Little Kenneth M, Friedman Allan H, Sampson John H, Wanibuchi Masahiko, Fukushima Takanori
Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
Neurosurgery. 2005 Mar;56(3):546-59; discussion 546-59. doi: 10.1227/01.neu.0000153906.12640.62.
Meningiomas arising from the petroclival region remain a challenging surgical problem. Because of the substantial risk of neurological morbidity, uniformly pursuing a gross total resection (GTR) to minimize tumor recurrence rates may not be justified. We sought to define optimal resection goals based on risk factors for postoperative neurological morbidity and tumor recurrence rates.
This series represents our experience with 137 meningiomas arising from the petroclival region resected between June 1993 and October 2002. There were 38 male and 99 female patients with a mean age of 53 years.
GTR was achieved in 40% of patients, and near total resection (NTR) was achieved in 40% of patients. One operative death occurred. Twenty-six percent of patients experienced new postoperative cranial nerve deficits, paresis, or ataxia when assessed at a mean follow-up of 8.3 months. The risk of cranial nerve deficits increased with prior resection (P < 0.001), preoperative cranial nerve deficit (P = 0.005), tumor adherence to neurovascular structures (P = 0.046), and fibrous tumor consistency (P = 0.005). The risk of paresis or ataxia increased with prior resection (P = 0.001) and tumor adherence (P = 0.045). Selective NTR rather than GTR in patients with adherent or fibrous tumors significantly reduced the rate of neurological deficits. Radiographic recurrence or progression occurred in 17.6% of patients at a mean follow-up of 29.8 months. Tumor recurrence rates after GTR and NTR did not differ significantly (P = 0.111).
Intraoperatively defined tumor characteristics played a critical role in identifying the subset of patients with an increased risk of postoperative deficits. By selectively pursuing an NTR rather than a GTR, neurological morbidity was reduced significantly without significantly increasing the rate of tumor recurrence.
起源于岩斜区的脑膜瘤仍是一个具有挑战性的外科问题。由于存在显著的神经功能缺损风险，一味追求全切以降低肿瘤复发率可能并不合理。我们试图根据术后神经功能缺损和肿瘤复发率的危险因素来确定最佳切除目标。
本系列代表了我们在1993年6月至2002年10月间切除的137例起源于岩斜区脑膜瘤的经验。有38例男性和99例女性患者，平均年龄53岁。
40%的患者实现了全切，40%的患者实现了近全切。发生了1例手术死亡。在平均8.3个月的随访评估中，26%的患者出现了新的术后颅神经缺损、轻瘫或共济失调。颅神经缺损的风险随着既往手术（P < 0.001）、术前颅神经缺损（P = 0.005）、肿瘤与神经血管结构的粘连（P = 0.046）以及肿瘤质地硬（P = 0.005）而增加。轻瘫或共济失调的风险随着既往手术（P = 0.001）和肿瘤粘连（P = 0.045）而增加。对于肿瘤粘连或质地硬的患者，选择近全切而非全切可显著降低神经功能缺损的发生率。在平均29.8个月的随访中，17.6%的患者出现影像学复发或进展。全切和近全切后的肿瘤复发率无显著差异（P = 0.111）。
术中确定的肿瘤特征在识别术后缺损风险增加的患者亚组中起关键作用。通过选择性地进行近全切而非全切，可显著降低神经功能缺损发生率，而不会显著增加肿瘤复发率。
