Sekhar L N, Swamy N K, Jaiswal V, Rubinstein E, Hirsch W E, Wright D C
Department of Neurological Surgery, George Washington University, DC.
J Neurosurg. 1994 Dec;81(6):860-8. doi: 10.3171/jns.1994.81.6.0860.
Neurological deterioration is commonly seen after surgical excision of clival meningiomas; however, an understanding of the risk factors associated with postoperative deterioration can lead to improvements in outcome. In 75 patients with clival meningiomas operated on over a 7-year period, the following data were studied; preoperative variables such as presenting Karnofsky scale score, age, sex, and prior operations or radiation therapy. Radiological findings on magnetic resonance imaging or arteriography, such as the development of the arachnoidal cleavage plane between tumor and the brain stem, brainstem edema, tumor size, extent of compression on the brain stem, vascular encasement, and blood supply from the basilar artery were among other data studied. In addition, intraoperative findings such as development of the arachnoid plane, vascular encasement, and the difficulty of dissection were noted. Finally, each patient's neurological and functional statuses were recorded at 1 week postoperatively and at follow-up examinations. Early postoperative functional deterioration occurred in 45 patients (60%) and ranged from mild (30 patients) to severe (three patients). Significant improvement had occurred by the time of follow-up examination in all but four patients; however, permanent postoperative dysfunction was present in 12 patients. Statistical analysis revealed significant correlations between early functional deterioration and preoperative Karnofsky scale scores, male gender, radiological findings of the absence of an arachnoid plane, edema of the brain stem, and arteriographic supply from the basilar artery. Operative features included difficulty with dissection, an absent arachnoidal cleavage plane, and incomplete tumor resection. Permanent functional deterioration was statistically associated with the following: blood supply from the basilar artery, difficulty of dissection, incomplete tumor resection, and early postoperative dysfunction. Logistical regression analysis revealed that the most important risk factor for early postoperative deterioration was tumor size. Patients with large or giant tumors had a 6.7 to 13 times greater risk of functional deterioration, respectively, than patients with small- or medium-sized tumors. Excluding tumor size, the most important factor for permanent deterioration was blood supply from the basilar artery. Patients in this category had a 4.4 times greater risk of permanent functional deterioration. Three stages of tumor relationship to the brainstem arachnoid and pial membranes are proposed. Based on the results of this clinical study of clival meningiomas, suggestions are made for changes in the management strategy of these difficult lesions.
斜坡脑膜瘤手术切除后常出现神经功能恶化；然而，了解与术后恶化相关的危险因素可改善治疗结果。在7年期间接受手术的75例斜坡脑膜瘤患者中，研究了以下数据；术前变量，如卡氏评分、年龄、性别以及既往手术或放疗情况。磁共振成像或血管造影的影像学表现，如肿瘤与脑干之间蛛网膜分离平面的形成、脑干水肿、肿瘤大小、脑干受压程度、血管包裹以及基底动脉供血等也是研究的数据。此外，还记录了术中所见，如蛛网膜平面的形成、血管包裹以及分离难度。最后，记录每位患者术后1周及随访时的神经和功能状态。术后早期功能恶化发生在45例患者（60%）中，程度从轻度（30例患者）到重度（3例患者）不等。除4例患者外，所有患者在随访时均有显著改善；然而，12例患者存在永久性术后功能障碍。统计分析显示，早期功能恶化与术前卡氏评分、男性、无蛛网膜平面的影像学表现、脑干水肿以及基底动脉供血的血管造影表现之间存在显著相关性。手术特征包括分离困难、无蛛网膜分离平面以及肿瘤切除不完全。永久性功能恶化在统计学上与以下因素相关：基底动脉供血、分离困难、肿瘤切除不完全以及术后早期功能障碍。逻辑回归分析显示，术后早期恶化的最重要危险因素是肿瘤大小。与中小型肿瘤患者相比，大型或巨大肿瘤患者功能恶化的风险分别高6.7至13倍。排除肿瘤大小因素，永久性恶化的最重要因素是基底动脉供血。此类患者永久性功能恶化的风险高4.4倍。提出了肿瘤与脑干蛛网膜和软脑膜关系的三个阶段。基于这项斜坡脑膜瘤临床研究的结果，对这些疑难病变的治疗策略变化提出了建议。
