经胼胝体入路切除第三脑室肿瘤

Transcailosal approaches for removing lesions occupying the third ventricular space

目的探讨31例第三脑室内肿瘤经胼胝体入路手术治疗的临床与神经心理结果。方法31例第三脑室前部肿瘤采用经胼胝体-穹隆间、胼胝体-室间孔、胼胝体-脉络膜裂结合室间孔入路手术治疗，患者在术前和术后用RanchoLosAmigos认识功能评定量表进行神经心理测试，术后行影像学复查和GOS评估。结果采用纵裂胼胝体-室间孔入路14例，纵裂胼胝体-穹隆间入路12例，纵裂胼胝体-脉络膜裂（脉络膜上、下）结合室间孔入路5例；全切26例，次全切除5例。手术死亡1例。8例垂体柄因肿瘤侵犯被切除后尿崩7例，5例完全恢复，2例持续尿崩。Rancho LosAmigos认识功能评定术后有明显改善。84％（26／31）术后GOS评估优秀（V级）。术后2例出现意识障碍超过24h，约72h恢复。术后2例出现失联系综合征，1例有明显记忆障碍，经康复治疗有好转。结论主体位于第三脑室内、后界未达到松果体的肿瘤都可以经上述胼胝体入路进行手术切除。选择经室间孔、经穹隆间、经脉络膜上下进入第三脑室可因病变的具体方位和周围血管布局而定。但是胼胝体、穹隆问、脉络膜上下可以切开的范围有限且值得进一步探讨，严格切开范围和控制牵拉幅度可以最大限度减少脑功能损害。

Objective The present study was undertaken to describe the clinical and neuropsychological results for our group of 31 patients who were treated using various transcallosal microsurgical approaches. Method 31 patients with space-occupying lesions located in the anterior part of the third ventricle were approached by transcallosal-interforniceal route,or transcallosal-transforaminal entry, or by a combined transcallosal-transchoroidal and transforaminal entry. The patients underwent pre-and postoperative neuropsychological testing by levels of cognitive functioning of Rancho Los Amigos, and their clinic results were analyzed with imaging and GOS. Results Fourteen patients undertook the transcallosal- transforaminal route, twelve patients undertook the transcallosal-interforniceal entry and five patients undertook the combined transcallosal-transchoroidal and transforaminal entry. Among them there were 26 case with total resection and 5 cases with subtotal resection. There were only 1 patient fatalities as a result of the operation. Eight cases required resection of pituitary stem that had been invaded by tumors, 7 of them had diabetes ,5 of these seven enjoyed a total absence of the condition within a week ;only 2 cases of these seven continued their diabetes. Rancho Los Amigos test showed an obvious improvement in these patients cognitive level after operation. Twenty-six of the 31 patients （84%） experienced excellent clinical outcomes （GOS Grade V）. There were 2 cases with disconnection symptoms （impaired attention function） and 1 case with memory disorder in the early post operation stage, but all of them recovered in the late post operation utilizing rehabilitative treatments. Conclusions The approaches described here can be successfully used for the resection of various space-occupying lesions in the anterior part of the third ventricle which have not reached the pineal body. The detailed approach （ transcallosal interforniceal, transcallosal-transforaminal or combined transcallosal-transchoroidal and transforaminal ） for one tumor depends on its special location and surrounding structures, but the ranges for section of these important structures are limited and require further discussion. Serious control of these sections and delicate retraction will decrease brain function injuries.