【摘要】 目的探讨和评价小硬脑膜窗口显露策略在切除颅内巨大脑膜瘤手术中预防急性脑膨出发生的实用性和价值。方法针对不同部位颅内脑膜瘤,采用各自经典手术入路。硬脑膜切开的总原则是:在开颅掀开骨瓣后发现硬脑膜张力显著增高(即有脑膨出先兆)表现情况下,采用合理的小硬脑膜窗口显露策略,防止术中发生急性脑肿胀和脑膨出,完好保护肿瘤周围重要功能区的脑组织。小硬脑膜窗口显露策略概念是:根据肿瘤部位和大小,合理确定初始硬脑膜开口的部位和大小;在经过初始硬脑膜开口能达到全部切除肿瘤时,应在硬脑膜张力消失后再对硬脑膜开口予以扩大,以实现最终肿瘤全切的目的。结果连续6例5个不同部位的颅内巨大脑膜瘤患者均在手术中避免了急性脑膨出的发生,保全了肿瘤周围脑组织,获得了无并发症性痊愈的效果。结论颅内巨大脑膜瘤手术采用小硬脑膜窗口显露策略,可预防术中急性脑膨出的发生;能确保肿瘤周围脑组织结构和功能完好保留,避免了使用术前腰穿脑脊液引流降颅压;同时对脑膜瘤导致脑膨出的发生机制及其策略有效机制的理解都有新的启示。更多还原

【Abstract】 Objective To investigate and assess the value of small dural window exposure strategy on preventing brain herniation during the operation for huge intracranial meningiomas. Methods Different classical operative approaches were used for the removal of intracranial meningiomas situated in different locations. When the dura was found to be under high tension, it was imperative that measures should be taken to prevent damage to the brain tissue in the important cortical areas as a result of acute intraoperative brain swelling and herniation. The strategy to be taken was to make a small dural window for exposure, thus the dura was used as a natural barrier to prevent acute brain swelling and herniation. The concept was to tailor the location and size of the dural opening to the location and size of the tumor, so that through the window only a part of the tumor was exposed, without exposing any important structures, such as bridging veins to the sagittal sinus and middle cerebral artery in the Sylvian fissure or any part of brain tissue initially. When necessary only a part of nonimportant brain tissue adjacent to the tumor could be exposed. Through this small dural window a huge tumor could be removed piecemeal till the high pressure under the dura was relieved. Then the dura could be opened more to remove the whole tumor. Results In 6 consecutive cases with extremely high tension under the dura, total tumor removal was successfully performed with complete avoidance of the risk of acute intraoperative brain swelling and herniation, and all the patients had uneventful recovery, and they were able to resume normal life. The locations of the said tumors were: in parasagitta falx region in 2 cases, and 1 case each in sphenoid, cerebellopontine angle, middle cranial fossa and temporal convexity region. Conclusion The small dural window exposure strategy can guarantee safe total removal of huge intracranial meningiomas avoiding the risk of acute intraoperative brain swelling and herniation. Peritumorous brain tissue can be kept intact. Preoperative spinal drainage of cerebrospinal fluid for lowering intracranial pressure is unnecessary in the majority of such cases. Some new knowledge for our understanding the etiological mechanisms and the mechanisms of the surgical strategy to avoid acute intraoperative brain swelling and herniation in removal of huge intracranial meningiomas can be learned.更多还原