显微外科手术治疗脑干海绵状血管瘤的初步临床经验

Microsurgical management of brainstem cavernous angioma

目的探讨脑干海绵状血管瘤显微外科手术治疗的有效性及其预后。方法回顾性分析进行显微手术治疗的12例脑干海绵状血管瘤患者的临床资料。术前均行MRI的弥散张量成像(DTI)检查,了解传导束(锥体束)受损或移位情况,指导手术入路。9例桥脑内海绵状血管瘤采用枕下后正中入路经第四脑室底部手术摘除,3例累及中脑和桥脑的海绵状血管瘤采用经颞下入路手术摘除,术中行全程神经电生理监测。结果 12例脑干内海绵状血管瘤均作显微镜下全切除,无手术死亡病例。9例术后神经功能障碍改善,3例神经功能缺失加重,但在术后2个月时神经功能已恢复至术前状态,术后1年复查已明显改善。病理检查均证实为海绵状血管瘤。术后平均随访(32.0±23.4)个月,按格拉斯哥预后评分(GOS)标准评定,其中5分(恢复良好)3例,4分(轻度病残)8例,2分(重度病残)1例,均未见肿瘤复发。结论脑干海绵状血管瘤,尤其是反复出血者,易出现严重的神经功能障碍,术前行MRI的DTI检查有利于手术入路的选择,适时采用恰当的手术方式,运用微侵袭神经外科技术结合神经电生理监测,完全切除肿瘤,术后可获得较好的治疗效果。

Objective To evaluate the efficacy and prognosis of microsurgical management for brainstem cavernous angiomas （BCA）. Methods Clinical data of 12 cases of BCAs with microsurgical treatment in neurosurgical department were retrospectively analyzed. All patients were examined with diffusion tensor imaging （DTI） for determination of pyramidal tract impairement or displacement to facilitate surgical approach. Sub - occipital posterior - midline and sub - temporal approaches were applied in 9 cases of pontine BCAs and 3 cases of mesencephalie and pontine BCAs, respectively. All neurosurgical procedures for BCAs were monitored with neuroelectrophysiology. Results All BCAs in 12 cases were completely resected with microsurgery causing no death. The neural function disorder was improved after operation in 9 eases, while it worsened in 3 cases. However, the impaired neural function was recovered gradually to the preoperative level two months after operation, and remarkably improved after one year follow - up. Pathological diagnosis of cavernous angioma was proved in all cases. A full follow - up in 12 patients with mean duration of 32 months was carried out According to Glasgow Outcome Scale （GOS） , 3 patients reached 5 （ good recovery） , 8 reached 4 （ mild disability）, and 1 reached 2 （ severe disability）. No residual or recurrent was reported after one year. Conclusion BCAs, especially in the patients with recurrent hemurrhage, may result in severe neural deficits. Pre - operative DTI sequence of MRI provides valuable method for identifying the pyramidal tract and its relation to lesions, thereby facilitates the surgical approach. Complete surgical resection with appropriate approach and minimal invasive technique under neuroelectrophysiologic monitoring is recommended for symptomatic BCAs with favorable outcome.