Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky.
Oper Neurosurg (Hagerstown). 2018 May 1;14(5):503-514. doi: 10.1093/ons/opx160.
Purely ventral foramen magnum meningiomas are challenging tumors to treat given their location, and proximity and relationship to vital neurovascular structures.
To present endoscopic endonasal surgery (EES) as a complementary approach to the far-lateral suboccipital approach (FLA) for ventral midline tumors.
From May 2008 to October 2013, 5 patients underwent EES and 5 FLA for primary ventral foramen magnum meningiomas. We retrospectively reviewed their records to evaluate outcomes.
Nine of 10 patients presented with long-tract and lower cranial nerve deficits. All patients who presented with deficits preoperatively completely normalized after tumor resection regardless of approach. Gross total resection was achieved in 2 cases in the EES group and 4 cases in the FLA group (the rest were near total). Vascular encasement was a limitation to gross total resection with both approaches. Preoperative median Karnofsky Performance Scale score was 80 and improved to 100 in both groups. Following EES, 1 patient developed cerebrospinal fluid leak with resultant meningitis. Two patients developed hydrocephalus, one of which developed an epidural abscess following necrosis of the nasoseptal flap, requiring debridement. In the FLA group, 1 patient developed a pseudomeningocele associated with hydrocephalus. One patient developed an abdominal fat graft site hematoma.
Both approaches provide excellent results for resection of ventral foramen magnum meningiomas, with reconstruction and hydrocephalus as the main sources of complication. In our practice, EES is a preferred technique in ventral, purely midline tumors with limited inferior extension and reduced lower cranial nerve manipulation, whereas FLA is preferred in tumors with lateral and caudal extension below the tip of the dens.
纯颅底正中脑膜瘤由于其位置、与重要的神经血管结构的毗邻关系，治疗极具挑战性。
介绍内镜经鼻入路（EES）作为远外侧枕下入路（FLA）的补充方法，用于治疗颅底正中肿瘤。
2008 年 5 月至 2013 年 10 月，5 例患者接受 EES，5 例患者接受 FLA 治疗原发性颅底正中脑膜瘤。我们回顾性分析了他们的病历资料，以评估手术结果。
10 例患者中有 9 例存在长束和颅神经低位症状。所有术前存在神经功能缺损的患者，无论采用何种手术入路，肿瘤切除后均完全恢复正常。EES 组有 2 例患者达到全切除，FLA 组有 4 例患者达到全切除（其余为近全切除）。两种手术入路都因血管包绕而限制了全切除。术前中位 Karnofsky 表现量表评分（KPS）为 80 分，两组术后均提高至 100 分。EES 术后 1 例患者发生脑脊液漏并继发脑膜炎。2 例患者发生脑积水，其中 1 例因鼻中隔瓣坏死导致硬膜外脓肿，需清创。FLA 组 1 例患者发生与脑积水相关的假性脑膜膨出。1 例患者发生腹部脂肪移植物部位血肿。
两种手术入路均可为颅底正中脑膜瘤的切除提供良好的结果，重建和脑积水是主要的并发症来源。在我们的实践中，EES 是一种首选的技术，适用于下极延伸有限且低位颅神经操作较少的颅底正中肿瘤；而 FLA 则适用于延伸至侧方和颅底、且延至齿状突尖下方的肿瘤。
