【作者】 王鹏；

【导师】 王勇；

【作者基本信息】 上海交通大学 ， 外科学（神经外科）， 2015， 博士

【摘要】 目的:分析总结显微手术治疗岩斜区脑膜瘤的效果,并初步探讨手术入路的选择,肿瘤切除程度的影响因素,患者预后的影响因素,来探索手术治疗岩斜区脑膜瘤的最优方案,提高手术治疗效果和患者术后生活质量。方法:回顾性分析上海交通大学医学院附属仁济医院神经外科从2010年1月到2014年12月显微手术治疗的24例岩斜区脑膜瘤患者的临床资料、影像学资料、手术资料及随访资料。男性10例,女性14例,男女比为1:1.4,平均年龄(49.1±8.9)岁(31-62岁),平均病程(16.3±29.6)个月(0.1-120个月)。患者主要症状包括饮水呛咳、头痛、行走不稳、面部感觉异常、听力下降、肌力下降、肢体感觉异常、面部疼痛、视力下降、复视等。肿瘤平均直径(3.9±1.0)cm(2.3-5.5cm)。手术入路包括枕下乙状窦后入路12例,乙状窦前入路5例,颞下经天幕入路5例,眶颧入路1例,远外侧入路1例。结果:24例患者中,肿瘤完全切除(Simpson II级)10例(41.7%),次全切除(Simpson III级)6例(25%),大部分切除(Simpson IV级)8例(33.3%)。术后并发症包括颅内感染1例(4.2%),肺部感染1例(4.2%),癫痫1例(4.2%),暂时性失语1例(4.2%)。术后新发神经功能障碍包括动眼神经麻痹4例(16.7%),面神经麻痹3例(12.5%),外展神经麻痹2例(8.3%),偏瘫2例(8.3%),三叉神经功能障碍1例(4.2%)。无围手术期死亡病例。24例患者全部得到随访,平均随访时间(31.4±17.5)个月(1-62个月),随访生活质量优秀18例(75.0%),生活质量良好4例(16.7%),生活不能自理2例(8.3%),8例大部分切除患者中有4例行伽马刀治疗,1例行普通放疗,未发现残余肿瘤进展或肿瘤复发病例。患者随访KPS评分与术前KPS评分(t=-2.174,P=0.040)和术后KPS评分(t=-3.301,P=0.003)的差异有统计学意义,肿瘤全切率与肿瘤质地(P=0.022)、海绵窦侵犯(P=0.024)、脑干粘连程度(P=0.005)显著相关,肿瘤质地对随访KPS评分有显著影响(P=0.001)。结论:1.岩斜区脑膜瘤多为良性肿瘤,生长缓慢,且手术难度大,术后并发症多,肿瘤直径小于3cm且无临床症状的患者可行定期影像学随访,一旦发现肿瘤直径超过3cm或患者出现临床症状,应行手术治疗;2.根据肿瘤特点选择合适的手术入路,有利于提高肿瘤的全切率,枕下乙状窦后入路是一种简单、安全、有效的切除岩斜区脑膜瘤的手术入路;3.肿瘤切除程度与肿瘤质地、海绵窦侵犯、脑干粘连程度显著相关;4.岩斜区脑膜瘤患者术后生活质量与肿瘤质地显著相关;5.辅助放射治疗可以有效的控制岩斜区脑膜瘤的生长,降低肿瘤复发进展率;6.充分的术前评估是十分重要的,综合考虑肿瘤特点、患者自身情况、术者经验及手术预期目标等多方面因素,选择正确合理的手术入路,制定个体化的治疗方案,找到最大限度保留患者神经功能和提高肿瘤切除程度之间的平衡点,争取获得肿瘤的完全切除,有利于降低术后并发症率,提高患者术后生活质量。更多还原

【Abstract】 OBJECTIVE: To review and analyze the therapeutic outcomes of microsurgical treatment of petroclival meningiomas(PCMs), and investigate the choice of surgical approach and the relative factors to the extent of tumor resection and patient’s prognosis, and explore the optimal surgical strategy of petroclival meningioma to improve surgical outcomes and postoperative quality of patient’s life.METHODS: A retrospective analysis of medical records, imaging studies, surgical information and follow-up date of 24 patients with PCMs who were received microsurgical treatment in Renji Hospital between January 2010 and December 2014 was reviewed. There were 10 males and 14 females(ratio, 1:1.4) with a mean age of(49.1±8.9) years(range 31-62 years). Patients complained of various initial symptoms including drinking cough, headache, unsteady gait, facial paresthesia, hearing impairment, decreased muscle strength, limb paresthesia, facial pain, blurred vision and diplopia with a mean duration of(16.3±29.6) months(range 0.1-120 months). The mean tumor diameter was(3.9±1.0) cm(range 2.3-5.5 cm). Surgical approaches were utilized including suboccipital retrosigmoid approach, presigmoid approach, subtemporal transtentorial approach, orbitozygomatic approach and far lateral approach.RESULTS: In 24 patients, gross total resection(Simpson Grade II) was achieved in 10 patients(41.7%), near total resection(Simpson Grade III) in 6 patients(25%), and partial resection(Simpson Grade IV) in 8 patients(33.3%). Postoperative morbidity included intracranial infection in 1 patient(4.2%), respiratory tract infection in 1 patient(4.2%), seizures in 1 patient(4.2%) and transient aphasia in 1 patient(4.2%). New-onset postoperative neurological deficits included oculomotor paralysis in 4 patients(16.7%), facial paralysis in 3 patients(12.5%), abducent paralysis in 2 patients(8.3%), hemiplegia in 2 patients(8.3%) and trigeminal nerve deficits in 1 patient(4.2%). There was no death during preoperative period. All 24 patients were followed up with a mean period of(31.4±17.5) months(range 1-62 month), and excellent quality of life in 18 patients(75%), good quality of life in 4 patients(8.3%), poor quality of life in 2 patients(8.3%). 5 of 8 PR received radiotherapy and there was no tumor progression/recurrence.The difference between follow-up KPS score and preoperative KPS score(t=-2.174, P=0.040) or postoperative KPS score(t=-3.301, P=0.003) was statistically significant. The rate of GTR was significantly associated with tumor consistency(P=0.022), cavernous sinus invasion(P=0.024) and brainstem adhesion(P=0.005). The follow-up KPS score was significantly affected by tumor consistency(P=0.001).CONCLUSION:1. Petroclival meningiomas were mostly benign, slow-growing, difficult surgery and high postoperative morbidity. If tumor’s diameter was less than 3cm and asymptomatic, patients could be followed up with serial imaging, and if tumor’s diameter was more than 3cm or became symptomatic, patients should be received surgical treatment;.2. Selected appropriate surgical approach according to tumor characteristics would improve the rate of GTR, suboccipital retrosigmoid approach was a simple, safe and effective surgical approach for petroclival meningiomas;3. The extent of resection was significantly associated with tumor consistency, cavernous sinus invasion and brainstem adhesion;4. The postoperative quality of life was significantly associated with tumor consistency;5. Adjuvant radiotherapy could control the growth of petroclival meningiomas effectively, and reduce tumor progression/recurrence;6. Adequate preoperative evaluation was very important. The tumor characteristics, patient’s condition, neurosurgeon’s experience and surgical goal should be considered to select the optimal surgical approach, individual treatment and find the balance between preserving maximal neurological function and increasing the extent of resection, GTR should be pursued to reduce postoperative morbidity and improve the quality of patient’s life.更多还原