前床突脑膜瘤的显微手术治疗及早期视力恢复分析

Microsurgical treatment of anterior clinoidal meningiomas and analysis of early visual acuity recovery

目的评估前床突脑膜瘤(ACM)显微手术治疗及早期视力恢复情况。方法回顾性分析海军军医大学(第二军医大学)第二附属医院神经外科2010年7月至2020年7月行显微手术治疗的64例ACM患者的临床资料。其中男19例(29.7%)、女45例(70.3%),平均年龄为(52.3±12.2)岁。32例(50.0%)为大型ACM(直径>4.0 cm),27例(42.2%)为中型ACM(直径2.0~4.0 cm),5例(7.8%)为小型ACM(直径<2.0 cm);46例(71.9%)肿瘤累及重要神经、血管结构。所有患者均经翼点入路(扩大翼点入路)或眶颧入路切除肿瘤。采用Simpson分级评估肿瘤的切除程度,统计患者并发症情况及术后1周内视力恢复情况。结果64例患者中,49例采用翼点入路(扩大翼点入路),15例采用眶颧入路;SimpsonⅠ~Ⅱ级切除52例(81.2%,52/64),Ⅲ级切除8例(12.5%,8/64),Ⅳ级切除4例(6.2%,4/64)。Ⅰ型ACM中,21例肿瘤质地均较硬,13例(61.9%,13/21)为SimpsonⅠ~Ⅱ级切除;Ⅱ型ACM中,33例肿瘤质地较软、6例肿瘤质地较硬,35例(89.7%,35/39)为SimpsonⅠ~Ⅱ级切除;Ⅲ型ACM中,4例肿瘤质地均较软,4例(100.0%,4/4)均为SimpsonⅠ~Ⅱ级切除。6例(9.4%,6/64)术后早期出现动眼神经损伤并发症,2例(3.1%,2/64)术后出现脑脊液漏,1例(1.6%,1/64)术后死亡。56例术前存在头痛、头晕的患者中,40例(71.4%,40/56)术后1周内得到改善;29例术前视力下降的患者中,12例(41.4%,12/29)术后1周内视力改善。结论部分视力下降的ACM患者在术后早期视力得到改善。质地较软的肿瘤完全切除(SimpsonⅠ~Ⅱ级切除)率高且神经功能恢复较好,质地较硬的肿瘤完全切除困难并可导致严重的神经功能并发症。

Objective To evaluate the microsurgical treatment of anterior clinoidal meningiomas(ACMs)and the early visual acuity recovery in ACM patients after surgery.Methods A retrospective review was performed on 64 patients with ACMs who were microsurgically treated in the Department of Neurosurgery,The Second Affiliated Hospital of Naval Medical University(Second Military Medical University)from Jul.2010 to Jul.2020.There were 19(29.7%)males and 45(70.3%)females with an average age of(52.3±12.2)years.Thirty-two(50.0%)cases had large ACMs(diameter>4.0 cm),27(42.2%)cases had medium ACMs(diameter 2.0-4.0 cm),5(7.8%)cases had small ACMs(diameter<2.0 cm),and 46(71.9%)cases involved important neural and vascular structures.All patients underwent tumor resection via the pterional approach(extended pterional approach)or orbitozygomatic approach.The extent of tumor resection was evaluated by Simpson classification,the complications were calculated,and the recovery of visual acuity was assessed within 1 week after surgery.Results Among the 64 patients,49 cases were surgically treated with the pterional approach(extended pterional approach),and 15 cases were treated with the orbitozygomatic approach.SimpsonⅠ-Ⅱresection was achieved in 52(81.2%,52/64)cases,Ⅲin 8(12.5%,8/64)andⅣin 4(6.2%,4/64).For typeⅠACMs,all 21 tumors had a hard texture,and 13(61.9%,13/21)were SimpsonⅠ-Ⅱresection;for typeⅡACMs,33 tumors had a soft texture,6 tumors had a hard texture,and 35(89.7%,35/39)were SimpsonⅠ-Ⅱresection;and for typeⅢACMs,4 tumors had a soft texture,and 4(100.0%,4/4)were all SimpsonⅠ-Ⅱresection.The complications of early oculomotor nerve injury occurred in 6(9.4%,6/64)cases after surgery,cerebrospinal fluid leakage occurred in 2(3.1%,2/64)cases and death occurred in 1(1.6%,1/64)case.Of the 56 patients with preoperative headache and dizziness,40(71.4%,40/56)cases were improved within 1 week after surgery;of the 29 patients with decreased preoperative visual acuity,12(41.4%,12/29)cases had improved visual acuity within 1 week after surgery.Conclusion For some ACM patients with decreased visual acuity,their visual acuity is improved in the early postoperative period.For the tumors with soft texture,the rate of complete resection(SimpsonⅠ-Ⅱresection)is high and neural function recovers well.For the tumors with hard texture,complete resection is very difficult and may cause severe neurological complications.