侧脑室肿瘤切除的根治性及术后出血并发症的危险因素

S. Maryashev, G. Danilov, Y. Strunina, A. I. Batalov, Y. Vologdina, I. Pronin, D. Pitskhelauri
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To evaluate the radicality and safety of lateral ventricular tumor removal through traditional approaches–transcallosal and transcortical – using arterial spin labeling (ASL perfusion) and to analyze the risk of hemorrhagic complications in the early postoperative period in the context of tumor location and blood supply.Materials and methods. At the N.N. Burdenko National Medical Research Center of Neurosurgery between 2017 and 2019 48 patients with space‑occupying lesions of the lateral ventricles were examined and treated with surgery. All patients were examined using the same MRI protocol before and after surgery: Т1‑weighted, Т1‑weighed contrast‑enhanced, 3D SPGR, Т2‑weighted, Т2‑FLAIR, DWI, T2‑FLAIR CUBE, SWAN, ASL perfusion. 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引用次数: 0

摘要

介绍。侧脑室肿瘤(肿瘤、血管肿瘤、囊肿)是罕见的,根据不同的来源,约占所有脑肿瘤的0.64 - 3.5%。由于肿瘤生长相对缓慢,在患者出现神经系统症状之前,肿瘤可达到显著的大小。手术是治疗侧脑室肿瘤的主要方法,在许多情况下可以根治性切除。术后主要并发症为脑积水和出血。后者经常导致神经系统症状的升级,有时需要重复手术干预。脑室内手术的成功在于合理的根治性和无并发症。目的评价经胼胝体和经皮质传统入路经动脉自旋标记术(ASL灌注)切除侧脑室肿瘤的根治性和安全性,并结合肿瘤位置和血供情况分析术后早期出血并发症的风险。材料和方法。2017年至2019年,在N.N. Burdenko国家神经外科医学研究中心,对48例侧脑室占位性病变患者进行了检查和手术治疗。所有患者在手术前和术后使用相同的MRI方案进行检查:Т1加权、Т1加权对比增强、3D SPGR、Т2加权、Т2‑FLAIR、DWI、T2‑FLAIR CUBE、SWAN、ASL灌注。28例(58%)采用经皮质入路(经额叶24例,经上颞叶2例,经顶叶2例);经胼胝体入路16例(33%);联合入路(晚期侧脑室肿瘤)3例(6%);1例(2%)采用小脑上幕下入路。根据肿瘤的体积和位置、性别、血流特征、是否存在脑积水等参数,评价不同入路切除侧脑室肿瘤的根治性及术后出血并发症的危险因素。在I组和II组中,观察到相似的肿瘤根治率:经皮质入路为63%,经胼胝体入路为71%。经皮质入路患者肿瘤床血肿发生率更高(64% vs.经胼胝体31%),但无统计学意义。总体而言,I组与II组手术治疗效果比较,差异无统计学意义(p >0.05);这一结论在通过倾向评分匹配选择的伪随机患者亚组中得到证实。对术后血肿与基线血流量水平的相关性分析显示,有血肿的组术前平均肿瘤血流量几乎是术后无出血并发症组的两倍(分别为80.6 ml/100 g/min和49.4 ml/100 g/min)。肿瘤床血肿发生的术后参数有统计学意义:脑积水的存在,术后早期Evans指数。考虑到肿瘤的解剖位置和进展、脑积水的存在和外科医生的喜好,正确和充分地选择手术入路,确保高根治性切除。影响术后早期出血性并发症风险的因素应考虑:性别、是否存在脑积水、肿瘤位置和血流水平。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Radicality of lateral ventricular neoplasms removal and risk factors of postoperative hemorrhagic complications
Introduction. Lateral ventricular neoplasms (tumors, vascular neoplasms, cysts) are rare and according to different sources comprise between 0.64 and 3.5 % of all brain tumors. Due to relatively slow growth, tumors can reach significant size before patient develops neurological symptoms. Surgery is the main method of treatment of lateral ventricular neoplasms, and in many cases radical removal can be achieved. The main complications after surgery are hydrocephalus and hemorrhages. The later frequently lead to escalation of neurological symptoms and sometimes require repeat surgical intervention. The success of intraventricular surgery consists of reasonable radicality and absence of complications.Aims. To evaluate the radicality and safety of lateral ventricular tumor removal through traditional approaches–transcallosal and transcortical – using arterial spin labeling (ASL perfusion) and to analyze the risk of hemorrhagic complications in the early postoperative period in the context of tumor location and blood supply.Materials and methods. At the N.N. Burdenko National Medical Research Center of Neurosurgery between 2017 and 2019 48 patients with space‑occupying lesions of the lateral ventricles were examined and treated with surgery. All patients were examined using the same MRI protocol before and after surgery: Т1‑weighted, Т1‑weighed contrast‑enhanced, 3D SPGR, Т2‑weighted, Т2‑FLAIR, DWI, T2‑FLAIR CUBE, SWAN, ASL perfusion. In 28 (58 %) cases, transcortical approach was used (through the frontal lobe in 24 cases, through the upper temporal lobe in 2 cases, through the parietal lobe in 2 cases); transcallosal approach was used in 16 (33 %) cases; combination approach (for advanced tumors of the lateral ventricles) was used in 3 (6 %) cases; supracerebellar infratentorial approach was used in 1 (2 %) case. Radicality of lateral ventricular tumor removal and risk factors for postoperative hemorrhagic complications using different approaches were evaluated based on the following parameters: tumor volume and location, sex, blood flow characteristics, presence of hydrocephalus.Results. In the compared groups I and II, similar rates of radical tumor removal were observed: 63 % for transcortical approach and 71 % for transcallosal approach. Hematomas in the tumor bed were more frequently observed in patients operated through transcortical approach (64 % vs. 31 % in transcallosal) without statistical significance. Generally, there were no statistically significant differences between surgical treatment results in groups I and II (p >0.05); this conclusion was confirmed in pseudo‑randomized patient subgroups selected through propensity score matching. Analysis of the association between hematoma in the postoperative period and baseline blood flow level showed that in the group with such hematomas mean tumor blood flow prior to surgery was almost twice as high as in the group without hemorrhagic complications after resection (80.6 vs. 49.4 ml/100 g/min, respectively).The following postoperative parameters are statistically significant for development of hematoma in the tumor bed: presence of hydrocephalus, Evans index in the early postoperative period.Conclusions. Correct and adequate choice of surgical approach considering anatomical location and advancement of the tumor, presence of hydrocephalus and surgeon’s preferences ensures high radicality of removal. Factors affecting the risk of hemorrhagic complications in the early postoperative period should be taken into account: sex, presence of hydrocephalus, neoplasm location and blood flow level.
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