目的 探讨颅内共存肿瘤的诊断、治疗及预后.方法 回顾性分析4例颅内共存肿瘤的临床资料,并复习相关文献.结果 3例行手术治疗,病理证实为脑膜瘤合并垂体腺瘤、颅咽管瘤、胶质瘤各1例,均与术前影像诊断一致,术后正常生活;1例术前考虑为脑膜瘤合并胶质瘤,未行手术治疗.结论 颅内共存肿瘤需进行充分的术前评估,大多可明确诊断,设计合理的手术方案,可获得良好的治疗效果,其预后主要取决于病变性质.

Rathke cleft cysts (RCCs) are nonneoplastic lesions that are thought to be the remnants of Rathke cleft pouch. The authors report a patient presented with a headache and was diagnosed with RCC on imaging. The lesion underwent spontaneous involution. The authors suggest that patients presenting solely with a headache to be treated conservatively, because it is uncertain whether a headache is definitively associated with RCCs and because there is the possibility of spontaneous regression.

目的：分析单纯钻孔引流法与钻孔尿激酶注入引流法治疗慢性硬膜下血肿的效果。方法选取86例慢性硬膜下血肿患者，根据手术方式不同分为单纯钻孔引流法组（对照组）与钻孔尿激酶注入引流法组（观察组），每组43例患者。对其临床资料、血肿消失时间、残存硬膜下积液、血肿复发等进行比较。结果观察组患者血肿消失时间明显短于对照组，10 d后复查残存硬膜下积液率及血肿复发率明显低于对照组，比较差异有统计学意义（P＜0.05）。结论钻孔尿激酶注入引流法治疗慢性硬膜下血肿的效果明显优于单纯钻孔引流法治疗慢性硬膜下血肿，使血肿消失时间缩短，残存硬膜下积液率及血肿复发率明显降低，值得临床推广应用。

目的:研究该颞下微骨窗入路的骨窗大小及范围,并指导其在临床上的应用.方法:取4具8侧由10％甲醛溶液固定并灌注好的尸头,在每一侧尸头上取起点为紧贴颧弓耳屏前1cm弧形向后越过耳廓的小马蹄形切口,铣下一3-4cm骨瓣,并在显微镜下测量骨窗大小及显微镜下结构等.结果:该颞下微骨窗八路的小马蹄弧形切口,弧形两端的距离平均为55±5mm,弧形的高度平均为40±5mm,骨窗大小为3×4cm,颧弓后根至小脑幕游离缘的距离为39.11±1.32mm,颊弓后根至脑桥中部的距离为45.93士3.52mm,并且从侧方可以无障碍观察到基底动脉分叉部及其主要的分支.结论:该颞下微骨窗入路在不损伤颠浅动脉及面神经的情况下,以一更加小的切口及骨窗到达基地动脉分又部及分支,可以指导临床用以处理基底动脉分叉部、大脑后动脉P1段动脉瘤等.

病人,女,33岁,4年前因松果体区肿瘤行开颅肿瘤切除术,术中见肿瘤质韧,血供丰富,镜下分块全切,手术顺利,术后恢复良好,病理结果示孤立性纤维性肿瘤(SFT).未行放、化疗,未行常规复查.2012年8月病人因头部不适,行颅脑MRI检查示松果体区占位性病变,大小约40 mm×28 mm×24 mm,与小脑幕相连,胼胝体压部受压,四叠体欠清晰(图1),考虑为肿瘤复发,行原切口人路肿瘤切除术,术中见肿瘤质韧,血供丰富,肿瘤基底附着于小脑幕,镜下全切肿瘤,术后恢复良好,无偏瘫、失语及视力、视野障碍.病理结果示松果体区SFT,术后1年复查CT无肿瘤复发,目前仍在随访中.

前父通动脉复合体(anterior communicating artery complex,ACoAC)周围区域是颅内病变常见的发病区域,了解此区域内镜下的解剖关系对进行相关病变的手术有很大的帮助.材料与方法1.材料:颅脑冠状位和矢状位CT扫描后,选取蝶鞍型蝶窦尸头10具,经乳胶灌注并放置48 h备用,另选取成人带有视神经及嗅神经的颅底标本10具;DELON硬质内镜及其相关配套器械和设备,选用0°、30°镜头,德国麦迪牌动脉瘤夹及角型动脉瘤夹钳,游标卡尺,量角器。

Objective To explore the treatment of expansive posterior fossa cranioplasty with occipital flips for Arnold-chiari Ⅰ malformation.Methods Methods 9 cases of the patients with Arnold-chiari Ⅰ malformation all use surgical treatment,do the decompression of posterior cranial fossa,duraplastic repair,resection of hernia below cerebellar tonsil and separation of adherence of arachnoid membrane.Results Postoperative MRI studies revealed that cerebellar tonsillar lower edge of the cases are rising to the foramen magnum level above,the posterior fossa volume increase,8 cases symptoms improved significantly,1 cases no improvement.Follow-up of 3-18 months,all patients got good clinical outcomes with symptoms relief.MRI showed syringomyelia disappeared in 2cases,significantly thinned in 5 cases,no improvem.Conclusion Conclusion Expansive posterior fossa cranioplasty using occipital flip is effective for arnold-chiari Ⅰ malformation.

患者 女,48岁.双眼视力进行性下降1年,头痛、头晕10 d.查体:视力左眼0.3,右眼0.4,神经系统和内分泌结果正常.颅脑MRI示:鞍内短T1异常信号,12.5 mm×12.5 mm×14.4 mm,病灶内信号欠均匀,环形强化,视交叉受压上抬,鞍底下陷(图1a).诊断为"垂体腺瘤".行经鼻蝶窦入路肿瘤切除术,病理为垂体腺瘤.患者术后出现脑脊液鼻漏,平卧位并行腰大池引流3d,未见缓解,遂行经鼻脑脊液鼻漏修补术,术后继续腰大池引流,术后3d出现高热,脑脊液出现感染征象(细胞数1 121×106/L,白细胞121×106/L,葡萄糖1.2 mrnol/L),脑膜刺激征阳性,给予抗感染+腰大池外引流.

目的 探讨利用自体骨瓣进行后颅窝扩大成形术治疗Chiari Ⅰ型畸形的临床效果.方法 本组9例Chiari Ⅰ型患者均采用手术治疗,行后颅窝自体骨骨瓣扩大成形、硬脑膜成形、小脑扁桃体切除及粘连蛛网膜分解术.结果 9例患者术后均复查MRI示小脑扁桃体下缘均上升到枕骨大孔水平以上,后颅窝容积增大.8例症状改善明显,1例改善不明显.随访3～18个月,所有病例症状体征较术前改善.MRI示7例合并脊髓空洞患者中,2例空洞消失,5例脊髓空洞明显缩小.结论 自体骨瓣后颅窝扩大成形治疗Chiari Ⅰ畸形患者,临床症状改善,效果满意.

Objective To explore clinical effects of large decompressive craniectomy by pterion-temple approach (P-TA) for treatment of indicative massive cerebral infarction. Methods A total of 34 cases who underwent decompression by standard craniectomy or P-TA craniectomy for treating massive cerebral infarction between 2006 and 2008 were reviewed and analyzed retrospectively. The curative effect was evaluated according to Barthel Index (BAI) and Glasgow Outcome Score (GOS). Results The ratios of bulged brain tissue volume of two groups 1 d after operation were significantly different (t=2.788,P0.05). All patients were followed-up after operation. There was no significant difference in the mortality of two groups 3 and 6 months after operation (P0.05); however,there was significant difference in the BAI and GOS of two groups 3 and 6 months after operation (t=7.329,4.076,8.734,3.818; P0.05). Conclusion Decompressive craniectomy via P-TA has the advantages of easy operating and sufficient exposure and decompression. It is a good option for the treatment of indicative massive cerebral infarction.

Objective To provide a new approach for the treatment of tumor in Meckel’s cave, by dissecting adjacent structures of the nasal cavity-maxillary sinus-pterygopalatine fossa-Meckel’s cave approach. Methods Fifteen adult cadaver heads (30 sides) were dissected and the correlated anatomic landmarks were observed, measured and analyzed in an operative route. Results The approach was divided into 3 steps: entering the maxillary sinus, the later pterygopalatine fossa and the final Meckel’s cave. Safe access to Meckel’s cave could be achieved by tracing the vidian neurovascular bundles and dissecting the quadrangular space (QS). The distances from the nasal columella to the apertura maxillaries, the sphenopalatine foramen, and the anterior foramen of the pterygoid canal were (44.08±2.61) mm, (64.83±2.42) mm, and (70.43±2.94) mm, respectively. The angles between the horizontal plate of the palatine bone and the link from nasal columella to apertura maxillaries, between the horizontal plate of the palatine bone and the link from nasal columella to sphenopalatine foramen were (38.10±2.46)° and (26.15±2.26)°, respectively. Conclusion The endoscopic approach of transnasal maxillary sinus-pterygopalatine fossa-Meckel’s cave (ENMPA) is a safe and direct way to access Meckel’s cave, and could be employed for the treatment of tumor in Meckel’s cave.

Objective To study the microanatomy on parasella through an extended transsphenoidal approach and provide morphologic foundation for clinical application. Methods A mimical surgery was performed on 15 adult-cadaver heads through an extended transsphenoidal approach,and some anatomic parameters measured. Results The relationship between nerves and blood vessels were different as shown through parasella or skull approach.From anterior to posterior part,it might be divided into optic strut triangle,upper triangle,upper quadrilateral area,and lower quadrilateral area. Conclusion The correlated features of parasella nerves and blood vessels may provide anatomic markers for endoscopic procedures through extended transsphenoidal approach.

Objective To study effect of double-C-shape decompression craniectomy(DC) on massive hemispheric infarction. Methods From August 2004 to August 2007,30 cases with massive cerebral infarction(MCI) were treated in our hospital,of which,20 underwent standard DC,and 10 underwent double-C-shape DC(modified group).The clinical effect was assessed according to Barthel Index(BAI) and Glasgow Outcome Score(GOS). Results All the patients were followed-up after operation.The case fatality of one and six months after surgery between the two groups did not show statistically different(P>0.05);but the difference of BAI and GOS between the two groups was significant(t=2.593-7.162,P<0.05). Conclusion Double-C-shape DC may decompress cortical vein,which is a better choice for therapy of massive cerebral infarction.

经扩大的鞍隔孔向鞍上生长的垂体腺瘤比较少见,我们曾收治3例.现报告如下.

Objective: To evaluate the utility of neuronavigator-guided microsurgery for brain tumors around the sulcus centralis.Methods: 26 patients with brain tumors around the sulcus centralis underwent microsurgery under the guidance of neuronavigator. The accuracy and the value of the navigation were assessed.Results: The mean fiducial error (MFE) was (2.71±1.03) mm. The total tumor removal was achieved in 19 cases, the subtotal removal in 6 cases and the part removal in 1 case. Neurological functions were improved or unchanged in 21 cases, worsen in 5 cases and no one died in 1 week postoperatively.Conclusions: The neuronavigation can guide the manipulation simultaneously. It is helpful to the increase in the total tumor removal, the decrease in the injury to brain and the reduction of the nervous dysfunction complications.

Objective To investigate the diagnosis of multiple arterial aneurysms of the brain, its treatment and selection of opportune moment. Methods Twenty-one cases of multiple arterial aneurysms of the brain were treated with microsurgery and/or endo-vessel embolism. Results Eighteen were cure and three died. Conclusion All aneurysms should be dealt with at one time and endo-vessel embolism is the first choice. The guilt aneurysm should be handled firstly if the patient is in poor health.

①目的探讨广泛性切除岛叶低级别胶质瘤的可行性和效果.②方法采用显微外科技术,在导航技术的辅助下利用脑的自然池、裂,对17例岛叶区低级别胶质瘤进行广泛性切除.③结果 17例病人术后头颅CT或MRI检查无明显肿瘤组织残存,除2例病人出现暂时性失语外,均恢复良好.④结论边缘系统的胶质瘤,广泛性切除肿瘤而不损伤重要功能结构是可行的,采用显微外科技术是成功的关键.

Arnoid-Chiari I(ACM)多数伴有脊髓空洞(SM),对于两者的相互关系以及发病机制众说纷纭,手术方法及精细程度直接关系到手术后治疗效果.

患者女,38岁,地毯编制工.因进行性右侧肢体无力,活动不灵12d,伴低热,体温38℃左右,轻微头疼,无恶心、呕吐,以 "偏瘫原因待查"收入我院神经内科病房.患肺间质纤维化4年.2个月前因肺部感染当地医院给予多种抗生素治疗(具体药物、剂量不详)和连续泼尼松治疗,现口服泼尼松50mg,每日1次.