Management of Hydrocephalus Associated with Vestibular Schwannoma and Other Cerebellopontine Angle Tumors
Management of Hydrocephalus Associated with Vestibular Schwannoma and Other Cerebellopontine Angle Tumors
复制标题
与前庭神经鞘瘤和其他桥小脑角肿瘤相关的脑积水的治疗
作者：
F. Pirouzmand;Charles Tator;J. Rutka
目的
小脑脑桥角（CPA）肿瘤导致的脑积水（HCP）并不罕见。本回顾性研究旨在调查284例CPA肿瘤患者中HCP的发生率以及其临床表现、治疗方案和预后。
方法
对1985年至1996年在多伦多西部医院由一个由神经外科医生和神经耳科医生组成的手术团队治疗的284例连续的CPA肿瘤患者（主要是前庭神经鞘瘤）进行回顾性研究。
结果
39例患者（13.7%）有脑积水的影像学和/或临床证据，其中37例在术前，2例在术后。肿瘤类型分布为33例前庭神经鞘瘤、5例脑膜瘤和1例海绵状血管瘤。只有5例患者（12%）在第四脑室水平有明显梗阻。在36例患者（92%）中，症状大多为慢性和轻度，符合正常压力脑积水。多变量分析证实肿瘤大小与脑积水发生率密切相关（P <.0001）。4例患者在显微外科肿瘤切除术前进行了永久性分流，主要是因为脑积水症状明显。23例患者在未进行术前分流的情况下进行了显微外科肿瘤切除，其中5例在肿瘤切除后的前2个月需要术后分流。18例患者（78%）在肿瘤切除后不需要分流。就肿瘤大小而言，术后分流组与进行了手术但不需要分流治疗的患者无差异（P < 0.50）。其余10例术前有脑积水的患者接受了分流作为唯一治疗（3例）、立体定向放射外科治疗（3例）或观察处理（4例）。另外2例术前无脑积水的患者在术后出现脑积水并需要分流。术后，我们观察到与无脑积水的术后患者相比，未分流患者假性脑膜膨出的发生率显著增加（P < 0.001），脑脊液漏（鼻漏和/或耳漏）的发生率有非显著增加（P < 0.1）。患者在任何治疗后平均随访3.2年（范围，6个月 - 10年）。对进行了手术但不需要分流的患者随访发现，与脑积水相关的临床症状减少了61%，脑积水的影像学征象减少了75%。
结论
在存在脑积水的情况下，CPA肿瘤的手术切除可以不进行永久性脑脊液分流。对于术前有脑积水的患者，降低术后脑脊液漏相关并发症发生率的预防措施包括仔细封闭任何暴露的气房，包括内听道周围的气房，准确恢复硬脑膜屏障，以及使用脑室或腰椎引流管暂时降低颅内压力。肿瘤切除后仍有症状性脑积水的患者应接受脑室 - 腹腔分流。将这一决定推迟到术后是安全的，并且避免了大多数患者不必要的分流。
OBJECTIVEHydrocephalus (HCP) resulting from cerebellopontine angle (CPA) tumors is not rare. This retrospective study was designed to investigate the incidence of HCP and the clinical presentations, management options, and outcomes of HCP in 284 patients with CPA tumors. METHODSA retrospective study of 284 consecutive patients with CPA tumors (mostly vestibular schwannomas) treated from 1985 to 1996 at Toronto Western Hospital managed by one surgical team consisting of a neurosurgeon and a neuro-otologist. RESULTSThirty-nine patients (13.7%) had radiographic and/or clinical evidence of HCP, 37 preoperatively and 2 postoperatively. Tumor type distribution was 33 vestibular schwannomas, 5 meningiomas, and 1 cavernous hemangioma. Only five patients (12%) had obvious obstruction at the fourth ventricular level. In 36 patients (92%), symptoms were mostly chronic and mild, consistent with normal pressure hydrocephalus. Multivariate analysis confirmed the strong association of tumor size and incidence of HCP (P < .0001). Four patients underwent permanent shunting before microsurgical tumor excision, mainly because of florid symptoms of HCP. Microsurgical tumor excision without preoperative shunting was performed in 23 patients, 5 of whom required postoperative shunting in the first 2 months after tumor excision. Eighteen patients (78%) did not need shunts after tumor resection. With regard to tumor size, the postoperatively shunted group did not differ from the patients who had surgery but did not require shunt treatment (P < 0.50). The remaining 10 patients with preoperative HCP received shunts as the only treatment (3 patients), stereotactic radiosurgery (3 patients), or expectant management (4 patients). Two other patients without preoperative HCP developed postoperative HCP and required shunts. Postoperatively, we observed a significant (P < 0.001) increase in the incidence of pseudomeningocele and a nonsignificant (P < 0.1) increase in cerebrospinal fluid leaks (rhinorrhea and/or otorrhea) in patients without shunts as compared with postoperative patients without HCP. The patients were followed after any treatment for a mean of 3.2 years (range, 6 mo–10 yr). Follow-up in the patients who had surgery but did not require a shunt revealed a 61% decrease in clinical symptoms related to HCP and a 75% decrease in radiographic signs of HCP. CONCLUSIONIn the presence of HCP, operative resection of CPA tumors can be performed without permanent cerebrospinal fluid shunting. Precautionary measures to decrease the incidence of postoperative complications related to cerebrospinal fluid leak in patients with preoperative HCP include meticulous obliteration of any exposed air cells, including those around the internal auditory canal, accurate restoration of the dural barrier, and temporary lowering of intracranial pressure with a ventricular or lumbar drain. Patients with persistent symptomatic HCP after tumor excision should be treated with a ventriculoperitoneal shunt. Delaying this decision until the postoperative period is safe and avoids unnecessary shunting in the majority of patients.