He Shi-Ming, Wang Yuan, Zhao Tian-Zhi, Zheng Tao, Lv Wen-Hai, Zhao Lan-Fu, Chen Long, Sterling Cole, Qu Yan, Gao Guo-Dong
Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China.
School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
World Neurosurg. 2016 Jun;90:701.e7-701.e10. doi: 10.1016/j.wneu.2016.02.064. Epub 2016 Feb 23.
Symptomatic cavernous malformations involving the brainstem are difficult to access by conventional approaches, which often require dramatic brain retraction to gain adequate operative corridor. Here, we present a successful endoscopic endonasal transclival approach for resection of a hemorrhagic, symptomatic mesencephalic cavernous malformation.
A 20-year-old woman presented with acute onset of headache, nausea, and vomiting. Computed tomography scan revealed a ventral midbrain hemorrhage. On day 3 of admission, the patient developed left-sided hemiparesis, restriction of medial and lateral left-eye movements, and loss of left pupillary light reflex. Subsequent magnetic resonance imaging demonstrated an increase of the midbrain lesion to 1.2 cm × 1.7 cm. Diffusion tensor imaging showed compression and lateral displacement of the right corticospinal tract near the thalamus and cerebral peduncle. Given the patient's clinical presentation and the findings on imaging, we suspected a mesencephalic cavernous malformation.
The patient underwent an endoscopic endonasal transclival resection of a ventral midline mesencephalon cavernous malformation. A dark red lesion was directly visualized under the endoscope. After a small cortiectomy, the pial and perforator vessels were dissected, and dark-brown blood was drained from the cavernoma cavity. Using a biopsy forceps and with careful attention to the cavernoma borders, the lesion was removed and hemostasis was achieved. Pathologic examination confirmed cavernous malformation. One week after the operation, magnetic resonance imaging demonstrated total resection of the lesion. A 3-month follow-up revealed improved neurologic symptoms with minimal surgical morbidity.
涉及脑干的有症状海绵状血管畸形难以通过传统方法处理，传统方法通常需要大幅度牵拉脑组织以获得足够的手术操作通道。在此，我们报告一例成功采用内镜经鼻经斜坡入路切除出血性、有症状的中脑海绵状血管畸形的病例。
一名20岁女性，急性起病，出现头痛、恶心和呕吐。计算机断层扫描显示中脑腹侧出血。入院第3天，患者出现左侧偏瘫、左眼内收和外展受限以及左侧瞳孔对光反射消失。随后的磁共振成像显示中脑病变增大至1.2 cm×1.7 cm。弥散张量成像显示丘脑和大脑脚附近右侧皮质脊髓束受压并向外侧移位。根据患者的临床表现和影像学检查结果，我们怀疑为中脑海绵状血管畸形。
该患者接受了内镜经鼻经斜坡入路切除中脑腹侧中线海绵状血管畸形。在内镜下直接观察到一个暗红色病变。在进行小范围皮质切除术后，解剖软脑膜和穿支血管，从海绵状血管瘤腔内引出深褐色血液。使用活检钳并仔细注意海绵状血管瘤边界，切除病变并实现止血。病理检查证实为海绵状血管畸形。术后1周，磁共振成像显示病变完全切除。3个月随访显示神经症状改善，手术并发症极少。
