1Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya City, Aichi, Japan.
2Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan; and.
J Neurosurg. 2023 Aug 4;140(2):469-477. doi: 10.3171/2023.6.JNS23324. Print 2024 Feb 1.
Surgical treatment of brainstem cavernous malformations (CMs) is challenging. Surgery using the endoscopic transsphenoidal transclival approach (eTSTCA) is reported as a useful alternative for ventral brainstem CMs. However, CMs located in the ventral midline of the brainstem are rare, and only a small number of case reports on these CMs treated with the eTSTCA exist. The efficacy and safety of the eTSTCA have not yet been fully examined.
A retrospective analysis was performed for 5 consecutive patients who underwent surgery via the eTSTCA for treating ventral pontine CMs.
The average maximum CM diameter was 26.0 mm (18-38 mm). All patients underwent MR-diffusion tensor imaging, which confirmed that the corticospinal tract (CST) deviated posteriorly or laterally to the CM. Direct brainstem cortical stimulation was performed to localize the CST before making the cortical incision. After the excision of the CM, the cavity was filled with artificial CSF to make an aqueous surgical field (wet-field technique) for observing the tumor cavity and confirming complete hemostasis and resection. Total removal was achieved in all patients. The preoperative modified Rankin Scale score was 3 in 3 patients and 4 in 2 patients, whereas it was 1 in 2 patients and 0 in 3 patients 3 months after surgery. Postoperative CSF leakage was observed in 1 patient, and transient abducens nerve palsy was observed in 1 patient. No other intra- or postoperative complications were observed.
MR-diffusion tensor imaging and direct brainstem cortical stimulation were useful to ascertain the proximity of the CST to the CM. The endoscope provides a clear view even underwater, and it was safe and effective to observe the entire CM cavity and confirm complete hemostasis without additional retraction of the brainstem parenchyma, including the CST. The eTSTCA provides a direct access point to the lesion and may be a safer alternative treatment for patients whose CST deviates laterally or posteriorly to the CM.
脑干海绵状血管畸形（CM）的手术治疗具有挑战性。经内镜经蝶窦经颅底入路（eTSTCA）被报道为治疗脑干腹侧 CM 的一种有用的替代方法。然而，位于脑干腹中线的 CM 很少见，仅有少数关于这些 CM 采用 eTSTCA 治疗的病例报告。eTSTCA 的疗效和安全性尚未得到充分检查。
对 5 例连续采用 eTSTCA 手术治疗腹侧桥脑 CM 的患者进行回顾性分析。
平均最大 CM 直径为 26.0 毫米（18-38 毫米）。所有患者均行磁共振弥散张量成像（MR-DTI）检查，证实皮质脊髓束（CST）偏离 CM 后或外侧。在做皮质切口前，行直接脑干皮质刺激以定位 CST。CM 切除后，用人工 CSF 填充空腔，形成水性手术视野（湿场技术），观察肿瘤腔并确认完全止血和切除。所有患者均实现完全切除。术前改良 Rankin 量表评分 3 分 3 例，4 分 2 例，术后 3 个月 1 例 1 分，3 例 0 分。1 例患者术后出现脑脊液漏，1 例患者出现短暂性展神经麻痹。无其他术中或术后并发症。
MR-DTI 和直接脑干皮质刺激有助于确定 CST 与 CM 的接近程度。内镜即使在水下也能提供清晰的视野，安全有效地观察整个 CM 腔，并确认完全止血，无需进一步牵拉包括 CST 在内的脑干实质。eTSTCA 为病变提供了直接的入路，对于 CST 偏离 CM 外侧或后侧的患者，可能是一种更安全的替代治疗方法。
