天幕脑膜瘤的显微外科治疗

Microsurgical treatment in tentorial meningiomas

目的进一步提高天幕脑膜瘤的治疗效果。方法1989～2003年经显微外科治疗天幕脑膜瘤患者53例,其中普通型天幕脑膜瘤42例(后外侧型32例、后内侧型10例);天幕游离缘脑膜瘤11例(前外侧型3例、后内侧型8例)。普通型天幕脑膜瘤经颞枕或枕部入路者9例,枕下正中入路6例,单侧枕下入路24例,幕上下联合入路3例;天幕游离缘脑膜瘤经枕-天幕入路7例,幕下小脑上入路2例,改良翼点入路2例。结果肿瘤全切除43例,次全切除7例,大部分切除3例;无一例手术死亡。手术后并发症主要有视野障碍(5例)、脑神经损害(7例)、偏瘫(3例)、癫痫发作(2例)、颅内感染(4例)以及手术区远隔部位硬膜外血肿(3例),均经对症治疗后痊愈。47例患者接受为期7个月～8年的随访,其中恢复正常生活学习者25例,改换工作11例,生活完全自理7例,部分自理4例。结论天幕脑膜瘤的临床表现多不典型,诊断主要依靠CT和MRI。显微手术是治疗该病的最佳方法。根据肿瘤的特点,选择适当的手术入路,合理地使用辅助器械以及熟练的手术技巧,可有效地提高天幕脑膜瘤的治疗效果。

Objective To improve the curative effects on tentorial meningiomas. Methods Fifty-three patients with tentorial meningioma were performed microsurgery during 1989-2003, including 42 cases of common type (postero-lateral type 32, postero-internal type 10) and 11 meningiomas located at the free edge of tentorial notch (antero-lateral type 3 and postero-internal type 8). In the patients with common type tentorial meningioma 9 cases were operated via temporal-occipital or occipital approach, 6 via the midline suboccipital approach, 24 via unilateral suboccipital approach and 3 via combined supratentorial and infratentorial approach. Seven cases with tentorial incisural meningioma were operated via occipito-tentorial approach, 2 via infratentorial supracerebellar approach and 2 via a modified pterion approach. Results Tumor was totally removed in 43 cases, subtotally resected in 7 and most part resected in 3, no one death from operations. The postoperative complications were as follows:visual field defect (n=5), cranial nerves injury (n=7), hemiplegia (n=3), seizure (n=2), intracranial infection (n=4) and epidural hematoma at far from surgical site (n=3), all of the patients with complication were recovered after expectant treatment. Forty-seven patients were followed up 7 months-8 years, among them 25 returned to normal life and work, 11 changed their jobs, 7 were living completely independent and 4 remained partly disabled. Conclusion The clinical manifestations of most tentorial meningiomas are atypical and the diagnosis is mainly relied on CT and MRI. Microsurgery is the best choice in treatments; the curative effects could be improved by appropriate selection of surgical approach, proper assist device and skillful operation technique.