本文關鍵詞： 聽神經鞘瘤 面神經 保護 乙狀竇后入路　出處：《大連醫(yī)科大學》2014年碩士論文　論文類型：學位論文

【摘要】：目的：聽神經鞘瘤是生發(fā)于聽神經鞘的一種良性腫瘤，多次復發(fā)亦不發(fā)生惡變和轉移，發(fā)病率約占顱內腫瘤的8%-12%，占小腦橋腦角腫瘤總數75%-95%。成年人多見，平均發(fā)病年齡37.3歲，發(fā)病年齡高峰為30-49歲，占總數的60%；15歲以下和65歲以上罕見，無明顯性別差異。腫瘤大多位于一側，基本平均分布于左、右兩側，少數為雙側，雙側聽神經鞘瘤屬于神經纖維瘤病，為神經纖維瘤�、蛐停且环N常染色體顯性遺傳的系統(tǒng)性疾病。聽神經鞘瘤的持續(xù)生長會造成顱神經的損傷，如聽力的減退、聽力喪失、面癱、小腦共濟失調等癥狀，造成患者心理、生理上的傷害。在手術治療上，如能全切腫瘤，即可獲得永久治愈。近年來隨著顯微技術的高速發(fā)展，神經外科醫(yī)生在治療聽神經鞘瘤上，已從全切腫瘤，發(fā)展到追求更加完美的愈后，，最小的損傷、面神經功能的保留等等。本文主要從手術入路的優(yōu)缺點、切口選擇的利弊、術中腫瘤切除要點、術后并發(fā)癥展開討論，以求在手術切除聽神經鞘瘤的同時增加面神經保留率上進一步提高。 方法：回顧性分析自2002年以來，我科聽神經鞘瘤手術治療患者共196例，其中包含6例為神經纖維瘤病II型。其中男性92例，女性104例。年齡27~70歲，平均50歲。病程1個月~28年，平均3年5個月。腫瘤位于左側89例，右側107例。術前表現：患側耳鳴、聽力下降144例，聽力喪失52例，面部麻木120例，聲音嘶啞、嗆咳32例，面癱60例，肢體共濟障礙80例，頭痛、視力下降56例，前庭神經功能障礙12例，患側肢體病理征陽性4例，卒中患者4例。總結手術經驗，在手術入路、骨瓣成型、關鍵孔的選擇、腫瘤切除方法等優(yōu)缺點比較，探討面神經保留手術技巧。 結果：196病例中腫瘤鏡下全切除181例，次全切除15例。術后病理均證實術前診斷。面神經解剖保留187例，保留未成功9例，面神經功能保留176例，術后出現小腦血腫1例，上呼吸道感染10例，無死亡病例。出院后1-12個月隨訪面神經功能狀態(tài)H-B分級：I級88例（45.0%）、II級64例（33.0%），III級33例（17.0%），IV級11例(6.0％)，V-VI級0例。 結論：通過本組手術病例的臨床實踐，得出90%以上聽神經鞘瘤可通過“乙狀竇后入路”手術治療，全切率不低于“迷路入路”，在面神經解剖保留率可達95%以上。對于經驗豐富的神經外科醫(yī)師，術中電測聽不是手術必須條件，我科手術中面神經解剖保留率與文獻報道術中電測聽保留率無明顯差異，但術中電生理監(jiān)測可降低手術醫(yī)生技術“門檻”，對于經驗不足醫(yī)生在切除腫瘤過程中，更好的提高面神經保留率。針對后顱窩手術，術中嚴密縫合硬膜減少腦脊液漏，可降低術后發(fā)熱機率。對于極個別巨大聽神經鞘瘤，無需分期手術，可一期行顳底乙狀竇聯(lián)合入路即可。
[Abstract]:Objective: acoustic neurilemmoma is a kind of benign tumor arising from acoustic nerve sheath. The incidence rate of acoustic neurilemmoma is about 8-12 in intracranial tumors and 75-95in cerebellopontine angle tumors. The average age of onset is 37.3 years. The peak age of onset was 30-49 years old, accounting for 60% of the total number of patients under 15 years old and over 65 years old, there was no significant gender difference. Most of the tumors were located on one side, basically distributed on the left, right side, and a few on both sides. Bilateral acoustic schwannomas belong to neurofibromatosis type II neurofibromatosis, which is an autosomal dominant inherited systemic disease. The sustained growth of acoustic neurinoma causes cranial nerve damage, such as hearing loss and hearing loss. Facial paralysis, cerebellar ataxia and other symptoms cause psychological and physiological injuries to patients. In surgical treatment, if the tumor can be completely removed, it can be cured permanently. In recent years, with the rapid development of microtechnology, In the treatment of acoustic schwannoma, neurosurgeons have developed from total resection of the tumor to the pursuit of a more perfect recovery, minimal injury, preservation of facial nerve function, etc. In this paper, the advantages and disadvantages of the surgical approach, the advantages and disadvantages of the incision selection, etc. The main points of tumor resection and postoperative complications were discussed in order to increase the rate of facial nerve preservation while removing acoustic schwannoma. Methods: a total of 196 patients with acoustic schwannoma were retrospectively analyzed since 2002, including 6 patients with neurofibromatosis type II, including 92 males and 104 females aged 2770 years. The mean age was 50 years. The course of disease ranged from 1 month to 28 years, with an average of 3 years and 5 months. The tumor was located in 89 cases on the left side and 107 cases on the right side. Preoperative manifestations included tinnitus, 144 cases of hearing loss, 52 cases of hearing loss, 120 cases of facial numbness, 120 cases of hoarseness, 32 cases of choking and coughing. There were 60 cases of facial paralysis, 80 cases of limb palsy, 56 cases of headache, 56 cases of visual acuity loss, 12 cases of vestibular nerve dysfunction, 4 cases of pathological sign of affected limbs and 4 cases of stroke. To compare the advantages and disadvantages of the choice of critical foramen and the method of tumor resection, the technique of facial nerve preservation surgery was discussed. Results among them, 181 cases had total resection of tumor under microscope, 15 cases had subtotal resection. Postoperative pathology confirmed preoperative diagnosis. The facial nerve was preserved in 187 cases, failed in 9 cases, facial nerve function in 176 cases, and cerebellar hematoma in 1 case after operation. There were 10 cases of upper respiratory tract infection, and no death cases. From 1 to 12 months after discharge, the functional status of facial nerve was followed up in 88 cases with grade 1: 1 of facial nerve function. There were 64 cases with grade I of grade 45.0 and 64 cases of grade II with 33 cases of grade III and 33 cases of grade III with 17.0D grade IV. There were 11 cases of grade IV with histopathological grade (n = 11) and grade V VI (n = 6. 0). Conclusion: through the clinical practice of this group of patients, it is concluded that more than 90% acoustic neurilemmoma can be treated by "retrosigmoid sinus approach". The rate of total resection is not lower than that of "labyrinth approach", and the anatomic retention rate of facial nerve can reach more than 95%. For an experienced neurosurgeon, electric audiometry during operation is not a necessary condition for surgery. There was no significant difference between the anatomic retention rate of facial nerve in our surgery and that reported in the literature. However, electrophysiological monitoring during operation can lower the technical threshold of the surgeon. For posterior cranial fossa surgery, close suture of dural to reduce cerebrospinal fluid leakage can reduce the chance of postoperative fever. For a few giant acoustic neurinomas, there is no need for staging surgery. One-stage sigmoid sinus approach can be performed.
【學位授予單位】：大連醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R739.4

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