单侧开颅显微手术切除累及双侧的大型嗅沟脑膜瘤

Unilateral frontal approaches for the removal of large bilateral olfactory groove meninjiomas

目的探讨经单侧额下入路切除大型双侧嗅沟脑膜瘤的手术方法、技术要点和治疗效果。方法回顾性分析神经外科2007年6月—2014年5月利用显微外科手术切除的181例大型双侧嗅沟脑膜瘤患者的临床资料及随访结果。首发症状为头痛头昏者95例,嗅觉减退或者丧失者53例,视力视野障碍者26例,认知功能下降3例,癫痫2例,偶然发现2例。手术均采用单侧额下入路,显微(后期部分病例辅以内镜)切除显露于视野的肿瘤,后切开大脑镰,必要时结扎上矢状窦切除对侧肿瘤;同期或分期切除侵入筛窦等处颅底肿瘤,重建颅底。结果围手术期无死亡。SimpsonⅠ级切除33例,Ⅱ级切除141例,Ⅲ级切除4例,Ⅳ级切除3例。术前视力损害者术后视力视野改善215只眼(215/229),无改善12只眼(12/229),加重2只眼(2/229)。术前嗅觉丧失59侧,术后均未恢复,术前有残余嗅觉者,术后仍保存有嗅觉者149侧(149/303)。随访(76.9±43.8)个月,术后复发或残瘤再长21例。结论因对侧眼和(或)鼻的功能补偿作用,嗅沟脑膜瘤早期不易发现;经单侧额下入路能够提供足够的手术空间切除大型双侧嗅沟脑膜瘤,视力视野改善明显,但嗅觉功能保存差;该入路创伤小、并发症少,如辅以内镜,可以提高全切率,符合微侵袭理念,可作为此类肿瘤优先考虑的术式。

Objective To investigate the effect of microsurgical therapy and the key techniques in resection of large bilateral olfactory groove meningiomas via unilateral subfrontal approach. Methods The clinical data and followup results of 181 patients with large bilateral olfactory groove meningiomas who underwent microsurgical removal between June 2007 and May 2014 were retrospectively analyzed. The initial symptom was headache or（and） dizzy in 95 cases, hyposmia or anosmia in 53, impairment of visual function or（and） visual field deficits in 26, cognitive deficits in 3,epilepsy in 2, and accidentally discovered in 2. Unilateral subfrontal approach was applied in all patients（neuroendoscopy was applied in some cases in the later period）; incision of falxcerebri, and when necessary, ligation of superior sagittal sinus to resect contralateral tumor were performed. Simultaneous or staged period resection of tumors invading skull base such as ethmoid sinus and superior meatus and reconstruction of the skull base were performed. Results There was no perioperative mortality. Simpson grade Ⅰ resection was obtained in 33 cases, grade Ⅱ resection was in 141, grade Ⅲresection was in 4, and grade Ⅳ resection was in 3. Among the 229 eyes with preoperative visual impairment,postoperative visual improvement was found in 215 eyes, unimproved was in 12, and aggravation was in 2. The 59 sides which lost their function of olfactory nerve before surgery obtained no recoveries after surgery, while olfactory nerve with residual function preoperative still kept sensing after surgery in 149 lateral sides（149/303）. The patients were followed up for（76.9±43.8） months, and postoperative recurrence or residual tumor growth were found in 21 cases. Conclusions Because of the contralateral ocular and（or） nasal compensation, early discovery is very difficult for patients with olfactory groove meningioma. The unilateral subfrontal approach can provide sufficient exposure for resection of large bilateral olfactory groove meningiomas and improve the visual acuity and visual field deficits. But it is poor at the preservation of olfactory function. The approach, better with the aid of neuroendoscopy, can improve the total cutting rate, with the advantages of minimally invasion and fewer complications. It is a worthy priority for these tumors.