避免开颅手术：术中亚甲蓝在中线皮样囊肿管理中的作用
Sparing a Craniotomy: The Role of Intraoperative Methylene Blue in Management of Midline Dermoid Cysts.
作者信息
Phelan Alannah L, Jones Christine M, Ceschini Ashley S, Henry Cathy R, Mackay Donald R, Samson Thomas D
机构信息
Hershey, Pa.
From the Division of Plastic Surgery, Penn State Hershey Medical Center.
出版信息
Plast Reconstr Surg. 2017 Jun;139(6):1445-1451. doi: 10.1097/PRS.0000000000003369.
BACKGROUND
Midline nasal dermoid cysts are rare congenital anomalies that extend intracranially in approximately 10 percent of cases. Cysts with intracranial extension require a craniotomy to avoid long-term complications, including meningitis, abscesses, and cavernous sinus thrombosis. Current guidelines recommend preoperative imaging with either magnetic resonance imaging or computed tomography to determine appropriate management.
METHODS
Patients who underwent excision of a midline nasal dermoid cyst between January 1995 and September 2016 were identified using Current Procedural Terminology codes. In cases with equivocal imaging findings or uncertain stalk extent during surgical dissection, methylene blue was used intraoperatively. Demographics, preoperative imaging findings, intraoperative dye findings, surgical approach, and complications were collected.
RESULTS
A total of 66 midline dermoid cyst excisions were identified; 17 (25.8 percent) had intracranial extension requiring craniotomy. Preoperative imaging showed a subcutaneous cyst in 41 (62.1 percent), intraosseous tracking in three (4.5 percent), and intracranial extension in 15 (22.7 percent). Twelve patients (18.2 percent) had preoperative imaging that was inconsistent with intraoperative findings. Methylene blue was used in 17 cases and indigo carmine was used in one case. Intraoperative dye findings changed management in five cases, and in three cases a craniotomy was avoided without evidence of cyst recurrence.
CONCLUSIONS
This report is the largest published series of midline dermoid cysts with intracranial extension. In almost 20 percent of cases, preoperative imaging was not consistent with intraoperative findings. Given disparate radiographic and intraoperative findings, methylene blue is a valuable tool that can facilitate appropriate, morbidity-sparing management of midline dermoid cysts.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
背景
中线鼻皮样囊肿是罕见的先天性异常，约10%的病例会向颅内延伸。伴有颅内延伸的囊肿需要开颅手术以避免包括脑膜炎、脓肿和海绵窦血栓形成在内的长期并发症。当前指南推荐术前使用磁共振成像或计算机断层扫描进行影像学检查以确定合适的治疗方案。
方法
使用当前手术操作术语编码识别1995年1月至2016年9月期间接受中线鼻皮样囊肿切除术的患者。在影像学检查结果不明确或手术解剖过程中囊肿蒂范围不确定的病例中，术中使用亚甲蓝。收集人口统计学资料、术前影像学检查结果、术中染料检查结果、手术方式和并发症。
结果
共识别出66例中线皮样囊肿切除术；17例（25.8%）有颅内延伸需要开颅手术。术前影像学检查显示皮下囊肿41例（62.1%），骨内蔓延3例（4.5%），颅内延伸15例（22.7%）。12例患者（18.2%）术前影像学检查结果与术中发现不一致。17例使用亚甲蓝，1例使用靛胭脂。术中染料检查结果改变了5例的治疗方案，3例避免了开颅手术且无囊肿复发迹象。
结论
本报告是已发表的伴有颅内延伸的中线皮样囊肿的最大系列研究。在近20%的病例中，术前影像学检查结果与术中发现不一致。鉴于影像学检查结果和术中发现存在差异，亚甲蓝是一种有价值的工具，可促进对中线皮样囊肿进行合适且能减少并发症的治疗。
临床问题/证据级别：治疗性，四级。
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