【作者】 陈杰飞；

【导师】 杨雷霆；

【作者基本信息】 广西医科大学 ， 神经外科， 2011， 硕士

【摘要】 目的探讨三叉神经鞘瘤的诊断和手术治疗。方法复习文献并回顾性总结分析广西医科大学第一附属医院神经外科自2003年1月至2010年12月采用显微手术治疗的41例三叉神经鞘瘤患者的临床表现,影像学特征,手术方式及疗效。结果三叉神经鞘瘤患者的临床表现以患侧的三叉神经症状及体征为主,常同时伴有Ⅲ、Ⅳ、Ⅵ、Ⅶ、Ⅷ颅神经受损,头颅CT和MRI对临床诊断及病变累及范围有重要意义。本组病例中颅窝(M)型3例,后颅窝(P)型8例,Mp型8例,M=P型12例,Pm型6例,中颅窝颅外(ME)型2例,中后颅窝颅外(MPE)型2例。本组病例采用断或不断颧弓的额颞硬膜外入路13例,颞底-天幕入路14例,乙状窦前入路3例,乙状窦后入路11例。35例全切,5例次全切,1例大部分切。术后颅内感染2例,脑脊液耳漏2例,颅内血肿2例,术后脑积水1例,肺部感染1例。术后新出现颅神经障碍13例,原有颅神经障碍加重者4例,涉及Ⅲ、Ⅳ、V、VI、Ⅶ、Ⅸ、Ⅹ颅神经。其余颅神经损害较术前均有好转。术前突眼征病例术后明显缓解。而高颅压征,锥体束征,小脑征及面部疼痛术后均得以缓解。术后随访13例,时间为3月~7年,其中2例复发。结论三叉神经鞘瘤有其明显的临床表现,但常被忽略,以患侧的三叉神经症状和体征及其临近颅神经、脑叶受累为主,结合头颅影像学的特征性表现,一般能做出正确诊断。需与脑膜瘤、听神经瘤和胆脂瘤鉴别。手术入路的方式,应根据肿瘤的类型,累及的结构选择。我们建议:对中颅窝为主的三叉神经鞘瘤(包括M型、Mp型、ME型),采用断或不断颧弓的额颞硬膜外入路,对中后颅窝均较大的M=P型采用颞底-天幕入路,对Pm型采用乙状窦前或乙状窦后入路,对P型采用乙状窦后入路,术野显露好,有助于提高肿瘤的全切率、降低病残率。更多还原

【Abstract】 Objective To investigate the diagnosis and the microsurgical management of trigeminal neurinomas.Methods Between January 2003 and December 2010, 41 patients with trigeminal neurinomas were managed with different microsurgical methods in the neurosurgery department in the First Affiliated Hospital of GuangXi Medical University, whose clinical manifestations, preoperative CT and MRI features, operative techniques and outcome were retrospectively analyzed. In the meantime, the relating reports of trigeminal neurinomas in the current literature were reviewed.Results The most frequent symptoms and signs were numbness and/or paraesthesia in one or more of the three trigeminal branches of the ipsilateral, which was frequently accompanied with the damage of oculomotor nerve, trochlear nerve , abducens nerve, facial nerve and vestibulocochlear nerve .The head CT and MRI were the major means for diagnosis of the lesions. There were 3 Type M tumors , 8 Type P tumors, 8 Type Mp tumors , 12 Type M=P tumors, 6 Type Pm tumors, 2 Type ME tumors and 2 Type MPE tumors. 13 patients were managed with Frontotemporal Epidural Approach with or without zygomatic osteotomy,14 patients with Subtemporal Transtentoria Aproach, 3 patients with Presigmoid Approach, 11 patients with Retrosigmoid Approach. Total resection was achieved in 35 patients , subtotal resection in 5 patients and partial resection in 1 patient. Bacterial meningitis, cerebrospinal fluid leakages and intracranial hematoma occurred in 2 cases respectively, pulmonary infections in 1 case. 13 patients with new incomplete paralysis of cranial nerve and 4 patients with cranial nerves deficits worsened after operation included oculomotor nerves, trochlear nerve, trigeminal nervs, abducens nerves, facial nerves and glossopharyngeal and vagus nerves . The rest damaged nerves were improved postoperatively. The symptoms and signs included exophthalmos, cerebellar ataxia, hypertensive intracranial syndrome, facial pain, hemiparesis obviously alleviated. 13 patients were followed up for 3 months to 7 years , tumor recurrence was found in 2 cases .Conclusion There are characteristic clinical manifestations in the patients with trigeminal neurinomas, whose most frequent symptoms are numbness and/or paraesthesia in one or more of the three trigeminal branches of the ipsilateral, which is frequently accompanied with the damage of the adjacent nerves and/or the adjacent brain tissue. A proper diagnosis is based on the characteristic clinical manifestations and the head imaging features. It is indispensable to distinguish from meningeoma, acoustic neurinoma and cholesteatoma. The basis of choosing individual surgical approach is the tumor type and the adjacent tissue. It is optimal to remove the mainly Type M tumor(include Type M tumor, Type Mp tumor, Type ME tumor) via Frontotemporal Epidural Approach with or without zygomatic osteotomy , the Type M=P tumor via Subtemporal Transtentoria Aproach, the Type Pm tumor via Presigmoid Approach or Retrosigmoid Approach, the Type P tumor via Retrosigmoid Approach. It can provide better exposure of these tumors and improve the surgical results in terms of increased complete tumor resection rate and reduced complications rate.更多还原