Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, No. 45 Chuangchun Street, Beijing 100053, China.
Chin Med J (Engl). 2010 Feb 5;123(3):274-80.
Vestibular schwannoma, the commonest form of intracranial schwannoma, arises from the Schwann cells investing the vestibular nerve. At present, the surgery for vestibular schwannoma remains one of the most complicated operations demanding for surgical skills in neurosurgery. And the trend of minimal invasion should also be the major influence on the management of patients with vestibular schwannomas. We summarized the microsurgical removal experience in a recent series of vestibular schwannomas and presented the operative technique and cranial nerve preservation in order to improve the rates of total tumor removal and facial nerve preservation.
A retrospective analysis was performed in 145 patients over a 7-year period who suffered from vestibular schwannomas that had been microsurgically removed by suboccipital retrosigmoid transmeatus approach with small craniotomy. CT thinner scans revealed the tumor size in the internal auditory meatus and the relationship of the posterior wall of the internal acoustic meatus to the bone labyrinths preoperatively. Brain stem evoked potential was monitored intraoperatively. The posterior wall of the internal acoustic meatus was designedly drilled off. Patient records and operative reports, including data from the electrophysiological monitoring, follow-up audiometric examinations, and neuroradiological findings were analyzed.
Total tumor resection was achieved in 140 cases (96.6%) and subtotal resection in 5 cases. The anatomical integrity of the facial nerve was preserved in 91.0% (132/145) of the cases. Intracranial end-to-end anastomosis of the facial nerve was performed in 7 cases. Functional preservation of the facial nerve was achieved in 115 patients (Grade I and Grade II, 79.3%). No patient died in this series. Preservation of nerves and vessels were as important as tumor removal during the operation. CT thinner scan could show the relationship between the posterior wall of the internal acoustic meatus and bone labyrinths, that is helpful for a safe drilling of the posterior wall of the internal acoustic meatus.
The goal of every surgery should be the preservation of function of all cranial nerves. Using the retrosigmoid approach with small craniotomy is possible even for large schwannomas. Knowing the microanatomy of the cerebellopontine angle and internal auditory meatus, intraoperating neurophysiological monitoring of the facial nerve function, and the microsurgical techniques of the surgeons are all important factors for improving total tumor removal and preserving facial nerve function.
前庭神经鞘瘤是颅内神经鞘瘤最常见的形式，起源于支配前庭神经的施旺细胞。目前，对于前庭神经鞘瘤的手术仍然是神经外科中最复杂的手术之一，需要手术技巧。微创侵袭的趋势也应该是影响前庭神经鞘瘤患者管理的主要因素。我们总结了最近一系列前庭神经鞘瘤的显微切除经验，并介绍了手术技术和颅神经保留，以提高全肿瘤切除率和面神经保留率。
对 7 年来通过小骨窗经枕下乙状窦后入路显微切除的 145 例前庭神经鞘瘤患者进行回顾性分析。术前 CT 薄层扫描显示内听道内肿瘤大小及内听道后壁与骨迷路的关系。术中监测脑干诱发电位。设计磨除内听道后壁。分析患者记录和手术报告，包括电生理监测、随访听力检查和神经放射学检查的数据。
140 例（96.6%）实现了全肿瘤切除，5 例实现了次全切除。面神经解剖完整性在 145 例患者中得到保留（91.0%，132/145）。7 例进行了面神经颅内端端吻合。115 例（79.3%，I 级和 II 级）患者面神经功能得以保留。本组无死亡病例。术中保护神经和血管与肿瘤切除同样重要。薄层 CT 扫描可显示内听道后壁与骨迷路的关系，有助于安全磨除内听道后壁。
每例手术的目标都应该是保留所有颅神经的功能。即使是大型神经鞘瘤，也可以采用小骨窗乙状窦后入路。了解桥小脑角和内听道的显微解剖结构、术中面神经功能的神经生理监测以及外科医生的显微外科技术都是提高全肿瘤切除率和保留面神经功能的重要因素。
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