脑干占位病变治疗及相关问题探讨

Treatment of space-occupying lesion in brain stem and its related problems

目的探讨脑干占位病变外科手术治疗和非手术治疗的适应证、方法、手术入路、切除方式和并发症防治等问题。方法分析总结1999￣2005年我院住院治疗的55例脑干占位病变的临床资料。接受显微手术治疗40例,其中颞下经天幕入路5例,经中孔-小脑延髓裂入路15例,经蚓体切开入路12例,经小脑半球切开入路2例,经桥小脑角脑干侧方入路4例,经纵裂-第三脑室入路2例。术后接受放疗和(或)化疗13例。非手术治疗15例,接受放疗5例,化疗3例。结果手术治疗者术后6个月随访,Karnofsky生活质量评分为90￣100分8例,70￣80分17例,40￣60分6例,20￣30分3例,10￣0分6例(手术后1个月内死亡)。非手术治疗者住院后6个月随访,Karnofsky生活质量评分为90￣100分1例,70￣80分4例,40￣60分2例,20￣30分3例,10￣0分5例(死亡4例)。结论脑干占位病变以出血性病变(包括海绵状血管畸形)、星型胶质细胞瘤和室管膜瘤多见。出血患者多数可在早期进行手术治疗,出血较少和已进入出血后期可采用非手术治疗。脑干肿瘤中胶质细胞瘤最常见,除弥漫生长型不适合手术和放化疗外,其他生长类型的肿瘤都可以进行显微手术治疗,术后根据病理性质接受放化疗。手术入路的选择和脑干切开的部位取决于病变在脑干中的位置,可以利用的神经功能缺损,患者可以耐受的神经功能缺损;在具体操作时采取循瘤原则、最短原则和避重就轻原则。经中孔-小脑延髓裂入路可以满足大部分经脑干背侧切除占位病变的需要。

Objective To explore the problems of surgical and non-surgical treatment for the space-occupying brain stem lesion in regard to indications, methods, operative approaches, resection maneuver and prevention of the complications. Methods The clinical data were analyzed retrospectively in 55 cases with space-occupying lesion in brain stem that were treated in our department in the last 5 years. There were 40 cases treated microsurgically, including 5 cases via the subtemporal transtentorial approach, 15 cases via the median aperture-cerebellomedullary fissure approach, 12 cases via the incision of vermis, 2 cases via the incision of cerebellum, 4 cases via the lateral approach of brain stem and 2 cases via the longitudinal fissure-III ventricle approach. 13 cases of them received radiotherapy and/or chemotherapy after operation. Another 15 cases received non-surgical operation, including 5 cases with radiotherapy and 3 cases with chemotherapy. Results Karnofsky performance status evaluated at 6th month postoperatively was 90-100 scores in 8 cases, 70-80 scores in 17 cases, 40-60 scores in 6 cases, 20-30 scores in 3 cases, 10-4） scores in 6 cases （died within 1 month after operation）. Karnofsky performance status evaluated at 6th month after non-surgical treatment was 90-100 scores in 1 cases, 70-80 scores in 4 cases, 40-60 scores in 2 cases, 20-30 scores in 3 cases, 10-0 scores in 5 cases （4 cases died within 6 month after non-surgical treatment）. Conclusion The space-occupying lesions in brain stem mainly consist of hemorrhagic lesion, astrocytic tumor and ependymoma. The most cases of hemorrhagic lesion can be operated in their early stage. Some cases with small hemorrhage or in their later stage can be treated non-surgically. Glioma was predominant in the brain stem tumors, in which most of them can be treated microsurgically excepting diffuse tumors and be treated continuously with radiotherapy and/or chemotherapy according to their pathological reports. The choice of operative approach and incision site at brain stem depends upon the depth of tumor away from brain stem surface, the available neurological deficits and the neurological deficits that could be tolerant. It should be followed in practice that proceeding along tumor, shortening the route and avoiding the eloquent areas. The median aperture-cerebellomedullary fissure approach can be available for the resection of most tumors which need posterior route.