经胼胝体-穹窿间入路切除第三脑室内部及其后部肿瘤的临床治疗探讨

摘要

目的 探讨经胼胝体-穹窿间入路显微手术切除第三脑室内部及后部肿瘤的优缺点及手术技巧.方法 回顾性分析2008年7月至2011年3月24例显微镜下经胼胝体-穹窿间入路切除第三脑室内部及后部肿瘤的患者资料,其中男性14例,女性10例；年龄17～65岁,平均32岁.病程范围:1个月至10年.分析讨论手术切口、引流静脉的处理、胼胝体切开、颅高压情况下肿瘤的暴露、如何预防术中并发症、肿瘤切除、合并梗阻性脑积水术中的处理、术后管理等问题.结果 病理结果证实松果体实质细胞瘤5例、生殖细胞瘤4例、星形细胞瘤3例、下丘脑错构瘤2例、室管膜瘤2例、混合生殖细胞瘤2例、淋巴瘤2例、松果体母细胞瘤1例、皮样囊肿1例、脊索瘤样胶质瘤1例、颅咽管瘤1例.其中9例肿瘤镜下全切除,6例次全切除,4例大部分切除,5例部分切除,无死亡病例；术中同时行第三脑室底造瘘术13例.术中发现额顶部硬膜外血肿1例；术后短期内记忆力下降3例,2例1个月恢复,1例3个月恢复；术后额顶部硬膜下积液1例,保守治疗后好转；术后行脑室腹腔分流术1例.结论 在熟练掌握胼胝体-穹窿间入路手术技术的前提下,该入路是切除第三脑室内部肿瘤及大多数第三脑室后部肿瘤的理想入路.术中同时行第三脑室底造瘘术是此入路的显著优势.%Objective To discuss the advantages and disadvantages of transcallosal-interforniceal approach for resection of the third ventrical and the pineal region tumors.Methods The clinical data of 24 cases from July 2008 to March 2011 were retrospectively analyzed.All 24 patients operated by transcallosal-interforniceal approach,among them,there were 14 males and 10 females,with a average age of 32 years ranged from 17 to 65 years and with medical history from 1 month to 10 years.Issues of managements were analyzed and discussed,including reasonable incision design,the managements of draining vein,the site and the length of the incision of the corpus callosum,tumor exposure in increased intracranial pressure,prevention of complications,skills of surgery,treatments of obstructive hydrocephalus,and postoperative managements.Results In the 24 cases,there were 5 cases of pineal parenchymal tumors,4 cases of germinoma,3 cases of astrocytoma,2 cases of hypothalamus hamartomas,2 cases of ependymoma,2 cases of mixed germ cell tumour,2 cases of malignant lymphomas,1 case of pineoblastoma,1 case of dermoid cyst,1 case of chordoid glioma and 1 case of craniopharyngioma.After surgeries,total removal achieved in 9 cases,and subtotal removal in 10 cases and partial removal in 5 cases.Operative mortality was 0.Combined third ventriculostomy were performed in 13 cases.Postoperative complications occurred in 5 cases,including frontoparietal epidural hematoma in 1 case; postoperative short-term memory loss in 3 cases,postoperative memory loss within 1 month in 2 cases and within 3 months in 1 case;frontoparietal subdural effusion in 1 case and the effusion disappeared without any treatment.Ventriculoperitoneal shunt was performed in 1 case.Conclusions The transcallosal-interforniceal approach is ideal for the removal of tumors in third ventrical as well as majority tumor in posterior of third ventricle in a skillful hand.Tumor resection combined with third ventriculostomy is the significant advantages in the approach.