Aboul-Enein Hisham, El-Aziz Sabry Ahmed Abd, Hafez Farhoud Ahmed
Department of Neurosurgery, Alexandria Medical School, Egypt.
Department of Neurosurgery, Alexandria Medical School, Egypt.
Clin Neurol Neurosurg. 2015 Dec;139:100-9. doi: 10.1016/j.clineuro.2015.08.009. Epub 2015 Sep 25.
Surgical treatment for lesions in the posterior third ventricle is technically challenging. Surgical approaches to this area carries a risk of both venous and neural injury, with subsequent morbidity. Several approaches are used to reach the pineal region. The supracerebellar infratentorial approach is the commonly approach used for such lesions.
This work describes adding a paramedian expansion to the "classical median supracerebellar infratentorial approach" for posterior third ventricular and pineal region lesions with lateral expansion. This study discusses the results concerning the extent of removal and surgical complications for this procedure. Contralateral paramedian expansion is used for targeting lesions inside the posterior third ventricle extending to the lateral ventricular wall and thalamus. Ipsilateral paramedian expansion was used in resecting collicular lesions.
The authors operated on patients suffering from lesions in the pineal region using a paramedian expanded SCTT approach between 2007 and 2014. The prone position was used in 25 cases. A typical median suboccipital craniotomy with a paramedian expansion was performed. Ipsilateral expansion of the approach has been used for targeting lesions in the pineal region but outside the posterior third ventricle. Contralateral expansion provides a direct view of the lateral walls of the third ventricle.
We encountered 28 cases of different pathologies: fourteen patients suffered from pineal body tumors while twelve had glial tumors, one case of cavernoma. Obstructive hydrocephalus was treated by CSF diversion before tumor surgery. Postoperative complications included ataxia, double vision, and Parinaud's syndrome.
The merit of the expanded supracerebellar infratentorial approach is adding a unilateral paramedian expansion to the classical approach. This paramedian expansion offers a better lateral and inferior tumor resection. This approach does not add any risk of more postoperative complications or jeopardizing the neurological state than the classical midline approach.
The paramedian expansion offers a better lateral and inferior tumor resection and a better view of the contralateral extension within the posterior third ventricle. Collicular lesions are better controlled using this approach by gentle inferior and lateral retraction of the cerebellum. The expanded supracerebellar infratentorial approach allows for working on the lateral tumor extension without jeopardizing the deep venous system.
第三脑室后部病变的手术治疗在技术上具有挑战性。该区域的手术入路存在静脉和神经损伤风险及相应的并发症。有多种入路可到达松果体区。小脑上幕下入路是针对此类病变常用的入路。
本文描述了在“经典的正中小脑上幕下入路”基础上增加旁正中扩展，用于治疗有侧向扩展的第三脑室后部及松果体区病变。本研究讨论了该手术在切除范围及手术并发症方面的结果。对侧旁正中扩展用于针对延伸至侧脑室壁和丘脑的第三脑室后部内的病变。同侧旁正中扩展用于切除顶盖病变。
作者在2007年至2014年间采用旁正中扩展的小脑上幕下（SCTT）入路对松果体区病变患者进行手术。25例采用俯卧位。进行了典型的正中枕下开颅并带有旁正中扩展。入路的同侧扩展用于针对松果体区内但在第三脑室后部以外的病变。对侧扩展可直接观察第三脑室侧壁。
我们遇到28例不同病理情况的病例：14例为松果体瘤患者，12例为胶质瘤，1例海绵状血管瘤。肿瘤手术前通过脑脊液分流治疗梗阻性脑积水。术后并发症包括共济失调、复视和帕里诺德综合征。
扩展的小脑上幕下入路的优点是在经典入路基础上增加了单侧旁正中扩展。这种旁正中扩展能更好地进行外侧和下方肿瘤切除。与经典中线入路相比，该入路不会增加更多术后并发症风险或危及神经状态。
旁正中扩展能更好地进行外侧和下方肿瘤切除，并能更好地观察第三脑室后部内的对侧延伸情况。通过轻柔地向下和向外侧牵拉小脑，使用该入路能更好地控制顶盖病变。扩展的小脑上幕下入路允许在不危及深静脉系统的情况下处理肿瘤的外侧延伸。
