经颅入路切除眶尖神经鞘瘤

Transcranial Approach Resecting Orbital Apex Neurilemoma

目的探讨经颅入路切除眶尖神经鞘瘤的手术方法。方法回顾性分析22例眶尖神经鞘瘤的临床表现、影像学检查及经颅入路手术方法。根据肿瘤的位置、大小以及是否颅内侵犯,选择合适的开颅骨瓣:单侧额部骨瓣、额-眶上缘骨瓣、翼点-眶上缘骨瓣。结果肿瘤全切除18例,近全切除3例,部分切除1例。术后6例有动眼神经麻痹,5例在3个月后恢复;2例患眼失明。无手术死亡及其他手术并发症。术后随访1个月至6年,平均34个月,有1例肿瘤复发。结论眶尖神经鞘瘤易通过眶上裂侵犯海绵窦,经颅入路可获得充分的眶尖减压和肿瘤显露,从而保护眶尖部神经血管,减少术后并发症,提高治愈率。肿瘤全切则预后良好。

Objective To explore the surgical experience for orbital apex and cranio-orbital communicating neurilemoma. Methods Retrospective study of clinical manifestations, neuroradiological features and operative techniques in 22 cases underwent transcranial approach from Dec. 1997 to May. 2005. Patients ages were from 4 to 63 years, 30.6 years in average; 15 male, 7 female. Chief compliants were progressive proptosis, loss of vision in 17 patients. Radiological findings： 15 cases invading the cavernous sinus through superior orbital fissure, and 1 cases invading pterygopalatine fossa through inferior orbital fissure. Suitable transcranial approaches were choosed subfrontal craniotomy, transorbitorimal subfrontal craniotomy, transorbitorimal pterional craniotomy according to the location, size and intracranial invading of the tumor. In the orbit, the lateral approach was directed through the space between the superior and the lateral rectus muscles. Results Tumor total removal were achieved in 18 cases, subtotal removal in 3 cases, partial removal in 1 case. 1 case suffered from neurofibromatosis type 1 and pathologically confirmed orbital malignant neurilemoma. Postoperatively, ophthalmoplegia was found in 6 cases, 5 cases were recovered after 3 months respectively, permanent oculomotor nerve palsy was found in 1 case. Blindness was occurred in 2 cases. There was no operative death or other significant complication. Duration of follow up was 1 month to 7 years, tumor recurred in 1 case. Conclusion Orbital apex neurilemoma inclines invading the cavernous sinus through the superior orbital fissure. Adequate orbital apex decompression and exposure of the tumor can be reached by suitable transcranio-orbital approach. Prognosis is excellent with complete surgical excision.