Serra Carlo, Türe Hatice, Yaltırık Cumhur Kaan, Harput Mehmet Volkan, Türe Uğur
Departments of1Neurosurgery and.
3Department of Neurosurgery, Clinical Neuroscience Centre, University Hospital Zürich, University of Zürich, Switzerland.
J Neurosurg. 2020 Oct 2;135(2):458-468. doi: 10.3171/2020.6.JNS20524. Print 2021 Aug 1.
The object of this study was to present the surgical results of a large, single-surgeon consecutive series of patients who had undergone transcisternal (TCi) or transcallosal-transventricular (TCTV) endoscope-assisted microsurgery for thalamic lesions.
This is a retrospective study of a consecutive series of patients harboring thalamic lesions and undergoing surgery at one institution between February 2007 and August 2019. All surgical and patient-related data were prospectively collected. Depending on the relationship between the lesion and the surgically accessible thalamic surfaces (lateral ventricle, velar, cisternal, and third ventricle), one of the following surgical TCi or TCTV approaches was chosen: anterior interhemispheric transcallosal (AIT), posterior interhemispheric transtentorial subsplenial (PITS), perimedian supracerebellar transtentorial (PeST), or perimedian contralateral supracerebellar suprapineal (PeCSS). Since January 2018, intraoperative MRI has also been part of the protocol. The main study outcome was extent of resection. Complete neurological examination took place preoperatively, at discharge, and 3 months postoperatively. Descriptive statistics were calculated for the whole cohort.
In the study period, 92 patients underwent surgery for a thalamic lesion: 81 gliomas, 6 cavernous malformations, 2 germinomas, 1 metastasis, 1 arteriovenous malformation, and 1 ependymal cyst. In none of the cases was a transcortical approach adopted. Thirty-five patients underwent an AIT approach, 35 a PITS, 19 a PeST, and 3 a PeCSS. The mean follow-up was 38 months (median 20 months, range 1-137 months). No patient was lost to follow-up. The mean extent of resection was 95% (median 100%, range 21%-100%), and there was no surgical mortality. Most patients (59.8%) experienced improvement in their Karnofsky Performance Status. New permanent neurological deficits occurred in 8 patients (8.7%). Early postoperative (< 3 months after surgery) problems in CSF circulation requiring diversion occurred in 7 patients (7.6%; 6/7 cases in patients with high-grade glioma).
Endoscope-assisted microsurgery allows for the removal of thalamic lesions with acceptable morbidity. Surgeons must strive to access any given thalamic lesion through one of the four accessible thalamic surfaces, as they can be reached through either a TCTV or TCi approach with no or minimal damage to normal brain parenchyma. Patients harboring a high-grade glioma are likely to develop a postoperative disturbance of CSF circulation. For this reason, the AIT approach should be favored, as it facilitates a microsurgical third ventriculocisternostomy and allows intraoperative MRI to be done.
本研究的目的是展示由单一外科医生连续治疗的大量患者经小脑幕下入路（TCi）或经胼胝体-脑室入路（TCTV）内窥镜辅助显微手术治疗丘脑病变的手术结果。
这是一项对2007年2月至2019年8月期间在同一机构接受手术的一系列丘脑病变患者的回顾性研究。所有手术和患者相关数据均前瞻性收集。根据病变与可手术到达的丘脑表面（侧脑室、小脑幕、脑池和第三脑室）之间的关系，选择以下手术TCi或TCTV入路之一：前半球间经胼胝体（AIT）、后半球间经小脑幕下脾下（PITS）、中脑旁小脑幕上（PeST）或中脑旁对侧小脑幕上松果体上（PeCSS）。自2018年1月起，术中MRI也成为方案的一部分。主要研究结果是切除范围。术前、出院时和术后3个月进行全面神经学检查。对整个队列进行描述性统计。
在研究期间，92例患者因丘脑病变接受手术：81例胶质瘤、6例海绵状畸形、2例生殖细胞瘤、1例转移瘤、1例动静脉畸形和1例室管膜囊肿。所有病例均未采用经皮质入路。35例患者采用AIT入路，35例采用PITS，19例采用PeST，3例采用PeCSS。平均随访38个月（中位数20个月，范围1 - 137个月）。无患者失访。平均切除范围为95%（中位数100%，范围21% - 100%），无手术死亡。大多数患者（59.8%）的卡氏功能状态有所改善。8例患者（8.7%）出现新的永久性神经功能缺损。7例患者（7.6%；高级别胶质瘤患者中6/7例）术后早期（术后<3个月）出现脑脊液循环问题需要分流。
内窥镜辅助显微手术能够以可接受的发病率切除丘脑病变。外科医生必须努力通过四个可到达的丘脑表面之一接近任何给定的丘脑病变，因为可以通过TCTV或TCi入路到达，对正常脑实质无损伤或损伤最小。患有高级别胶质瘤的患者术后可能会出现脑脊液循环障碍。因此，应优先选择AIT入路，因为它便于进行显微手术第三脑室造瘘术，并允许进行术中MRI检查。
