乙状窦后经小脑中脚入路治疗脑桥海绵状血管畸形：多中心经验

文献信息

中文摘要

背景： 脑桥内源性海绵状血管畸形因其位置深在且紧邻关键脑干核团和长传导束，是神经外科最具挑战性的病变之一。传统手术入路因需穿越重要神经组织而伴随相当高的并发症率。经小脑中脚（trans-MCP）入路的发现，使得对部分脑桥病变的更安全进入成为可能。然而，除了引入trans-MCP入路的中心（Phoenix）的发表外，关于其使用和手术结局所知甚少。
方法： 在三个学术神经外科中心，对症状性脑桥内源性海绵状血管畸形患者采用乙状窦后经trans-MCP入路治疗。数据来自机构数据库，包括临床表现、影像学特征、手术细节和随访结局。
结果： 共纳入5例患者（3男2女；平均年龄44.8岁）。所有病变均位于脑桥内，无软膜或室管膜表面表现，并显示典型的出血MRI特征，对邻近结构有占位效应。术前mRS中位数为4（范围1-4），3/5例患者术前发生再出血。在神经生理监测下实施乙状窦后经trans-MCP入路。所有病例均实现全切除。术后神经功能障碍发生于全部5例患者，但主要为暂时性。随访时（范围4-14个月），MRI未检测到残留或复发性海绵状血管畸形。所有病例神经功能状态均有改善。残留症状轻微，包括轻度共济失调、面部感觉减退、构音障碍或眩晕。功能结局良好，随访mRS中位数为1（范围1-2）。
结论： 乙状窦后经trans-MCP入路对于选定的脑桥海绵状血管畸形是一种相对安全、有效且可重复的手术策略。由经验丰富的外科医生实施时，该入路可在专科中心成功开展。

英文摘要

BACKGROUND: Intrinsic pontine cavernous malformations represent one of the most challenging entities in neurosurgery because of their deep location and close proximity to critical brainstem nuclei and long tracts. Traditional surgical approaches are associated with considerable morbidity due to transgression of eloquent neural tissue. The identification of the trans-middle cerebellar peduncle (trans-MCP) approach, has enabled safer access to selected pontine lesions. However, apart from publications of the center where the trans-MCP approach was introduced (Phoenix), little is known about its use and surgical outcome.
METHODS: Patients with symptomatic intrinsic pontine cavernous malformations were treated via a retrosigmoid trans-MCP approach at three academic neurosurgical centers. Data were obtained from institutional databases and included clinical presentation, imaging characteristics, surgical details, and follow-up outcomes.
RESULTS: Five patients (3 men, 2 women; mean age 44.8 years) were included. All lesions were intrinsically located within the pons without pial or ependymal surface presentation and demonstrated typical hemorrhage MRI characteristics with mass effect on adjacent structures. The median preoperative mRS was 4 (range 1-4), and recurrent hemorrhage before surgery occurred in 3/5 patients. The retrosigmoid trans-MCP approach was performed with neurophysiological monitoring. Gross total resection was achieved in all instances. Postoperative neurological morbidity occurred in all five patients but was predominantly transient. At follow-up (range 4-14 months), no residual or recurrent cavernous malformations were detected on MRI. Neurological status had improved in all cases. Residual symptoms were minor and included mild ataxia, facial hypesthesia, dysarthria, or vertigo. Functional outcomes were favorable, with a median follow-up mRS of 1 (range 1-2).
CONCLUSION: The retrosigmoid trans-MCP approach represents a relatively safe, effective, and reproducible surgical strategy for selected pontine cavernous malformations. When performed by experienced surgeons, this approach can be successfully implemented across specialized centers.