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避免松果体脑瘤术后急性小脑肿胀

编辑:INC|发布时间:2019-11-13 17:25|点击次数:
避免松果体脑瘤术后急性小脑肿胀
Avoidance of postoperative acute cerebellar swelling after pinealtumor surgery
英文摘要:

Broggi and colleagues present an interesting case in this issue of Acta Neurochirurgica and describe a well-known complication of pineal tumor surgery . Their patient, a 56-year-old female, underwent removal of a WHO grade 3 pineal tumor via the supracerebellar infratentorial route. After an uneventful early postoperative course acute cerebellar swelling occurred that required emergency decompressive craniectomy.
 
Indeed, surgical removal of tumors arising within the pineal region belongs to the most challenging neurosurgical procedures. Due to their deep location and close anatomical relationship to the cerebellum, midbrain tectum, bilateral pulvinar and Galenic venous draining group, these tumors must be resected in the most efficient fashion without causing any harm to these important adjacent structures. Postoperative acute cerebellar swelling as described by Broggi and colleagues constitutes a serious complication that may rapidly cause the patient to develop a life-threatening condition because of the compressive effect on the brainstem. Because of severe clinical implications, occasionally even with fatal outcomes, this complication has received attention for a long time in the literature. Apparently, and in concordance with my own experience, the most frequent pathomechanism is a combination of venous obstruction, sometimes combined with postoperative local hemorrhage. Using a cerebellar selfretaining retractor during surgery significantly increases the risk for this complication as the retractor may cause local ischemia, produce cerebellar contusion and venous congestion, or even cause rupture of superficial bridging veins.
 
These problems may be accentuated in the presence of obstructive hydrocephalus or a tight posterior fossa. If such postoperative cerebellar swelling occurs, the only way to efficiently treat and possibly save the patient’s life is rapid decompression and/or removal of a local hematoma or hemorrhagic residual tumor in a fashion similar to what Broggi and colleagues have eloquently described in their article.
 
During my career I have removed a number of tumors located in the pineal region, among them pineal cysts,pineocytomas, pineoblastomas, pilocytic, fibrillary and ana plastic astrocytomas, rosette-forming glioneuronal tumors,germinomas, ependymomas, anaplastic choroid plexus papillomas, meningiomas, mature teratomas, carcinoma metastases, etc. I applied a versatile surgical technique to achieve good results as these tumors varied widely in size, extent,consistency, vascularization, adhesion to adjacent vessels,presence or absence of the dissection plane, etc. Each time I planned the microsurgical resection of such tumors, I tried to be aware of possible factors that could lead to postoperative acute cerebellar swelling, taking appropriate precautions to avoid this serious complication. At least seven issues seem important to me in this context.


中文摘要:

Broggi和他的同事在本期《神经外科学报》上提出了一个有趣的案例,并描述了松果体肿瘤手术的一个知名并发症。他们的患者是一名56岁的女性,通过小脑上幕下路径切除了世卫组织3级松果体肿瘤。术后早期无大碍,发生急性小脑肿胀,需要紧急去骨瓣减压术。
 
事实上,手术切除松果体区域内的肿瘤属于最具挑战性的神经外科手术。由于这些肿瘤位置深,与小脑、中脑顶盖、双侧丘脑枕和Galenic静脉引流组解剖关系密切,必须以最有效的方式切除,不能对这些重要的邻近结构造成损害。Broggi及其同事描述的术后急性小脑肿胀是一种严重的并发症,由于脑干受压,可能会迅速导致患者发展为危及生命的状况。由于严重的临床意义,有时甚至是致命的结果,这一并发症在很长一段时间内受到了文献的关注。显然,与我自己的经验一致,较常见的病理机制是静脉阻塞,有时合并术后局部出血。在手术中使用小脑牵开器可以明显增加这种并发症的风险,因为牵开器可能导致局部缺血,造成小脑挫伤和静脉充血,甚至导致浅桥静脉破裂。
 
这些问题可能在阻塞性脑积水或紧密的后颅窝存在时加重。如果发生这种术后小脑肿胀,有效治疗和可能挽救患者生命的唯一方法是快速减压和/或切除局部血肿或出血残留肿瘤,其方式与Broggi和同事在他们的文章中雄辩地描述的相似。
 
在我的职业生涯中,我切除了许多位于松果体区域的肿瘤,其中包括松果体囊肿、松果体细胞瘤、松果体母细胞瘤、毛细胞性、纤维性和假性星形细胞瘤、罗塞特形成的胶质神经元瘤、生殖细胞瘤、室管膜瘤、间变性脉络膜丛乳头状瘤、脑膜瘤、成熟畸胎瘤、癌转移等。由于这些肿瘤的大小、范围、稠度、血管化程度、与邻近血管的粘连、解剖平面的有无等方面差异很大,所以我采用了一种通用的手术技术,取得了很好的效果。每次我计划进行此类肿瘤的显微手术切除时,我都试图了解可能导致术后急性小脑肿胀的因素,采取适当的预防措施,避免这种严重的并发症。在这种情况下,至少有7个问题对我来说很重要。
松果体肿瘤手术

Tag标签:松果体脑瘤

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