method can expose the operative structures completely and clearly. The disconnected fiber tracts can be seen in the post-operative images. The operative time (from skin incision to suture) ranged from 126 to 179 minutes (150 ± 13. 3),the amount of bleeding during operation is from 110 to 450 mL (233 ± 58) and the new method is time-saving,safe and no additional complications compared with the classical "U"or "T"shaped craniotomy surgery. Conclusions The modified hemispherotomy has the advantages of less invasion,shorter operation time,less bleeding,faster healing of the incision and fewer complications. It is worth further popularizing in clinical work in the future.
Objective To explore an improved surgical method and effect of hemispherotomy via"Sylvian-peri-insular"approach. Methods The clinical data of 16 children underwent sylvian-periinsular approach were analyzed retrospectively,and the pros and cons of the modified operation were summarized. The main points of the new method were as follows. (1) The skin incision was a "T"shaped enclosing the sphenoid ridge region. (2) The scope of craniotomy mainly covered the whole length of the sylvian fissure. (3) The location and scope of the peri-insular window were determined according to the degree of brain atrophy. (4) The exposure of the anterior cerebral artery (ACA) totally was the anatomical basis for the adequate disconnecting the fibers of orbito-frontal lobe and corpus callosum. Results The new method can expose the operative structures completely and clearly. The disconnected fiber tracts can be seen in the post-operative images. The operative time (from skin incision to suture) ranged from 126 to 179 minutes (150 ± 13. 3),the amount of bleeding during operation is from 110 to 450 mL (233 ± 58) and the new method is time-saving,safe and no additional complications compared with the classical "U"or "T"shaped craniotomy surgery. Conclusions The modified hemispherotomy has the advantages of less invasion,shorter operation time,less bleeding,faster healing of the incision and fewer complications. It is worth further popularizing in clinical work in the future.
引文
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[15]赵瑞,周渊峰,扬皓玮,等.改良大脑半球离断术治疗儿童半球病变导致的难治性癫痫[J].中华神经外科杂志,2017,33:1224.
[16]林久銮,周文静,左焕棕,等.大脑半球切除治疗难治性癫痫的术前评估及手术改良(附58例报告)[J].中华神经外科杂志,2012,28:1049.
[2]Cbt A.Hemispherectomy-a modification[J].J Neurol Neurosurg Psychiatry,1983,46:617.
[3]Rasmussen T.Hemispherectomy for seizures revisited[J].Can JNeurol Sci,1983,10:71.
[4]Schramm J,Behrens E,Entzian W.Hemispherical deafferentation:an alternative to functional hemispherectomy[J].Neurosurgery,1995,36:509.
[5]Delalande O,Bulteauc C,Dellatolas G,et al.Vertical parasagital hemispherotomy:Surgical procedures and clinical long-term outcomes in a population of 83 children[J].Neruosurgery,2007,60:ONS19.
[6]Villemure JG,Daniel RT.Peri-insular hemispherotomy in paediatric epilepsy[J].Childs Nervous System,2006,22:967.
[7]Sood S,Marupudi NI,Asano E,et al.Endoscopic corpus callosotomy and hemispherotomy[J].J Neurosurg Pediatr,2015,16:681.
[8]Villemure JG,Mascott CR.Peri-insular hemispherotomy:surgical principle and anatomy[J].Neurosurgery,1995,37:975.
[9]秦广彪,张培胜,马康平,等.大脑半球切开术治疗儿童顽固性癫痫[J].临床神经外科杂志,2016,13:285.
[10]Cook SW,Nguyen ST,Hu B,et al.Cerebral hemispherectomy in peadiatric patients with epilepsy:comparison of three techniques by pathological substrate in 115 patients[J].J Neurosurg,2004,100:125.
[11]Vadera S,Griffith SD,Rosenbaum BP,et al.National trends and inhospital complication rates in more than 1600 hemispherectomies from 1988 to 2010:a nationwide inpatient sample study[J].Neurosurgery,2015,77:185.
[12]Koubeissi MZ,Syed TU,Syed I,et al.Hemispherectomy-associated complications from the kid’s inpatient Database[J].Epilepsy Res,2009,87:47.
[13]Piastra M,Pietrini D,Caresta E,et al.Hemispherectomy procedures in children:haematological issues[J].Childs Nervous System,2004,20:453.
[14]Lew SM,Koop JI,Mueller WM,et al.Fifty consecutive hemispherectomies:outcomes,evolution of technique,complications,and lessons learned[J].Neurosurgery,2014,74:182.
[15]赵瑞,周渊峰,扬皓玮,等.改良大脑半球离断术治疗儿童半球病变导致的难治性癫痫[J].中华神经外科杂志,2017,33:1224.
[16]林久銮,周文静,左焕棕,等.大脑半球切除治疗难治性癫痫的术前评估及手术改良(附58例报告)[J].中华神经外科杂志,2012,28:1049.