显微手术切除岩斜坡区脑膜瘤预后相关因素分析

Microsurgical removal and prognostic analysis of petroclival meningiomas

目的 分析显微手术切除岩斜坡区脑膜瘤后影响患者预后的相关因素.方法 回顾性分析1991年7月至2010年4月采用显微手术治疗的71例岩斜坡区脑膜瘤患者的临床及随访资料,其中男性18例,女性53例;年龄15 ～ 68岁,平均（47±11）岁.病程1周至180个月,平均（32±30）个月.肿瘤最大径15 ～72 mm,平均（44 ±11）mm.主要表现为头痛、平衡功能障碍、轻偏瘫、饮水呛咳或声嘶、面部麻木或疼痛、面瘫及听力下降等.采用Karnofsky生存质量评分（KPS评分）评估患者生存质量.术前KPS评分40 ～ 100分,平均（69±11）分.手术主要采用枕下乙状窦后（经天幕）入路共65例（91.5％）.采用组内x2检验单因素分析和Logistic逐步回归多因素分析影响预后的相关因素.结果 肿瘤全切除48例（67.6％）,术后死亡1例.术后KPS评分20～ 100分,平均（73±16）分.术后主要神经功能障碍为不同程度的颅神经麻痹及偏瘫等.获得随访64例,随访时间4～132个月,平均（61±48）个月.末次随访KPS评分50～ 100分,平均（83±13）分,死亡7例,肿瘤复发6例,进展8例.肿瘤切除程度（OR=0.280,95％ CI：0.081 ～0.967,P=0.044）、术前脑干是否水肿（OR =0.100,95％ CI：0.027 ～0.372,P=0.001）、是否包裹神经血管（OR=0.288,95％ CI：0.084 ～0.985,P=0.047）及是否侵犯海绵窦（OR =0.254,95％ CI：0.061～1.057,P=0.048）是影响预后的独立因素.结论 围绕手术入路的选择、肿瘤的切除程度、瘤周神经血管结构的保护及围手术期的处理制定合理的个体化治疗方案,有利于改善患者预后.

Objective To identify factors that predictive of quality of life after microsurgical removal of petroclival meningiomas.Methods A consecutive series of 71 cases of petroclival meningiomas received microsurgical removal between July 1991 and April 2010 were analyzed retrospectively.Quality of life was measured using Karnofsky performance scale （KPS）.Complete pre-operative,post-operative and follow-up data were obtained from all 71 patients including 18 male and 53 female patients with the mean age of （47 ± 11） years （aging from 15 to 68 years）.The duration between onset of symptoms and diagnosis ranged from 1 week to 180 months with the mean duration of （32 ± 30） months.And the tumor size was 15-72 mm with the average of （44 ± 11）mm.Main presentations included headache,unsteady gait,hemiparesis,dysphagia,hoarseness,facial numbness or pain,Bell＇s palsy,hearing impairment etc.The preoperative KPS was 40-100 with the average of 69 ± 11.The retrosigmoid （-transtentorial） approach was performed in most cases （91.5％）.Intergroup x2 test and logistic regression analysis were conducted for prognostic factor characterization.Results The gross total resection （all were Simpson grade Ⅱ） reached in 48 cases （67.6％） and 1 case died postoperatively.The main new neurological dysfunctions were cranial nerve paralysis and hemiplegia with the postoperative KPS of 20-100 with the average of 73 ± 16.Sixty-four cases were followed for 4-132 months with the average of （61 ± 48） months.Seven patients died during follow-up,tumor recurrence and progression were identified in 6 and 8 cases,respectively.The KPS at the last visit ranged from 50 to 100 with the average of 83 ± 13.The extent of tumor resection （OR =0.280,95％ CI：0.081-0.967,P =0.044）,preoperative brainstem edema （OR =0.100,95％ CI：0.027-0.372,P =0.001）,relationships between tumor and neurovascular structures （OR =0.288,95％ CI：0.084-0.985,P =0.047） and depth of invasion into cavernous sinus （OR =0.254,95％ CI：0.061-1.057,P =0.048） had significant correlations with the prognostic quality of life.Conclusions With regard of the choice of surgical approaches,the extent of tumor resection,the protection of neurovascular structures surrounding the tumor and the management of perioperative period,the therapeutic strategies for each patient should be customized to achieve better prognosis.