毛颖医生的科普号

发表在《中华神经外科杂志》2015.5脑干海绵状血管瘤（Brainstem Cavernous Malformation, BSCM）的生物学行为，尤其是考虑脑干体积计算的发病率和病灶的显性出血率，与其他部位的海绵状血管瘤殊为不同。随着MRI普及，发现许多原发性脑干出血是由BSCM引起，早期出血呈现均一的血肿信号或夹杂少许不规则低信号，在随后1-6周随着血肿液化和吸收，在高信号背景下呈现出较为典型的海绵状血管瘤特征，但少数微小BSCM仍然仅表现为小的结节灶附于血肿侧壁。所谓的显性出血大多表现为头昏、呕吐、肢体麻木或行动障碍、面瘫、吞咽或发音障碍等，少数出现嗜睡，极少数会危及生命[1]。症状一般会在几天内达峰并在此后数周持续缓解，后遗症状可能非常轻微，但有较高的再出血危险，尤其是在前一次出血的两年内。部分患者可能在短期内反复出血，导致神经功能持续或波浪式加重。远期部分患者能够自愈。这些认识上的进步主要来自医生的经验，缺乏经过科学设计的BSCM自然史研究。目前大致认为BSCM占所有颅内海绵状血管瘤的9%-35%，年出血率为0.5%-6%，并且年再出血率会明显上升[1]。近年来针对BSCM的医学进步更主要体现在手术效果上。一方面虽然对手术指征、时机、入路还存在一定的争议，但已经逐渐趋向统一的认识，这对提升手术效果大有裨益；另一方面得益于手术技术和工具的进步。一、BSCM的手术指征和时机是否手术？何时手术？这是需要高度个体化考虑的问题。实际上对于这类疾病，有经验的医生对患者术后状态的预估是非常准确的。Lawton根据BSCM的体积大小、是否越过脑干轴心中点、是否存在静脉畸形、年龄是否大于40岁、出血后时间长短制定了一个7分制的BSCM手术预后评估分级量表，与患者的真实预后存在很好的相关性[2]。相比之下，目前对自然史的把握反而未知甚多。笔者经验，关键要看患者症状和MR表现，且不妨提出三个问题：（1）症状是否持续加重或威胁生命？（2）MR上是否能够从高信号血肿背景下分辨出BSCM病灶？（3）是否有合适的入路到达病灶？回答分为是（Y）或非（N）。建议：1Y——急诊手术减压[3, 4]。由于脑干水肿和胶质增生带未形成，不强求切除BSCM以免加重脑干急性期损伤；2Y3Y——手术切除病灶，并追求全切；1N2N3Y，MR只有血肿没有发现BSCM病灶，建议保守并反复复查MR，可以每周一次，在看清BSCM后早期手术。这样做的优点在于探查目的更加明确，避免病灶遗漏，同时血肿已液化而机化尚未形成，便于减压和分离病灶，并且避开了脑干出血后的水肿高峰期[1, 5]。另外问题3的回答有个合适程度的问题，需要权衡后决定。对反复出血、入路简单者当然更倾向于手术，特别是病灶部位表浅，向外生长到达或突出于脑干软脑膜表面者，是手术治疗的理想对象[2, 5]。对病灶较小且埋藏于脑干内深部，入路损伤较大者，可先保守，在患者再次或反复出血后手术[1, 5, 6]。对偶然发现的无症状BSCM，仍缺乏循证推荐方案。由于患者得到的益处是隐性的，而手术损伤和风险是显性的，所以即使病灶位于手术较易到达位置、估计手术损伤较轻时，也要做到患者及家属充分地知情同意，特别注意如实告知病灶未来出血风险的不可预测性。二、BSCM的手术入路这同样是需要高度个体化考虑的问题。经典是采用两点法（Two-point Method）找到距离病灶最近的线路和到达病灶中心点最好的角度，并以此决定手术入路[7]。新的经安全区（Safe entry zone）入路有时会舍近求远，但更有利于保护脑干功能区。解剖上，从脊髓到脑干，中央导管向背侧敞开形成四脑室底部，同时伴随传导束的移位和灰质核团功能柱形成。敞开的四脑室底部多重要灰质核团。由于侧方传导束相对次要，应尽可能利用。特别推荐的是乙状窦后经三叉神经根部周围安全区入路，对同时凸向四脑室底部和桥脑侧方的病灶效果优于经四脑室底入路。为进一步降低手术入路损伤，笔者提出安全点（Safe entry point）入路。因为随着显微技术的进步，已经不需要将入路直接朝向病灶的中心，只需要找到一点，通过细致的分离和牵拉，就可以将病灶从侧方拖出并完全切除，必要时还可以用神经内镜辅助探查。在具体运用时，可将BSCM的入路分为两步：（1）暴露脑干表面，（2）切开脑干表面暴露病灶。第一步根据MR结构相，包括传导束成像决定体位和切口，缺乏经验者可采用影像融合与虚拟现实技术[1, 8]。经小脑延髓裂入路可以减少小脑损伤，显露四脑室底部和延颈背侧；延髓下部和延颈交界可采用小脑扁桃体间入路；俯卧位行幕下小脑上旁正中入路可无牵拉下显露中脑背侧和背外侧，下界可达滑车神经根部；脑干腹侧传统采用眶颧经外侧裂入路，但内镜下经蝶或经斜坡入路会是更加不错的选择[9, 10]。位于脑干侧方者，要注意其与神经根的关系：位于三叉神经上方，可采用经侧裂或颞下入路；位于三叉下方者适用枕下乙状窦后入路；位于后组颅神经附近特别是腹侧者宜采用远外侧入路[1, 11]。第二步需根据脑干局部颜色、形变、核团或重要传导束位置决定脑干表面切开位置。若病灶浅表，显微镜下可见局部黄染或隆起，定位不难，若表面正常则需要根据解剖标记或导航定位决定切开位置。需要提醒的是虽然病灶在T2相会比较明显，但直径也会比实际略大，显得更加靠近甚至突出于脑干表面。为避免误导，主张结合T1增强导航。对切开附近的重要运动结构如锥体束、面神经核等，应采用电刺激精确定位并避开。三、BSCM的切除技巧需要细致、耐心的显微操作，不可贪快。技术要点如下：（1）先减压后分离。通过释放液化血肿，并逐步清除泥沙样血块来减低张力并腾出牵拉的空间。（2）沿浅黄色柔软胶质增生带分离，超出会损伤脑干。但也注意不要遗漏病灶，某些滤泡被掩藏在胶质皱襞内，要剥出来。如果残留不仅不会降低出血率，相反近期出血概率会很高[1, 6, 12]。要点是在直视下小心维护和分离界面，通过钝性游离，病灶多可完整取出。周良辅院士提出的脑棉牵拉法是非常实用的技巧。（3）避免热损伤。电凝止血时产生的热量会灼伤脑干组织，所以要尽可能调低电凝功率，并精确电凝。BSCM常有数支细小的供血动脉和引流静脉，应该在分清楚后电凝血管本身而非畸形团或胶质帯。（4）注意保护附近相对粗大的引流静脉或静脉畸形，避免术后严重的脑干水肿[5]。回顾对BSCM的认识过程，脑干曾被认为是手术者的禁区，在国外Spetzler、Bertalanffy，国内王忠诚、周良辅等大师引领下，手术不断取得突破，而神经导航、功能磁共振、神经电生理等技术的发展，也为BSCM手术的安全性提供了有力的保障[1,3，6, 10, 11]。目前国内许多单位已能开展此类手术，体现出我国神经外科整体诊疗水平的提高。当前，BSCM首选的治疗方案仍为手术切除[2-4]，我们需谨记恰当的病例选择、良好的入路设计、完善的术中定位和监护是BSCM手术成功的重要前提，最后才是通过精细的显微外科操作来保证手术疗效。有意见认为立体定向放疗（SRS，Stereotactic radiosurgery）可以降低BSCM的出血机会[13]，但该meta分析计算治疗前的年出血率时，仅统计出现症状或发现病灶到SRS治疗这一发作期时间窗的年化出血率，很容易夸大真实风险，以此推测治疗后年出血率下降很不科学。若与有症状BSCM的自然史比较，SRS治疗后2年内的年再出血率为6.8%-12.5%，但出现症状后的BSCM即便未经治疗2年内的年出血率也仅为6.1%-16.3%，两者差别并不明显[13, 14]。因此SRS降低BSCM年出血率的依据不足。此外，SRS的副作用如脑干严重水肿、出现继发血管瘤样改变等证据较为确凿，新发神经功能障碍率达11.8%[13]。因此不建议贸然采用放射治疗。参考文献[1] Chen L, Zhao Y, Zhou L, et al. Surgical strategies in treating brainstem cavernous malformations[Z]. 2011:68,609-620, 620-621.[2] Garcia R M, Ivan M E, Lawton M T. Brainstem Cavernous Malformations: Surgical Results in 104 Patients and a Proposed Grading System to Predict Neurological Outcomes[J]. Neurosurgery,2015:1.[3] 王亮，张俊廷，吴震，等. 脑干海绵状血管瘤的外科治疗进展[J]. 中国微侵袭神经外科杂志,2007(03):139-141.[4] 毛颖，周良辅，杜固宏，等. 脑干海绵状血管瘤的手术指征和方法[J]. 中华外科杂志,2001,39(9):672-674.[5] Abla A A, Spetzler R F. Brainstem Cavernoma Surgery: The State of the Art[J]. World Neurosurgery,2013,80(1-2):44-46.[6] Garrett M, Spetzler R F. Surgical treatment of brainstem cavernous malformations[J]. Surgical Neurology,2009,72:S3-S9.[7] Brown A P Y, Thompson B G, Spetzler R F. The two-point method: evaluating brain stem lesions[J]. BNI Q,1996(12):20-24.[8] Flores B C, Whittemore A R, Samson D S, et al. The utility of preoperative diffusion tensor imaging in the surgical management of brainstem cavernous malformations[J]. Journal of Neurosurgery,2015:1-10.[9] Sanborn M R, Kramarz M J, Storm P B, et al. Endoscopic, endonasal, transclival resection of a pontine cavernoma: case report[J]. Neurosurgery,2012,71(1 Suppl Operative):198-203.[10] Kimball M M, Lewis S B, Werning J W, et al. Resection of a pontine cavernous malformation via an endoscopic endonasal approach: a case report[J]. Neurosurgery,2012,71(1 Suppl Operative):186-193, 193-194.[11] 毛颖，周良辅，梁勇，等. 脑干海绵状血管瘤的显微手术治疗[J]. 中华医学杂志,2001(06):9-10.[12] Gross B A, Batjer H H, Awad I A, et al. Brainstem cavernous malformations: 1390 surgical cases from the literature[J]. World Neurosurg,2013,80(1-2):89-93.[13] Lu X Y, Sun H, Xu J G, et al. Stereotactic radiosurgery of brainstem cavernous malformations: a systematic review and meta-analysis[J]. J Neurosurg,2014,120(4):982-987.[14] Li D, Hao S, Jia G, et al. Hemorrhage risks and functional outcomes of untreated brainstem cavernous malformations[J]. Journal of neurosurgery,2014,121(1):32.

Emotion and cognitive function assessment of patients withcentral neurocytoma resection through transcortical frontalapproach: a 5-year postoperative follow-up study SHI Zhi-feng, SUN Da-liang, SONG Jian-ping, YAO Yu and MAO Ying Background Central neurocytoma accounts for 0.1% of primary brain tumor that often occurs in young adults. Surgeryis the main treatment for central neurocytoma and the rate of 5-year survival reaches up to over 90%. This study aimed toassess the effect of transcortical frontal approach to surgical resection of central neurocytoma on emotion and cognitivefunction 5 years after surgery. Methods Telephone following-up visits were used in this study. By means of neuropsychological testing, assayedemotion, memory and abstract thinking ability of 18 patients undergoing central neurocytoma resection by transcorticalfrontal approach for 5 years or more, with another 21 normal cases as control group were enrolled. The data wereanalyzed statistically by paired t test with SPSS11.5. Results Patients whose central neurocytoma was removed by transcortical frontal approach were not affected oncalculating ability 5 years after operation while ability of memory declined sharply (P=0.000), the older, the more sharply(P=0.036). Ability of abstract thinking was significantly reduced (P=0.000), the older, the more significantly as well(P=0.012); additionally, anxiety and depression occurred in patients rather more than those of control group (P=0.000),especially cognitive impairment. Conclusions Transcortical frontal approach for surgical resection of central neurocytoma has certain long-terminfluence on patients’ life quality, vulnerable to anxiety, depression and cognitive impairment, the severity of which wascorrelated to age. Therefore, improving surgical approach will be of value for better long-term life quality of patients.Chinese Medical Journal 2011;124(17):2593-2598

吴劲松，章捷，庄东晓，姚成军，邱天明，路俊锋，朱凤平，毛颖，周良辅背景：目前胶质瘤的治疗日益趋向个体化。胶质瘤手术有助于组织学诊断，减轻肿瘤占位效应，更为重要的是延长患者生存期。在过去的二十年中，许多手术技术和辅助技术应用到胶质瘤手术之中，这使得胶质瘤手术领域得到迅速发展。本文回顾了国内胶质瘤手术的相关研究并对中国胶质瘤手术治疗的现状进行总结。方法：利用文献检索，涵盖了目前国内胶质瘤手术的主要技术和辅助技术。检索的数据库如下：Pubmed数据库（1995年1月至今）；中国知识资源综合数据库（CNKI）（1995年1月至今）和中国科技期刊VIP数据库（1995年1月至今）。通过筛选标准排除重复和无关的文献，再从纳入研究的文献中提取相关结果和方法。结果：初步检索结果3307篇，69篇相关研究文献被纳入并进行进一步分析。结论：在中国，胶质瘤手术治疗的理念正经历着巨大的改变。现在，中国神经外科医生更关注术后病人神经功能情况。胶质瘤手术的目标不仅仅是更广泛的肿瘤切除，还要达到最大的安全性。如何在更长的生存期和更高的生活质量两者之间达到良好平衡，应该视每个病人具体情况而定。

毛颖 周良辅 陈亮 朱巍 赵曜BACKGROUND: Optimal therapy of brainstem cavernous malformations (BSCMs)remains controversial because their biological behavior is unpredictable and surgicalremoval is challenging.OBJECTIVE: To analyze our experience with BSCMs and to conduct a review of theliterature to identify a rational approach to the management of these lesions.METHODS: Fifty-five patients harboring 57 BSCMs underwent surgery and 17 patientswere treated conservatively during the 10-year period from 1999 to 2008. The operativestrategy was to perform complete CM resection and to preserve any associated venousmalformation with minimal functional brainstem tissue sacrificed. The National Institutesof Health Strength Scale (NIHSS) was used to assess neurological status. RESULTS: The average hemorrhagic and rehemorrhagic rates were 4.7% and 32.7% perpatient-year, respectively. Total lesional resection was achieved in all operated patients.Their mean NIHSS score was 4.6 after the first episode, 3.5 preoperatively, 3.2 at dis-charge, and 1.4 after a mean follow-up of 49 months. Complete recovery rates of motordeficits and sensory disturbances from the preoperative state were 70.4% and 51.7%,respectively. Complete recovery rates for cranial nerves III, V, VI, and VII and the lowergroup were 60%, 63.2%, 25%, 57.1%, and 80%, respectively. For the conservative pa-tients, the mean NIHSS score was 5.9 after the first episode and 1.7 after a mean follow-up of 40 months. CONCLUSION: NIHSS is optimal for evaluating the natural history and surgical effect ofpatients harboring BSCMs. Surgical resection remains the primary therapeutic optionafter careful patient screening and preoperative planning.

LI Pei-liang, MAO Ying, ZHU Wei, ZHAO Nai-qing, ZHAO Yao and CHEN Liang Background Resection of petroclival meningioma (PCM) is difficult for neurosurgeons and usually brings poorperformance status. In this study, we evaluated the possible risk factors for unfavorable clinical outcomes ofsurgical treatment of PCM, and tried to explore the optimal surgical strategies for better postoperative quality oflife. Methods We recruited 57 patients (14 male, 43 female, mean age, 50.5 years) who underwent surgical resection ofPCM in Huashan Hospital during 2002–2006. The primary outcomes including postoperative neurological deficits,modified Rankin scale (mRS) score and recurrence rate were evaluated, and all potential risk factors were assessed bythe χ2 test. Odds ratio and 95% confidence interval were calculated by univariate Logistic regression. The mean follow-uptime was 34 months. Results Gross total resection was achieved in 58% of patients. One patient died during the perioperative periodbecause of intracranial hemorrhage. Sixty-seven percent of patients experienced new postoperative neurological deficitsand 26% had a higher mRS score at follow-up assessment. Postoperative complications were observed in 24 patients.Within the follow-up period, radiographic recurrence occurred in 12.3% of patients at a mean follow-up of 42 months.Postoperative radiosurgery was administered to 19 patients who had residual tumors or recurrence and no furtherprogression was found. Tumor adhesion, hypervascularity and engulfment of neurovascular structures were three riskfactors for increased mRS score (P=0.0002; P=0.0051; P=0.0009). Tumor adherence to adjacent structures clearlyaffected the extent of resection (P=0.0029). The risk of postoperative cranial nerve deficits increased with tumorengulfment of neurovascular structures (P=0.0004). Conclusions Intraoperatively defined tumor characteristics played a critical role in identifying postoperative functionalstatus. An individual treatment strategy after careful preoperative evaluation could help improve quality of life.

Wei Zhu, Yan-Long Tian, Liang-Fu Zhou, Dong-Lei Song, Bin Xu, Ying Mao OBJECTIVE: Direct surgeryfor complex internal carotid artery (ICA) aneurysms can be difficult. Incertain situations, sacrificing the parent artery is a unique way to obliteratethe aneurysm and extracranial-to-intracranial (EC-IC) bypass is indispensableto prevent postoperative cerebral ischemia. This article discusses theindications for direct ICA occlusion, and the strategies, techniques, andoutcomes in a series of patients treated for complex ICA aneurysms in a singleinstitution. METHODS: During a 7-year period,49 patients with complex ICA aneurysms underwent direct ICA sacrifice, or ICAsacrifice combined with EC-IC bypass. The appropriate type of bypass wasdetermined by the results of balloon occlusion test and computed tomographicperfusion. The technique of ICA sacrifice used was selected based on theevaluation of retrograde filling of the aneurysm during balloon occlusion test. RESULTS: Ten patientsunderwent direct ICA sacrifice and no ischemia- related complications wereevident during the 5–12 months of follow-up. A total of 39 patients weretreated by ICA sacrifice combined with EC-IC bypass, including 21 cases ofsuperficial temporal artery–radial artery–middle cerebral artery and 18 casesof external carotid artery–radial artery–middle cerebral artery. ICA sacrificewas achieved in 38 patients by using prolonged occlusion (25 cases) or acuteocclusion (13 cases). Five patients presented with minor ischemia aftersurgery, but four patients recovered completely. Two patients developed brainswelling postoperatively and one developed intracranial hem- orrhage, whichrequired evacuation of the hematoma. CONCLUSION: Balloonocclusion test combined with computed tomographic perfusion can be an efficientway to evaluate the compromised cerebrovascular reserve in patients withcomplex ICA aneurysms after ICA occlusion. In conjunction with EC-IC bypass,ICA proxim