伽玛刀治疗失败的听神经瘤补救性显微手术的手术挑战与功能结局：一家机构12年的经验
Operative challenges and functional outcomes of salvage microsurgery in Gamma Knife-failed vestibular schwannoma: A 12-year institutional experience.
文献信息
| PMID | 42925652 |
|---|---|
| 原文 | 在 PubMed 查看原文 ↗ |
| 发表日期 | 2026 |
| 作者 | Gyani J S Birua |
| 作者单位 | Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, 560029, INDIA. Electronic address: drgjsbirua@gmail.com. |
| 期刊 | Clinical neurology and neurosurgery |
| SCI 分区 | Q2 |
| IF | 1.9 |
| 研究类型 | 临床研究 · 临床 |
| 所属专科 | 耳科 |
中文摘要
引言： 听神经瘤（VS）是前庭神经的良性肿瘤。在部分病例中，由于伽玛刀放射外科（GKRS）的微创性及约90%的报道肿瘤控制率而被采用。GKRS失败后的补救性显微手术并不常见，其技术难度仍存在争议。一些作者报告手术挑战增加，而另一些作者则发现与初次显微手术相比无显著差异。本研究介绍我们对GKRS失败后VS行补救性显微手术的经验，重点关注手术挑战与结局。
材料和方法： 本回顾性观察研究在印度国家精神卫生和神经科学研究所（NIMHANS）进行。2012年至2023年间，1633例患者因听神经瘤接受手术，包括初发和复发病例。其中，24例患者既往接受过GKRS，随后需要补救性显微手术。我们从机构病历和PACS影像中检索临床、影像学和手术数据。GKRS参数，包括肿瘤体积和放射剂量，从GKRS部门获取。
结果： 24例患者中，8例因右侧肿瘤手术，16例因左侧肿瘤手术。平均肿瘤体积从GKRS前的7.8 cc增加至手术时的19.13 cc。从症状出现至GKRS的中位间隔为28.91个月，而从GKRS至手术的中位持续时间为28.81个月。GKRS后6个月，66.7%的病例中央对比增强减少。平均手术时间为332.92分钟，平均失血量为570 mL。58.3%的病例肿瘤质地坚韧，75%的病例肿瘤中度富血供。第五和第七脑神经分别在62.5%和75.0%的病例中被识别。17例观察到肿瘤与脑干粘连，而仅4例存在明显的蛛网膜增厚。
结论： 听神经瘤伽玛刀放射外科失败后的补救性显微手术是可行且安全的。然而，放射外科后的组织改变，如脑神经与肿瘤粘连以及脑神经识别困难，使其在技术上比初次显微手术更具挑战性，导致全切除率较低和面神经并发症发生率较高。在这种情况下，推荐优先考虑最大安全切除和功能保留，而非完全清除肿瘤的策略。
英文摘要
INTRODUCTION: Vestibular schwannoma (VS) is a benign tumor of the vestibular nerve. In selected cases, Gamma Knife radiosurgery (GKRS) is used due to its minimally invasive nature and reported tumor control rates of approximately 90%. Salvage microsurgery after failed GKRS is uncommon, and its technical difficulty remains debated. Some authors report increased surgical challenges, while others find no significant differences compared to primary microsurgery. This study presents our experience with salvage microsurgery for VS following failed GKRS, focusing on operative challenges and outcomes.
MATERIALS AND METHODS: This retrospective observational study was conducted at the National Institute of Mental Health and Neurosciences (NIMHANS), India. Between 2012 and 2023, 1633 patients underwent surgery for vestibular schwannoma, including primary and recurrent cases. Among these, 24 patients had previously received GKRS and subsequently required salvage microsurgery. We retrieved clinical, radiological, and operative data from institutional medical records and PACS imaging. GKRS parameters, including tumor volume and radiation dose, were obtained from the GKRS department.
RESULTS: Of the 24 patients, eight were operated on for right-sided tumors, and sixteen for left-sided tumors. The mean tumor volume increased from 7.8 cc before GKRS to 19.13 cc at surgery. The median interval from symptom onset to GKRS was 28.91 months, while the median duration from GKRS to surgery was 28.81 months. Central contrast enhancement decreased at six months post-GKRS in 66.7% of cases. The mean operative time was 332.92 min, and the mean blood loss was 570 mL. Tumors were firm in 58.3% of cases and moderately vascular in 75%. The fifth and seventh cranial nerves were identified in 62.5% and 75.0% of cases, respectively. Tumor adherence to the brainstem was observed in 17 cases, while significant arachnoid thickening was present in only four cases.
CONCLUSION: Salvage microsurgery after failed Gamma Knife radiosurgery for vestibular schwannoma is feasible and safe. However, post-radiosurgical tissue changes, such as adherence of the cranial nerves to the tumor and difficulty identifying the cranial nerves, make it technically more demanding than primary microsurgery, resulting in lower rates of gross total resection and a higher incidence of facial nerve morbidity. In this setting, a strategy prioritising maximal safe resection and functional preservation, rather than complete tumour clearance, is recommended.