目的:验证经改良的颞下入路(颞下经岩前入路 ,ATPA)切除岩斜区及脑干病变的可行性。方法:2010年来,我们采用(颞下经岩前入路,对43例颅底病变进行手术切除,手术中进行神经电生理监护。包括岩斜区脑膜瘤脑膜瘤20例,三叉神经鞘瘤11例,胆固醇样肉芽肿3例,桥脑海绵状血管瘤4例,脑干胶质瘤2例,脑干腹侧胆脂瘤3例。使用耳前弧形皮肤切口,小骨窗。电凝小脑天幕和岩骨尖硬脊膜, 然后切开并充分暴露岩尖骨。在硬膜下磨除岩尖骨,磨除范围从三叉神经压迹开始,横向不超过 1.5 厘米,距岩脊后端不超过8毫米, 距岩骨表面深度不超过8毫米。为了减小对颞叶的损害伤,我们用了如下方法:①降低肺气道压力,术中低于16厘米,②使用250 毫升 20%甘露醇,③对巨大肿瘤的患者,术前腰椎置管脑脊液引流。引流静脉损伤往往是与术后出血和颞叶严重水肿的高风险相关联的。因此,所有的颞叶引流静脉应尽可能保护。若颞下引流静脉进入颅中窝硬脑膜,应沿静脉走向剪开硬脑膜以获得静脉动力。如果海绵窦内肿瘤且粘连紧密,肿瘤会紧紧附着周围的颅神经和血管,建议次全切除或部分切除。结果:34例肿瘤被完全切除,8例次全切除,1例部分切除。暂时性的神经功能缺损包括2例的轻微动眼神经麻痹,3例外展神经麻痹,1例语言障碍和1例轻度偏瘫。6名患者在术后面部麻木加重,六个月后改善。没有死亡案例。改进的 ATPA 是一种有效的替代方法治疗大型或巨型的位于耳道中间或内侧的PCMS,且并发症的风险较低。目的目的结论:改进的ATPA 具有以下优点: (1) 它可以使位于岩斜区中部和上部、和IAM中部的PCMs充分暴露。(2) 比常规ATPA更充分暴露颅中窝底。(3) 神经外科医生更熟悉这个过程,相比常规 ATP,颞肌萎缩和术后面神经麻痹和CSF渗漏的风险更小。(4)不需要其他手术以获得脂肪组织来修复颅底。
什么是颅骨缺损?颅骨缺损是由于开放性颅脑创伤或火器性穿通伤或手术减压、颅骨病变所致的穿凿性破坏或切除颅骨病损所致。 颅骨缺损了怎么办?颅骨缺损可行颅骨修补术,颅骨修补术是针对脑外伤及开颅手术等导致的颅骨缺损进行修补的神经外科常见手术。能不能不做颅骨修补手术呢?以前的观点认为颅骨修补手术主要目的是修补材料可以保护脑组织,避免脑组织移位(膨隆、凹陷等),减轻骨窗边缘皮肤牵拉引起的疼痛,减轻精神负担,更好融入工作和日常生活等。所以很多昏迷的病人要等到醒后才考虑行颅骨修补术。但是临床实际情况仅仅是这样吗?图片转自(Neurosurgery.2016 Oct;79(4):525-34. doi: 10.1227/NEU.0000000000001366. )这张图看着很高大尚有木有?翻译过来就是“环锯综合征”或者叫“皮瓣下陷综合征”说的简单一点:骨瓣缺损处大气压力直接作用在缺损处的大脑皮层,导致缺损区域脑组织的血流减少,脑代谢降低,颅内脑脊液循环变慢,在压力梯度的作用下加重早期水肿,易形成水瘤。再简单一点:就是影响病人后期的康复!!!所以在临床上我们会观察到有些病人康复进程变得缓慢,反应越来越差,甚至停滞不前。所以昏迷的病人也应该做颅骨修补手术什么时候可以做颅骨修补手术?病人病情平稳,颅内压已得到有效控制并稳定,伤口完全愈合无感染,无禁忌手术症。以往多主张在首次术后3~6个月修补,目前多主张在首次手术后6~8周修补为宜;5岁以下儿童不主张行颅骨修补;5~10岁酌情修补,15岁以后颅骨修补与成人相同。颅骨修补手术前需要做哪些检查?除常规的术前检查外,还需要进行薄层CT扫描,将数据传至计算机,完成颅骨的三维重建,将缺损部位颅骨按照原始形状将修补材料塑形,这样制作出来的钛网与原来颅骨生理结构一致,外形更加美观。常用修补材料有哪些?有何区别?目前以三维重建塑形的钛网和PEEK(聚醚醚酮)最为常用。 颅骨修补手术有风险吗?颅骨修补手术在神经外科手术中风险相对较低,绝大部分都会达到良好效果,但是仍有极少数的病人有可能会出现皮下积液、头皮感染、修补材料排异、修补材料内陷、术区或远隔部位出血、慢性切割性头皮溃疡和癫痫等。所有手术都有风险(看看手术同意书那满满的一页),告诉你没有风险那就是在SLM,大家千万不要相信!!!颅骨修补术后需要注意哪些?1、勿抓破修补部位皮肤防止感染,忌剧烈运动,避免外力撞击所修补颅骨部位。2、进食富含高蛋白、维生素及粗纤维饮食,避免辛辣刺激性食物,禁烟酒、咖啡、浓茶,合理安排作息时间,养成良好的生活习惯,以促进切口的生长愈合。3、癫痫病人应定期服用抗癫痫药物,不能单独外出、登高、游泳等,以防意外。4、定期门诊随访,如有异物反应等特殊情况随时就诊。
脑干素有“生命禁区”之称,其中密集排列着颅神经的核团和肢体与大脑联系的上下传导束,另外脑干中有维持我们清醒的脑干上行激活系统和心血管和呼吸的中枢。脑干出血是神经系统急重症,轻则肢体偏瘫,重则出现昏迷危及患者的生命,病死率高。由于脑干的解剖和功能的特殊性,脑干出血非死即残,存活的病人大部分遗留有重残,生存质量很差。一旦发生,对医生或家属而言,其治疗选择变得相当棘手。从整体上看,脑干出血,可谓是挑战与机遇并存! 一、棘手的脑干出血 现实中的脑干出血是一种什么样的存在? 我们常听到发生这类疾病的人都是预后不良的例子,但也有幸运者。 为什么一旦诊断脑干出血,医生和患者都会心生恐惧呢? 如果说大脑是全身的司令部,那脑干即是司令部的总司令。脑干素有“生命禁区”之称,其中密集排列着颅神经的核团和肢体与大脑联系的上下传导束,其主要功能分区:心血管中枢和呼吸中枢;维持我们清醒的脑干上行激活系统;同时它是大脑与脊髓联络的必经之道,包括四肢的感觉与运动等。一旦受损,其后果不堪设想。 脑出血是神经系统急重症,脑干出血更是神经系统急重症,病死率极高。有报道脑干出血死亡率高达79%,出血量大于5ml者死亡率高达95%(这个数字有不同的报道)。 脑干出血的病人出现昏迷早且重,多数在发病24小时内昏迷,血压相对较高,同时出现呼吸障碍和循环系统障碍,伴构音障碍及呛咳,交叉瘫,四肢瘫,眼球震颤,瞳孔改变、共济失调,大小便障碍等。脑干出血是促进脑出血死亡的重要原因之一。 二、脑干出血的预后相关因素? 脑干出血患者治疗后还会留下不同程度的后遗症,重则死亡,轻则残疾。 哪些因素与脑干出血的预后相关呢? 脑干出血患者的预后与血肿量、血肿位置、意识状态、处理时机和方案的选择、并发症的防治等密切相关。 1、血肿量:出血量越大的患者预后效果就越差。3ml以下症状相对较轻,预后较好;3ml以上则可能面临着一定的神经功能损失。 2、血肿位置:桥脑出血;中脑出血;延髓出血;其中延髓出血预后最差。 3、患者的一般状况和当前病情。年龄:年龄越大的患者预后效果就越差。高血压:高血压病史越长、血压越高的患者,预后效果也就越差。昏迷时间:昏迷的时间越长,预后效果越差。病情越重的患者预后效果越差。一般状况意味着患者的抗病能力与自身修复力,而当前症状意味着此次病情严重程度。 4、干预措施:治疗方案有显微开颅手术、立体定向术、内镜手术等,不同的治疗方法有不同的结果。脑出血引起症状的主要原因有二:a、血肿的直接占位破坏效应;b、继发脑水肿。而手术在带来一定创伤时可以清除血肿,减少血肿的直接占位效应,并直接阻断继发性脑水肿的发生机制。而以立体定向和内镜为代表的微创手术相对简单,在二者间达到一种理想的平衡。 三、脑干出血的机遇 由于脑干出血整体上预后不佳,因此治疗的主流观点:出血部位特殊,手术难度大,风险大,认为手术治疗价值有限,而偏向保守治疗,较少选择外科治疗。 手术虽然提高了存活率,但存活下来的患者生存质量整体上并不理想,临床疗效和手术价值尚待进一步探索和评估。 是手术,还是内科治疗? 是积极,还是保守? 积极,激进? 难以回答,难以决定... 事实上由于微创技术在神经外科的应用越来越成熟,脑干禁区的概念已经被打破,显微手术治疗部分脑干肿瘤以及血管病已经得到广泛的认同,脑干血肿的积极手术也正在慢慢地开展。 脑出血致残致死的病理机制是什么? 脑出血的病理机制主要包括以下两条:1、血肿可造成神经元、胶质细胞的机械性直接破坏,和机械性压迫,继发造成损害(机械破坏与压迫,直接占位效应);同时继发产生脑缺血;进一步可致谷氨酸释放、钙内流,线粒体衰竭;钠潴留,细胞毒性水肿,坏死; 2、凝血酶、亚铁离子、氧化血红素(血肿分解产物),造成小胶质细胞激活,自由基和、炎性因子大量释放,瀑式反应,最后造成血管源性水肿。因此针对其损伤的主要作用来源于血肿的机械作用与血肿分解产生导致的毒性反应,因此在继发性损害发作前阻止它是一条有效的策略;现今的脑出血后脑水肿的治疗主要针对这个思路,对半暗带的有效保护,防止继发损伤是主要方式。但脑出血的另一风险是再出血,而侵袭性手术可能导致再出血增加,或二次损伤减少手术的收益,因此对不同的手术方式有不同的结论。 而对于脑出血指南,外科治疗的主要目标在于及时清除血肿、解除脑压迫、缓解严重颅内高压及脑疝、挽救患者生命,并尽可能降低由血肿压迫导致的继发性脑损伤。作为微创立体定向手术和内镜清除血肿手术方式在脑出血治疗中得到推荐。(参考美国AHA/ASA 2015自发性脑出血管理指南) 脑出血(ICH)的微创血肿清除术:最选几项随机研究比较观察微创穿刺抽吸术与标准开颅血肿清除术,微创治疗具有更好的转归。对12项临床试验进行的汇总分析显示,微创手术较开颅手术更具优势。ICH微创手术联合rtPA血肿清除试验Ⅱ(Minimally Invasive Surgery Plus Recombinant Tissue—Type Plasminogen Activator for ICH Evacuation TrialⅡ,MISTIE-Ⅱ)旨在明确微创手术联合rtPA对ICH患者的安全性。该研究对79例手术患者和39例内科治疗患者进行比较,结果证明血肿清除组的血肿周围水肿显著减轻,而且有临床转归改善的趋势。一项微创血肿清除术的3期临床随机试验(MISTIE一Ⅲ,Minimally Invasive Surgery + rt-PA for ICH Evacuation)正在进行中,它对脑出血病人采用微创手术(立体定向血肿腔置管抽吸+引流)结合术腔注射阿替普酶方法。这进一步强化了我们对立体定向手术微创手术治疗脑干出血的信心。 ? 立体定向手术精准、安全、微创,可以使手术创伤最小化,最大化地保护神经功能。其整体手术设想是通过早期的微创手术使脑干的大血肿转化为小血肿,同时采用冲洗、药物溶血、引流等方式,排空血肿,使患者获得生存机会。后期的康复促醒提高患者生存质量,这项微创技术尤其适应于脑干这样精密而且神经功能密集的部位,相信立体定向手术在脑干出血的治疗中的作用值得期待! 四、脑干出血手术的推荐 脑干血肿按出血位置分型:0型--血肿主要位于表层,脑干仅受压;1型--血肿在一侧脑干,未超过中线;2型--血肿由一侧脑干向对侧扩展,超过中线,但未达3/4边界;3型--血肿由一侧脑干向对侧扩展,超过对侧3/4边界。 立体定向作为一种有效的方法正在慢慢地被推广应用。 1、手术治疗的适应症:①、血压相对稳定:90mmHg
谁能想到,平静的躺在病床上的她,曾在一个月前经历了一场13小时的生死闯关!而在床边为她细致入微查体的,正是她的主刀医生,中国人民解放军武汉总医院神经外科的姚国杰主任,和其治疗团队的韦可医生,杜威医生,伍杰医生,吴文俊医生等。 家住武汉的曾女士,47岁的她本该过着幸福的生活,2年前突然出现没有明显诱因的头痛,就诊当地一家著名三甲教学医院,做头部核磁共振,结果显示:斜坡区占位性病变,当时医生因手术难度,建议保守治疗!治疗后,曾女士自觉头痛没有明显缓解,而后在2017年10月出现双眼视力下降,经常出现黑懵,休息后自觉好转,当时也未重视,2018年的2月曾女士逐渐出现四肢无力,并发展为只能卧床,失明,严重影响生活质量。曾女士和家人多方打听,慕名找到中国人民解放军武汉总医院神经外科姚国杰主任。 姚国杰主任凭借多年娴熟显微外科技术和医生的责任和担当,顶着巨大的压力,因较两年前,肿瘤进展,已压迫运动神经,并且严重脑积水造成失明,姚主任跟天坛医院颅底肿瘤顶级专家和南昌大学第一附属医院著名神经内镜专家反复沟通,商讨手术方案,专家们认为肿瘤巨大,匍匐性生长,质地硬韧,包裹了椎基底动脉和颅神经,存在巨大手术风险。很可能会因手术导致死亡和出现严重的并发症。且患者在手术前已出现严重肺部感染,长时间全身麻醉也存在极高的风险。姚主任和团队一丝不苟的精神,给了曾女士和家属莫大的信心,选择和病魔殊死一博。2018年7月31日全麻下行:“开颅脑干肿瘤切除术”,姚主任和他的团队奋战十余小时,让曾女士生命得以再续! 术后,曾女士意识已经完全恢复。失明,肢体瘫痪没有完全好转。姚主任每天多次查房,细致入微查体,鼓励曾女士积极做康复理疗。 斜坡脑膜瘤,由于其位置深在,常累积多条脑神经及血管结构的重要结构或功能区,关系到病人的生命、神经、内分泌调节和传导等重要神经功能,任何一处的手术损伤,都可能引起重大的神经功能障碍。并且此类病变多处于脑或颅底深部,手术显露困难,因而既要切除肿瘤,又要最大限度地避免损伤脑干、颅神经、重要血管等临近的脑重要结构,手术难度较大,要求有良好的神经解剖基础、先进的显微手术及神经监测等配套设备,尤其是必须有扎实的显微手术技巧和丰富的手术经验。
中部战区总医院姚国杰: 报告昨天做了一例经颞下入路脑干出血的手术。 手术顺利,术后自主呼吸恢复,刺激肢体屈曲。我们近两年做了20余例脑干出血的病人,存活率90%,清醒率40%。
神经导航辅助下显微手术切除脑干海绵状血管瘤广州军区武汉总医院神经外科中国人民解放军神经外科研究所 姚国杰 龚杰 徐国政 等脑干海绵状血管瘤临床上不少见,多因出血就诊。因伽马刀疗效不确切,寻求显微手术全切除成为临床医生的追求目标。导航和神经电生理监护增加了我们的信心。我科自2013年3月至2013年7月在神经导航辅助下显微显微手术切除脑干海绵状血管瘤9例,中脑背侧2例,中脑背侧1例,桥脑侧方1例,桥脑背侧3例,延髓腹侧1例,均获良好疗效。术中同时采用神经电生理监测。根据国内外学者以及我们的经验,应积极开展脑干海绵状血管瘤的显微外科治疗,但应严格掌握适应证:①由脑干向外生的肿瘤、脑干内生长的囊性肿瘤或部分囊性肿瘤、以及脑干内生长的局限性肿瘤是最好的手术适应证②进行性神经功能障碍③反复出血。从部位上分,桥脑海绵状血管瘤发病率最高,同时其手术效果也最佳,尤其是生长于桥脑背外侧的病变,脑干腹侧正中的髓内肿瘤,特别是中脑和延髓的肿瘤手术暴露困难,技术要求更高。Kyoshima提出了经第四脑室底枕下入路的两个安全进入区:“面丘上三角”,内侧以内侧纵束为界,外侧至小脑脚,下端至面神经;“面丘下三角”,内侧以内侧纵束为界,外侧至面神经,下端至髓纹。Bogucki等进一步认为上述两个三角的内侧边界是中间沟偏外侧2mm处,目的是避免损伤内侧纵束。中脑也有两个可以安全切开的部位:四叠体下滑车神经上的区域横向切开,中脑侧方下丘臂以下大脑脚与四叠体之间的区域竖向切开;延髓尽可能从中线切开。手术注意:脑干切口位置应选择病变表浅处,若肿瘤位置深,应从脑干后正中切开,有利于避开血管、网状结构及神经核团,因而损伤小,术后恢复顺利,切除肿瘤时严格在显微镜下操作。动作轻柔、准确,避免牵拉与挤压脑干,应用双极电凝要调小功率,随时喷水降温防止热传导损伤,小的出血用止血纱布轻轻填压即可。对某些肿瘤将瘤壁切除手术时可保留自主呼吸,并密切观察心率变化,若发现病人心率变慢,呼吸变浅应停止手术,待恢复正常后再开始手术,术中一旦出现呼吸节律或心率异常要及时暂停或结束手术,尤其是在延髓手术中,心率的变化最敏感。必须保留引流静脉,否则容易引起灾难性的后果。术中电生理监护+神经导航是目前切除脑干海绵状血管瘤的最佳组合。
锥颅治疗脑内血肿单孔引流与多孔引流的疗效对比姚国杰 龚杰 徐国政 李成才 杜威韦可 张戈 刘征 秦尚振 马廉亭广州军区武汉总医院神经外科,湖北武汉,430070 摘要 目的:比较简易头皮下定位锥颅单孔引流与多孔引流治疗自发性脑内血肿的疗效。 方法:回顾性分析55例自发性颅内血肿患者,头皮定位单孔引流31例(血肿量大小52.9±13.2ml),头皮定位多孔锥颅24例(血肿量大小55.3±15.4ml ),术后给予尿激酶溶解血肿。比较引流时间,血肿残留量及ADL 评分。结果:多孔引流组比单孔引流组引流时间缩短,且预后改善明显。结论:对于较大的且形状不规则的血肿则应该在定位下实施多点穿刺。微创穿刺血肿腔引流加尿激酶冲洗简单易行,血肿清除率高,术后恢复好。【关键词】脑出血;锥颅引流术;多点穿刺,微创手术Comparation of one-point puncture hematoma aspiration and multi-pointpuncture followed by brinolysis throughdrilling skulls on patients with great intracerebral hemorrhage Yao Guo-jie,et al.Department of Neurosurgery ,WuhanGeneral Hospital of Guangzhou Command,PLA (Wuhan,430070)Abstract Objective:This study compared the technical implications and clinical outcome of patientstreated for great intracerebral hemorrhage using two minimally invasiveprocedures through drilling skulls: one-point puncture hematoma aspiration and multi-pointpuncture followed by brinolysis. Methods:55 patients with a spontaneous supratentorial intracerebral hemorrhage,which was treated by scalp marker-guided one-point puncture (n=31, the volumeof the hematoma was 52.9±13.2 mL ),multi-point puncture (n=24, the volume of the hematoma was 55.3±15.4 mL)hematomaaspiration followed by subsequent brinolysis with urokinase,were retrospectively reviewed. The data for the two subsets of patients wereanalyzed with regard to hematoma reduction, ADL Scale and days of catheter duration. Results:There were statistically signicant differences between two groups . In 5 days,the resolution rate of brain hematoma of the multi-point group was 77.40%,significantly higher than that of the one point puncture group (57.28%, P <0.05). The drainage catheterwas in place for a mean duration of 8.5±2.7 days,significantly lower than that of the one-point puncture group (12.6±3.2 days, P < 0.05)。 Conclusion: Multi-point puncture andcontinuous irrigation decrease the intracranial pressure quickly and suck thehematoma more effectively, especially for the great and irregular hematoma of brain. Continuous urokinaseirrigation-drainage is able to keep the concentration of urokinase at aneffective level, thus continuously washing, liquefying, draining, and resolvingthe brain hematoma.Keywords: intracerebral hemorrhage ,drillng skulls and continuousirrigation-draining ,multi-point puncture, minimally invasive procedures锥颅软通道血肿引流技术治疗自发性脑内血肿越来越被神经内外科医生接受[1,2]。但是对于颅内大血肿采用单纯锥颅引流因血肿引流不彻底而脑水肿越来越明显往往需转行开颅手术。为了更加高效地清除血肿,减轻脑水肿,现在主张多点穿刺多孔引流。我院自2008年12月至2010年12月对55例大型或不规则的脑实质出血患者采用单孔或多点锥颅加局部尿激酶灌洗治疗,并进行疗效对比。报告如下。资料与方法1 临床资料 我院自2008年12月至2010年12月采用简易头皮定位下单孔或多孔锥颅治疗大型或不规则的脑实质出血55例。其中男23例,女32例,年龄15-79岁,平均年龄46.8岁,55例患者中47例存在明确高血压病史,4例原因不明,4例因心脏换瓣或支架植入术后长期服用抗凝药物诱发出血。部分疑似病例通过DSA或320排CTA检查排除动脉瘤、动静脉畸形或肿瘤卒中引起的脑出血。31例采用血肿腔单孔引流(头皮简易定位后经最近径路穿刺低位引流或经额部沿血肿长轴穿刺),24例采用额部及颞顶部(头皮定位)多点锥颅。病例采用随机分组方式入组。术后均通过引流管注入尿激酶溶解血肿或者灌洗治疗。2 方法:2.1 CT检查和定位 全部病例均剃头。根据患者出血部位在体表的大致投影贴充满造影剂的输液管,使其形成网格状,水平方向与OM线平行。然后在医生陪同下以OM线为基线进行颅脑CT检查,根据血肿与网格的相对关系确定其体表的垂直投影位置并以划线笔标记,确定其中心作为穿刺点。出血部位:基底节42例(其中破入脑室22例),靠近皮层的脑实质内7例,丘脑出血并破入脑室6例。血肿量采用多田公式进行计算。40~50 m1 22例, 50 m1以上者33例。2.2 治疗方法 采用山东威海村松公司生产的锥颅钻及密闭式引流管,按颅内血肿微创穿刺清除技术规范化治疗指南进行操作。手术时机选择:时间<6h 29例,6-24h 18例,24h-3d 8例。①55例经简易定位的患者扫描定位后,选取CT图象最大出血层面作为穿刺靶点层面,血肿中心为靶点,血肿边缘离皮层最近径路作为穿刺点,由靶点分别测定到体表投影中心(穿刺点)的垂直距离(cm)。②24例多点穿刺者同时经额部沿长轴穿刺点选择:由CT扫描的OM线(外耳道口与外眦的连线)依次向上测算出CT图象最大出血层面的层次,平行于该平面在头皮上标记,再在CT上测算出血肿中心偏离中线的距离,两线相交即为进针点(常在眉弓上2cm 左右),穿刺时应严格平行于中线进针。③锥颅方法:插入带针芯的14号穿刺硅胶管,随后拔出针芯,留置硅胶管。如有陈旧性黑色血液流出,可用5ml注射器轻轻无阻力抽吸血肿,抽吸顺畅,表明引流管尖端在血肿腔内,如有坏死脑组织流出,则提示引流管尖端在血肿腔周边靠近脑实质,如抽吸有阻力,不可强行抽吸,管尖可能偏离血肿,简易调整引流管方向或深度。抽取部分已经溶解的血肿,残余血肿黏稠不易抽出,需从留置的每根硅胶管内注入尿激酶30000~50000U(2ml盐水稀释),夹管2~3小时再开放。上述操作可根据情况每天重复2-3次。多孔引流穿刺成功后在确保引流通畅的情况下可自额部引流管滴入稀释的尿激酶(尿激酶10万U+100ml生理盐水)冲洗,自颞部或枕部引流管流出,可加快血肿清除速度。3.评估指标:术前对每位患者进行ADL评分,术后每天根据CT扫描结果了解血肿清除情况调整尿激酶用量,必要时调整管尖深度。一般待血肿清除80%左右即可拔出引流管。术后常规配合高压氧针灸理疗等康复治疗以促进神经功能恢复。术后3月再次进行ADL评分。4.统计处理:采用SPSS11.0统计软件,显著性差异P<0.05。临床计量资料采用两样本间的t检验进行比较。结果55例患者均在10天以内获得80%的血肿清除率。单孔引流组有3例出现血肿腔再出血,另2例因脑水肿中线偏移明显而改行开颅血肿清除及去骨瓣减压术。死亡2例。多孔引流组有4例出现血肿腔再出血,经过抽吸及多孔对流冲洗后出血终止,死亡1例。两组术后当日血肿量比较无显著性差异(P>0.05),术后5日血肿量及术后3月 ADL评分比较有显著性差异(P<0.05)。且多孔引流组引流管的留置时间明显小于单孔引流组(P<0.05)。讨论采用锥颅手术治疗脑出血,创伤小,手术时间短,局麻即可完成,对病人内环境干扰小,有利于术后神经功能恢复,特别适合年老体衰或者合并严重心、肺、肾疾患及凝血功能障碍的患者[2]。为了精确穿刺,对于锥颅手术多主张立体定向定位。但是立体定向技术辅助下锥颅[3]和无框架神经外科手术导航系统辅助下锥颅[4-6] 的缺点是设备昂贵,成本高,术前准备时间长,需要全身麻醉,不适合在基层医院推广。采用标记物体表定位容易被临床医生接受。该法在头皮贴造影剂充管、金属片(丝)、钙片[7]、三角形定位板后行CT平扫,将CT片数据转换成体表投影,确定穿刺入颅点。其弊端是穿刺方向和深度不能很好把持,有一定的误差,受术者水平影响大。但对于较大血肿或靠近皮层的血肿而言,影响不大。对大多数基层医院而言简单实用。本组对54例患者经头皮造影剂冲管简易定位后经最近径路穿刺低位引流单纯基底节血肿或皮层下脑实质内血肿,或多点穿刺引流较大且不规则的血肿,定位准确,疗效满意。该定位方法相对徒手定位有明显的优势,定位准确,术后基本无需调整引流管方向,个别病人仅需行深度调整。留管时间短。对于颅内大血肿如果采用单纯锥颅引流因血肿引流不彻底而脑水肿越来越严重往往需转行开颅手术。为了更加高效地清除血肿,减轻脑水肿,更多的学者主张多点穿刺多孔引流。huang[8]等通过对巨大血肿的多点穿刺与单孔引流者比较,发现对于大型且形状不规则的血肿应该考虑多点锥颅引流。国内赵卫忠等[9]根据不同的出血量采用不同数量的靶点在局麻下进行锥颅抽吸、尿激酶灌注冲洗引流治疗高血压脑出血67例,结果证实多点锥颅能明显加快血肿清除效率。我们认为,对于血肿量超过50 ml,形态不规则的脑实质出血患者,或者同时合并血肿破入脑室的患者,主张多孔引流。本组对24例该类患者采用额部及颞顶部(头皮定位)多点锥颅加局部尿激酶灌洗治疗,赶在脑水肿高峰来临之前快速高效地清除了血肿,减轻了血肿的占位效应,同时减轻了脑水肿面积,疗效明显优于单孔引流者,术后5日血肿量明显减少,引流管留置时间明显小于单孔引流组。术后3月 ADL评分显著增高。关于术后再出血的处理 不论采用何种方案,锥颅后原血肿腔内再出血是该手术的最大风险,临床报道在4%~16%。如何减少此类并发症及发生后的处理原则探讨较多。作者认为,在短时间内将血压控制在目标血压范围之内,能防止出血事件的发生,一般术前将血压控制在130~150mmHg/80~95mmHg比较稳妥[10]。血压控制方法:早期可使用静脉用降压药经过微量泵注射。待可以进食后逐渐调整为口服药物降压。锥颅多在局麻下进行,术前5分钟静注安定可获得良好的术中配合。术中掌握次全血肿清除,无阻力抽吸、等量置换的原则,术后用低温盐水持续灌洗的方法能预防再出血[11]。对于超早期手术者,术中尽量少抽吸或无阻力抽吸,让未凝固的血液通过引流管自然流出。待出血时间超过6小时后再注射尿激酶。
————颅内动脉瘤所致的蛛网膜下腔出血简介:在2005年卫生部公布的我国城乡居民十大死因调查结果中,脑血管病已成为继恶性肿瘤之后排名第二的杀手。其中自发性蛛网膜下腔出血(颅内血管破裂,血液流入蛛网膜下腔,称为蛛网膜下腔出血)是脑血管病中死亡率及致残率极高的病种之一。在以往治疗过程中,由于对其的认识不足,常是采用内科保守治疗方法来促使蛛网膜下腔出血吸收,大多放弃了对出血原因的检查和治疗,这样做的后果是病人存在再次出血的可能,增加了死亡率和致残率,使病人错过了最佳治疗时机。近十余年来,随着对蛛网膜下腔出血的认识不断深入,人们已经认识到蛛网膜下腔出血不是一个内科病,而是一个需要急诊手术处理的外科病。当您或您的家人出现以下症状时,需要高度警惕自发性蛛网膜下腔出血并尽快就医:(1)头痛是最常见的首发症状,突发,呈劈裂般剧痛,遍及全头或前额、枕部,再延及颈、肩腰背和下肢等。(2)意识障碍:可有短暂意识模糊至昏迷,一般不超过1小时,但也有的病人持续昏迷直至死亡。(3)恶心呕吐、面色苍白、出冷汗。约75%的病人在发病后可出现头痛、恶心及呕吐。(4)神经功能障碍主要因动脉瘤部位不同而出现各种神经功能障碍。主要表现有视力突然减退或原有视力障碍加重;动眼神经麻痹引起患侧眼睑不能抬举,眼球运动受限;外展神经麻痹造成复视、偏瘫、失语及脑干症状。(5)全身症状:可由于蛛网膜下腔出血致下丘脑损害而出现中枢性高热、尿崩症、胃肠道大量出血、急性肺水肿等。同时由于老年人及儿童特殊的体质常使症状不典型,老年人发病时一般头痛表现少且不明显,但常伴有严重的意识障碍,颈项部强硬多见。在儿童头痛少见,但一旦出现应引起重视,同时儿童常伴发系统性病变,如主动脉弓狭窄、多囊肾等。 为什么会出现自发性蛛网膜下腔出血?蛛网膜下腔出血并不完全是一个独立的疾病,引起蛛网膜下腔出血的病因主要有:颅内动脉瘤、脑血管畸形、烟雾病、高血压病、动脉粥样硬化、肿瘤和血液病等。随着瘾君子人群的增加,由吸食可卡因等毒品导致蛛网膜下腔出血病例也在不断增加。其中动脉瘤破裂出血占蛛网膜下腔出血患者的75%-80%,据统计动脉瘤第一次破裂后,死亡率高达30%~40%,其中半数在发病后48小时内死亡,存活的病例中1/3可发生再次出血,发生再次出血者的死亡率高达70%~80%。脑动静脉畸形占蛛网膜下腔出血的患者中约有10%~15%,初次出血死亡率10%左右。因此,颅内动脉瘤和脑动静脉畸形被称为“人体内不定时的炸弹”。蛛网膜下腔出血后最主要的危害是可能有再次出血、脑血管痉挛及脑积水。所以蛛网膜下腔出血的病人首要任务是明确出血的原因,并进行积极的治疗。 1/3的自发性蛛网膜下腔出血病人发生在夜间睡眠过程中;1/3的病人没有明确的诱因;其余1/3的病人与一些诱因有关,如情绪激动、排便、负重、咳嗽、分娩、创伤、外科手术和性生活等。如何确诊:出现上述症状后为明确诊断,您可能需要进行下列检查:1.头部CT 诊断急性SAH准确率几近100%,显示脑沟与脑池密度增高。其中CTA是非创伤性的脑血管成像方法,对头颈及颅内血管性疾病可作为诊断的筛选手段。2.数字减影血管造影(DSA) 是确定SAH病因必须的重要手段,对SAH病人应视为常规检查。尽早的脑血管造影检查,能及时明确动脉瘤大小、部位、单发或多发,有无血管痉挛;动静脉畸形的供应动脉和引流静脉,以及侧支循环情况。对怀疑脊髓动静脉畸形者还应行脊髓动脉造影。必要时根据您的具体病情可能还需行腰椎穿刺等其他检查。如何治疗?以最常见的病因颅内动脉瘤为例。颅内动脉瘤是颅内血管壁的囊性扩张,其最主要的临床表现就是自发性蛛网膜下腔出血。本病因为容易引起再次出血而危及患者的生命,因而必须接受外科治疗。目前外科治疗有两种方法,一是手术治疗,二是神经介入放射血管内治疗。开颅手术治疗疗效好,但是风险大、创伤大、对脑组织的损伤大,而血管内栓塞治疗因其创伤极小、疗效好,能解决开颅手术无法解决的问题,已成为治疗颅内动脉瘤的首选方法。我科在颅内动脉瘤治疗方面具有丰富经验和国内一流的技术水平。
African Journal of Microbiology Research Vol. 6(8), pp. 1624-1628, 29 February, 2012Available online at http://www.academicjournals.org/AJMRDOI: 10.5897/AJMR11.1322ISSN 1996-0808 2012 Academic JournalsCase ReportResolution of intracerebral Bacillus cereus infection following open neck injury after comprehensive treatmentGuo-Jie Yao, Jie Gong*, Ge Zhang, Cheng-Cai Li, Zheng Liu, Wei Du, Guo-zheng Xu, Ke Wei.Department of Neurosurgery, Wuhan General Hospital of Guangzhou Command, PLA, No. 627, Wuluo Road, Wuhan, Hubei, China, 430070, China.Accepted 24 January, 2012Bacillus cereus can cause a wide range of infections that are often overlooked in clinical practice. A case of intracerebral B. cereus infection following open neck injury in a 5-year-old child which was successfully treated with comprehensive therapy consisting of antibiotics and ventriculoperitoneal shunt placement is reported.Key words: Bacillus cereus, comprehensive therapy, ventriculoperitoneal shunt placement.INTRODUCTIONCase reportA 5 year old child weighing 15 kg was admitted to our hospital on May 8, 2010 with a complaint of neck and chest pain for 6 h following a road accident causing a puncture wound to the neck with a wooden stake. Brain and neck CT showed mild pneumatosis in the pontine cistern (Figure 1A) and bubble shadows in the muscular layer of the neck and vertebral canal; there were no residual foreign bodies or cervical spine fracture(s). Chest X-ray revealed pulmonary contusion. On physical examination, the child was disoriented and tachpnoic with mild collapse in the right thoracic cage together with extensive coarse rales bilaterally. Debridement in combination with foreign body removal was performed immediately. During surgery, a wound 3 mm in length which extended into the muscular layer was found on the left side of the neck. 2 wooden foreign bodies (3×1 cm) were removed during surgery. Post-operatively, intravenous ceftriaxone (1 g once daily) was administered for anti-infection therapy (Figure 2). The rales in both*Corresponding author. E-mail: jiegong163@163.com; leosoko@sina.com. Tel: +86-027-68878529.Abbreviations: CSF, Cerebral spinal fluid; CT, computed tomography; MRI magnetic resonance imaging.lungs improved and sputum culture was positive for Klebsiella pneumoniae sensitive to aztreonam. After treatment with aztreonam from May 13 to 18, the pulmonary infection was controlled. However, brain and neck magnetic resonance imaging (MRI) revealed a cystic mass in the neck (Figure 1B).On May 18, the patient developed high-grade fever with maximum body temperature reaching 39.3°C (Figure 2). From May 25 to June 5, intravenous ceftriaxone (1 g once daily) was given. CSF culture was negative. The cystic mass in the neck enlarged over time accompanied by tenderness and an increase in local skin temperature. Cyst fluid culture on June 15 was negative. On July 9, a second CT scan of the brain revealed hydrocephalus (Figure 1C). Cyst puncture was performed on July 12, 15 and 20 and cyst fluid culture was tested using Kirby-Bauer antibiotic testing (disk diffusion antibiotic sensitivity testing). The testing was positive for Bacillus cereus which was sensitive to erythromycin, penicillin, ceftriaxone, clindamycin, piperacillin-tazobactam and chloramphenicol. Following consultation between pediatricians and infectious disease physicians, combination therapy was recommended. Subsequently, intravenous piperacillin-tazobactam (2.25 g once every 8 h) and chloramphenicol (3 ml twice daily) were administered for 15 days. During the treatment, recurrent fever occurred and the maximal body temperature was 39.6°C. 2 weeks after the start of combination therapyfluctuating fever was still present and the maximal body temperature still reached 39.6°C. After a second consultation, intravenous meropenem (0.5 g 3× daily) was administered for 33 days. To prevent fungal infection secondary to long-term antibacterial treatment, prophylactic fluconazole was also given for 33 days. The patient’s body temperature recovered gradually and anti-infection therapy was discontinued on September 2.One week later, the patient still had fluctuating low-grade fever but body temperature was generally normal. The maximal body temperature was 38.5°C. 2 consecutive CSF cultures were positive for B. cereus which was sensitive to gentamicin. The neck cyst was connected to the subarachnoid space. It was difficult to resolve the cyst with hydrocephalus being present. The patient had ventriculomegaly and there was the possibility of further enlargement of the bilateral lateral cerebral ventricles and third and fourth ventricles. Following consultation with neurosurgeons and neurologists, right external ventricular drainage was performed on September 9. At the same time, gentamicin in normal saline (20,000 U/100 ml) was used to irrigate the cerebral ventricles. During irrigation, purulent fluid was noted. Subsequently, the CSF became clear and the size of the cerebral ventricle(s) decreased.From September 9 to 14, the increase in body temperature was not controlled, and cefepime (1 g twice daily) was administered with the addition of metronidazole. During the treatment, fluctuating low-grade fever was still present and the maximal body temperature reached 38.3°C. Cerebrospinal fluid culture was positive for B. cereus which was sensitive to penicillin and gentamicin. From September 14 to October 1, intravenous penicillin (1,600,000 U three times daily) was administered. Computed tomography showed that the size of the cerebral ventricle had returned to normal (Figure 1D). We attempted to replace the external ventricular drainage with a ventriculoperitoneal shunt. However, 1 CSF culture was positive for B. cereus (September 18), although 5 cultures were negative (September 17, 20, 23, 25 and 27). Thus, ventriculoperitoneal shunt placement was not carried out. On October 3, right external ventricular drainage was alternated with left external ventricular drainage, and intravenous penicillin (1,600,000 U three times daily) was given in combination with ornidazole, which was added to prevent meningitis from anaerobic infection. However, CSF cultures on October 10, 14 and 18 were positive for B. cereus, and the CSF again became cloudy. Following external drainage, the CSF became clear, and the cerebral ventricle remained unchanged (Figure 1E). On October 19, left external ventricular drainage was discontinued. Because of the risk for infection following long-term external ventricular drainage, ventriculoperitoneal shunting was performed. Post-operatively, fever was not noted. On November 8, the CSF became clear and three consecutive CSF culturesYao et al. 1625were negative for B. cereus (November 8, 11 and 14). Brain CT revealed that the cerebral ventricle was normal (Figure 1F). The patient recovered and was discharged 2 weeks later.For monitoring treatment, serum C-reactive protein was also measured to assess the stress response, and evaluate trauma, infection, inflammation and surgery (Figure 2). Immunoturbidimetry was performed to measure C-reactive protein using a kit (YZB/USA 1479-2008) in an immunology analyzer (Beckman Immage; Beckman Coulter, Inc, Fullerton, CA USA). It has been found that C-reactive protein has considerable value for the prognosis/diagnosis of postoperative infections (Nunes et al., 2011).DISCUSSIONB. cereus is a member of the family Bacillaceae and is widely distributed in dust, air and water. B. cereus is a motile, aerobic or facultatively anaerobic, spore-forming, gram-positive or gram-variable bacterium. With regard to being a human pathogen, B. cereus is probably known best as a mediator of self-limited foodborne illness. However, there is increasing awareness that B. cereus can be an opportunistic pathogen, causing infections in critically ill and debilitated patients, transplant recipients, patients with foreign bodies, intravenous drug abusers and other immunocompromised patients (de Almeida et al., 2003; Hilliard et al., 2003; Gaur and Shenep, 2001). In clinical practice such infections are frequently overlooked as members of the family Bacillaceae, except for the B. anthracis, are usually regarded as laboratory contaminants (Ebrahimi et al., 2009).Our patient had a clear history of trauma, and foreign bodies had penetrated into the brain. Although we lacked direct evidence that there was a correlation between the neck injury and infection, we speculated that B. cereus was the pathogen. We believe the pathogen originated from the wooden foreign bodies and entered the brain causing intracerebral infection. The CSF culture was performed using pediatric blood culture bottles (Pedi-Bac T; BioMerieux, Inc., Durham, NC). When the result of blood culture was positive gram stain smear was performed and subcultured on blood agar at the same time for identification. Based on the combined results of gram stain, blood agar plate culture and biochemical tests we identified the pathogen. When the CSF culture was negative, fever and other symptoms resolved rapidly.As far as we know, only 11 cases of brain abscess caused by B. cereus have been reported previously (Mochiduki et al., 2007; Kuwabara et al., 2006; Mori et al., 2002; Psiachou-Leonard et al., 2002; Sakai et al., 2001; Bert et al., 1995; Jones et al., 1992; Jenson et al., 1989; Pennington et al., 1976). There have also been case reports of B. cereus meningitis (Barrie et al., 1992; Berner et al., 1997). A survey conducted by Hilliard et al.1626 Afr. J. Microbiol. Res.Figure 1. (A) Pneumatosis in the pontine cistern at 3 hours after trauma (May 8, 2010); (B) Cystic mass in the neck on MRI (May 18, 2010); (C) Hydrocephalus (July 9, 2010); (D) After right external ventricular drainage (September 17, 2010); (E) After left external ventricular drainage (October 15, 2010); (F) Normal cerebral ventricle two months after ventriculoperitoneal shunt placement (December 20, 2010).Yao et al. 1627Figure 2. Body temperature, drugs, and C-reactive protein level during the treatment.(2003) reported systemic B. cereus infection in 22 patients among whom 16 were premature infants. Although the mortality rate of B. cereus infection in neonates is not high, the actual incidence of infection of B. cereus or other bacilli is probably higher than reported (Hilliard et al., 2003). This may be attributed to not attempting to identify the exact type of bacilli.Generally, B. cereus is resistant to penicillin and cephalosporins. Studies have reported that B. cereus is sensitive to aminoglycosides, clindamycin, vancomycin, carbapenems, chloramphenicol and erythromycin (Weber et al., 1988). As for systemic infection, vancomycin in combination with another antibiotic (such as an aminoglycoside, clindamycin, etc) is empirically recommended before the results are obtained from susceptibility testing. In addition, contami-nant foreign bodies such as the intravascular catheters and tubes for ventricular shunt should be removed or replaced to avoid persistent and recurrent infection (Sakai et al., 2001).Previous studies have confirmed the effective-ness and necessity of surgical intervention in theBody temperature (°C) Body temperature C reaction protein Right ventricular drainage Left ventricular drainage Ventriculoperitoneal drainage1628 Afr. J. Microbiol. Res.treatment of brain abscess and necrotizing fasciitis, although such surgery may cause damage to tissues. In the present study, a ventriculoperitoneal shunt was considered at the early stage of hydrocephalus, but this strategy was not adopted due to uncontrolled intracerebral infection and positivity of CSF culture. Following long-term anti-infection therapy and external ventricular drainage, the CSF became clear, and the symptoms resolved significantly following ventriculoperi-toneal shunt placement. Although the culture was positive before surgery, following surgery and anti-infection therapy the culture was negative.The improvement of the brain abscess in the present report is attributed to comprehensive therapy. When hydrocephalus was identified, we hesitated to perform ventriculoperitoneal shunting. We postulate that appropriate pharmacotherapy can cure B. cereus-induced brain abscess. Weber et al. (1988) showed in their susceptibility testing that B. cereus was sensitive to imipenem, vancomycin, chloramphenicol, gentamicin, and ciprofloxacin, but insensitive to penicillin and cephaloridine. Except for the treatment with imipenem, their results were largely consistent with those in our report. Luna et al. (2007) found that all 42 B. cereus isolates tested were sensitive to chloramphenicol, ciprofloxacin, gatifloxacin, gentimicin, levofloxacin, linezolid, moxifloxacin, rifampicin, streptomycin, tetracycline, tigecycline and vancomycin. Three B. cereus isolates were insensitive to clindamycin and one isolate was insensitive to clarithromycin and clindamycin. However, not all patients will recover after pharmacotherapy.Generally, when the size of a brain abscess is larger than 2.5 cm in diameter, surgical drainage is required following 6-8 weeks of anti-infection therapy regardless of the pathogen. For patients with hydrocephalus, early surgical cerebral drainage is preferred. In addition, early anti-infection therapy is necessary, but the symptoms may not completely resolve. The residual symptoms may resolve after surgical intervention. Besides anti-infection therapy, for patients with neutropenia, granulocyte colony-stimulating factor is recommended to increase the leukocyte count, which is also critical.Based on the treatment of B. cereus infection, we speculate that early and long-term treatment with sufficient doses of multiple antibiotics is crucial. Once intracerebral infection with or without hydrocephalus is confirmed, active surgical intervention is preferred.REFERENCESBarrie D, Wilson JA, Hoffman PN, Kramer JM (1992). Bacillus cereus meningitis in two neurosurgical patients: an investigation into the source of the organism. J. Infect. 25: 291-297.Berner R, Heinen F, van Velthoven V, Sauer M, Korinthenberg R (1997). Ventricular shunt infection and meningitis due to Bacillus cereus. Neuropediatrics, 28: 333-334.Bert F, Ouahes O, Lambert-Zechovsky N (1995). Brain abscess due to Bacillus macerans following a penetrating periorbital injury. J. Clin. Microbiol., 33: 1950-1953.de Almeida SM, Teive HA, Brandi I, Nabhan SK, Werneck LC, Bittencourt MA, Medeiros CR, Pasquini R, de Mello HH (2003). Fatal Bacillus cereus meningitis without inflammatory reaction in cerebral spinal fluid after bone marrow transplantation. Transplantation, 76: 1533-1534.Ebrahimi CM, Kern JW, Sheen TR, Ebrahimi-Fardooee MA, van Sorge NM, Schneewind O, Doran KS (2009). Penetration of the blood-brain barrier by Bacillus anthracis requires the pXO1-encoded BslA protein. J. Bacteriol., 191: 7165-7173.Gaur AH, Shenep JL (2001). The expanding spectrum of diseases caused by Bacillus cereus. Pediatr. Infect. Dis. J., 20: 533-534.Hilliard NJ, Schelonka RL, Waites KB (2003). Bacillus cereus bacteremia in a preterm neonate. J. Clin. Microbiol., 41: 3441-3444.Jenson HB, Levy SR, Duncan C, Mcintosh S (1989). Treatment of multiple brain abscesses caused by Bacillus cereus. Pediatr. Infect. Dis. J., 8: 795-798.Jones BL, Hanson MF, Logan NA (1992). Isolation of Bacillus licheniformis from a brain abscess following a penetrating orbital injury. J. Infect., 24: 103-104.Kuwabara H, Kawano T, Tanaka M, Kobayashi S, Okabe G, Maruta A, Nagao T, Ishigatsubo Y, Mori H (2006). Cord blood transplantation after successful treatment of brain abscess caused by Bacillus cereus in a patient with acute myeloid leukemia. Rinsho Ketsueki Japanese, 47: 1463-1468.Luna V, King D, Gulledge J, Cannons AC, Amuso PT, Cattani J (2007). Susceptibility of Bacillus anthracis, Bacillus cereus, Bacillus mycoides, Bacillus pseudomycoides and Bacillus thuringiensis to 24 antimicrobials using Sensititre automated microbroth dilution and Etest agar gradient diffusion methods. J. Antimicrob. Chemother., 60: 555-567.Mochiduki Y, Amemiya T, Yabe M (2007). Brain abscess induced by Bacillus licheniformis complications in acute myeloid leukemia (AML) (in Japanese). Kansenshogaku Zasshi, 81: 592-596.Mori T, Tokuhira M, Takae Y, Mori S, Suzuki H, Abe T, Takeuchi T (2002). Successful non-surgical treatment of brain abscess and necrotizing fasciitis caused by Bacillus cereus. Intern. Med., 41: 671-673.Nunes BK, Lacerda RA, Jardim JM (2011). 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听神经瘤 听神经瘤是比较常见颅内肿瘤之一,为桥小脑角常见的良性肿瘤,占80%~90%。多见于30~50岁的中年人,女性多于男性,由于本病的早期初期耳鸣、耳聋和头晕,故多初诊于耳科。 临床表现听神经瘤发生于内听道,压迫内耳道的耳蜗神经、面神经及内听动脉。随着肿瘤的进一步长大,挤压三叉神经、脑干、小脑及后组颅神经,并使脑脊液循环受阻而发生颅内压增高。典型病例的症状、体征出现顺序依次为:耳蜗与前庭功能异常、小脑源性运动失调、邻近神经受累、颅内压增高、脑干受压、小脑危象等。 (1)早期症状:肿瘤直径<2.5cm时为听神经瘤的早期。由于肿瘤在内听道内压迫听神经的耳蜗支和前庭支,早期多表现为缓慢发生的耳鸣、听力减退、眩晕以及步态不稳感等耳蜗与前庭功能障碍的症状。这些常见早期症状可出现其中一个或几个,也可能同时发生,症状出现频率和严重不知程度因人而异,轻者可能不被患者觉察,重者可因反复发作的眩晕或持续存在的步态不稳而影响日常生活。比较少见的早期症状有耳内痒感或刺痛、外耳道后壁麻木、患侧泪液减少等,系中间神经在内听道内受压所致。 (2) 中、晚期症状:伴随肿瘤的不断增大,症状逐渐加重。当肿瘤扩展至桥小脑角,累及周围结构,出现典型桥小脑综合征:累及三叉神经,出现患侧面部感觉异常和麻木、角膜反射迟钝或消失等;若肿瘤阻塞脑脊液循环,可引起脑积水和严重颅内高压症;肿瘤压迫小脑,可出现患侧手足精细运动障碍,行走步态蹒跚不稳等小脑功能障碍;肿瘤压迫脑干,可导致肢力减弱、肢体麻木、感觉时候减退等。肿瘤增大到一定程度,可致颅内压增高,出现头痛、恶心呕吐等症状。患者可因突发脑疝而致死。辅助检查:听神经瘤的诊断首选MRI等影像学检查。如还残留有听力时,可作听力测定,用于比较手术前后疗效评估。1、影像学检查:(1)MRI:为首选的诊断方法,特异性及敏感性均很高。典型听神经瘤表现以内听道为中心的圆或卵圆形肿瘤,T1像上为略低或等信号,T2像上为高信号,可有囊性变或出血。增强扫描见肿瘤明显强化。(2)CT:显示肿瘤效果差于MRI,多为筛查时检查用。但在显示内听道扩大方面有一定优势。2、听力测定及耳科检查:(1)音叉试验:表现为神经性耳聋。(2)电测听检查:表现为神经性耳聋和复聪试验阴性,可与其它神经性耳聋鉴别。(3)脑干听觉诱发电位检查:有助于早期发现听神经瘤。治疗方案听神经瘤的治疗方法主要有三种:随访观察、显微手术切除及立体定向放射治疗(伽玛刀)。对年龄较大(超过70岁)或寿命有限,没有脑干受压或脑积水的病人,可随访观察,定期复查MRI,监测肿瘤生长情况。对于肿瘤直径小于3cm、不愿意行手术治疗、一般身体状况差的老年病人,可采用伽玛刀治疗,伽玛刀还用于手术后肿瘤残留的辅助治疗。一般而言,伽玛刀对肿瘤的控制率低于手术,但安全性及面神经保存明显优于手术。手术是治疗听神经瘤最有效的方法,随着显微技术的发展,听神经瘤的手术全切率、听神经的保全率均显著提高。手术入路的选择需考虑到肿瘤的大小、位置、病人的听力及术者的经验,主要有以下三种入路:枕下乙状窦后入路、经迷路入路及颅中窝入路。对肿瘤突出内听道且直径大于3cm者一般采用枕下乙状窦后入路,术中在尽可能地切除肿瘤,同时尽量减少对脑干的牵拉,避免神经的损伤,特别是面神经的保护,可在术中行面神经监测,提高面神经保全率。