三维CT血管造影辅助下经枕下小脑幕上入路治疗松果体区脑膜瘤

Suboccipital transtentorial approach to pineal region meningiomas by 3D-CTA assistance： surgical considerations

目的探讨三维cT血管造影（3D－CTA）辅助下枕下小脑幕上入路（Poppen人路）治疗松果体区脑膜瘤的方法及可行性。方法2005年1月至2010年1月采用Poppen入路治疗松果体区脑膜瘤8例，其中男性3例，女性5例；年龄41～64岁，平均（54±10）岁。术前依照KPS评分标准进行生存质量评分（KPS）：满意者（≥80）5例、不满意者（〈80）3例。8例均经MRI检查确诊，而后行3D－CTA检查了解脑膜瘤的血运及供血动脉以辅助手术治疗。手术时切开小脑幕及大脑镰，并根据3D－CTA提供的影像保护静脉复合体。对于术前并发的脑积水，给予随访观察；对术后无缓解者予分流手术。结果8例患者脑膜瘤均予以分块全切除。术后发生颅内感染者1例，给予抗感染治疗后恢复良好；其余7例无并发症出现。术后随访6～24个月，术前并发脑积水的7例患者中，术后脑积水好转、继续随访观察者6例；脑积水加重而行分流手术者1例。8例在随访结束时复查MRI均未见脑膜瘤复发；患者评分：KPS／〉80者7例、KPS〈80者1例。术前与术后KPS比较差异有统计学意义（X＾2=1．33，P〈0．05）。结论对于松果体区脑膜瘤，3D－CTA能对脑膜瘤的血运、供血动脉及脑膜瘤与静脉复合体的解剖关系做出有效的判断，在其辅助下采用Poppen入路进行治疗，可获得满意的疗效。

Objective To evaluate the three-dimensional CT angiography （3D-CTA） assisted suboccipital transtentorial approach （ Poppen＇ s approach ） in the treatment of pineal region meningioma. Methods During the period of January 2005 to January 2010, 8 patients with pineal region meningioma were successfully treated using Poppen＇s approach through cerebral falx and tentorium. There were three male patients and five female patients were aged at a range of 41-64 years, average age was （54 ± 10） years. According to the Karnofsky performance scale （KPS）, 5 patients＇ KPS scores were more than or equal to 80 and 3 were less than 80. MRI was used for the diagnosis of meningioma. 3D-CTA was applied to detect meningioma staining and blood supply. For preoperative concurrent hydrocephalus, follow-up observations were given. If hydrocephalus didn＇t get better or even became worse, ventriculoperitoneal shunt should be considered. Results All the surgery were successfully performed, and venous complexes （ VC ） were well protected according to the CTA images. Out of the eight cases whose meningiomas were removed, one patient had got postoperative intracranial infection and recovered after given antibiotics. All patients were followed up for a period of 6-24 months. Preoperative concurrent hydrocephalus in 7 patients were improved. However, there was an aggravation of the hydrocephalus in one patient who was treated with ventriculoperitoneal shunt. The MRIs which were performed at the end of follow-up period, showed no recurrence of meningiomas, and preoperative symptoms were improved to varying degrees, 7 patients＇ KF＇S scores were more than or equal to 80 and 1 was less than 80. A X^2 test was used to analyze and to make comparisons between preoperative and postoperative KPS. The significance was indicated （X^2 = 1.33, P 〈0. 05）. Conclusions For meningiomas in the pineal region, 3D-CTA is of great clinical value todistinguish the anatomic relationship among the meningioma, blood supply and VC. This case study has strongly supported using Poppen＇s approach assisted by 3D-CTA to proceed with the operation.