前纵裂经终板入路切除第三脑室内外大型颅咽管瘤

Anterior interhemispheric approach through the lamina terminalis for large intra-and extraventricular craniopharyngiomas

目的 探讨前纵裂经终板入路切除第三脑室内外大型颅咽管瘤的方法和疗效.方法 回顾性分析2008年3月至2013年12月解放军总医院神经外科采用前纵裂经终板入路手术切除的52例第三脑室内外大型颅咽管瘤患者的临床资料.其中男性28例,女性24例;年龄3～ 67岁,平均33.5岁.术前MRI示肿瘤的最大径范围为4.0～7.8 cm,平均5.1 cm.术后t～3个月复查头颅MRI判断肿瘤切除程度.结果 肿瘤全切除47例（90.4％）,次全切除5例（9.6％）.术中离断前交通动脉6例,保留垂体柄33例（63.5％）.术后视力好转或者无改变44例（84.6％）.无手术相关死亡病例.术后46例患者获得随访,随访时间3 ～ 68个月,平均25.4个月.随访中,需长期激素替代治疗23例,长期口服药物控制尿崩18例.死亡3例,肿瘤复发6例.结论 前纵裂经终板入路适合切除第三脑室内外的大型颅咽管瘤,容易辨别及保护垂体柄,对视神经、颈内动脉、下丘脑等重要结构的影响较小.

Objective To investigate the techniques and effect of surgical resection of large intraand extra-ventricular craniopharyngiomas via anterior interhemispheric trans-lamina terminalis approach.Methods Fifty-two patients who were surgically treated for large intra-and extra-ventricular craniopharyngiomas were retrospectively analyzed.All patients underwent surgery via anterior interhemispheric trans-lamina terminalis approach.Of the 52 patients,28 were male and 24 were female,with age ranging from 3 to 67 years （mean age 33.5 years）.The maximum tumor diameter varied from 4.0 to 7.8 cm,with mean diameter of 5.1 cm.Contrast-enhanced MRI was underwent to determine the extent of tumor resection on the 1 to 3 months after surgery.Results Total removal of the lesion was achieved in 47 cases （90.4%）,5 patients underwent subtotal resection （9.6%）.Division of the anterior communicating artery was performed in 6 patients with no early or late complications related to division of the artery.Visual acuity was preserved or improved in 44 patients （84.6%）.Preservation of the pituitary stalk were achieved in 33 patients （63.5%）.No surgery-related deaths occurred.The postsurgical follow-up period varied from 3 months to 68 months （mean 25.4 months）.Twenty-three cases had endocrinological deficit and received some form of hormonal replacement after surgery.Permanent diabetes insipidus occurred in 18 cases.Three patients died and 6 patients suffered recurrence during the followed-up period.Conclusions The anterior interhemispheric approach,with opening of the lamina terminalis,is a valid choice for large intra-and extra-ventricular craniopharyngiomas.These tumors can be removed without significant sequelae related to the surgical approach because optic nerves,optic chiasm,internal carotid artery,hypothalamic structures and pituitary stalk can be seen and effectively protected.