【作者】 吴国庆；

【导师】 刘玉光；

【作者基本信息】 山东大学 ， 神经外科， 2011， 博士

【摘要】 目的通过术前面神经3D-TOF-MRA及3D-FIESTA扫描,达到术前明确责任血管；通过术前颅脑T2像扫描,测量桥小脑角池的大小,判断手术的难易程度；通过术后面神经3D-TOF-MRA扫描,评估病人的预后情况。方法我院2004-2011年共收治原发性面肌痉挛125例,其中80例术前进行了面神经MRA扫描。分析80例病人的术前、术后面神经MRA情况,判定责任血管的来源、数目、位置等,与术中所见比较；根据术后面神经出脑干端(REZ)有无可疑血管,判断病人预后。采用SPSS10.0统计软件分析。根据术前颅脑MRI扫描T2轴位像测量桥小脑角池(CPA)的大小,与手术的难易程度做比较,采用SPSS10.0统计软件分析。本组手术采用横切口枕下乙状窦后入路微血管减压术(MVD)。结果80例面肌痉挛病人术前MRA检查均发现了责任血管。单一血管者60例(占75%),其中,小脑前下动脉57例,小脑后下动脉1例,小脑上动脉1例,椎动脉1例。2根及以上责任血管者9例(占11.25%),其中,小脑前下动脉+内听动脉8例,小脑后下动脉+内听动脉1例。术前不能确定责任血管来源的11例。术中解剖发现：单一责任血管者59例,其中,小脑前下动脉53例,小脑后下动脉4例,小脑上动脉1例,椎动脉1例。多根血管者14例,其中,小脑前下动脉+内听动脉7例,内听动脉+小脑后下动脉2例,小脑前下动脉+脑干穿动脉3例,小脑前下动脉+静脉血管2例。不确定责任血管7例。经统计学分析,术前MRA检查与术中解剖发现比较,两组间无明显差异(P>0.05)。术前颅脑MRI扫描T2轴位像显示的桥小脑角池大小与年龄及手术的难易程度比较,经统计学分析,均有显著性差异(P=0.000)。术后面神经MRA检查显示REZ有无可疑血管与预后的比较,经统计学分析,有显著性差异(P=0.000)。结论1、原发性面肌痉挛术前面神经MRA特殊序列扫描,可以明确责任血管的情况；测量桥小脑角池的大小,可以判断手术的难易程度。故术前面神经MRA检查对手术具有明确的指导价值。2、对于多支责任血管存在的情况,特别是面神经REZ存在静脉血管或脑干小穿支动脉的压迫时,术前3D-TOF-MRA尚难以准确判断。3、年龄大于40岁尤其是60岁以上的病人,桥小脑角池明显增大,有利于术中显露面神经REZ,分离垫开责任血管较容易些,使手术操作更方便。4、术后面神经3D-TOF-MRA扫描,可以了解术后责任血管的移位情况、术后面神经REZ有无可疑血管压迫等,对预后判断具有重要意义,更可为复发病例二次手术提供参考。更多还原

【Abstract】 Objective Identify the responsible blood vessels before operation by facial nerve 3D-TOF-MRA and 3D-FIESTA scan; measure the size of the cerebellopontine angle cistern by preoperative brain T2 image scan to determine the difficulty of the operation; assess the patient’s prognosis by postoperative facial nerve 3D-TOF-MRA scanning.Method Our hospital has treated 125 cases of primary hemifacial spasm from 2004 to 2011, of which 80 cases had preoperative facial nerve MRA scan. Analyze preoperative and postoperative facial nerve MRA of 80 cases to determine the source, number, location and etc. of responsible blood vessels, comparing with intraoperative facts; determine the prognosis of patients according to existence of suspicious vessels in postoperative facial nerve REZ. SPSS10.0 statistical software was adopted to analyze data. Measure the size of cerebellopontine angle (CPA) cistern by the preoperative axial T2 brain MRI scan, compare the difficulty of operation, and analyze data by SPSS10.0. The transverse incision of suboccipital retrosigmoid approach for microvascular decompression (MVD) was adopted in the surgery.Result Responsible blood vessels were found in all 80 cases of hemifacial spasm patients by the preoperative MRA scan.60 patients (75%) were single vessel cases, of which 57 cases were anterior inferior cerebellar artery(AICA), 1 for posterior inferior cerebellar artery(PICA),1 for superior cerebellar artery(SCA),1 for vertebral artery(VA).9 patients (11.25%) were two or more vessels, of which 8 cases were AICA+internal auditory artery,1 for PICA+ internal auditory artery. The source of responsible vessels of 11 cases cannot be determined before surgery. By intraoperative anatomy, we found that:59 patients were single vessel cases, of which 53 cases were AICA,4 for PICA,1 for SCA,1 for VA.14 patients were multiple vessels cases, of which 7 cases were AICA+internal auditory artery,2 for internal auditory artery+PICA,3 for AICA+brain stem perforating artery,2 for AICA+vein.7 cases were uncertain. Comparing the preoperative MRA scan with the intraoperative anatomy by statistical analysis, there was no significant difference between the two groups (P> 0.05). Comparing the size of cerebellopontine angle cistern displayed by preoperative axial T2 brain MRI scan with patients ages and the difficulty of operation through the statistical analysis, the differences were significant (P= 0.000). The comparison between the existence of suspicious vessels in REZ displayed by postoperative facial nerve MRA scan and prognosis showed that the difference was significant according to the statistical analysis(P= 0.000).Conclusion1. Special sequences of preoperative facial nerve MRA scan can identify the situation of responsible blood vessels of patients with primary hemifacial spasm; cerebellopontine angle cistern measurement can determine the difficulty of operation. In that case, preoperative facial nerve MRA scan plays a guided role in the surgery obviously.2. It is difficult to determine the presence of multiple responsible vessels before operation by 3D-TOF-MRA, especially the compression in veins and brain stem perforating arteries.3. The cerebellopontine angle cistern increased in patients over the age of 40, especially those over the age of 60. It is quite beneficial for the exposure of facial nerve REZ in the surgery, making the operation much easier.4. Postoperative facial nerve 3D-TOF-MRA scan can obtain the drift of the responsible blood vessels and the presence of suspicious vessels in facial nerve REZ after operation, which are important for prognosis judgement. Objective Identify the responsible blood vessels before operation by facial nerve 3D-TOF-MRA and 3D-FIESTA scan; measure the size of the cerebellopontine angle cistern by preoperative brain T2 image scan to determine the difficulty of the operation; assess the patient’s prognosis by postoperative facial nerve 3D-TOF-MRA scanning.Method Our hospital has treated 125 cases of primary hemifacial spasm from 2004 to 2011, of which 80 cases had preoperative facial nerve MRA scan. Analyze preoperative and postoperative facial nerve MRA of 80 cases to determine the source, number, location and etc. of responsible blood vessels, comparing with intraoperative facts; determine the prognosis of patients according to existence of suspicious vessels in postoperative facial nerve REZ. SPSS10.0 statistical software was adopted to analyze data. Measure the size of cerebellopontine angle (CPA) cistern by the preoperative axial T2 brain MRI scan, compare the difficulty of operation, and analyze data by SPSS10.0. The transverse incision of suboccipital retrosigmoid approach for microvascular decompression (MVD) was adopted in the surgery.Result Responsible blood vessels were found in all 80 cases of hemifacial spasm patients by the preoperative MRA scan.60 patients (75%) were single vessel cases, of which 57 cases were anterior inferior cerebellar artery(AICA), 1 for posterior inferior cerebellar artery(PICA),1 for superior cerebellar artery(SCA),1 for vertebral artery(VA).9 patients (11.25%) were two or more vessels, of which 8 cases were AICA+internal auditory artery,1 for PICA+ internal auditory artery. The source of responsible vessels of 11 cases cannot be determined before surgery. By intraoperative anatomy, we found that:59 patients were single vessel cases, of which 53 cases were AICA,4 for PICA,1 for SCA,1 for VA.14 patients were multiple vessels cases, of which 7 cases were AICA+internal auditory artery,2 for internal auditory artery+PICA,3 for AICA+brain stem perforating artery,2 for AICA+vein.7 cases were uncertain. Comparing the preoperative MRA scan with the intraoperative anatomy by statistical analysis, there was no significant difference between the two groups (P> 0.05). Comparing the size of cerebellopontine angle cistern displayed by preoperative axial T2 brain MRI scan with patients ages and the difficulty of operation through the statistical analysis, the differences were significant (P= 0.000). The comparison between the existence of suspicious vessels in REZ displayed by postoperative facial nerve MRA scan and prognosis showed that the difference was significant according to the statistical analysis(P= 0.000).Conclusion1. Special sequences of preoperative facial nerve MRA scan can identify the situation of responsible blood vessels of patients with primary hemifacial spasm; cerebellopontine angle cistern measurement can determine the difficulty of operation. In that case, preoperative facial nerve MRA scan plays a guided role in the surgery obviously.2. It is difficult to determine the presence of multiple responsible vessels before operation by 3D-TOF-MRA, especially the compression in veins and brain stem perforating arteries.3. The cerebellopontine angle cistern increased in patients over the age of 40, especially those over the age of 60. It is quite beneficial for the exposure of facial nerve REZ in the surgery, making the operation much easier.4. Postoperative facial nerve 3D-TOF-MRA scan can obtain the drift of the responsible blood vessels and the presence of suspicious vessels in facial nerve REZ after operation, which are important for prognosis judgement.更多还原