脑干海绵状血管瘤的临床特点及显微手术治疗
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摘要
目的探讨脑干海绵状血管瘤(BSCM)的临床特点及显微手术治疗效果。方法回顾性分析南京军区南京总医院神经外科2008年5月至2018年5月连续收治的25例行显微手术治疗BSCM患者的临床及影像资料(头部CT、MRI),其中急性出血患者14例,非急性出血患者11例。所有患者术前行头部CT及MRI检查。术中采用枕下正中入路14例,枕下远外侧入路7例,颞下入路3例,枕下乙状窦后入路1例,术后病理均证实为海绵状血管瘤。采用卡氏评分(KPS)评估患者术前及术后的功能状况。术后定期进行临床及影像学随访。结果 (1)25例患者中,病灶位于桥脑18例,中脑4例,延髓2例,桥脑-延髓交界区1例。病灶最大径<2 cm 5例,2～<3 cm 14例,3～<4 cm 6例,最大径平均值为(2.3±0.7)cm。(2)14例急性出血患者中,13例术后复查头部CT示术区无出血,复查头部MRI示病灶全切,术后(12±3)d KPS显示患者的功能状况较术前明显改善[术前、术后分别为(57±17)和(72±11)分,配对t=26.419,P<0.01],其中6例患者术后定期随访[3～24个月,中位随访时间8(3,15)个月,复查头部MRI]无不适主诉及复发。14例急性出血患者中,术后1例死亡,2例出现并发症,其余患者无明显并发症,临床症状较术前均有不同程度的改善。11例非急性出血患者术后复查头部CT示术区无出血,复查头部MRI示病灶全切,术后(12±3)d KPS显示患者的功能状况较术前明显改善[术前、术后分别为(75±10)和(87±12)分,配对t=13.203,P<0.01],其中6例患者术后定期随访[3～18个月,中位随访时间8(4,14)个月,复查头部MRI]无不适主诉及复发。11例非急性出血患者中,术后1例出现并发症,其余患者术后无明显并发症,临床症状较术前均有不同程度的改善。结论 BSCM有较高的出血倾向,显微手术是治疗BSCM有效的方法,有助于患者功能状况的改善。
Objective To investigate the clinical characteristics and microsurgical treatment effect of brainstem cavernous malformation( BSCM). Methods From May 2008 to May 2018,the clinical and imaging data( head CT,MRI) of 25 consecutive patients with BSCM admitted to the Department of Neurosurgery,Jinling Hospital,Nanjing University School of Medicine and treated with microsurgery were analyzed retrospectively,including 1 4 patients with acute hemorrhage and 1 1 with non-acute hemorrhage. All patients received head CT and MRI examinations before operation. Fourteen patients were treated via suboccipital posterior midline approach,7 were treated via suboccipital far lateral approach,3 were treated via subtemporal approach,and 1 was treated via suboccipital retrosigmoid approach. The postoperative pathology proved to be cavernous malformation in all patients. The Karnofsky performance scale( KPS) score was used to evaluate the preoperative and postoperative functional status of the patients. The clinical and imaging follow-ups were performed regularly after operation. Results( 1) Of the 25 patients,the lesions of 18 patients located in pons,4 in midbrain,2 in medulla oblongata,and 1 at the junction of pons and medulla oblongata. The maximum diameter of the lesions in 5 cases was < 2 cm,maximum diameter 2-<3 cm in 14 cases,and 3-4 cm in 6 cases. The mean maximum diameter was 2. 3 ± 0. 7 cm.( 2) Of the 14 patients with acute hemorrhage,postoperative head CT revealed that 13 had no hemorrhage in the operative region,and head MRI revealed that the lesions were totally removed. Postoperative 12 ± 3 d KPS showed that the functional status of patients was improved significantly compared with that before operation( The preoperative and postoperative scores were 57 ± 17 and 72 ± 11 respectively,t = 26. 419,P < 0. 01),and 6 of them were followed up regularly after surgery( 3-24 months,median 8 [3,15] months,head MRI re-examination) without complaints and recurrence. Of the 14 patients with acute hemorrhage,1 died and 2 had complications after operation,other patients did not have obvious complications. Their clinical symptoms had different degrees of improvement compared with before operation. Postoperative head CT revealed no hemorrhage in the operation region in 11 patients with non-acute hemorrhage,and head MRI revealed that the lesions were totally removed. The KPS score showed that the functional status of patients was significantly better than before operation at 12 ± 3 d after operation( The preoperative and postoperative scores were 75 ± 10 and 87 ±12 respectively,t = 13. 203,P < 0. 01). Six of them were followed up for 3-18 months,median 8( 4,14) months. Head MRI re-examination revealed no complaints and recurrence. In 11 patients with non-acute hemorrhage,1 had a complication after operation,other patients did not have obvious complications after operation. Their clinical sym ptom s were im proved to som e extent com pared with before operation.C onclusions BSCM has higher bleeding tendency. Microsurgery is an effective method for the treatment of BSCM. It is helpful to improve the functional status of patients.
Objective To investigate the clinical characteristics and microsurgical treatment effect of brainstem cavernous malformation( BSCM). Methods From May 2008 to May 2018,the clinical and imaging data( head CT,MRI) of 25 consecutive patients with BSCM admitted to the Department of Neurosurgery,Jinling Hospital,Nanjing University School of Medicine and treated with microsurgery were analyzed retrospectively,including 1 4 patients with acute hemorrhage and 1 1 with non-acute hemorrhage. All patients received head CT and MRI examinations before operation. Fourteen patients were treated via suboccipital posterior midline approach,7 were treated via suboccipital far lateral approach,3 were treated via subtemporal approach,and 1 was treated via suboccipital retrosigmoid approach. The postoperative pathology proved to be cavernous malformation in all patients. The Karnofsky performance scale( KPS) score was used to evaluate the preoperative and postoperative functional status of the patients. The clinical and imaging follow-ups were performed regularly after operation. Results( 1) Of the 25 patients,the lesions of 18 patients located in pons,4 in midbrain,2 in medulla oblongata,and 1 at the junction of pons and medulla oblongata. The maximum diameter of the lesions in 5 cases was < 2 cm,maximum diameter 2-<3 cm in 14 cases,and 3-4 cm in 6 cases. The mean maximum diameter was 2. 3 ± 0. 7 cm.( 2) Of the 14 patients with acute hemorrhage,postoperative head CT revealed that 13 had no hemorrhage in the operative region,and head MRI revealed that the lesions were totally removed. Postoperative 12 ± 3 d KPS showed that the functional status of patients was improved significantly compared with that before operation( The preoperative and postoperative scores were 57 ± 17 and 72 ± 11 respectively,t = 26. 419,P < 0. 01),and 6 of them were followed up regularly after surgery( 3-24 months,median 8 [3,15] months,head MRI re-examination) without complaints and recurrence. Of the 14 patients with acute hemorrhage,1 died and 2 had complications after operation,other patients did not have obvious complications. Their clinical symptoms had different degrees of improvement compared with before operation. Postoperative head CT revealed no hemorrhage in the operation region in 11 patients with non-acute hemorrhage,and head MRI revealed that the lesions were totally removed. The KPS score showed that the functional status of patients was significantly better than before operation at 12 ± 3 d after operation( The preoperative and postoperative scores were 75 ± 10 and 87 ±12 respectively,t = 13. 203,P < 0. 01). Six of them were followed up for 3-18 months,median 8( 4,14) months. Head MRI re-examination revealed no complaints and recurrence. In 11 patients with non-acute hemorrhage,1 had a complication after operation,other patients did not have obvious complications after operation. Their clinical sym ptom s were im proved to som e extent com pared with before operation.C onclusions BSCM has higher bleeding tendency. Microsurgery is an effective method for the treatment of BSCM. It is helpful to improve the functional status of patients.
引文
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[12]Li D,Yang Y,Hao SY,et al.Hemorrhage risk,surgical management,and functional outcome of brainstem cavernous malformations[J].J Neurosurg,2013,119(4):996-1008.
[13]Taslimi S,Modabbernia A,Amin-Hanjani S,et al.Natural history of cavernous malformation:Systematic review and meta-analysis of 25 studies[J].Neurology,2016,86(21):1984-1991.
[14]Atwal GS,Sarris CE,Spetzler RF.Brainstem and cerebellar cavernous malformations[J].Handb Clin Neurol,2017,143:291-295.
[15]Negoto T,Terachi S,Baba Y,et al.Symptomatic srainstem cavernoma of elderly patients:timing and strategy of surgical treatment.Two case reports and review of the literature[J].World Neurosurg,2018,111:227-234.
[16]Mokin M,Agazzi S,Dawson L,et al.Neuroimaging of cavernous malformations[J].Curr Pain Headache Rep,2017,21(12):47.
[17]Wang Z,Qian C,Shi L,et al.Surgery approaches to brainstem cavernous malformations[J].J Craniofac Surg,2015,26(7):577-580.
[18]Davies JM,Kim H,Lawton MT.Surgical treatment of cerebral cavernous malformations[J].J Neurosurg Sci,2015,59(3):255-270.
[19]Bradac O,Majovsky M,de Lacy P,et al.Surgery of brainstem cavernous malformations[J].Acta Neurochir(Wien),2013,155(11):2079-2083.
[20]Tumturk A,Li Y,Turan Y,et al.Emergency resection of brainstem cavernous malformations[J].J Neurosurg,2018,128(5):1289-1296.
[21]辛灿,许双祥,王煜,等.显微手术治疗脑干海绵状血管瘤的临床分析[J].中国临床神经外科杂志,2016,21(12):737-739.
[22]Zenonos GA,Fernandes-Cabral D,Nunez M,et al.The epitrigeminal approach to the brainstem[J].J Neurosurg,2018,128(5):1512-1521.
[23]Poorthuis MH,Klijn CJ,Algra A,et al.Treatment of cerebral cavernous malformations:a systematic review and metaregression analysis[J].J Neurol Neurosurg Psychiatry,2014,85(12):1319-1323.
[24]Chotai S,Qi S,Xu S.Prediction of outcomes for brainstem cavernous malformation[J].Clin Neurol Neurosurg,2013,115(10):2117-2123.
[25]孔东生,孙正辉,武琛,等.脑干海绵状血管瘤术中扩散张量成像联合电生理学监测研究[J].中国现代神经疾病杂志,2017,17(5):370-375.
[26]孔东生,孙正辉,武琛,等.术中磁共振导航技术在脑功能区周围动-静脉畸形切除术中的应用[J].中国现代神经疾病杂志,2016,16(12):839-844.
[2]Zhang S,Li H,Liu W,et al.Surgical treatment of hemorrhagic brainstem cavernous malformations[J].Neurol India,2016,64(6):1210-1219.
[3]Gross BA,Du R.Cerebral cavernous malformations:natural history and clinical management[J].Expert Rev Neurother,2015,15(7):771-777.
[4]Ramina R,Mattei TA,de Aguiar PH,et al.Surgical management of brainstem cavernous malformations[J].Neurol Sci,2011,32(6):1013-1028.
[5]周德祥,詹升全,周东,等.脑干海绵状血管瘤显微手术治疗分析[J].中国脑血管病杂志,2016,13(8):431-435.
[6]Li H,Ju Y,Cai BW,et al.Experience of microsurgical treatment of brainstem cavernomas:report of 37 cases[J].Neurol India,2009,57(3):269-273.
[7]Petr O,Lanzino G.Brainstem cavernous malformations[J].J Neurosurg Sci,2015,59(3):271-282.
[8]陈见清,包映辉,崔华,等.显微外科治疗脑干海绵状血管瘤的研究进展[J].中国脑血管病杂志,2015,12(3):155-159.
[9]Akers A,Al-Shahi Salman R,A Awad I,et al.Synopsis of guidelines for the clinical management of cerebral cavernous malformations:consensus recommendations based on systematic literature review by the angioma alliance scientific advisory board clinical experts panel[J].Neurosurgery,2017,80(5):665-680.
[10]陈立华,李文德,徐如祥.脑干海绵状血管瘤的特征性分析[J].中华神经创伤外科电子杂志,2015,1(6):41-45.
[11]Lu XY,Sun H,Xu JG,et al.Stereotactic radiosurgery of brainstem cavernous malformations:a systematic review and meta-analysis[J].J Neurosurg,2014,120(4):982-987.
[12]Li D,Yang Y,Hao SY,et al.Hemorrhage risk,surgical management,and functional outcome of brainstem cavernous malformations[J].J Neurosurg,2013,119(4):996-1008.
[13]Taslimi S,Modabbernia A,Amin-Hanjani S,et al.Natural history of cavernous malformation:Systematic review and meta-analysis of 25 studies[J].Neurology,2016,86(21):1984-1991.
[14]Atwal GS,Sarris CE,Spetzler RF.Brainstem and cerebellar cavernous malformations[J].Handb Clin Neurol,2017,143:291-295.
[15]Negoto T,Terachi S,Baba Y,et al.Symptomatic srainstem cavernoma of elderly patients:timing and strategy of surgical treatment.Two case reports and review of the literature[J].World Neurosurg,2018,111:227-234.
[16]Mokin M,Agazzi S,Dawson L,et al.Neuroimaging of cavernous malformations[J].Curr Pain Headache Rep,2017,21(12):47.
[17]Wang Z,Qian C,Shi L,et al.Surgery approaches to brainstem cavernous malformations[J].J Craniofac Surg,2015,26(7):577-580.
[18]Davies JM,Kim H,Lawton MT.Surgical treatment of cerebral cavernous malformations[J].J Neurosurg Sci,2015,59(3):255-270.
[19]Bradac O,Majovsky M,de Lacy P,et al.Surgery of brainstem cavernous malformations[J].Acta Neurochir(Wien),2013,155(11):2079-2083.
[20]Tumturk A,Li Y,Turan Y,et al.Emergency resection of brainstem cavernous malformations[J].J Neurosurg,2018,128(5):1289-1296.
[21]辛灿,许双祥,王煜,等.显微手术治疗脑干海绵状血管瘤的临床分析[J].中国临床神经外科杂志,2016,21(12):737-739.
[22]Zenonos GA,Fernandes-Cabral D,Nunez M,et al.The epitrigeminal approach to the brainstem[J].J Neurosurg,2018,128(5):1512-1521.
[23]Poorthuis MH,Klijn CJ,Algra A,et al.Treatment of cerebral cavernous malformations:a systematic review and metaregression analysis[J].J Neurol Neurosurg Psychiatry,2014,85(12):1319-1323.
[24]Chotai S,Qi S,Xu S.Prediction of outcomes for brainstem cavernous malformation[J].Clin Neurol Neurosurg,2013,115(10):2117-2123.
[25]孔东生,孙正辉,武琛,等.脑干海绵状血管瘤术中扩散张量成像联合电生理学监测研究[J].中国现代神经疾病杂志,2017,17(5):370-375.
[26]孔东生,孙正辉,武琛,等.术中磁共振导航技术在脑功能区周围动-静脉畸形切除术中的应用[J].中国现代神经疾病杂志,2016,16(12):839-844.
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