经颅海绵窦病变直接手术24例临床分析

Transcranial direct operation on the cavernous sinus: clinical analysis of 24 cases

目的 讨论海绵窦 (CS)内病变的手术方法及手术指征。方法 2 4例病人包括 4例CS硬膜动静脉瘘 (AVF)、 1例CS内异物及 19例肿瘤。手术经额颞开颅 16例 ,额颞眶颧弓开颅 7例 ,幕上下联合经岩骨开颅 1例。进入CS的方法包括经其上壁的上方入路 4例 ,经侧壁的硬膜下入路 14例及硬膜外入路 1例 ,上方 +硬膜下侧方联合入路 5例。结果 4例硬膜AVF以止血海绵添塞CS静脉间隙 ,术后漏口完全消失 3例 ,1例部分消失又行血管内治疗。异物经Parkinson三角取出。 19例肿瘤全切 12例 (6 3 2 % ) ,部分及次全切 7例 (36 8% )。术后死亡 1例 ,出现新的动眼、外展功能障碍 4例。先行颅内外血管搭桥 ,二次手术行肿瘤及CS大块切除 1例。结论 血管内治疗无效的复杂海绵窦AVF ,可行直视CS填塞术。对肿瘤病人 ,应根据情况决定单纯观察、放射外科治疗或肿瘤部分、全部切除 ,必要时血管搭桥后行肿瘤及CS内结构全部切除。

Objective To discuss the operative indications and methods on the surgical treatment of the lesions of the cavernous sinus(CS). Methods Twenty four patients were consisted of 4 CS dural arterovenous fistulae (AVF), 1 intracavernous foreign object and 19 tumors. The operations were performend by frontotemporal craniotomy on 16 cases, by frontotemporal orbitozygomatic craniotomy on 7 cases, by combined super infra tentorial transpetrousal craniotomy on 1 cases. The approach into the CS included superior approach through its superior wall in 4 cases, the lateral intradural approach in 14 cases, lateral extradural approach in 1 case, combined intradural lateral and superior approach in 5 cases. Results In dural AVFs, the venous space of the CS was filled with hemostatic sponge. Postoperatively, the fistulae were disappeared totally in 3 cases while another case only partially disappeared and successive endovascular therapy was used. The foreign object was removed through Parkinsons triangle. Among the 19 CS tumors, 12(63 2%) were resected totally, subtotal or partial removal in 7(36 8%). One patient died postoperatively. Other 4 cases with normal preoperative cranial nerves function appeared deficit of Ⅲ and/or Ⅵ nerves postoperatively. For one recurrent meningioma, saphenous ven by pass was performed firstly, and the tumor and intracavernous structures were removed en bloc later. Conclusions Direct operation on the CS for complex intracavernous AVF intractable to the treatment of the endovascular method could be considered, Radisurgery, partial or subtotal removal of the tumor depends on the situation of the tumors. Only in occasion, the tumor and the intracavernous structures could be removed totally after entra intra cranial arterial by pass.