大型、巨大型上矢状窦中后1/3侵犯颅外复发脑膜瘤的手术治疗

Surgical treatment of large and giant recurrent meningiomas near the middle and posterior third part of the superior sagittal sinus with extracranial invading

目的:探讨大型、巨大型侵犯颅外的上矢状窦中后1/3复发脑膜瘤的手术策略。方法:回顾性分析2019年5月至2022年5月于北京大学第三医院神经外科行手术治疗的16例大型、巨大型侵犯颅外的上矢状窦中后1/3复发脑膜瘤患者的临床资料。所有患者术前完善头颅增强磁共振(magnetic resonance imaging,MRI)、磁共振静脉成像(magnetic resonance venography,MRV)、X线电子计算机断层扫描血管成像(computed tomography angiography,CTA)和颅骨三维X线计算机断层扫描(computed tomography,CT)等,评估肿瘤侵及范围、脑水肿情况、颅骨受侵程度、肿瘤血液供应、上矢状窦受压程度等,制定个性化手术方案。术后1周、1个月、3个月评估患者的神经功能,术后3个月、6个月、1年行头颅增强MRI评估肿瘤情况。结果:16例患者肿瘤均位于上矢状窦中后1/3段,侵犯至颅外,3例肿瘤直径≥4 cm,13例肿瘤直径≥7 cm,其中,第二次手术8例,第三次手术6例,第四次手术2例;末次手术采用原骨瓣复位4例,采用钛网修补12例;术前行数字减影血管造影(digital subtraction angiography,DSA)栓塞肿瘤血管3例。10例患者实现SimpsonⅠ级切除,6例实现SimpsonⅡ级切除;术中行去骨瓣减压2例,同期行颅骨修补14例;处理头皮时,直接缝合14例,转移皮瓣修复头皮缺损2例;术后肢体肌力均较术前改善,术后3个月卡尔诺夫斯基量表(Karnofsky performance scale,KPS)评分100分。本次手术随访过程中1例患者于术后1年肿瘤原位复发,行伽马刀治疗,余患者随访期间无复发。结论:大型、巨大型侵犯颅外的上矢状窦中后1/3复发脑膜瘤首选手术治疗,术前详细评估,根据脑水肿情况、肿瘤血液供应、静脉窦受压程度、头皮受侵犯程度等采取个体化手术方案是一种安全有效的手术方式。

Objective:To investigate the surgical strategy for large and giant recurrent meningiomas near the middle and posterior third part of the superior sagittal sinus with extracranial invading.Methods:The clinical data of 16 patients with large and giant recurrent meningioma in the middle and posterior third part of the superior sagittal sinus with extracranial invasion who underwent surgery in the Department of Neurosurgery of Peking University Third Hospital from May 2019 to May 2022 were retrospectively analyzed.All the patients underwent brain-enhanced magnetic resonance imaging(MRI),magnetic resonance venography(MRV),computed tomography angiography(CTA)and three-dimensional skull computed tomography(CT)before,to evaluate the extent of tumor invasion,the edema of brain tissue,the degree of skull damage,the blood supply of the tumor,and the degree of compression of the superior sagittal sinus,etc,and to formulate an individualized surgical plan.The neurological function of the patients was evaluated 1 week,1 month,and 3 months after the operation,and the tumor condition was evaluated by brain-enhanced MRI 3 months,6 months,and 1 year after the operation.Results:The tumors in the 16 patients were all located in the middle and posterior 1/3 part of the superior sagittal sinus and invaded extracranially.Among them,8 cases were operated for the second time,6 cases for the third time,and 2 cases for the fourth time;In the last operation,the bone flap was used to repair the skull in 4 cases,and the titanium mesh was used in 12 cases;Tumor arterials of 3 cases were embolized under digital subtraction angiography(DSA).Tumors of 10 cases were resected at Simpson gradeⅠ,and 6 cases at Simpson gradeⅡ;2 cases underwent decompressive craniectomy during operation,and 14 cases underwent cranioplasty at the same time;scalp incisions of 14 cases were directly sutured,and flap transposition was used in 14 cases.When evaluating nerve function after operation,the limb muscle strength was improved compared with that before operation,and the Karnofsky performance scale(KPS)score reached 100 points 3 months after operation.During the follow-up,1 patient’s tumor recurred after 1 year and received Gamma Knife treatment,and the rest of the patients had no recurrence during the follow-up period.Conclusion:Surgical treatment is the first choice for large and giant recurrent meningiomas near the middle and posterior third part of the superior sagittal sinus with extracranial invading.It is a safe and effective surgical method to take individualized surgical plan after detailed preoperative assessment of cerebral edema,tumor blood supply,venous sinus compression,and scalp invasion.