Griessenauer Christoph J, Tubbs R Shane, Cohen-Gadol Aaron A
Division of Neurosurgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
Int J Surg Case Rep. 2013;4(10):842-5. doi: 10.1016/j.ijscr.2013.07.005. Epub 2013 Jul 16.
The authors explore a combined infratentorial-supracerebellar and telovelar approach in an adult, while avoiding vermian-splitting methods for a large, midline, fourth-ventricular tumor, unapproachable though a single traditional route. Experience with a combined surgical approach for pediatric patients has been published, but the authors believe that describing this combined method in an adult will provide a preliminary experience for further exploration of this approach in other adult patients.
The authors present a review of the literature along with the case of a 60-year-old man with slight ataxia who presented with a 1-month history of gait difficulty and memory lapse. His MRI of the brain showed mild hydrocephalus and a large tumor of the fourth ventricle. Surgical removal through a suboccipital craniotomy was attempted, and part of the tumor overlying the tectum and the superior cerebellar velum was removed without difficulty. However, despite inferior retraction of the vermis, which allowed further resection of the tumor from the fourth ventricle, residual tumor in the caudal surgical resection cavity was present. Partial transection of the vermis was considered, but avoided because of potential neurological deficits. Instead, the authors redirected their approach and exposed the residual tumor by transecting the inferior medullary velum and removed additional tumor while avoiding the floor of the fourth ventricle. The infratentorial-supracerebellar and telovelar approach resulted in total gross resection of the tumor.
For patients with large midline tumors that arise from the superior vermis or the quadrigeminal plate and fill the upper third of the fourth ventricular space, this combined approach may offer a unique possibility of safe tumor removal.
This case demonstrates the benefit of a combined approach for a select group of patients.
作者探讨了一种针对成人的联合幕下小脑上和小脑幕下入路，用于处理巨大的、位于中线的第四脑室肿瘤，避免采用蚓部切开方法，因为单一传统入路难以处理此类肿瘤。关于小儿患者联合手术入路的经验已有报道，但作者认为描述成人的这种联合方法将为在其他成年患者中进一步探索该入路提供初步经验。
作者在回顾文献的同时，介绍了一名60岁男性患者的病例，该患者有轻微共济失调，有1个月的步态困难和记忆力减退病史。他的脑部MRI显示轻度脑积水和第四脑室巨大肿瘤。尝试通过枕下开颅手术切除肿瘤，轻松切除了覆盖顶盖和小脑上蚓部的部分肿瘤。然而，尽管对蚓部下牵，使得能够从第四脑室进一步切除肿瘤，但在手术切除腔的尾部仍有残留肿瘤。考虑过部分切断蚓部，但因可能导致神经功能缺损而避免。相反，作者改变入路，通过切断下髓帆暴露残留肿瘤，并在避免损伤第四脑室底部的情况下切除了更多肿瘤。联合幕下小脑上和小脑幕下入路实现了肿瘤的全切除。
对于起源于上蚓部或四叠体板、占据第四脑室上部三分之一空间的巨大中线肿瘤患者，这种联合入路可能提供安全切除肿瘤的独特可能性。
本病例证明了联合入路对特定患者群体的益处。
