Microsurgical therapy for relapsing high-level symon side meningioma

High-level meningioma mainly occurs in the brain convex surface, saky sinus side and butterfly bone, imaging performance edema is obvious, reinforced uneven, no meninges tail sign strengthening, etc., has a higher tendency to relapseHigh-level meningioma that occurs in the sinuses is susceptible to aggression, leaching the sinuses and functional brain tissue, resulting in difficult surgery and difficulty in total excisionShandong University Qilu Hospital (Qingdao) Neurosurgery January 2014-October 2018 the application of neuroelectrophysiological joint navigation vascular fusion imaging technology to assist microsurgery to remove 8 cases of recurrence of high-level sinus meningocodone, the patient's surgical effect and prognosis reported as follows1Object and method1.1 Clinical data
5 cases ofmen and 3 cases of females; age 46 to 73 years old, average 59.1 years oldThe interval between first and second surgery was 2 months to 4 years, with an average of 19.1 months, and the preoperative KPS score was 40 to 100 points, with an average score of 76.5 to 18.2The first operation Simpson II-class excision 4 cases, class III excision 1 case, IV-class excision 3 casesFirst postoperative pathology: 4 cases of atypical meningioma (WHOII), spinal strain-like meningengoum 1 case (WHOII), cross-sectional amacrossion-like meningioma 1 case (WHOIII), interstitial meningioma 2 cases (WHO IIIgrade)1.2 clinical performance
to headache, nausea, vomiting and other intracranial pressure increase symptoms mainly 5 cases, limb activity disorders and paraplegia 6 cases, seizures 3 cases, double vision loss 2 cases, speech problems 1 case1.3 imaging examination and imaging fusion (Figure 1)1.3.1MRI, MRV scan and enhanced scan: showing the tumor site, tumor perimeter edema degree and functional area of the affectedAfter three-dimensional reconstruction of the MRV vascular imaging scanning image, it clearly shows the conditions such as the smooth pressure, blocking and circulation of the sinusesFigure 1 relapses of the left frontal top sinus transverse amamponia before and after the operation of imaging examinationMr1A to 1D preoperative MRI-based tumor and vascular fusion, 1E, 1F postoperative MRI imaging1.3.2 neuronavigation: using the Stealth Station S7 navigation system (Brainlab, Germany) to transmit MRI, MRV imagetothe to the navigation workstation, through software automatic fusion, to obtain the structure of the sinus, its relationship with the tumor location and tumor attack or compression of the sinusesThis group of 1 cases only affected the first 1/3 of the sinus, the remaining 7 cases are affected by the central or central sin of the sinus, and the compression of the central ditch around the functional area1.4 surgical planaccording to the results of tumor and vascular imaging fusion, design surgery plan and incision range, on the basis of using the original surgical incision, along the middle line to make appropriate extension; If the skull is retained after the first surgery, it is necessary to use the original surgical hole reasonably, or to drill symmetrically on both sides of the sacrosanct sinus, carefully separate the epidural, use a milling knife to pay attention to the protection of the epidural, the sinus and the veins that may enter the sinus, to reveal the sacrosanct sinuses and tumors before and after extremely careful hemorrhsuppression, the bleeding of the sinuses to the small power electrococidal or glioblastion spongecut the epidural under the microscope, because the epidural is more tightly bonded to the cerebral cortex during secondary surgery, and when the epidural is cut, special attention is paid to the protection of the cortical and cortical veins, including the use of N20 neuro-induced potential monitoring movement functional area potential changesCareful sharp separation and protection of the tumor-week cortex into the sinus veins, no tension to pull away the brain tissue, first of all to deal with the base of the tumor, cut off part of the tumor blood supply, the tumor fully decompression, the use of cobweb membrane natural interface, no contact to isolate the tumor envelope to make it free from the surrounding brain tissue, completely remove the part of the tumor2Results2.1 the degree of attack on the sinuses6 cases of violation of the sacrosanct sinus cavity and the saly sinus wall, of which 5 cases of the sinuses were not completely blocked;2.2 degree of tumor removal 6 cases of invasion of the sacrosanct sinus cavity and saly sinus wall, 4 cases of Simpson II-level excision, 2 cases of class III excision; 2.3 postoperative pathology 4 cases of atypical meningioma (WHOII grade), spinal strain-like meningioma 1 case (WHO II grade), cross-sectional myocardial meningioma 1 case (WHOIII), mesomorphic meningioma 2 cases (WHO III grade) 2.4 follow-up results
1 case of intermorphic meningioma died of cerebrospinal fluid infection 2 months after surgery, the remaining 7 routine radiation therapy Follow-up 4 to 48 months, of which 1 case followed 11 months when relapse, again surgery-assisted radiation therapy After surgery, there were 2 cases of paraplegia, follow-up for 12 months, 1 case fullrecovery, 1 case partial recovery The remaining 4 cases recovered well and did not have new neurological dysfunction 3 Discuss the importance of 3.1 surgical removal
high-level meningioma patients have poor prognosis, the median survival period is less than 2 years Surgical treatment is the preferred treatment for this kind of patient, and the total survival of patients receiving tumor-full-cutting is longer than that of the second-cut patient AIZER and other patients observed 64 cases of malignant meningioma 5 year survival rate, found that the 5-year survival rate of the full-cut surgery was 64.5%, significantly higher than the partial excision of 41.1% The degree of aggression of high-level sinus side meningioma on the structure of the upper sinuses, drains veins and cortical brain tissue is directly related to the surgical effect, and also encourages neurosurgeons to use feasible techniques or surgical techniques to improve tumor removal neuronavigation has a positive effect on defining tumor boundaries and avoiding cortical veins in surgery, helping to identify the sinus structure early, determining the appropriate bone window range, effectively and accurately treating the base of the tumor, controlling the blood supply of the tumor, in order to facilitate the whole cut of the tumor, to avoid the reflux veins and central cortical brain tissue and other important structures caused by excessive pull of the medical injury 3.2 surgical treatment points 3.2.1 functional area cortical protection: 7 cases in this group of functional cortex around the central ditch were affected, because of the second surgery when the cortical venous adhesion is serious, so the difficulty of total-cut tumor significantly increased Through neuro-navigation vascular fusion imaging, it is possible to dynamically and accurately determine the position of the central back, central groove vein and enhanced epidural and the relationship between the three, such as pushing backward or forward, should not affect the tumor removal, as far as possible to hide it under the bone edge, bone window forward or backward extension, can avoid the injury caused by local tissue extrusion when cutting the epidural In the separation of tumor and functional area cortical adhesion, must be carried out under the monitoring of neuroelectrophysiological N20 potential, to pay special attention to the central groove veins and the nearby upper-matched veins, intervening intervening cavity protection, can be cut along the veins under the microscope, carefully free the vein, cotton tablet protection, to avoid electrocoagulal direct damage to the veins, reduce the occurrence of functional area cortical reflux disorder 3.2.2 the treatment of the sinuses: recurrent tumor and sinus wall tightly adhere dissociated not easy to separate, sinus wall more tumor, the first parallel sinus wall cut off the tumor, the removal of sinus tumor This group of 6 cases of violation of the sacrosanct sinus cavity and the savea sinus wall, preoperative neuronavigation vascular fusion imaging suggested that 5 cases of sinus were not completely blocked, the operation was confirmed After the tumor load reduction treatment, the surgical person continued to remove the tumor in the sinus cavity, while continuously stitching the syllable sinus wall, spherical hemostatic gauze compression filling hemorrhage, in order to protect the induced passageves that were obviously violated by the tumor and severely adhered to, in 6 patients, Simpson II-class excision 4 cases, class III excision 2 cases 3.3 the role of auxiliary radiotherapy Although there is no convergence between the results of the study on high-level meningioma recurrence and prognosis, but most scholars believe that tumor aggression type, tumor perimeter edema degree and tumor size and other factors may affect the recurrence of patients, surgical resection is an independent factor affecting the recurrence of malignant meningioma, however, the role of radiotherapy in the efficacy of high-level meningioma is not clear DURAND et al believe that radiotherapy does not improve the survival rate after high-level meningioma STESSIN and other summary 244 cases of postoperative supplementation with radiation therapy WHO II and CLASS III meningioma cases, stratified analysis results did not indicate the role of postoperative radiotherapy, and ADEBERG and other advocates of radiation treatment on malignant meningioma treatment, recommended radiotherapy should be implemented as soon as possible after surgery Chen Fuye and other analysis of 74 cases of atypical meningioma survival results, found that postoperative radiotherapy and unradiolated patients of PFS and OS there is no significant difference, the radiotherapy did not benefit all atypical meningioma patients, but pointed out that: the first symptoms for paraplegia, secondary tumors, skull attacks, Ki-67 to 10% for atypical meningioma recurrence of high-risk factors, recommended to perform radiation on the basis of surgery as far as possible group of 6 cases of the first postoperative line simple general radiotherapy, 1 routine simple general radiotherapy plus 1 gamma knife treatment, 2 routine general radiotherapy plus fit-shaped radiotherapy In view of the small number of cases in this group and the fact that the first operation did not reach The Simpson I excision, the therapeutic type and radiation dose on the therapeutic effect of high-level meningioma need to be further explored In short, the high-level meningioma located next to the sinuses has a high aggression, coupled with the particularity of the tumor site leading to surgery difficult, more prone to recurrence, treatment is difficult Simply surgical removal of lesions for malignant meningioma is not enough, but surgery full-cut lesions plus postoperative radiotherapy is also difficult to completely avoid tumor recurrence, the need to expand the sample size to confirm the surgical full-cut and radiotherapy program of the positive effect