手术治疗颅内巨大型听神经瘤：657例经验总结

The surgical management of giant intracraniai vestibular schwannoma via retrosigmoid approach： a retrospective review of 657 cases

目的探讨经枕下乙状窦后入路切除颅内巨大型听神经瘤的手术治疗经验。方法复旦大学附属华山医院自1999年1月至2014年12月收治的采用经枕下乙状窦后入路切除的大型听神经瘤患者1263例。根据听神经瘤肿瘤大小的国际分级标准，其中巨大型听神经瘤（肿瘤直径大于4em）657例。回顾性分析巨大型听神经瘤患者的围手术期临床资料（术后2周内）和随访结果（时间6～191个月，平均59．6个月），探讨其临床表现、手术策略和常见并发症及其影响因素、处理方法等。结果657例巨大型听神经瘤患者中，男289例（44．0％），女368例（56．0％），平均年龄46．8岁。最常见的临床表现为听力丧失239例（36．4％）、听力下降418例（63．6％）以及面部麻木452例（68．8％）。657例患者中肿瘤全切556例（84．6％），次全切99例（15．1％），部分切除2例（0．3％）；主要手术后并发症为新增听力丧失326例（49．6％），颅内感染50例（7．6％），一过性声音嘶哑、饮水呛咳49例（7．5％），肺炎41例（6．2％）。术中面神经解剖保留589例（89．6％）。以House—Braekmann（HB）分级Ⅰ～Ⅲ级界定为面神经功能保留，术后2周面神经功能保留率为79．8％；随访6个月以上患者共566例（86．1％），其中面神经预后良好及中等（HBⅠ～Ⅲ级），即面神经功能保留428例，占75．6％。结论术前详细的面听神经功能评估，熟悉枕下乙状窦后入路解剖；术中熟练的显微外科手术技巧（包括术中严密控制血供，充分囊内减压）、内听道的妥善处理、重要血管神经的保护、多组颅神经监测技术以及多学科合作治疗是提高颅内巨大型听神经瘤诊治效果的关键。

Objective To discuss the surgical technique and common complications from the microsurgical treatment of giant intracranial vestibular sehwannoma via suhoccipital retrosigmoid approach and to propose strategies for minimizing such complications. Methods Surgical outcomes and complications were evaluated in a consecutive series of 657 unilateral giant vestibular schwannomas treated in Shanghai Huashan Hospital via suhoceipital retrosigmoid approach from 1999 to 2014. According to the international classification of vestibular schwannoma, giant tumor means tumor＇ s size over 4 cm in diameter. Clinical status and complications were assessed postoperatively within 14 days and at follow-ups （range, 6-191 months; mean, 59. 6 months）. Results Follow-up data were available for 566 of the 657 patients （86. 1% ）. The most frequent clinical symptoms were hearing loss in different levels （ 100% ）, deafness （36.4%）, facial numbness （68.8%）. Total tumor resection was achieved in 556 patients （ 84. 6% ）, subtotal resection in 99 patients （ 15.1% ） , and partial resection in 2 patients （0.3%）. The common postoperative complications included new deafness （49. 6% ）, intracranial infection （7.6%）, low cranial nerve defect （7.5%） and pneumonia （6. 2% ）. The facial nerve was preserved anatomically in 589 cases （89. 6% ） after operation, and the functional valuation of facial nerve according to postoperative House- Brackmann showed 216 patients （32. 9% ） in grade I - I[ , 308 cases （46.9%） in grade II, 133 patients （20. 2% ） in grade IV-VI. Long-term followed-up results showed 428 patients （75.6%） in grade I -lll one year after surgical treatment. Conclusions Many of these complications are avoidable. Surgical experiences and the clinical anatomy of the approach, accompany with using intraoperative nerve monitoring, preoperatively study the individual imaging and clinical data and multidisciplinary cooperation are the key points to avoid the complications of giant intracranial vestibular schwarmoma via suboccipital retrosigmoid approach.